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Thursday 28 February 2013

What is Microdochectomy?

What is Microdochectomy?



Microdochectomy is the surgical removal of the dilated lobule of the lactiferous duct called Duct Ectasia.
The incision for Microdochectomy is a nipple splitting incision. First cannulate the dilated duct from which the blood stained discharge comes out. Note the blood stained discharge from the opening of a single lactiferous opening over the nipple.
The incision is made around the cannulated duct and then extended radially towards the lump.
The name of the incision is called Tennis Racket Incision.
An important thing to remember!
When we plan an incision on breast for the excision of a benign lump always keep the possibility of a histological surprise. The present incision must be included in a possible MRM incision later if the pathological report comes as Malignant.
Where else we use  Tennis Racket Incision?
Tennis Racket Incision is also used for the Ray amputation of a Digit or a Toe.
What is the difference between Microdochectomy and Hadfield’s operation?
Duct ectasia is the dilatation of a single duct of the breast. When it involves many ducts it is called Periductal Mastitis. The surgical treatment of peri ductal mastitis is complete excision of all the major ducts of the breast and is known by the name Hadfield’s operation.

Saturday 23 February 2013

What is a Phantom Hernia?

What is a Phantom Hernia?



A hernia which is formed due to a nerve injury leading to the muscle weakness and ultimately resulting in a Hernia later, is known as the Phantom Hernia.
Classical Example is injury to the Ilio Hypogastric nerve due to a previous appendicectomy can later give rise to Inguinal Hernia formation.
Note the scar of previous Appendicectomy and the Indirect inguinal hernia sac!

Friday 15 February 2013

Lipoma- The Universal Tumour

Lipoma- The Universal Tumour



Lipoma is a benign tumour arising from adipose tissue.

It is also called Universal Tumour as it can occur anywhere in the body where there is fat or adipose tissue.

Multiple Lipomas are called Dercum’s Disease

Complications of Lipoma

Pressure effects

Myxomatous Degeneration

Saponification

Calcification

Malignant Transformation


Malignant Transformation is more with:-

1.Retro peritoneal  Lipoma
2. Gluteal Lipoma

10 Planes in which Lipoma can occur

Subcutaneous

Subfascial

Submucosal

Subsynovial

Inter Muscular

Intra Muscular

Intra Glandular

Intra Articular

Periosteal

Extra Dural

An organ in which a lipoma cannot occur is- Brain

Wednesday 13 February 2013

Difference between Ischemic limb and Neuralgic limb

Difference between Ischemic Limb and Neuralgic Limb



Limb Ischemia is associated with Skin  changes like

1.     Colour Change
2.     Loss of Subcutaneous Fat
3.     Shiny Skin
4.     Loss of Hair
5.     Brittle nail
6.     Superficial ulcers
           Whereas the Neuralgic limb is not associated with any skin changes.

Friday 8 February 2013

Panda sign / Raccoon Eyes in Head Injury

Panda sign / Raccoon Eyes in Head Injury

Seen in Anterior Cranial Fossa fracture



 Symptoms of Head Injury

n Bleeding through Nose and Ear
n  Loss of Consciousness
n  Vomiting
n  Convulsions
n  CSF Leak

       Signs of Head Injury

  • Panda sign / Raccoon Eyes
  • Anisocoria
  • CSF ottorrhoea
  • CSF rhinorrhoea
  • Sub conjunctival Haemorrhage with no posterior margin

Wednesday 6 February 2013

Incisional Hernia Repair


Incisional Hernia or Ventral Hernia Repair



Various types of Mesh Repairs for Incisional Hernia are:-

1.On Lay Mesh Repair- Mesh is kept over the Rectus sheath

2.Sub Lay Mesh Repair- Mesh is kept under the Rectus sheath

3.In Lay Mesh Repair –Mesh is kept in the Pre peritoneal plane.

Size of the mesh must be 4 cm from the edge of the defect on all sides.

In Lay Mesh Repair ie, Pre peritoneal mesh repair has least chance of Recurrence.

