Short cases Flashcards
7D’s of nipple sign
- Discoloration
- Discharge
- Depression (often referred to as inversion)
- Deviation
- Displacement
- Destruction
- Duplication (unlikely in exam)
What is Mid-inguinal point?
- Halfway between the ASIS and symphysis pubis
- Used for palpation of femoral pulses
What is Midpoint of inguinal ligament?
- Halfway between the ASIS and pubic tubercle
- Deep ring located 1cm cranial to the point
Lymph node on neck palpation
- Submental
- Submandibular
- Pre-auricular
- Post-auricular
- Cervical
- Supraclavicular
- Occipital
Most common location of lipoma
- Neck and trunk
What is a lipoma
- Benign tumor consisting of mature fat cells
Do lipoma undergoes malignant change?
- Very rare
- Liposarcomas arise de novo and usually occur in older age group in deeper tissue of the lower limb
Lipoma management
- Non-surgical: reassure and ‘watch and wait’
- Surgical: pain/ cosmetic reason. Excisional biopsy or suction lipolysis
Differential of thyroid mass based on surface characteristic
> Solitary
- Dominant nodule of MNG
- Follicular adenoma
- Cyst
- Carcinoma
> Multinodular
- Toxic MNG
- Hashimoto’s thyroiditis
> Diffuse enlargement
- Grave’s disease
- Simple, non-toxic goitre
- Hashimoto’s thyroiditis
- Sub-acute thyroiditis
Type of open inguinal hernia repair
- Herniotomy (removal of hernia sac only): done in kid
- Herniorrhaphy (herniotomy + repair of posterior wall of inguinal canal using nearby structure): non-mesh technique
- Hernioplasty (reinforcement of the posterior inguinal canal wall with a synthetic mesh): Lichtenstein tension-free mesh repair
Complication of hernia repair
> Early:
- seroma/ hematoma (present as scrotal swelling),
- urinary retention (due to GA),
- SSI
> Late:
- recurrence,
- testicular atrophy (due to testicular artery damage),
- ejaculatory problems (due to damage vas deferens),
- mesh migration and erosion (Primary: mechanical, pathway of least resistance; Secondary: gradual move to adjacent structure due to foreign body reaction)
Location of inguinal vs femoral hernia
- Inguinal hernia: above and medial to the pubic tubercle
- Femoral hernia: below and lateral to it
Indication for stoma
- Decompression: bypass distal obstruction
- Diversion: protection of distal anastomosis, urinary diversion following cystectomy
- Permanent stoma: post APR
Ileostomy vs Colostomy
> Ileostomy
- Right iliac fossa
- Spout
- Watery
- Permanent: Post pan proctocolectomy
- Temporary: Loop ileostomy after LAR
> Colostomy
- Left iliac fossa
- Flush
- Formed feces
- Permanent: APR
- Temporary: Hartmann’s procedure
How to measure ABPI
- Cuff is placed over the cuff
- When the dorsalis pedis pulse has been located with the Doppler, the cuff is inflated until the pressure is high enough to occlude the artery and thus the Doppler sound disappears
- Slowly lower the cuff pressure until the Doppler sound restarts; this is the ankle pressure
- The index is the ankle pressure divided by the brachial pressure
ABPI range
- > 1.1: calcified or incompressible vessels (eg: in DM)
- 0.7-0.9: mild ischemia (intermittent claudication)
- 0.4-0.7: moderate ischemia
- <0.4: severe ischemia
Classification of gangrene
> Dry
- Gradual occlusion
- Marked pain
- Dried, mummified, shiny and greasy
- No infection
