Simple Mastectomy, Total Mastectomy and Modified Radical Mastectomy

What is Simple Mastectomy, Total Mastectomy and  Modified Radical Mastectomy for Carcinoma Breast?

Simple Mastectomy

Surgical removal of the whole of breast tissue superficial to  the pectoral fascia is called Simple Mastectomy. That means superficial fascia is left behind or not removed.

Total Mastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia is called Total Mastectomy.

Modified Radical Mastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia and level I, II and III axillary lymph nodes is called Modified Radical Mastectomy.

In other words Modified Radical Mastectomy is Total Mastectomy with Axillary clearance of lymph nodes.

Indication of Simple Mastectomy

Simple Mastectomy is done for Metastatic Breast Disease. It is also called Toilet Mastectomy. The purpose of doing Simple Mastectomy in Carcinoma Breast with metastasis is to prevent fungation and local ulceration of the tumor.

Indication of Total Mastectomy

Indication of Total Mastectomy is Paget Disease of the Breast with no palpable lump.

The treatment of Paget Disease of the Breast with a palpable lump is Modified Radical Mastectomy.

Indication of Modified Radical Mastectomy

Indication of Modified Radical Mastectomy is Early Breast Carcinoma and Paget Disease of the Breast with a palpable lump.

Different levels of Axillary Lymph Nodes

Axillary Lymph Nodes are broadly classified in to Level I, II and III nodes.

Level I axillary lymph nodes are the nodes located lateral to Pectoralis minor muscle.

Level II axillary lymph nodes are the nodes located beneath  or over the  Pectoralis minor muscle.

Level III axillary lymph nodes are the nodes located medial to Pectoralis minor muscle.

Types of Modified Radical Mastectomy

Patey’s Modified Radical Mastectomy :- Pectoralis  major muscle is  preserved and Pectoralis minor removed               

Scanlon’s Modified Radical Mastectomy :–   Pectoralis minor muscle is divided but not removed.             

Auchincloss’ Modified Radical Mastectomy :– Pectoralis minor is retraced but not divided.

Auchincloss’ Modified Radical Mastectomy is widely practiced nowadays.

Halstead’s Radical Mastectomy

In Halstead’s Radical Mastectomy both Pectoralis  major and Pectoralis minor muscles are removed along with the whole breast and the axillary lymph nodes.

What are the structures removed in Modified Radical Mastectomy (MRM)?

Whole of the breast tissue including the axilliary tail, along with the Tumor, Nipple Areola complex, Skin and the Level I, II and III Axillary lymph nodes are removed.

                                                 Images Courtesy: Madurai CME 2013



Follicular Carcinoma Thyroid

Follicular Carcinoma Thyroid

Follicular Carcinoma Thyroid

Pulsatile tumor in the scalp and a thyroid swelling is typical of Follicular carcinoma thyroid.

Follicular carcinoma is diagnosed histologically based on the capsular and vascular invasion.

The capsular and vascular invasion cannot be better appreciated in a Fine Needle Aspiration Cytology (FNAC).

Hence the type of Thyroid malignancy which cannot be diagnosed with FNAC is Follicular Carcinoma Thyroid.

Haematogenous spread is more common in Follicular Carcinoma Thyroid.

Clinically skull metastasis is pulsatile in nature because of the increased vascularity.

Hurthle Cell Tumor is a variant of Follicular Neoplasm.

The cell of origin of Follicular Carcinoma Thyroid is the Follicular epithelium of the gland.

Follicular Carcinoma Thyroid is grouped under Differentiated Thyroid Cancer.

Differentiated Thyroid Cancer is the only human cancer where age of the patient is included in the tumor staging system.

Surgical Treatment of Follicular Carcinoma Thyroid is Total Thyroidectomy, Functional Neck Dissection for the nodal disease and Radio Iodine ablation with suppression of TSH.

Functional Neck Dissection means removal of all the lymphatics and lymph nodes on the affected side of neck with preservation of Sterno Cleido Mastoid Muscle, Spinal Accessory Nerve and Internal Jugular Vein.

The treatment of metastasis in Follicular Carcinoma Thyroid is Radio Iodine Therapy.

For Radio Iodine Therapy, the whole of thyroid tissue must be removed surgically. If there is some remnant thyroid is left, the metastasis will not take up the radio iodine.

Thyroid Stunning Effect

Scanning dose of I¹³¹ used for thyroid scan can cause damage of follicular cell resulting in decreased uptake in the thyroid remnant or metastasis. This can inturn impair the therapeutic efficacy of subsequent I¹³¹ therapy.This is called thyroid Stunning Effect.

Stunning effect occurs at the cellular level.

