Circumcision-Indications and Operative Surgery Steps

Circumcision

Circumcision is An Operative procedure

                           -which reduces the chance of Ca Penis

                           -which reduces the risk of transmission of HIV

Indications:

                  1.True Phimosis( due to Balonitis Xerotica Obliterans-BXO-Lichen Sclerosis – Sclerosing Inlfammatory Dermatosis- resultinfg in scarring of prepuce & prepuceal aperture becomes tight )

                   Physiological adhesion between the fore skin and the glans penispersist until 6 years of age 

                2.Paraphimosis( Failure of retracted foreskin to return to its original position over glans penis)

               3.Religious ( Most common)

              4.Recurrent balanoposthitis( Diabetes)

              5.Prior to Radiotherapy for Ca Penis

Anesthesia: Local / General

Position of the Patient: Supine

Incision:

                  Prepuce is divided in the midline dorsally up to corona &  the incision is extended circumferentially across the prepuce  5 mm beyond and parallel to corona.

Step 1. Three artery forceps are applied at 2, 6 & 10’ O clock position.

Step 2. Adhesion between prepuce and glans are released up to corona.

Step 3. Between the artery forceps at 2 and 10’ O clock position the prepuce is incised at 12’ O clock position up to corona.

Step 4. The outer skin and inner skin over the glans are cut all around anddivided parallel to corona leaving a ‘ v ’ shaped flap at the frenulum.

Step 5. A figure of 8 suture is placed over the frenulum ( As it contain the Arteryof Frenulum)

Step 6. Inner skin is sutured to the outer skin of prepuce with 2 0 absorbable interrupted sutures. 0.5Cm Inner skin has to be there to prevent the disfigurement

Branches of Facial Nerve Identification In Parotidectomy

Branches of Facial Nerve

Branches of Facial Nerve

There are Five Branches of Facial Nerve.

These five branches are located in the Facio Venous Plane of Patey.

Tragal Pointer- (Triangular Tragal Cartilage) helps to identify the Facial Nerve as it emerges from the Stylo Mastoid Foramen.

The Five branches are-

1.     Temporal

2.     Zygomatic

3.     Buccal

4.     Marginal Mandibular

5.     Cervical

Two most important branches of Facial Nerve are Zygomatic and Marginal Mandibular. 

If Zygomatic  branch is damaged it produces  inability to close the eyelid .

If Marginal Mandibular  branch is damaged it produces  Deviation of angle of Mouth.

Because of these two important cosmetic effects the above mentioned branches of the facial nerve are considered as the most important .

Hence if any one of these branches are accidentally cut, has to be repaired with Nerve Cable Graft.

The nerves used for cable graft are Sural Nerve and Great Auricular Nerve.

 

Diagnosis of Tuberculosis

Diagnosis of Tuberculosis is made in Four ways



1.Clinical- Eg -Matting of Lymph nodes

2.Radiological Eg-Chest X Ray( Right Upper Zone),Deformities of Spine/Vertebra etc

3.Culture Eg-Microbiological culture in LJ Medium

4.Histological Eg- Casseation and Granuloma formation

Complications of Multinodular Goitre

Complications of Multinodular Goitre

• Mechanical Compression of Trachea/Oesophagus              ( Produces Dyspnoea & Dysphagia)
• Secondary Thyrotoxicosis
• Calcification of nodule
• Degeneration of nodule
• Haemorrhage in to the nodule ( Produces Pain & sudden enlargement of thyroid gland)
• Malignant Transformation( Follicular/Papillary Carcinoma)
• Cosmetic Disfigurement

Types of Diathermy/Cautery in Surgery

Types of Diathermy/Cautery

Two electrodes-Bipolar  (Left) and Single electrode- Monopolar (Right)

Bipolar Cautery in Use

Two types of Diathermy are Monopolar  and  Bipolar Diathermy

In surgery diathermy is used for coagulation and cutting of tissues. Lateral conduction and tissue damage is more for coagulative  mode and lateral conduction and tissue damage is minimal for cutting mode.

These are used in open surgery as well as in endoscopic surgery.

Difference between Monopolar  and  Bipolar Diathermy

In Monopolar Diathermy the patient is a part of the diathermy circuit. Of  the two electrodes one electrode is active ( cautery tip) and  the other electrode is indifferent( cautery plate/Patient plate). As the surface area of contact is  less in the cautery tip, it produces more heat at the operative site.