- Marked line of demarcation
- No spread
- No toxemia
- Eg: arthrosclerosis, Buerger’s disease
> Wet
- Sudden occlusion
- Dulled pain
- Swollen, blistering, soft and palpable crepitus
- ++ infection
- Absent/ Poor line of demarcation
- Rapidly spread
- Marked toxemia
- Eg: diabetic gangrene, strangulation
Causes of gangrene
- Diabetes
- Embolus and thrombosis
- Raynaud’s syndrome
- Thromboangitis obliterans (Buerger’s disease)
Clinical features of acute limb ischemia
> 6P’s
- Pain
- Pallor
- Paresthesia
- Paralysis
- Pulselessness
- Perishingly cold
Definition of intermittent claudication
It is muscle pain (ache, cramp, numbness, sense of fatigue), classically in the calf muscle, but may also be in thigh or gluteal, which occurs during exercise, and relieve by a short period of rest
Management of chronic ischemic limb
> Conservative
- stop smoking
- moderate exercise
- improve diet and weight reduction
- aggressive control of HPT, DM, dyslipidemia
- antiplatelet agent
> Non-surgical
- Percutaneous transluminal balloon angioplasty
- Stenting - for failed angioplasty
> Surgical
- Bypass procedures
Explain Buerger’s disease/ Thromboangitis obliterans
- Nonatherosclerotic, segmental, inflammatory disease most commonly affects the small to medium size arteries of extremities
- Characterized by highly cellular and inflammatory occlusive thrombus
- Mostly in men (90%) and strong association with smoking
Locate Saphenofemoral junction
- 2.5cm below and lateral to pubic tubercle (approximately 2 finger breadths)
Type and cause of ulcer edge
- Slopping: Healing, Venous
- Punched out: Trophic, Ischemic, Diabetic
- Undermined: Pressure, Tuberculous
- Everted: SCC, Marjolin’s
- Rolled: BCC
The more gentle way to do rebound tenderness
- By percussion (Dr Sohail)
Definition of sebaceous cyst
- Form of retention cyst containing keratinous-debris lined by keratinizing squamous epithelium
Characteristic of lipoma
- Lobulated surface with well-defined margin
- Soft in consistency
- Positive slipping sign
- Pseudo-fluctuation (due to soft consistency)
Characteristic of sebaceous cyst
- Smooth surface
- Cystic in nature
- May be a punctum on skin
- Attached to skin
- May be indentation sign and molding sign
- Fluctuation test negative
Management of sebaceous cyst
- Excision or incision and avulsion of cyst wall
Hypertrophic scar vs Keloid
> Hypertrophic scar
- Fibroblast overactivity in proliferative phase
- Confined to the scar
- Not progressive
- Frequent in children
- Do not recur if excised properly
> Keloid
- Intense fibroblast activity into the maturation phase
- Extension beyond the original wound
- Continue to grow
- Rare before puberty
- Common in pigmented skin
- Recur despite excision
Clinical features of Grave disease
- Hyperthyroidism
- Eye signs (eg: exophthalmos, lid lag)
- Diffuse goiter
- Thyroid thrill and bruit
- Thyroid acropachy
- Pre-tibial myxedema
Investigation to confirm Grave disease
- Thyroid function test: decrease TSH, increase free T3/ T4
- Thyroid receptor antibodies
- Thyroid scan in case of toxic multinodular goiter/ toxic adenoma
Pathophysiology of exophthalmos
- Infiltration of the retrobulbar tissues with fluid and round cells,
- leading to enlargement of the retroocular muscles and retroocular fibrous and fatty tissue.
