Yaser..Surgery 5th Year Theoritical Curriculum

7/27/2019 Yaser..Surgery 5th Year Theoritical Curriculum

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Surgery5thyear

Theoritical Curriculum

Yas'er

presents


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1 :

SKIN & SUBCUTANEOUS TISSUES

SEBACEOUS (EPIDERMOID) CYST

DERMOID CYST

Definition : blockage of a sebaceous gland duct ----> retention of sebaceous secretion Retention cyst.

Microscopic picture :

Clinical features :

Complications :

composed of Keratin

lined by st. sq. epithelium

foul smellinggranular debris

hairs or sebaceous glands may grow from wall of cyst

epithelial cells

contains sebaceous material

liningst. sq.

epithelium

contentwhitematerial

slowly growing rarely seenbefore

adolescence

* most commonly seen in :Scalp,Face, Neck or Scrotum.* occurs anywhere except palmor sole of foot which are devoidof sebaceous glands

cyst characters* small* well-defined* cystic* usually att. to

skin at one ptwhich is duct site* a punctum maybe seen

mobile overdeep

structures

sometimesit may attainlarge size

may besolitary ormultiple

Infection Sebaceous horn Ulceration Localizedalopecia

commonest rare

* cyst becomes painful and tender* an overlying redness and an abscess may form* If early, may subside by antibiotics

* If an abscess forms , it should be drained and cyst wallcuretted* makes cyst more difficult to excise as it becomes moreadherent to surrounding SC tissue

* contents come outslowly &become

inspissated insuccessive layers overthe base

*raisededges

*overgrowing

granulations* may be mistaken forcarcinomaCocks Peculiar tumor

Definition : cyst

Types :

POC SequesterationDermoids

Tubulodermoids InclusionDermoids

TeratomatousDermoids

ImplantationDermoids

Def. D. due to SC inclusion of portions ofsurface epith. along lines of fusionof cut. dermatomes during fetal life

D. due todistention ofremnants ofembryonic ducts

D. due toinclusion ofepidermis duringclosure of a cavity

benign forms ofteratomas

D. 2ryto puncturedwounds displacingsome epith. into

SC tissues

Features * well-defined , globular & cystic* not att. to skin* underlying bone may behollowed out* a pedicle may conncet its deepaspect to dura mater * Althoughsince birth , appears clinically afterfew yrs for cyst to distend

* cyst lined bysq. epithelium* BUT containsteeth, hairs,bone, cartilageor glands.

*displaced cellsretain viability andform dermoid cyst* small & tense* overlying skinsometimes scarred

Site *outer eye angle ext. angular*root of nose *around ear*along body midline

*thyroglossal duct

--->thyroglossal cyst*Cx sinus-->branchial cyst

*sublingual*suprasternal*intra-cranial & spinal

*mostly ovary*occasionally testisor post, mediastin.

*mainly fingers, palmor sole

Treatment : * SURGICAL EXCISION only. *In childeren with D. cyst in scalp --> wait till closure of sutures because somecysts may communicate with dura. *since dermoid cyst is deeper than sebaceous cyst ---> surgery is more difficult.

infectedcystmayundergoulceration

Treatment : * COMPLETE EXCISION with an elipse overlying skin containing punctum is done to avoid recurrence * if small cyst ----> local anaesthesia.


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2 :

Lipoma

benign tumor composedof fatty areolar tissuearranged in lobules

enclosed in a thinfibrous capsule butcan be enucleated

easily from within thiscapsule

grows veryslowly

& its common

to find a ptwho has thetumor for 10 or

more yrs

may contain

excessfibroustissue

angiomatoustissue

myxomatous

tissuefibrolipoma

angiolipoma myxolipoma

Lipoma Presentations

Solitarywell-defined

swelling

MultipleLipomatosis

Diffuse lipomatous deposits

esp. in

limbs ortrunks

DD of

multipleswellings

patients withmyxoedema have

supraclavicularfatty deposits

elderly personsmay develop

deposits belowchin

femalesmay develop

painful fattydeposits in thighDercumsDisease

e.g.

