Surgery Revalida Review

Surgery Revalida Review 2017

*Review: Cervical Lymph Nodes (w/ landmarks)

I. Thyroid

Laboratory Procedures: • Request for TSH o Low TSH – Thyroid scan may indicate if it’s a hot (hyperfunctioning) or cold (nonfunctioning) nodule § Cold – Neck ultrasound § Hot – evaluate/treat for hyperthyroidism • Neck Ultrasound NOT Thyroid UTS – to view accompanying lymph nodes

Potency Protein Binding Plasma halflife

T4 (Thyroxine) 1 Highly protein bound Longer

T3 (Triiodothyronine) 4 Weakly protein bound

Shorter



LYMPH NODES: Features suspicious for malignancy

THYROID NODULE: Features suspicious for malignancy

Loss of fatty hilum

>1 cm

Round shape

Taller than wide shape

Hypoechogenic

Hypoechogenic

Cystic change

Irregular margins

Calcifications

Microcalcifications

Peripheral vascularity

Intranodal vascularity

Other symptoms: Hoarseness, dysphagia, & other signs and symptoms leading to hyper or hypothyroidism

Solitary nodule – FNAB o Palpable - FNAB without ultrasound guidance (Better yield w/ guidance) • Multinodular – Total Thyroidectomy directly for management (less than 10% chance of being malignant) • No nodule - return back to your TSH (hypo/hyper) • Possible malignancy – Biopsy of lymph nodes for assessment o Will prompt additional neck dissection upon total thyroidectomy Bloody aspirate at FNAB – Must then be ultrasound guided

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Physical Examination: • Mass at midline (Not moving/Moving w/ deglutition) o Midline mass that moves when you stick out your tongue – Thyroglossal duct cyst (not common in OPD) • Palpate cervical lymph nodes • Landmarks: SCM, level 2, 3 and 4 (5 is posterior, 6 is supraclavicular)

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*Review: Graves’ disease & Thyroiditis Malignancy: • Papillary – Lymphatic spread • Follicular – Hematogenous spread • Staging – NCCN o Anaplastic – automatically Stage 4 • 45 years old and ABOVE o >45 – malignancy at a higher stage

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) • Is it related to their menstrual cycle or not? • History of breastfeeding • Biopsy history • Check for risk factors: o OCP/Hormone replacement o Menarche of the patient o MIDAS o Menopause duration o OB history • Cancer in the family

Physical Examination: • Do it both upright and supine • Check for dimpling, discoloration • Palpation of breast: Circular (areolar to outside), Radial o Irregular, regular o Tender or nontender o Movable or fixed + position (o’clock position) o 3 Zones: § A – Nipple-areolar complex § B – Between areola to farthest zone § C – Farthest from areola o Laterality • Always check for lymph nodes (axillary) • Check all tissues between clavicle and costal margins

Avoid having the patient extend their arm/s during PE (Axillary fascia is stretched & it will be harder to palpate the deep lymph nodes) Check the clavicles and supraclavicular area Check for nipple discharge (pinch for any discharge)

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1

Negative

0% likelihood

2

Benign

0% likelihood

3

Probably Benign

>0% but ≤ 2%

Suspicious Low suspicion Moderate suspicion High suspicion

>2% but 2% to ≤ 10% >10% to ≤ 50% >50% to ≤ 95%

5

Highly Suggestive of Malignancy

≥ 95%

6

Known Biopsy Proven Malignancy

N/A

4 4A 4B 4C

PE Results: • Pain with no mass: o Standard screening – (Schwartz – 45 or 50) usually 50 y.o. § Rationale: Less breast volume for older women – better delineation of the mass w/ mammography (Follow up 3-6 months) § Usually for younger patients – ultrasound § Nipple discharge § Pathologic: • Anything bloody, spontaneous, not associated with trauma, single § Physiologic • Further work-up • No mass – Follow-up after 3-6 months • If w/ mass (and > 40 y.o.) • Ultrasound • Aspirate for cyst – 3 times (although it may resolve on its own) Lab findings: • Simple cyst – Pure fluid usually means benign BIRADS

ASSESSMENT

0

Needs additional imaging

LIKELIHOOD OF CANCER

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Fibroadenoma – if more than 3 cm, excise Microcalcifications – may be a finding in performing mammogram Watch out for spiculated or radial lesions Core needle – to check for tumor invasion of the basement membrane Most common malignancy: Intraductal papilloma Invasive carcinoma Tumor Staging Advise patient to avoid caffeine, chocolates as consumption has been speculated to cause fibroadenomas