- Earliest sign is visible inferior limbus
Medication for thyrotoxicosis
- Anti-thyroid drugs/ Thionamides: carbimazole, propylthiouracil
- Beta-blocker: propranolol
How to follow up after medical treatment of hyperthyroid
- During the early treatment, serum TSH may remain low for several weeks and rarely for several months
- Initial monitoring of therapy, therefore, should consist of periodic clinical assessment, measurements of serum free T4 and T3 levels
- Thioamides: 4-6 weeks interval until stabilize -> 3-6 months interval
2 other modalities of treatment for thyrotoxicosis other than medical
- Radio-iodine: for small to moderate goitre; CI in pregnant, breast feeding, young (<25)
- Surgery: for large goitre, multinodular goitre, solitary nodule with eye sign, relapse after medical treatment
4 specific complication for thyroid surgery
- Hypothyroidism
- Recurrent laryngeal nerve injury
- Hypocalcaemia/ hypoparathyroidism
- Dysphagia (due to postoperative adhesion, cricothyroid inflammation, perithyroidal nerve damage)
Definition of basal cell carcinoma
- Slow growing malignant tumor
- Arising from basal cells of the epidermis
- Rarely metastasis
Site of basal cell carcinoma
- Nose
- Near inner and outer canthi of the eye
- Near the nasolabial fold
Treatment for basal cell carcinoma
- Excision: margin of 1cm followed by primary closure
- Curettage
- Cryotherapy: useful for multiple small BSS
- Radiotherapy
Pathology of venous ulcer
- Fibrin cuff theory: pericapillary fibrin cuffs act as a barrier to oxygen diffusion
- White cell rheology: reduction in capillary blood flow causing WBC attached to capillary endothelium, activated and release free radicals, proteolytic enzyme, and cytokines, leading to tissue damage and ulceration
Classification of varicose vein
- Primary (95%): idiopathic or familial
- Secondary (5%): DVT, AV malformation
Definition of varicose veins
- Dilated, elongated, tortuous subcutaneous veins >= 3mm in diameter
Investigation of varicose veins
- Site of incompetency between deep and superficial venous system (Doppler/ Duplex ultrasound)
- Deep venous system patency (Duplex ultrasound)
- Venous outflow of pelvic and abdominal veins (MRI venography)
2 complication of varicose veins
- Superficial thrombophlebitis (sterile inflammation of vein wall due to local thrombosis)
- Venous hypertensive skin changes (eg: lipodermatosclerosis, pigmentation, ulceration)
Management for varicose veins
> Non-surgical
- Graduated compression stocking
- Sclerotherapy
> Surgical
- Open surgery with junction ligation and stripping of veins
- Multiple stab avulsion
Surface anatomy of saphenofemoral junction
- 3.5cm (approx 2 finger breadths) below and lateral to the pubic tubercle
Conservative treatment for varicose veins
- Gradual elastic compression stocking
- Encourage weight loss and regular exercise
- Sclerotherapy
Investigation for dry gangrene
- ABPI
- Duplex doppler ultrasound
- Contrast angiography
Management of gangrene
> General
- Control of diabetes, hypertension, infection, hypercholesterolemia
- Correction of anemia, nutrition
- Relief of pain
- Change of lifestyle, eg: stop smoking, reduce weight
> Local
- Surgical debridement
- Life saving amputation
Complication of brachial cyst
- Infection
- Malignancy
Suggestive feature of malignancy for melanoma
- Increase in size
- Loss of homogeneity with area of darker pigmentation
- Irregularity of outline
- Nodularity
- Bleeding
- Ulceration
- Satellite lesion
Diagnosis of melanoma
- Excisional biopsy (full thickness with 2mm clearance margin)
Prognosis of melanoma measured using which classification
- Breslow thickness
- Clarke levels
- AJCC staging
Constant perforator vein of lower limb
- Dodd: mid-thigh
- Boyd: upper leg/ gastrocnemius
- Cockett: 3 at lower legs
How to perform vein ligation and stripping
- Small oblique groin incision is made at the SFJ
- Flush ligation of the great saphenous vein at the saphenofemoral junction with narrowing of the femoral vein is performed to avoid a residual stump as a potential source for thromboembolism
- Stripping refers to removal of an extended segment of the vein either with external stripper, intraluminal stripper or perforation-invagination stripper
Positive Perthes test interpretation
-0
What to look for in Doppler/ Duplex USS for varicose veins
- Detect presence or absence of retrograde flow at top, middle, and bottom of long and short saphenous veins
Difference of Doppler and Duplex USS
- Duplex is more modern version of Doppler (combination of Doppler and traditional USS); apart from producing coloured image and detects the flow of blood, it also provides 2-D greyscale images of ultrasound of the tissue
Describe lipodermatosclerosis
- Hyperpigmentation
- Atrophy and diffuse fibrosis of subcutaneous tissue
- Loss of dermal elasticity
- Chronic inflammatory changes
Reason for performing arterial examination in varicose vein
- Assessing for potential suitability of compression therapy, if required
Advice for patient with varicose vein
- Walk around, and try not to sit or stand in one place for a long time
- Raise the leg up 3 or 4 times a day, for 30 minutes each time
- Do exercise to point your toes and feet down and up a few times each day
Differentiating point between inguinal and femoral hernia
> Relation to pubic tubercle
- Inguinal: above and medial
- Femoral: below and lateral
Complication of hernia
- Reducible -> Irreducible -> Obstructed -> Strangulated
- Irreducible/ Incarcerated: contents of hernia sacs cannot be replaced into abdomen
- Obstructed: loop of bowel, but not blood supply is obstructed leading to IO
- Strangulated: blood supply to trapped bowel is cut off, 6 hours to gangrene
Management of incarcerated hernia
- Non-surgical: NBM, IV drip, NG tube on suction, IV abx
- Immediate surgery if suspected incarceration: reduce bowel +- excise hernia sacs, reinforced posterior wall
Inguinal hernia what to look for in abdominal, chest and DRE examination?