c l a s s i f i e d a c c o r d i n g t o s i t e o f o r i g i n i n t o

Subcutaneouslipomata

Subfasciallipomata

Submucouslipomata

Parosteallipomata

Extradurallipomata

Intra-articularlipomata

Intermuscularlipomata

commonest

characters

underdeep fascia

not att. to skin& no slippery

edge difficult todiagnose

hard &growsrapidly

erosionof bones

paraplegia

masked byoverlying ms

has to bediff. from

fibrosarcoma

fixed deeply

and becomemore

prominentif they arepushed out

of ms ordisappearif they aredrawn intoms when itcontracts

slowlygrowingin SCtissues

painless

& nottender

softconsistencyBUT some , esp. in warm

weather , givepseudofluctuation, this isdue to mobility of tumor

in its bed & because fat atwarm temp. may undergo

liquefaction, so trial ofaspiration fails

lobulatedsurface & maybe attached toskin at multiple

points

mobile overdeep structures

well-defined slipperyedge due to

movement of tumor

inside its capsule

arise inlarynx

Respiratoryobstruction

stomach

intestine

initiateintussusception

intestinalobstruction

arise inrelation

to cranialbones

may befound

withinspinal

canal

Gross picture : *false capsule *lobulated surface * yellowish color

Complications : rare

Treatment : * lipoma is a very innocent tumor & does not cause any problem EXCEPT incertain situations

* Subcutaneous lipoma : - usually excised for cosmetic reasons - easy operation & depends on enucleation of tumor from its

capsule

Degenerative changes ---> liquefaction & calcification

Submucous lipoma in intestine

Extradural lipoma in spinal canal

Malignant transformation (very rare) BUT may occur in retroperitoneal lipoma


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3 :

NeurofibromatosisDefinition : proliferative condition of endoneurium of nerves --> tumor formation skin pigmentationVarieties : 1) Solitary Neurofibroma 2) Generalized Neurofibromatosis von Recklinghausens disease 3) Cutaneous Neurofibromatosis Molluscum fibrosum 4) Plexiform Neurofibroma 5) Elephantiasis Neuromatosa 6) Acoustic Neuroma 7) Neurofibrosarcoma

+_

Solitary Neurofibroma (NF)

Generalized Neurofibromatosis (NFs)

von Recklinghausens disease

Age : mostly between 20-50 yrs Site: usually nerves of upper limb BUT may occur inPathology : small - elongated - firm - tender swelling - liable to cystic degenerationTreatment : tumor should be completely excised

spine

mediastinumviscera

cerebrospinal nervesnerve roots within the cranial cavity and spinal canalnerve fibers in the skin, muscles & bones

Gross : * widespread affection of

* affected nerves are diffusely and irregularly thickened + formation of tumor-like swellingsMicroscopic : a) cells : proliferation of cells of endoneurium b) composition : composed of CT fibers arranged in strands, bundles and whorls with little or no

intracellular substance c) nuclei : elongated and hyperchromatic & often arranged in rows palisade appearance d) nerve fibers : may traverse the substance of tumor or may be displaced to one side BUT they

are not the seat of degeneration e) Myxomatous degeneration : common

f ) Sarcomatous changes 2ry Neurosarcoma : may follow, particularly after trauma or incompleteremoval

Clinical features : * Aetiology : often familial * Onset : usually in adolescence * Characters : - commonly preceded with localized areas of pigmentation in the skin Cafe-au-lait patches - multiple tumors appear allover the body - affected nerves may or may not be papably thickened BUT pain is absent - when a spinal nerve root is affected

Treatment : * Excision of all tumors is impossible * Operation only indicated for * tumors should be completely resected

grow slowly to form fusiform swellings with thelong diameter in the axis of affected nerve

vary greatly in size : the largest usually lying inrelation to the plexuses at roots of limbs

firm or soft in consistencymovable in lateral direction BUT not in line ofnerve

may grow intospinal canal withsigns of intra- orextradural tumor

may grow intomediastinum with

signs ofmediastinal tumor

sometimes itenlarges in bothdirections as a

dumb-bell tumorNB : Malignant change

is associated within territory of nerve

painanaesthesiaparalysisprogressive increasein size of lesion

large tumorspainful tumorstumors producing pressure symptoms

POC Cutaneous NFs

(Molluscum fibrosum)