FIBROCYSTIC DISEASE

FIBROADENOMA

Common in menstruating women

Most common benign breast lesion

30 to 50 y/o

Second to decades of life

Lumpy “cobblestone” breasts with ridges of tissue

Well defined, solitary, rubbery, mobile nodule

Symptoms improve with OCP and abate with menopause

third

Indications Chemotherapy

Breast Conservation Therapy - Lymph node dissection - Post op radiotherapy Modified Radical Mastectomy – removal of whole breast + axillary node dissection (Level 1 & 2) If patient is pregnant – no radiotherapy

for

Indications Therapy

for

Hormonal

Tumor > 1cm

Hormone receptor positive (ER+ and/or PR+)

(+) Axillary LN

Premenopausal – Tamoxifen Postmenopausal – Aromatase Inhibitor

Node negative cancers with adverse prognostic features Lymphovascular invasion High nuclear or histologic grade HER2Neu overexpression Negative hormone receptor status

Indications for Radiation

T Tx

Primary tumor cannot be assessed

T0

No evidence of primary tumor

Tis

Carcinoma in situ

T1

Tumor ≤ 2 cm

T2

Tumor > 2 cm but ≤ 5 cm

T3

Tumor > 5 cm

T4

Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules)

Common areas of metastasis: • Lung • Bone • Liver • Brain

BCT ≥ 4(+) Axillary LN Tumor > 5 cm Close surgical margins ( 5cm Persistently positive surgical margins after reexcision Active Connective Tissue Disease (Scleroderma or Lupus erythematosus) III. Cholelithiasis

Rule out signs of cholangitis: • Epigastric pain • Bloating • Colicky pain Diagnosis of choice: Ultrasound (high sensitivity: 90%) as compared to CT Scan Usual findings: Posterior acoustic shadowing, mobility of the stone/s, wall thickness to check for inflammation. pericholecystic fluid Gall bladder wall - 0.4 cm (N) Bile ducts - 0.5-1 cm (N)

Gold standard: Laparoscopic cholecystectomy, although performing open is also an option

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Risk factors: • Seaman, elderly, diabetes • Porcelain gall bladder – high risk for malignancy • Blood dyscrasias • Complications usually arise from patients who are elderly and diabetic

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Obstructive Biliary Disease PTBD – usually performed by radiologists, inserting a catheter to the intrahepatic duct for draining

The inguinal canal is an approximately 4- to 6 cmlong cone-shaped region situated in the anterior portion of the pelvic basin The canal begins on the posterior abdominal wall, where the spermatic cord passes through the deep (internal) inguinal ring, a hiatus in the transversalis fascia. The canal concludes medially at the superficial (external) inguinal ring, the point at which the spermatic cord crosses a defect in the external oblique aponeurosis. The boundaries of the inguinal canal: o External oblique aponeurosis anteriorly o Internal oblique muscle supero- laterally o Transversalis fascia and transversus abdominis muscle posteriorly o Inguinal ligament inferiorly. Spermatic cord traverses the inguinal canal, and it contains o Three arteries, three veins, o Two nerves, o The pampiniform venous plexus, o and the vas deferens.

Triangle of Calot – Cystic artery (Content) IV. Inguinal Hernia

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Inguinal hernias are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach's triangle.

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The borders of the triangle: • inguinal ligament inferiorly • lateral edge of rectus sheath medially • inferior epigastric vessels superolaterally. Femoral hernias protrude through the small and inflexible femoral ring. The borders of the femoral ring iliopubic tract and inguinal ligament anteriorly Cooper's ligament posteriorly lacunar ligament medially femoral vein laterally

Nerves in the inguinal region • Commonly damaged nerves: o Ilioinguinal o Iliohypogastric • Ilioinguinal nerve – supplies somatic sensation to the skin of the upper and medial thigh. o In males, it also innervates the base of the penis and upper scrotum. o In females, it innervates the mons pubis and labium majus. • Iliohypogastric nerve- supplies both internal oblique and transversus abdominis • Genitofemoral nerve o Genital branch § Males –supplies the ipsilateral scrotum and cremaster muscle. § Females- it supplies the ipsilateral mons pubis and labium major o Femoral branch supplying the skin of the upper anterior thigh. • Lateral femoral cutaneous nerve- supply the lateral thigh

Triangle of Doom • medially by the vas deferens • laterally by the vessels of the spermatic cord • The contents of the space • external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve.