- Abdominal: scars, masses, ascites, acute urinary retention, constipation, IO
- DRE: BPH, impacted stool
- Respiratory: COPD
How to differentiate BPH and prostate cancer?
- BPH: firm and smooth, rectal mucosa smooth and not attached to prostate
- Prostate ca: hard and irregular, rectal mucosa not mobile
Richter hernia
- Segment of bowel is trapped and ischemic but lumen is patent -> no IO
Location of deep and superficial inguinal ring
- Deep inguinal ring: 2cm above midpoint of inguinal ligament (defect in transversalis fascia)
- Superficial ring: above and medial to pubic tubercle (defect in aponeurosis of external oblique)
Content of inguinal canal
- Males: spermatic cord + ilioinguinal nerve
- Female: round ligament of the uterus + ilioinguinal nerve
Other examination for patient with inguinal lymphadenopathy
- Legs: any infection/ malignancy
- Perineum: scrotal wall, penis, clitoris, vulva
- Per vaginal exam: lower third drain to superficial inguinal LN
- Per rectal exam: lower ½ of anal canal drain to superficial inguinal LN
- Urethra: external ½ drain to inguinal LN
- Abdominal wall (below umbilicus)
Definition of hernia
Hernia is a sac containing part or whole of a viscus protruding through a normal or abnormal opening in the wall of the containing cavity
Types of incisional hernia
- Simple: asymptomatic, reducible
- Complex: incarcerated, strangulated
Risk factor for incisional hernia
- Technical failure by surgeon: defective closure of abdominal wound, tension
- Patient factor: age, obesity, malnutrition, infection, immunosuppression, malignancy
- High risk incision: upper/ lower midline, subcostal, parastomal
- Preoperative condition: cardiopulmonary disease, diabetes mellitus
Investigation for incisional hernia
- CT abdomen/ pelvis: to confirm the presence of hernia (if PE unable to confirm) and identify any contents that might be contained within the hernia sacs
Treatment for incisional hernia
Surgery
- Anatomical repair
- Mesh repair
- Keel operation
Definition of fistula
- Abnormal connection between 2 body parts, such as an organs or blood vessels
Complication of AV fistula
- Bleeding
- Venous hypertension
- Aneurysm/ mega fistula
- Infection
- Failure of mature AV fistula
Test for the patency of AV fistula
- Feel for a thrill and a pulse; absent means fistula may be thrombosed
- Auscultate for bruit that indicate patency
- Handheld doppler device/ duplex ultrasound
Differential diagnosis for swelling that moves with tongue protrusion
- Thyroglossal cyst
- Ectopic thyroid tissue
Investigation for thyroglossal cyst
- US show cystic lesion
- Radioisotope scan: cyst is cold
- Histology of excised tissue
Management for thyroglossal cyst
- “Sistrunk op”
- Excision of the cyst, track, and central part of hyoid bone
How thyroglossal cyst occur
- The thyroglossal duct is a connection that serves as a pathway for the primordium thyroid gland in its embryogenesis
- The distal part of the thyroglossal duct differentiates into the pyramidal lobe of the thyroid gland in 50% of the cases
- The rest of the duct is, supposedly, expected to obliterate by the 10th week of gestation
- Persistence of any portion of the thyroglossal duct become the gateway to the formation of thyroglossal duct cyst
Thyroglossal tract
- Descent from the base of the tongue, at the foramen caecum
- Passing anterior to the hyoid and thyroid cartilage to reach its final position anterolateral to the superior part of the trachea
What is Berry’s sign
- Absence of a carotid pulsation as a direct result of the tumour encasing the carotid artery and muffling the pulsation
Difference between T3 and T4
> T3
- 25% by gland, 75% by conversion
- Half-life of 1 day
- 3-4 times more potent than T4
> T4
- Solely by gland
- Half-life of 7 days
- Less potent than T3
What is grave disease