Clinical Examination of an Ulcer

                  Clinical Examination of an Ulcer

 

 

Definition of an Ulcer
  An  ulcer  is  defined  as  a  break   in  the  continuity  of   surface  epithelium   with     superadded    infection.
Clinical Classification of Ulcer
  Spreading- with surrounding inflammation
  Healing – Slopping edge with red granulation tissue
  Callous- Ulcer with no tendency to heal-with pale granulation tissue.
Pathological Classification of Ulcer
  Specific- Tuberculous, Syphylitic,Actinomycotic
  Non specific- Traumatic( Mechanical, Physical,Chemical)
Cryopathic, Arterial, Venous, Neurogenic, Trophic, Tropical, Bazin’s, Martorell’s, Meleney’s ulcer
  Malignant- Squamous cell carcinoma, Basal Cell Carcinoma, Melanoma
Classification of Ulcer based on duration
  Acute  Ulcers    < 12 weeks
  Chronic  Ulcers  > 12 weeks
Classification Based on Pain
  Painful Ulcers
        Tuberculous
        Arterial
        Advanced Malignancy

  Painless Ulcers-
       
        Syphilitic
        Trophic
        Early Malignancy
Modes of Onset of Ulcer
      Traumatic
      Spontaneous-
      Secondary changes on a Swelling-Tuberculous lymphadenopathy
      From a Previous Scar-Marjolin’s Ulcer

Causes for Chronic Ulcers
1.     Malnutrition
2.     Anemia
3.     Immunosuppression
4.     Systemic Diseases (Diabetes)
5.     Site & Size of an Ulcer
6.     Arterial / Venous Disorders
7.     Neurological Disorders
8.     Infection
9.     Chronic Irritation ( Dental Ulcers )  or  Lack of Rest ( Ulcer over a Joint )
10.   Malignancy
Discharge from the ulcer – Note the Colour, Amount & Smell
  Serous-Healing ulcer
  Sanguinous ( Blood Stained )- Malignant/Chronic
  Purulent-Bacterial infection
  Greenish- Pseudomonas infection
  Yellowish - Sulphur Granules ( Actinomycosis )
Parts of an Ulcer
      Margin-line of demarcation between normal and abnormal
      Floor-the exposed part of an ulcer ( Inspection)
      Edge-the part between the margin and the floor of an ulcer
      Base-the structure on which the ulcer rests (Palpation)
Types of Floor of an Ulcer
  Slough-Moist dead tissue
  Scab-Dry dead tissue
  Unhealthy granulation tissue
  Healthy granulation tissue
  Subcutaneous fat
  Muscle/tendons
  Bone
Types of Edges of an Ulcer
  Slopping- Healing ulcer
  Punched out-Decubitous ulcer/Gummatous ulcer
  Undermined- Tuberculous ulcer
  Raised / Beaded- Basal cell carcinoma
  Rolled out / Everted- Squamous cell carcinoma
Examination of an Ulcer-Inspection
  Site
  Size
  Shape
  Number
  Margin
  Edge
  Discharge
Importance of Site of Ulcer

 

Face-Basal Cell Carcinoma

 

Neck-Tuberculous/Actinomycotic


Decubitus ulcer-Over pressure points like sacral/occiput/heel


Shin-Gummatous


Medial malleolus-Varicose ulcer



Examination of an Ulcer – Palpation
  Local rise of Temp & tenderness
  Exact dimensions - depth
  Induration ( thickening ) of edge-in chronic ulcer and in malignancy
  Base – fixity to underlying structures
  Bleeding on touch-is a feature of malignant/ Chronic ulcer
Examination of the Surrounding Area of an Ulcer
  Skin
  Adjacent Joint
  Regional Lymph nodes
  Arterial pulse
  Varicose veins
  Neurological deficit
  Gait of the patient
A Golden Rule
Whenever you see a lesion look for an enlarged draining lymph node;
Whenever you come across an enlarged lymph node in our body look for a lesion in the area of its lymphatic drainage.