Plexiform NF Elephantiasis

Neuromatosa

Acoustic

Neuroma

Neurofibrosarcoma

Characters - Multiple soft fibrous swellings- arise in connection withterminal filaments of cut. nerves

- vary in size from pins head to alemon size or larger and may besessile or pedunculated

- diffuse fibromatous thickeningof branches of nerve formingbeaded swelling under skin- in more than 1/

2cases

manifestations of generalized NFexist

- related to & maycoexist with cut. NFs- appears in childhood- affected part graduallyincrease in size & tillbeing enormous- skin & SC tissues aregreatly thickened- variable no of tumorsmay exist

- in rare casesNF is associated

with acoustic n.tumors-striking familialincidence- associated

with tumors ofdura & choroidplexus

- de novo innormal nerve or asmalignantdegeneration of NF- spindle-cell ormyxosarcomatous- painful & rapidlygrowing

Site - Scalp, limbs, abdomen & back- palms & soles escape- skin is the seat of

pigmentation Cafe-au-laitpatches or Frank Melanomata

- SC tissues of head & neck- large nerves of limbs- autonomic plexuses of abdomen

- overlying skin is pigmented &thickened & hang as pendulousfolds Pachydermatocele

- usually one ofextremeties esp. lower- skin may be

pigmented and hairy

- invade surround.tissues -->anaesthesia &

paralysis & formsdistant metastases

Treatment Large & unsightly tumors areexcised

Localised wide excisionBUT amputation inextensive and postop.recurrent tumors


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4 :

vascular anomalies

Hemangioma

vascular malformations

Hemangioma Vascular malformations

Current nomenclature is biologically based, and includes two major classes

Low flow lesionsCapillary malformationVenous malformation

ArterialArteriovenous

High flow lesions

Lymphatic malformations

a) Proliferation stage

b) Involution phase

c) Involuted phase

Definition : benign proliferative neoplasm of endothelial lining of vascular spaces

Aetiology : embryological error --> sructural abnormality in blood vesselsGrowth nature : grow proportionately with the child & do not regress or involute

Diagnostic imaging :

Comparison between types of low-flow lesions :

Doppler Ultrasound MRI &/or Magnetic Resonance Angiography (MRA) Angiography

differntiate high-flowfrom low-flow lesions

most useful study for assessing extent of lesion &degree of involvement of surrounding structures

useful in somecases

Incidence : *affects 10% of white infants *female : male ratio = 3 : 1

Site : majority of lesions affect Head & Neck

Stages : usually presents be 3 stages

Complications : in certain circumstances :

Treatment : 1) Reassurance of parents + Observation --> as skin appearance after involution may be betterthan scar following excision

2) If it is necessary to interfere , the following are helpful

Synonym : strawberry mark

Onset : at birth butoften noticed later

Onset Character

shortly afterbirth

*pale or reddish patch*increases in size over next months

at end of 1styear

*central pallor and color slowly fades*progressive decrease in lesion size*stage continues till age of 10 years

----------*in 50% of patients, skin is normal*some residual skin changes persist as

discoloration , scarring & telengectasiaperi-orbital

hemangioma

encroach onvisual field

auditory canalobstruction

congestivecardiac failure

entrapment ofplatelets

Oral or intra-lesional corticosteroids

Laser photocoagulation

Surgical debulking

thrombocytopenia

amblyopia

parotid glandhemangioma large cutaneous

or visceralHemangiomata

large visceralHemangiomata

POC Capillary Malformation( Port wine stain )

Venous malformation

Characters * present since birth & does not undergo involution* dark purble in color & not raised above surface* Pressure causes btanchlng but the color returns

immediately after release of pressure* Sometimes, lesion takes distribution of one of the branches of the trigeminal nerve, BUT the lesion does not

cross the rniddle line* Sometimes, a port wine stain of the face is associated with

similar lesions in the meninges (Sturge-VVeber syndrome)

* it does not undergo involution likehemangioma, as it is a malformation

* similar to hemangioma in C/P butusually appears later

Treatment a) during childhood* ttt of choice is Pulsed Dye Laser

* general anesthesia is required* multiple sessions may be needed

b) during adulthood* YAG laser ttt BUT no favorable results as in children

a) compression therapy --> relieve pain & edemab) percutaneous sclerosis via hypertonic saline,