- Syndrome consist of hyperthyroidism, goiter, thyroid eye disease, and occasionally pretibial myxedema
- Caused by autoantibodies that bind to the thyrotropin receptor, stimulating growth of the thyroid and overproduction of thyroid hormone
Clinical features of fibroadenoma
- Common in early post pubertal years (15-30)
- Usually presents with smooth, firm, well circumscribed, very mobile (breast mouse)
- Often multiple or bilateral
Management for fibroadenoma
- Reassurance: if the size is 2-3 cm
- Surgical: excision biopsy is advisable (if the lump is large/ patient request/ diagnosis in doubt)
Differential diagnosis for breast lump
- Benign nodularity (Fibrocystic changes)
- Fibroadenoma
- Carcinoma of breast
- Breast cyst
- Abscess
- Lipoma
Malignant VS Benign finding of breast lump ultrasound
> Malignant
- Hypoechoic
- Margin (Irregular, spiculate, angular)
- Taller than wide
- Microlobulation
- Internal calcification
> Benign
- Hyperechogenicity
- Thin echogenic capsule
- Smooth and well defined
- Wider than deep mass
- Macrolobulation
How to perform excisional biopsy
- Because surgical biopsy removes more tissue as a single specimen, conscious sedation or general anaesthesia may be needed
- Incision into the skin and remove the entire abnormal mass
- Careful documentation of the site of biopsy, patient name, and medical record number on the biopsy specimen
- Core and surgical biopsy specimen should be placed immediately into formalin and immediately sent to a pathology lab and promptly processed into paraffin blocks
Lignocaine vs Bupivacaine Onset and Duration of action
- Lidocaine: onset of action 2-5 minutes, duration varies from 30 min to 2 hours; addition of epinephrine provides local vasoconstriction which prolongs the duration of action up to 3 hours
- Bupivacaine: onset of action 5-10 minutes, duration up to 6 hours
Management of keloid scar
- Intralesional corticosteroid: soften and flatten the scar by diminishing collagen and glycosaminoglycan synthesis and by inhibiting fibroblast proliferation
- Intralesional fluorouracil: if not respond to corticosteroid, induce fibroblast apoptosis without necrosis and inhibit TGF-beta signalling in production of collagen type I
- Silicone gel sheets
- Surgical excision: if conservative alone unsuccessful, but associate with recurrence up to 100%, can reduce the rate using intralesional injection/ radiation therapy
Venous system of lower limb and Course of Saphenous Veins
> Deep veins
- 3 paired veins (no valve): posterior tibial, anterior tibial and the peroneal veins
- 2 muscular veins (with valves): soleal veins and gastrocnemius veins
- All join and form the popliteal veins -> femoral veins
> Superficial veins
- Long saphenous vein: runs from anterior to the medial malleolus, along the medial side of the leg and terminated at the saphenofemoral junction where it joins to femoral vein
- Short saphenous vein: from behind the lateral malleolus and runs along the postero-lateral side of the calf to pierce the deep fascia and join the popliteal vein in the popliteal fossa
Causes of varicose veins
> Increase in venous pressure c/b:
- Inadequate muscle pump function
- Incompetent venous valve
- Non-thrombotic venous obstruction
Lobulation sign
- Lobulation sign occurs in encapsulated lipoma. The overlying skin or edges show series of curves and dimples due to attachment of fibrous septa from the capsule of the lipoma to the overlying skin
- Absent of lobulation sign indicate it’s a diffuse type, aka “Pseudo lipoma”
Complication of lipoma
- Secondary infection leading to abscess
- Trauma
- Hemorrhage within tumour
- Ulceration
- Calcification
- Sarcomatous changes
Which lipoma prone to sarcomatous changes
- Retroperitoneal lipoma
- Intermuscular (eg: thigh)
FNAC vs Core needle biopsy
> FNAC
- less invasive, less painful, smaller wound, does not require any local anesthetic