Higher the dose of I¹³¹, more the incidence of Stunning

The following methods are used to avoid stunning:-

-Use smaller dose of Iodine ¹³¹ for diagnosis

-Use of Iodine ¹²³

-Shorter interval between diagnostic and therapeutic doses, that is less than 72 hours.

                                               Image Courtesy: Madurai CME 2013

 

Omental Metastasis – Carcinoma Ovary

Omental Metastasis – Carcinoma Ovary

Omental Metastasis – Carcinoma Ovary ( Black Arrow)

Exfoliated malignant cells from the ovary  first reach the para colic gutter. The negative pressure associated with respiratory movement causes upward migration of the tumor cells towards diaphragm.

Omental metastasis typically occurs along the attachment of mesentery with the bowel because of the increased vascularity of the region required for the tumor angiogenesis.

Hence as a part of Cytoreductive surgery for advanced ovarian carcinoma Gastro colic omentectomy is also done along with Hysterectomy and Bilateral Salpingo Oophorectomy.

 

Lord’s Plication for Small Hydroceles

Lord’s Plication for Small Hydroceles

                                

Hydrocele Fluid Being Drained from the TV Sac

Opened Tunica Vaginalis Sac

Lord's Plication of Hydrocele

Lord's Plication of Hydrocele

Lord’s Plication is done for a  Small Hydrocele.

Done under Spinal Anaesthesia.

Vertical Para median incision is made.

Layers of Scrotum are divided along the line of the incision.

Tunica vaginalis ( TV ) sac is identified.

Tunica vaginalis Sac is opened and the Hydrocele Fluid is drained out.

Plicating sutures are placed around the cut opened Tunica vaginalis sac.

Achieve complete haemostasis.

A suction drain is placed.

Wound is closed in layers.

Scrotal suspensory bandage is given.



Fibro Adenoma Breast

What is Fibro Adenoma?

Definition:- Fibro Adenoma is the Benign Hyperplasia of a Single Lobule of Breast.

Fibro Adenoma is also called 'Breast Mouse' as it is very mobile inside the breast tissue.

Usual Age group of Fibro Adenoma : 15-25 yrs

What is the Treatment of Fibro Adenoma?

Surgical Excision  through a Cosmetically Acceptable Incision.

What are the types of Incisions on Breast for Benign Breast Diseases?

Circum Areolar and Radial.

Advantage of Circum Areolar Incision- Better Cosmesis

Disadvantage of Circum Areolar Incision- More Injury to Lactiferous Ducts.

Advantage of Radial  Incision- Less Injury to Lactiferous Ducts.

Disadvantage of Radial Incision- Cosmetically less appealing

What is Giant Fibro Adenoma?

Fibro Adenoma of size more than 5cm is called a Giant Fibro Adenoma.

What is the Risk of Malignancy in Fibro Adenoma?

Very less. (1 in 1000 only)

Carcinoid Tumor of Appendix

Carcinoid Tumor of  Appendix

The word Carcinoid means ‘carcinoma like appearance’.

 In the the small bowel Carcinoid tumors arise from Kulchistsky cells located in the crypts of Lieberkuhn.

Kulchistsky cells are also called Argetaffin cells as these cells can be stained by the silver compounds.

Usual age group of Carcinoid Tumor  : Fifth/Sixth Decade of Life

The Most Common Siteof Carcinoid Tumor  : Appendix

Vermiform Appendix

Other Sites of G I Carcinoid Tumor  : Small Intestine, Rectum, Colon, Stomach

Non Intestinal sites of Carcinoid Tumor  : Lungs, Pancreas, Thymus, Ovary, Testis, Biliary tract

Embryologic Classification of Carcinoids

1.     Foregut Carcinoids-Lungs, Stomach & Pancreas

2.     Midgut Carcinoids-Small Intestine & Appendix

3.     Hindgut Carcinoids-Colon & Rectum

Carcinoid Syndrome

• Seen in 10% of cases of
• Due to release of ,Serotonin, Histamine, Bradykinin, Prostaglandin
• Clinical features : Flushing, Watery Diarrhea, Sweating, Wheezing, Breathlessness, Abdominal pain and Hypotension.

Investigations

Urinary 5-HIAA, Chromogranin A

CT Scan Abdomen

CT Scan Chest-for Bronchial Carcinoids

Treatment of Carcinoid Tumor Appendix

If the Carcinoid Tumor Appendix is less than 2 cm and is away from the base, the treatment is Appendicectomy.

Open Appendicectomy

If the Carcinoid Tumor Appendix is close to the base of the appendix or the size is more than 2cm the treatment is Right Hemi Colectomy.

What is Carcinoid Crisis?

Life threatening form of Carcinoid syndrome.