100% alcohol or Na Tetradecyl sulfate BUT withhigh recurrence rate & multiple sessionsc) surgical excision with preoperative

embolization or sclerosis to facilitateintraoerative. hemostasis

d) interstitial laser coagulation


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5 :

Arterial malformation

(CIRSOID ANEURYSM)

Lymphatic

Malformations (LMs)

Arterial venous

Malformations(AVMs)

-represent abnormal development of arterial structures including

-classified as Microcystic or Macrocystic + may have component of venous malformation

-Site : Most commonly in scalp esp. & may involve underlying bone

-Site : Head & Neck or Axilla in majority of cases

-Character : soft - compressible - pulsating + marked bruit

-Complications : * Neck masses --> may extend into mediastinum or prepectoral area * LMs are the most common cause of

* Skeletal involvement ---> distortion

-Characters : * abnormal connections between arteries & veins without an intervening capillary bed * present at birth BUT may not be evident until late childhood * localised or diffuse * presents as localised swelling + increased surface temp. + palpable thrill or murmur * generalized AVMs --> growth disturbance or skeletal distortion

-Complication : ulceration of overlying skin --> serious hge ,since its arterial bleeding

-N.B. : Hereditary Hgic telengectasia : - autosomal dominant disease- characterized by multiple cutaneous,visceral & mucosal AVMs

-Treatment : - DIFFICULT , bec. swelling is supplied by multiple feeding arteries that need ligation - preliminary embolization of feeding vessels may be tried

-Treatment : 1) Percutaneous aspiration followed by Sclerosis --> short term improvement BUT usuallu reqquires additional ttt 2) Surgical excision requires multiple & staged procedures -its technically easier as child grows so wait until at least 3 yrs of age

-Treatment : - ligation or embolization of feeding vessels --> rapid enlargement of collateral

vessels ----> increasing size of lesion - Excision Preoperative angiography & embolization of feeding arteries + excisionnext day + extensive coverage by a free-flap may be needed

tortousityduplicationhypoplasiastenosis

HIGH FLOWLESIONS

temporal regionoccipital region

congnital macroglossiamacrocheilia (lip enlargement)macrotia


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6 : ABDOMINAL WALL & HERNIA

abdominal incisionsRequirements : SEGA : Safety - Extensibility - Good cosmetic result - Accessibility

POC Midline incision Paramedian incision Paramedian transrectal incision

technique -incision passes through thelinea alba and the two recti areretracted apart

-incision in the linea alba

should be closed by anon-absorbable suture materialas prolene to avoid incisionalhernia and burst abdomen

-upper or lower, right or left-skin incision is one inch fromthe middle line

-anterior rectus sheath is incised

vertically, and the rectus muscleis displaced laterally to preservethe vessels and nerves supplying

the rectus muscle from lateralside- posterior rectus sheath and

peritoneum are incised as onelayer

-similar to classical paramedianincision BUT rectus muscle is split

longitudinally in the same lineof incision in the anterior rectus

sheath

advantages -good exploratory incisionallowing access to both sides ofthe abdomen

-quick and can be enlarged freely

-safe and the healing power isstrong-readily extensible and can giveexposure to any abdominal

organ

- quick , therefore,not recommended inemergencies.

- most useful in children because

atrophy is compensated for during growth

disadvantages -time consuming , therefore,not recommended inemergencies

-scar is not as strong as that of theparamedian incision due todevitalization of the medial part

of the rectus muscle

POC 2) Transverse incisionsa- Subcostal incision b- McBurneys incision

Characters&

Technique

-Upper transverse epigastric andlow transverse suprapubic

(Pfannenstiel)-in Pfannenstiel incision, anteriorrectus sheath is cut transversely,and then the two recti areseparated

-finally the peritoneum isopened

- it is called Kochers incision if onright side

- a muscle cutting incision , oneinch below & parallel to costalmargin

-Medially, rectus muscle and theanterior and posterior rectus

sheaths are divided-Laterally, the three abdominalmuscles may be divided

-a muscle splitting incision, usuallyused for appendicectomy

-5-6 cm and perpendicular to aline passing from the A.S.I.S tothe umbilicus at the junction of

its outer 1/3with the inner 2/

3

-external oblique aponeurosis isopened in the same direction ofthe skin incision

-internal oblique and transversusabdominis muscles are split in

the direction of their fibres

advantages -scar is cosmetic as wound lies inLangers lines- minimal ms tension on suture &

so pt can cough safely postop.