- Only cells are obtained with no histology
- Cannot differentiate between in-situ cancer and invasive cancer
> Core needle biopsy
- More invasive, required LA, will result in larger wound, more painful
- Risk of complication higher (improper angling may result in puncture of the lung or heart)
- Can obtain tissue specimen (differentiate between invasive and non-invasive)
- Can stain for ER/ PR status
What is Dermoid cyst
- Cystic teratoma consisting predominantly of structures derived from the primitive ectoderm
- Contains mature tissue, so almost always benign
Where Dermoid cyst can be found
- Congenital: line of embryonic fusion (eg: midline of body, scalp, periorbital areas at inner/ outer angle, post-auricular)
- Acquired: found in area of repeated trauma due to indriven epithelium following punctured injury (eg: fingers, palm, soles)
Common site for sebaceous cyst
- Scalp, neck, face, shoulder, and scrotum
- Never in palm and sole
2 technique for laparoscopic approach of hernia
- Totally extraperitoneal (TEP) repair, Transabdominal preperitoneal patch (TAPP) repair
- Both of which require the use of mesh and are consider tension-free repairs
Follow up for fibroadenoma
- For patient with a benign biopsy, suggest repeating clinical examination and imaging every 6 months for 2 years, and if stable, may return to routine follow up screening after that
- If there’s changes clinically or radiographically, eg: increasing in size, the mass should be re-evaluated and excised
Where open hernioplasty incision be made?
- Incise skin over the inguinal canal and angle slightly cephalad as the incision progresses laterally
How to perform open hernioplasty
- Once incision has been made, the groin is explored to identify the hernia
- The hernia sac is mobilized from surrounding structures
- Once mobilized, separated from surrounding, and reduced, tissue repair is accomplished using one of the specific hernia repair techniques
- Subcutaneous layer can be approximated with a running suture of 3-0 absorbable suture
Once you enter into the inguinal canal, where would you find the hernia sac?
- Internal inguinal ring and Hesselbach’s triangle
- If fails to identify, preperitoneal space should be explored to allow inspection of the femoral canal by incising the transversalis fascia over Hesselbach’s triangle
Investigation of thyroid nodule
- Thyroid function test
- Thyroid receptor antibodies
- USG: to see if it is prominent nodule in MNG, a solitary nodule or cyst
- Thyroid scan: to determine whether hyperfunctioning (rarely cancer) or hypo functioning (require FNAC)
- FNAC
Malignant features of thyroid nodule
- Rapidly increase in size
- Hoarseness of voice
- Hard in consistency
- Fixity
- Berry’s sign
- Enlarge cervical lymph node
Management of thyroid nodule
- Benign and asymptomatic: reassured
- Need to be removed (eg: pressure symptoms, cosmesis, patient wishes, FNA suspect malignancy): total lobectomy (hemithyroidectomy)
- Hyperthyroid: drugs followed by surgery/ radioiodine
Complication of sebaceous cyst
- infection,
- calcification,
- Cock’s peculiar tumour (suppurating and ulcerating leading to granulating ulcer that resemble SCC),
- sebaceous horn (hyperkeratotic epithelial lesion, mechanism unknown)
Management of sebaceous cyst
- Excision or incision and avulsion of cyst wall
Differential diagnosis of inguinal scrotal/ scrotal swelling
> Cannot get above it
- Indirect inguinal hernia
- Varicocele
> Can get above it, cannot feel testis separately
- Testicular tumor
- Hydrocele
- Orchitis
> Can get above it, cannot feel testis separately, transilluminable
- Hydrocele
- Epididymal cyst
> Can get above it, can feel testis separately, not transilluminable
- Epididymis
- Spermatocele
Extent of hernia classification