Usually precipitated by Anesthesia, Surgery, Chemotherapy

Prophylactic agent used prevent Carcinoid crisis is Octreotide ( Somatostatin Analogue)

 

Colonic Pseudo Obstruction/ Ogilvie Syndrome

Colonic Pseudo Obstruction/ Ogilvie Syndrome

Plain Abdominal Radiograph-Ogilvie Syndrome

CT Scanogram-Colonic Pseudo Obstruction

Obstruction of Colon without any mechanical cause is termed as Ogilvie Syndrome or Colonic Pseudo Obstruction.

Patient can present with features of Intestinal Obstruction namely

• Abdominal Distension
• Constipation
• Colicky Abdominal Pain
• Vomiting

10 Common causes of Colonic Pseudo Obstruction/ Ogilvie Syndrome

1.      Hypokalaemia

2.      Uremia

3.      Septicemia

4.      Burns

5.      Trauma

6.      Myocardial Infarction

7.      Diabetes mellitus

8.      Tricyclic Anti Depressants ( Drugs )

9.      Pancreatitis

10.Idiopathic

 

Depressed Fracture Skull

Depressed Fracture Skull

CT Scan Head -Depressed Fracture Right Frontal Bone

CT Scan Head -Depressed Fracture Right Frontal Bone

Depressed Fracture Skull can damage brain parenchyma and can result in Pressure effect or Midline shift.

Indications of Surgical Elevation of a Depressed Fracture Skull are

1.     Paediatric patients

2.     Seizures

3.     Depression more than 1.5cm in to the brain parenchyma.

In other cases conservative line of management with Neurosurgery observation ( Head Injury Chart ) may be sufficient.

Head Injury Chart Includes Hourly Monitoring of

1.     Pulse Rate

2.     Blood Pressure

3.     GCS

4.     Pupils- Size and Reaction to Light

5.     Respiratory Rate

6.     Body Temperature

7.     Power of Upper Limbs

8.     Power of Lower Limbs

 

Necrotizing Fasciitis/ Fournier’s Gangrene

Necrotizing Fasciitis/ Fournier’s Gangrene

Fournier’s Gangrene is Necrotizing Fasciitis affecting the perineum.

 It is a rapidly spreading poly microbial infection caused mainly by Gram Positive Cocci and Gram Negative Bacilli (  Both Aerobes and Anerobes). Hence called Synergistic Gangrene.

The skin over the affected area becomes gangrenous because of the thrombosis of underlying small blood vessels.

Extensive tissue necrosis occurs between the tissue planes resulting in Inflammatory Degloving, Septicemia and Renal failure.

Diagnosis can be made by clinical grounds and can be confirmed by biopsy of the necrosed tissue.

The enzyme elevated in Necrotizing Fasciitis is Creatinine kinase.

Treatment-

• Radical Surgical Debridement to remove the devitalized tissues.
• Antibiotics ( Penicillin, Third generation Cephalospoirns and Metronidazole).
• Hyperbaric Oxygen Therapy.

 

Pyogenic Granuloma

 Pyogenic Granuloma Scalp



Pyogenic Granuloma Scalp



Pyogenic Granuloma is a superficial polypoid mass formed of Granulation Tissue. It is formed as a result of chronic infection. Often associated with pain. Dull Red in color.

Clinical Features :Can occur anywhere in the body. Common sites are Face, Fingers, Toes etc

Complications:- Bleeding, Infection.

Treatment:- Surgical Excision



Intestinal Obstruction

Intestinal Obstruction

Multiple Air Fluid Levels

Intestinal Adhesion

Intestinal Adhesion

Intestinal Adhesion

The most Common Extra Mural Cause of Intestinal Obstruction is Intestinal Bands or Adhesions.

The Intestinal Bands or Adhesions can be Congenital or Acquired.

Previous surgery in the abdomen can later result in adhesions between the loops of the intestine.

Clinical Features of Intestinal Obstruction

• Constipation
• Vomiting
• Colicky Abdominal Pain
• Visible Peristalsis
• Abdominal Distension

In the plain radiograph the dilated bowel loops becomes visible.

Multiple Air Fluid Levels are seen.

Basis of Visible Intestinal Loops in a Plain Radiograph in Intestinal Obstruction

Normally Intestinal loops are not visible in a plain radiograph. This is because the intestine are in a state of constant peristaltic movement and there is no tissue oedema. When there is obstruction the peristalsis is abolished and the mucosa of the intestine becomes oedematous. Due to these two reasons the intestinal loops becomes visible in a plain radiograph.

The basis of Air fluid levels in Intestinal Occlusion

Normally Air and Food inside the intestine are in a mixed form. But when the obstruction occurs due to stagnation of the content separation of the Air and Fluid occurs.

How many Air Fluid levels are clinically significant?

Normally Air Fluid Levels are seen at sites inside the Abdomen. One  in the Fundus of the stomach, another in the First part of Duodenum and the third in the Ileo Caecal Region. Hence more than three Air Fluid Levels are considered as abnormal.