Whereas in Bipolar Diathermy only the tissue which is held between the two electrodes becomes the part of the circuit.

Contra indications of using cautery :-Contra indications of using cautery are patient with Pacemaker implant.

Harmonic scalpel is ideal in such patient with Pacemaker implant, for cutting and coagulation of tissues. Harmonic scalpel is based on the principle of ultrasound .

Minimally Invasive Thyroidectomy- TrivandrumTechnique (MITT)

Minimally Invasive Thyroidectomy- TrivandrumTechnique (MITT)

Multti Nodular Goitre Removed through a Minimal Incision



Recurret Laryngeal Nerve Identified in MITT



Minimal Incision For MITT

Principles of MITT

—  Neck is kept in – Neutral position

—  Intrinsic mobility of the Thyroid Gland and the mobility of Tracheo laryngeal Apparatus are taken into advantage

—  Either the gland is brought to the incision site by traction or the incision is brought to the area of dissection by retraction.

—  ‘Harmonious retraction’ using Long thin Langenbecks’ retractors

—  Meticulous haemostasis and gentle and precise handling of tissues.

—  Order of Devascularisation of thyroid gland -Inferior thyroid veins-> Middle Thyroid Vein-> Superior pole-> Pyramidal lobe-> Tracheo  Esophageal Groove dissection.

•  Suture less – Using Bipolar coagulation

                                       Courtesy - Dr SK Ajaiyakumar,Trivandrum

What is Homeostasis?

What is Homeostasis?

The coordinated physiological process which maintains a steady state of ‘internal constancy’ or ‘mileau interior’ is called Homeostasis.

In other words , ‘internal constancy’  is maintained by various organs of our body like- Brain, Heart, Lungs,Liver, Kidney etc

This internal constancy is a ‘closed loop system’ and is responsible for the independent existence of an individual .

Primary insults like injury or sepsis makes this closed loop system in to an 'open loop.' The aim of medical/surgical intervention is to make this 'open loop' back in to 'closed loop.'

Artificial augmentation of homeostasis is called Resuscitation.

Provision of organ support for homeostasis is called Critical Care.

What is meant by Universal precautions?

What  is meant by Universal precautions?

   Considering every patient as biohazard and taking adequate precautions to prevent infection is known as Universal precautions.

   Such precautions must be taken whenever a health care personnel handles blood, semen and other body fluids of the patients.

   The protective gowns, goggles & ankle high shoes the surgeon wear are not only  for the safety of the patient but also for the safety of the Surgeon and other patients!

   Modern Surgery is safe to the patient. Surgical interventions are made at the optimal time of the disease process so as to minimize the interventions as well as the complications!

  

Risk Factors for Carcinoma Penis

Risk Factors for  Carcinoma Penis

•     Smoking

•     Accumulation of Smegma - Poor Hygiene / Phimosis

•     Chronic Balanoposthitis

•     HPV 16 Infection 

Carcinoma in situ (Tis) of the penis involving the glans penis or prepuce is called Erythroplasia of Queyrat .

Carcinoma in situ (Tis) of the penis involving the the penile shaft or the remainder of the genitalia or perineal region is called Bowens disease.

JACKSON’S Staging of Carcinoma Penis

— Stage I - Cancer has only affected the glans and/or foreskin.

— Stage II - Cancer has spread to the shaft of the penis.

 Stage III - Mobile (operable) inguinal lymph nodes

 Stage IV - Fixed (inoperable) inguinal lymph nodes or distant metastasis

Surgical Treatment of Carcinoma Penis is Partial or Total Amputation of Penis

 

Nipple Retraction in Carcinoma Breast

Nipple Retraction in Carcinoma Breast

Note the Circumferential type of Nipple Retraction in Carcinoma Breast

Retraction of Nipple can be of Congenital or Recent in onset

Causes of Nipple retraction of Recent onset are

           Mastitis/Breast Abscess

           Previous Surgery in the Breast

           Tuberculosis of the Breast

           Malignancy

Type of nipple retraction in benign disorders are slit like. Where as in malignancy, circumferential nipple retraction is obtained.

What is Ghostectomy?