- Bubonocele: just beyond the deep ring
- Funicular: just beyond the superficial ring
- Complete/ Scrotal: fundus is in the scrotum
Where to put hernia mesh
- Between the internal oblique muscle/ aponeurosis/ inguinal ligament and external oblique aponeurosis/ spermatic cord
Complication of thyroglossal cyst
- Infection
- Malignant changes
- Sinus formation leading to discharge on skin
How to advice patient with thyroglossal cyst
- Should be treated surgically unless the patient is not a surgical candidate
- If TGDC is not removed, as many as ½ become infected
- May also contain thyroid or lymphoid tissue, which can undergo malignant change
Difference between spider veins, reticular veins and varicose veins
- Spider veins: 1-1.5mm; sometime accompanied by pain and discomfort in the affected area
- Reticular veins: about 2mm, often cause burning and itching
- Varicose veins: >2.5mm; often protrude above the surface of the skin and can lead to pain, burning and spasms
In which case ileal conduit will be seen
- Cancer of the bladder
- Neuropathic bladder
- Resistant urinary incontinence
Describe briefly ileal conduit procedure
- Isolation of a segment of ileum
- One end of the ileum is closed
- 2 ureter is anastomosed to it
- The open end of ileum is brought out onto the skin as an everted spout
Lipoma vs Sebaceous cyst
> Lipoma
- Lobulated surface
- Positive slipping sign
- Not attached to skin
> Sebaceous cyst
- Smooth surface
- Punctum at overlying skin
- Always attached to skin
- Indentation sign and moulding sign
- Do not show slipping sign nor lobulation sign
Explain Perthes test
- To check the patency of deep veins
- Place a tourniquet around upper thigh after emptying the veins below, should be tight enough to obstruct the superficial but not deep veins
- Ask patient to stand up and tip toes 10 times
- Watch for filling of superficial veins or complaining of bursting pain
- Veins become less tense if the perforating calf veins are patent with competent valves, or if the muscle pump is functioning
- Critically important because, if deep vein are not patent, superficial varices are an important pathway for venous return and must nor be sclerosed or surgically removed
Management incisional ventral hernia
> Conservative
- Offer corset or truss
- Weight loss and control the risk factor
> Surgical
- Offer if complications of hernia are present
- Control CVS and resp disease, encourage pre-op weight loss
- Principle: dissect the sac and close the defect using mesh overlapping
- Avoid placing polypropylene mesh in direct contact with the intestine because of the risk of adhesion formation and fistulation
Component of hernia
(*palpable part)
- Mouth
- Neck*
- Body*
- Fundus*
- Contents
Possible content of hernia
- Omentum (omentocele)
- Coils of intestine (enterocele)
- A portion of the circumference of intestine (Richter’s hernia)
- Portion of the bladder
- Ovary
- Meckel’s diverticulum (Littre’s hernia)
- Fluid
Anatomical site for lipoma
- Subcutaneous (commonest)
- Intermuscular
- Submucous
- Retroperitoneal
etc. …
Informed consent for excisional biopsy
> Indication
- Lesions have the potential to be cancerous
- Require further resection of the borders to ensure optimum clearance
> Procedure briefly
> Complication
Intra-operative
- Bleeding
- Anaesthetic risks
Early
- Pain (reduce using LA during procedure, oral during post-op)
- Bleeding
- Infection (need debridement/ course of antibiotics)
- Scarring
Late
- Recurrence
- Further resection (if found to be malignant)
Landmark for carotid artery
- Between SCM and Trachea roughly at the level of cricoid cartilage
Significance of slipping sign
- Positive means that the lump is freely mobile
- Pathognomic sign of encapsulated lipoma
Describe lobulation sign
