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.

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!

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

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.

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

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.