Triangle of Pain • bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves.

Pathophysiology: Congenital: Patent processus vaginalis (5th-6th weeks, goes down to 8 weeks) Peritoneum goes down & becomes the hernia sac Acquired: weakness in the abdominal wall musculature (weak floor), but really needs a patent processus vaginalis also to happen Diagnosis • History • Groin pain • Inguinal bulge (increases in size over time) • Change in bowel habits or urinary symptoms

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Physical examination • Standing & lying down • Palpation is performed by advancing the index finger through the scrotum toward the external inguinal ring. This allows the inguinal canal to be explored. The patient is then asked to perform Valsalva's maneuver to protrude the hernia contents. Imaging • Ultrasound (sensitivity:86% specificty:77%) • For a protruding mass & ruling out torsion • CT(sensitivity:80% specificty:65%) • For bone/masses • MRI(sensitivity:95% specificty:96%) • Best because it also evaluates soft tissue

Proper diagnosis: • Direct or indirect • Complete or incomplete (For indirect only) – necessitates that it now protrude down to the scrotum – complete • Reducible (spontaneous or manual) • Incarcerated (does not go back, acutely 6 hours, can try to reduce it such as taxis or chronically, more than 6 hours, part of the bowel may die) • Strangulated (whatever is inside is beginning necrosis, pain tenderness swelling vomiting red area septic possibly tachycardic, tachypneic) Treatment • Surgical repair is the definitive treatment • Open hernia repair • Mesh repair • Tissue repair • Laparoscopic hernia repair • Gold standard: Open mesh repair (least chance of recurrence) – Fibroses at the floor to prevent recurrence Complications • Hernia recurrence • Pain • Cord injury

V. Benign Anal Diseases (Fistula, etc.)

Dentate line – squamocolumnar junction Surgical line: 1-2 cm above the dentate • Rectum – 12 to 15 cm – Valves of houston extend into lumen – Presacral fascia separates rectum from presacral venous plexus and pelvic nerves – Waldeyer’s fascia (s4 level) extends forwards and downward attaching to the fascia propria of the anorectal junction – Denonvillier’s fascia seprarates rectum from prostate/vagina in men/women – Lateral ligaments support lower rectum • Anatomic anal canal – Dentate or pectinate line to the anal verge – Dentate or pectinate line marks transition between columnar and sqaumous anoderm – Columns of morgagni surround dentate line into which anal crypts empty (source of cryptoglandular abscesses) • Surgical anal canal – 2 to 4cm in length, longer in men, begins at anorectal junction ends at anal verge

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Sphincters – Internal anal sphincter • Inner smooth muscle • Surrounded by the subcutaneous, superficial, and deep external sphincter – Deep external anal sphincter • Extension of puborectalis muscles • Puborectalis + iliococcygeus + pubococcygeus = levator ani muscle

Thrombosis may cause significant pain because anoderm is richly innervated • Skin tag is redundant fibrotic skin at the anal verge as a residua of external hemorrhoids Internal hemorrhoids – above dentate • May prolapse or bleed, rarely painful unless thrombosed and necrosed • 1st deg – prolapse on straining • 2nd deg – reduce spontaneously • 3rd deg – reduced manually • 4th deg – irreducible Mixed hemorrhoids = external + internal hemorrhoids • Don’t classify mixed hemorrhoids with stages Treatment: • 1st deg – medical (fiber, stool softeners, increase fluid, avoid straining), rubber band ligation infrared photocoagulation, sclerotherapy • 2nd deg – medical treatment, rubber band ligation, infrared photocoagulation, sclerotherapy • 3rd deg – Non-surgical treatments rubber band ligation, infrared photocoagulation, sclerotherapy; If intractable hemorrhoidectomy • 4th deg - Surgery • *Rubber band complication urinary retention, infection, bleeding “Emergency” hemorrhoidectomy • Excision of thrombosed external hemorrhoids • Acutely thrombosed external hemorrhoids • Intense pain with palpable anal mass • Excise the hemorrhoid = symptomatic relief Surgical hemorrhoidectomy • Closed hemorrhoidectomy (parks and ferguson) • Open hemorrhoidectomy (milligan and morgan) • Whitehead’s hemorrhoidectomy Others • Procedure for prolapse hemorrhoids/stapled hemorrhoidectomy • Doppler guided hemorrhoidal artery ligation Complications of surgical • Post op pain • Fecal impaction • Bleeding • Infection – uncommon