In Locally Advanced Carcinoma of the Breast, after  Neo adjuvant Chemotherapy if the primary lesion disappears completely, the surgical removal of whole breast and axillary lymph node s (Level 1 & 2) is called Ghostectomy.  It is called so because there is no primary tumour macroscopically. The rationale of doing  Ghostectomy is to remove any microscopic disease .

Risk factors of Carcinoma Breast

Risk factors of Carcinoma  Breast

                         

1.    Female Sex ( Incidence is more in Females - 50 times more )

2.   Age (Incidence increases steadily with Age>20yrs)

3.   Number of menstrual cycles between menarche & 1st Full      Term  Pregnancy ( Longer the period- More the Risk )

4.    Early menarche, late menopause

5.    Breast denied of its function ( Nulliparity increases the risk and lactation is protective)

6.    Previous History of Carcinoma Breast in a Patient

7.    Family History of Carcinoma Breast in First Degree Relatives

      ( Mother, Sisters and Daughters) – BRCA 1 & 2

8.    Exogenous Hormone Use ( Hormone Replacement Therapy )

9.    Diet- Decreased in take of Phyto Estrogen

10.  Obesity ( Due to increased conversion of Steroid hormones to Oestrodiol in  the Body Fat )

11.  Previous Radiation to Chest- Hodgkin’s Disease

12.  Alcohol Intake

Histological Risk factors for Carcinoma Breast

1.   Proliferative Breast Disease

2.   Atypical Ductal Hyperplasia ( ADH ) – ( 4 - 5 Times increased risk)

3.   Atypical Lobular Hyperplasia ( ALH ) – ( 4 - 5 Times increased risk)

Causes of Free Gas Under The Diaphragm

 Free Gas Under The Diaphragm in a Plain X Ray

Causes

1. Perforation of a Hollow viscous- Gastric/Duodenal/Ileal ( Peptic ulcer Disease,/Typhoid/Crohn’s/Malignancy)

2.Penetrating injury Abdomen

3.Following Laparoscopic procedure

4.Following  Tubal Insufflation Test

5.Infection with gas forming organisms

6.Most common cause of free gas under the Diaphragm is -Laparotomyor post operative patients.

7.Chilaiditi's sign-due to interposition of colon between the Diaphragm and the Liver such a gas shadow can be obtained even in a normal individual.

 

Submandibular Silaladenectomy- Indications and Operative Surgery Steps

Submandibular Silaladenectomy-

•      Indications

                1.Chronic Sialadenitis (due to Calculi)

                2.Benign Tumour of S/m sal gland

                3.Malignant Tumour of S/m sal gland

                4.As a part of Commando operation/MRND

•      Anesthesia – General

•      Position – Supine with neck extended and turned to opposite side

•      Incision – Oblique incision 2.5 cm below and parallel to lower border  of mandible, anterior to the level of Angle of Mandible

This is to safeguard Marginal Mandibular Nerve and Cervical branch of the Facial Nerve.

Operative Procedure

•      Step 1

Incision deepened by dividing subcutaneous tissue and platysma. Sub platysmal flap-Superficial lobe of Sub mandibular gland is exposed.

•      Step 2

   Facial artery and common facial vein are divided between ligatures separately.

Facial artery has an ‘S’ shaped relationship with the Submandibular gland. It enters the gland from the supero lateral  aspect of the gland. Soon it divides in to two. Ideally the branch which goes into the submandibular gland is ligated and divided, leaving the main trunk.

Adjacent to Facial Artery  lies the Submandibular Ganglion which is secretomotor to both Submandibular gland and Sub lingual salivary gland.

The branches to the Submandibular gland alone are divided.

•      Step 3

  Mylohyoid muscle is retraced medially and deep lobe of the gland is dissected out, safe guarding Lingual nerve and Hypoglossal nerve, on either side of the Submandibular duct. 

  

•      Step 4

  Sub mandibular duct is ligated & divided near its termination in the mouth and the gland is removed.

Submandibular duct (Wharton's duct) Lies on the Hyoglossus between the lingual (above) and hypoglossal nerve (below)

Commando Operation  

 En block removal of 1º malignancy of the oral cavity, partial removal of the mandible, floor of the mouth and/or tongue & a radical neck dissection.  

 Commando Operation is not done nowadays becuse earlier it was thought that  the lymphatic drainage from the oral cavity passes through the mandible.