-good exposure to the biliaryapparatus or the spleen esp. in

obese patients with wide costalangle

-good exposure to caecum &appendix -safe incision

-cosmetic esp. with transverse skinincision ( Lanz incision )

disadvantages -time consuming-excessive bleeding

-ms cutting -not exploratory-not extensible -injury to 8th,9thor10thintercostal n. --> hyposthesia orpartial abdominal wall paralysis

-not exploratory -not recommendedif appendicitis diagnosis is not sure

-if extended up or down it will bea ms cutting incision

Accessibility Extensibility Safety Good cosmetic result

incision should providegood exposure of thediseased area

should be possible toenlarge the incision, ifneeded, to give moreexposure

should inflict the minimal damage tomuscles, blood vessels and nervese.g. : Muscle splitting incisions are prefer-able than muscle cutting ones

e.g. : a transversesuprapubic incision isbetter looking than alow mid line incision

Types : Vertical incisions1) Vertical incisions

Transverse incisions Oblique incisionsoror

3) Oblique incisions


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7 :

Precautions during closure of an abdominal incision Complications of abdominal incisions

1. A non-absorbable monofilamentous suture material,e.g., polypropylene (prolene) is used

2. - Sound closure of the strongest layer ( linea alba or the anterior rectus sheath ) is essential for safety of wound

closure - Wide bites (1 cm) are taken from the edge of the fascial incision - Suture length to the wound length should be 4:13. Sutures should not be under tension to avoid ischaemia of the wound4. If there is a peritoneal defect, leave it as the peritoneum will regenerate in a few days

1. Haematoma : may be due to a bleeding tendencyin the patient but far more commonly due to careless

surgical haemostasis - causes dull aching pain in the wound which is

indurated and may be discoloured. - If small --> left for spontaneous absorption - If enlarging or large --> evacuated to avoid

secondary infection2. Infection3. Wound disruption (burst abdomen) : a serious complication which may lead to an incisional hernia or may even cause mortality4. Incisional hernia : causes of incisional hernia are the same as burst abdomen, and as a matter of fact many patients with incisional hernia had partial disruption of the deeper layers of the abdominal wound during the immediate or early post-operative period5. Desmoid Tumor

Burst ABdomenPredisposing factors :

Types :

Clinical features :

Treatment : Urgent surgical closure

Pre-operative factors Operative factors Post-operative factors

1. Obesity2. Factors causing poor healing as

malnutrition, cirrhosis, DM, jaundice& corticosteroid intake

3. Patients with respiratory problems

as chronic bronchitis, bronchialasthma and chronic obstructive lungdisease

4. The nature of the 1rydisease forwhich the operation was performed,e.g., patients with abdominalmalignancy are usually malnourishedand patients with peritonitis will haveabdominal distension and woundsepsis

1. Ms cutting incisions Ms splitting ones2. Vertical incisions Transverse incisions3. Rough surgical technique with

excessiye trauma to the muscles,blood vessels & nerves

4. Use of absorbable sutures in theclosure of the aponeurotic layer of an abdominal wound , so, non-absorbable

sutures as polypropylene are recommended & good bites should be taken on either side of this layer5. Insertion of drainage tubes through the main wound

1. Poor recovery from anaesthesia leading to strong coughing2. Persistent increase in

intra-abdominal pressure due to repeated coughing, vomiting,

hiccough or abdominaldistension3. Haematoma of the wound4. Surgical site infection is the

most important factor , tissuesbecome friable due to collagen

lysis allowing the sutures to cut through them

Partial Complete Evisceration Dehiscence

deep layers burst butthe skin is intact

incisional hernia

if the intestine prolapses out of thewound

if the intestine is retained insidethe abdomen

Red sign Onset Symptoms

- warning sign to the occurrence of burst- serosanguinous discharge soaks the dressing- due to straqgulation of a piece of omentum or a loop of bowelwhich is prolapsed through a defect in the muscles