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• Blood supply • Superior rectal artery from inferior mesenteric a. • Middle rectal artery from internal iliac a • Inferior rectal artery from internal pudendal a. • Rich network of collaterals between terminal arterioles of the arteries Procedures: • Anoscopy – measures approx. 8cm – Do not do if with anorectal pain – May be used in conjunction with rubber band ligation/sclerotherapy of hemorrhoids • Proctoscopy – 25 cm – Polypectomy, coagulation, detorsion of sigmoid volvulus • Flexible sigmoidoscopy – 60 cm – Till splenic flexure • Colonoscopy – 100 to 160cm – Entire length of colon • *Delineating the different parts of the colon: o Transverse colon lumen - triangular o Ascending/Descending colon lumen – circular Hemorrhoids • Cushions of submucosal tissue containing venules, arterioles, smooth muscle fibers • Left lateral, right anterior, right posterior – locations of major hemorrhoidal cushions • Part of continenece mechanism and aid in complete closure of the canal at rest • Causes • Portal hypertension • Excessive straining • Increased abdominal pressure • Hard stools • Treat only if symptomatic • External hemorrhoids – distal to dentate line

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White head deformity – ectropion Incontinence stenosis

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• Anal Fissure • Tear in the anoderm distal to the dentate line • Related to trauma from passage of hard stool or prolonged diarrhea • Spasm of internal anal sphincter – pain increased tearing and decreased blood supply to anoderm – Cycle develops poor healing wound becoming a chronic fissure • Majority occur at posterior midline • Symptom – Tearing pain during defacation and hematochezia – Intense painful anal spasm • Physical Examination – Often too tender to tolerate DRE – Acute fissure • Superficial tear and always heals with medical management – Chronic fissure • Develop ulceration and heaped up edges • Often associated external skin tag or hypertrophied anal papilla – Lateral location of chronic anal fissure maybe evidence of underlying disease such as crohn’s/hiv/syphilis/tuberculosis/leukemia • Medical therapy – Bulk agents, stool softeners, warm sitz bath – Calcium channel blockers diltaizem and nifedipine used to heal but may have side effects – Arginine, bethanechol topical – 50% effective for chronic anal fissure – Mostly effective for acute • Surgical therapy for chronic fissures failing medical therapy • Lateral internal sphincterotomy is the choice Fistula In Ano

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Infected cryptoglandular crypts in intersphincteric plane > ducts traversing internal sphincter empty into anal crypts > abscess formation Perianal space surrounds anus and becomes continuous to buttocks Intersphincteric space separates internal and external anal sphincters and continous with perianal space Ischiorectal space located lateral and posterior to the anus bounded medially by the external sphincter, laterally by ischium, superiorly by levator ani and inferiorly by transverse septum Perianal abscess most common Ischiorectal abscess if spread through the external sphincter below the level of the puborectalis Intersphincteric abscess between sphincters Pelvic and supralevator abscess uncommon Mostly diagnosed by a palpable mass Complex or atypical presentations may require CT scan or MRI Treat by draining (incision and drainage) 50% of treated abscess heals, 50% turns into fistula in ano • Starts from an infected crypt (internal opening) and ends/tracks to an external opening • Other causes • Crohns, malignancy, radiation, unusual infections such as TB Intersphincteric fistula (Most common) • tracks through the distal internal sphincter and intersphincteric space to an external opening near the anal verge Transsphincteric fistula • often results from an ischiorectal abscess and extends through both the internal and external sphincters Suprasphincteric fistula • originates in the intersphincteric plane and tracks up and around the entire external sphincter Extrasphincteric fistula • Originates in the rectal wall and tracks around both sphincters to exit laterally, usually in the ischiorectal fossa

*50% of patients with perianal abscess will develop into fistula in ano Treatment • Goal – eradicate sepsis without incontinence • Fistulotomy – opening the tract • Fistulectomy – removal of tract • Seton – To maintained drainage or induce fibrosis • Fibrin glue • Endorectal advancement flap • Ligation of the intersphincteric fistula