- In encapsulated lipoma, the overlying skin or edge show series of curves and dimples due to the attachment of fibrous septa from the capsule of the lipoma to the overlying skin
Significance of transillumination test
- To assess whether a mass is fluid-filled or not
- Fluid will transilluminate and solid masses will not
Pathophysiology of lipodermatosclerosis
- Dermal fibrosis may be the result of TGF-B1 fibrogenic cytokine release form activated leukocyte that have migrated out of the abnormally permeable vessels into the tissues
- TGT-B1 cytokine increases the production of collagen and subcutaneous fibrosis
- As the fibrosis increases, it may become so extensive and constrictive and strangle the lower leg
- The lack of blood flow explains the tendency to develop ulcer
Risk factor for varicose veins
- Strong family history
- Obesity
- Pregnancy
- OCP
- Hormonal replacement therapy
- Occupation that required standing for long period
Differential for simple diffuse goitre
- Physiological (increase demand of thyroid hormone eg: pregnancy, puberty)
- Dietary iodine deficiency
- Dietary goitrous agents
- Congenital (eg: enzyme deficiency)
- Treated Grave’s disease
Differential for simple solitary thyroid nodule
- Dominant nodule of MNG (50%)
- True solitary thyroid nodule (eg: Thyroid adenoma 80%, Cancer 10%, Cyst/ Thyroiditis/ Fibrosis 10%)
Border of triangle of neck
> Anterior
- Superiorly: inferior border of the mandible
- Laterally: anterior border of the SCM
- Medially: sagittal line down the midline of the neck
> Posterior
- Anterior: posterior border of the SCM
- Posterior: anterior border of the trapezius
- Inferior: middle 1/3 of the clavicle
Swelling with transillumination test positive
- Spermatocele
- Hydrocele
- Hydrocephalus
- Simple cyst
- Cystic hygroma
- Lipoma (might positive also)
Why thyroid move with swallowing
- Because the thyroid is attached to the cartilage of the larynx by the suspensory ligament of Berry
What are the types of thyroid ca?
- Differentiated (Papillary ca 75%; Follicular ca 10%)
- Medullary 7%
- Anaplastic ca 3%
Complication of incisional hernia repair
- Infection
- Abdominal adhesion formation
- Late mesh erosion
- Recurrence
Indication for total thyroidectomy in MNG
- Local symptoms (eg: dysphagia, tracheal deviation)
- Enlarging dominant nodule
- Recurrent laryngeal nerve palsy
- Cosmesis
- Hyperthyroidism
Complication of sistrunk operation
- Recurrence
- Laryngotracheal injury (result in airway, swallowing and/or voice problem)
- Hypoglossal injury (result in paralysis of half of the tongue)
Level of axillary LN
- Level 1: below the lower edge of the pectoralis minor muscle
- Level 2: lying underneath the pectoralis minor muscle
- Level 3: above the pectoralis minor muscle
Which nerve can be damaged in axillary LN dissection?
- Long thoracic nerve: winged scapula
- Thoracodorsal nerve: weakens shoulder adduction and internal rotation
- Medial pectoral nerve: atrophy of the lateral aspect of pectoralis major muscle
- Intercostobrachial nerve: numbness and paraesthesia of inner upper arm
Gaiter area
- Area of skin extending from just above the malleolus to below the knee
- 95% of venous ulcer occur in this area
Name of umbilical hernia repair
Mayo repair
Sign of obstructed and strangulated hernia
- Painful to palpation
- Febrile
- Erythema of groin skin may be apparent
Treatment for thyroid carcinoma
- Surgical resection: Total thyroidectomy + LN clearance (if biopsy proven LN mets)
- Adjuvant: Radioablation for metastatic or residual cancer
- TSH suppression: levothyroxine to decrease recurrence and improve survival
Papillary vs Follicular Thyroid Ca
> Papillary
- 75%, 30-50 years old
- Orphan Annie nuclei, nuclear pseudo inclusion, psammoma bodies
- Spread by lymphatic
- 70% multicentric
> Follicular
- 10%, 40-60 years old
- Follicular structure similar to normal thyroid
- Hematologic spread
- Solitary