6thto the 8thday post-operatively

- patient often feels as if somethinggives way

- Symptoms of intestinal obstructionmay be present

2- Insert a nasogastric tube and start an IV infusion 3- using general anaesthesia, wash protruding loopswith saline & return them to abdominal cavity, omentum is spread over intestine, abdominal wall is closed asone layer by through-and-through sutures, using strong non-absorbable polypropylene Retention suturesas they are retained for at least three weeks + Care should be taken not to puncture a loop of bowel4- Antibiotics are prescribed and an abdominal binder is recommended

1- Cover the prolapsed bowel by a sterile dressing


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8 :

Minimal Access surgery

Diseases of abdominal wall

- many operations can now be performed through natural body orifices via fibre-optic endoscopy

fine stabs for introducing rigid endoscopes into

Frequently performed Iaparoscopic operations:

Steps :

Diagnostic laparoscopy :

Conversion of laparoscopic surgery --> conventional open surgery in the following situations :

for abdominal surgery

rapidly gaining popularity in certain situations

to determine cause of acute lowerabdominal pain , e.g. : acute pelvic

appencicits or torsion of an ovarian cyst

to determine extent of malignantdisease , e.g. : small liver

secondaries or peritoneal nodules

to detect the exactinjuries in blunt

abdominal trauma

peritoneumpleura

joint cavities

Tubal ligation

Tubal adhesiolysis

laparoscopy

Diseases of umbilicus

1- Cholecystectomy 2- Appendicectomy 3- Inguinal hernia repair 4-Bariatric surgery5- Fundoplication for gastro-oesophageal reflux 6- Gynaecologic operations :

2- Insufflation of peritoneal cavity with CO2using Veress needle that possibility of puncturing viscera during

its introduction ---> gas in peritoneal cavity makes space between ant. abdominal wall & viscera --> allows visualization of organs & manipulation of instruments3- Insertion of a trocar & cannula ( usually at umbilicus ) ,then trocar is removed while cannula (port) is used to introduce telescope that is connected to a video camera ---> displays its its image on monitor ---> allows the surgeon & assistants to see the interior of abdominal cavity4- Inspection of peritoneal cavity5- Insertion of other ports under direct vision through abdominal wall to allow introduction of instruments for

dissection , coagulation , retraction & cutting

1- Equipment failure2- Dense adhesions or anatomical abnormalities precluding safe performance of procedure3- Uncontrolled bleeding 4- Accedintal injuries reqiring open repair

1- General anaesthesia

considering the safety of patient is the absolute priority

Advantages Drawbacks

1. Minimal postoperative pain2. Minimal impairment of pulmonary functions3. Fast recovery and early return to normal activities4. Ability to visualize and explore the whole abdominal and

pelvic organs5. Video recording of the operative procedures with obvious

educational advantages6. Better appearance and decreased wound problems as

dehiscence or infection

1. Need for well-trained surgeons2. High cost of the equipment3. Postoperative shoulder pain, which is caused by

irritation and stretching of the diaphragm by CO2

7 : fistula - sinus - stone - polyp - granuloma - hernia - tumors

Umbilical fistula Umbilical sinus Umbilical stone

1- Faecal fistula : - congenital from patent vitello-intestinal duct -traumatic -inflammatory from TB of small intestine

-malignant from carcinoma of transverse colon that ulcerates2- Urinary fistula : -congenital from patent urachus

-rarely acquired3-Biliary fistula : -very rare - due to operative bile duct injury

in cholecystectomy

- discharges pus- due to abdominal wall abscess orumbilical infection

- Pilonidal sinus ofumbilicus is rare -->

persistent discharge

- due to chronic inflammation of umbilicus or from umbilical granuloma- should be removed- granuloma is excised by diathermy

& antiseptics applied

Umbilical polyp Umbilical granuloma Umbilical Tumors

- due to persistence of the umbilical extremityof the vitello- intestinal duct which becomes

everted outwards- irritative hyperplasia of epithelial

surface from friction --> polypoidal mass at bottom of umbilicus- should be excised

- mass of granulation tissuedue to chronic infection of

umbilical scar- should be curetted & then cauterized by silvernitrate

1. SCC : rare & gives metastasis to axillary& inguinal lymph nodes on both

sides2. 2ry carcinoma nodules :may be present

at umbilicus due to spread fromcarcinoma of stomach , pancreas, liveror breastU

mbilical

Hernia


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9 :

Desmoid Tumor

Hematoma of rectus sheath

Pathology :

Clinical features :

Clinical features :

Treatment :

Definition :Aetiology :

Components :

Diagnosis :

Treatment :

-nature is not exactly known & may be considered as locally malignant fibrosarcoma

due to trauma --> rupture of inferior epigastric vessels

-it arises from the anterior or less commonly the posterior rectus sheath , or from the anterior abdominal wallmuscles -may occur on top of scars or incisions-may be associated with intestinal polyposis Gardners syndrome-Gross : non-encapsulated - slowly growing - infiltrate surroundings - pinkish white in cut section-Microscopic : formed of cellular fibrous tissue

-usually affects females about age of 40 years

- pain - tenderness - swelling over rectus muscle

-if large --> evacuation of hematoma & ligation of epigastric vessels

protrusion of a viscus or part of it ,usually within a peritoneal sac, through an abdominal wall defect

EXCISION with safety margin of at least one inch & RECONSTRUCTION of defect by flaps of fascia or syntheticmesh BUT recurrence is very common if not adequately excised

-patient presents by : painless - hard - ill-defined - slowly growing mass of abdominal wall with nodular surface

General principles ofexternal abdominal hernias

Congenital (preformed) sac Acquired causes

- unobliterated processus vaginalis --> congenital inguinal hernia

- unobliterated physiological umbilical hernia of fetus --> congenital umbilical hernia (exomphalos)

- Raised intra-abdominal pressure due to : chronic cough,straining at micturition or stools , heavy work, obesity orhuge abdominal swelling (splenomegaly or pregnant uterus)- Weak abdominal wall due to : obesity , senility , debility , pregnancy , weak scar & damaged n. supply of muscles

Sac Contents Coverings-peritoneal pouch which bulges outthrough abdominal wall defect-it has a neck (junction with peritoneum),body & fundus

-any abdominal viscus can protrude out into sac except pancreas-usual contents are intestine, omentum or both-contents pass out through a defect in abdominal wall-reduction of hernia means reduction of its contents into peritonealcavity while empty sac remains in place

-structures thatare stretched overthe sac

Special Conten ts

Richters hernia Littres hernia Maydls (W) hernia Urinary bladder (Sliding hernia)

-content is part ofbowelcircumference

- common infemoral hernia

-content isMeckelsdiverticulum

-contains 2 loops ofintestine while an

intermediate loop liesin peritoneal cavity

-part of it may protrude into inguinal orfemoral hernia

-usually protrudes along inner side ofsac lying outside it forming a

SLIDING HERNIA

POC Intestine (enterocele) Omentum (omentocele)

Consistency soft doughy

Gurgling during reduction none

ease ofreduction

1st part is more difficultto reduce than last

last part is moredifficult to reduce

Percussion may be resonant dull

when a clinical diagnosis of hernia is suspected , 7 questions need to be answered :

1- Is this swelling a hernia ? hernia is characterized by

2- Which type ? depends on3- What are the contents ?

4- Is it Complicated ?

-History & examination of chest,abdomen,UT & anus are essential-such causes should be ttt before hernia operation-Weak abd. ms presents by: a) Multiplicity of hernias

cardiac complicationsrespiratory complicationsHTN & DM-History & examination for the following before surgery

b) Divarication of rectic) bulge of lower abd. on straining

(Malgaigne bulge)

6- Is there any other hernia ?7- Is patient fit for surgery ?

a) present at one of anatomical sites e.g. : inguinal, femoral, umbilical, epigastric or incisionalb) has an expansile impulse on cough EXCEPT if

strangulated

c) reducible EXCEPT if (irreducible-obstructed- strangulated)

d) opaque by transillumination EXCEPT in infants

exact sitespecial featuresspecial tests

5- Is there any causes for intra-abdominal P or weak

abdominal wall ?


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10 :

Treatment :

Complications :

Definition :Incidence :

Causes :

Pathology :

Consequences :

1- Operation is always advised to

N.B. : hernia complications are those of contents 6 complications as follows :

2- It is better to avoid truss to control herniation BUT may be used for extremely unfit patients

- Uncomplicated hernias arerepaired by elective surgery aftereradication of predisposing factors

avoid complications of hernia

prevent its progressive enlargement which widens thedefect & weakens musculoaponeurotic layers around it

Herniotomy (herniectomy) Herniorrhaphy Hernioplasty -excision of sac-done alone or as part ofherniorrhaphy or hernioplasty

-entails herniotomy& repair of defectby approximationof local tissues

-entails herniotomy & closure of defect without tension using importedmaterial ,which are not from the vicinty of the defect

-this material may be tissues from distant parts of the body, e.g., fascia lataor synthetic material. The usual example is the use of synthetic mesh,e.g., polypropylene

- No-tension repair by mesh hernioplasty is popular nowadays as it has thelowest incidence of hernia recurrence

Irreducibility Obstruction Inflammation

- failure to return contents into abd.

-causes: a) Adhesions forming within sac either between contents & sac or between contents themselves b) Protrusion of more omentum within sac-presidposes to obstruction &strangulation,so operations essential

-if without other symptoms of obstruct.---> diagnostic of an omentocele

-occurs in irreducible hernias

due to occlusion of intest.lumen from without or fromwithin-if purely obst. --> bl. supply isunaffected

-symptoms of intest. obst. arevomiting-distention-colics &constipation

-picture simulates strangul. butless severe

-locally, hernia becomesdistended, irreducble BUT stillsoft

-Distinction between it &

strangulation may be difficultso its safer to ttt it as strang.

& performing an early surgery

-uncommon & means inflammation of contents

-causes: rough taxis - ill-fitting truss - spont. inf. ofcontents (appendix-fallopian tube-ovary)-clinical features: tenderness BUT NOT tense &

overlying skin is red & oedematous-ttt : operation is essential as strangulation cant be

excluded

-in narrow-necked sacs if contents return to abdomen& fail to descend in sac again-neck becomes occluded by omentum & serous fluidcollects in sac-clinically : cystic swelling in upper part of spermatic

cord

Strangulation

Hydrocele of the hernia sac

Torsion of the omentum

Strangulated hernia most serious hernia complication

contriction of contents --> interruption of their bl. supply & if not relieved --> gangrene within hrs

- varies according to type of hernia

constricting agent may be

if contents are intestine

1- Straining --> extrusion of new contents 2- Repeated reduction attempts --> Oedema

- Although its higher in femoral hernias ,yet, strangulated inguinal hernias accountfor 50% of all strangulated ext. hernias

- Strangulation may occur at any age& is commoner after prolonged useof a truss

2-4% : inguinal

a resistant structure outside sac as

3-5% : incisional

neck of the sac

15-20% : paraumbilical

bands of adhesion within sac

25-30% : femoral

superficial inguinal ringdeep inguinal ringGimbernats ligament

proximal intestine Strangulated loop distalintestine

-Obstructed-progressiveDistention

-Hyperperistalsis

1- Impeded venous return : it becomes congested & distended with accumulating gas & fluid ( congestion secretions & absorption ) , increased congestion --> Hge in intest. wall , into its lumen & from its surface into sac2- Later, Impaired arterial supply & devitalized intestine exudes its content(fluid-blood-

bacteria) through its wall to sac and so it contains dark highly toxic fluid3- Finally, Gangrene occurs : starts at constriction ring --> affects antimesenteric border(convexity) of loop --> perforation may occur at these sites & later gangrene affects wholeloop & its mesentery

4- Peritonitis is the terminal event , as there is infection spread from sac to peritoneum--> septic shock & dehydration in neglected cases --> death

-collapsed


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11 :

Clinical Features :

Clinical Features :

Treatment :

Treatment :

Symptoms Signs

1- Acute pain in the hernia2- Sudden enlargement --> bigger hernia3- Irreducibility (hernia which used to disappear on

lying down or by pressing it ) now fails to reduce , sometimes a hernia presents for the 1sttime by strangulation4- If hernia contains intestine --> symptoms of intest. obstruction (colicky abd. pain-vomiting-absolute

constipation-distenaion) N.B.: Intest. Obst. is NOT present if content is : a) omentum b) part of bowel circumferenceRichters hernia c) Meckels diverticulum Littres hernia

General examination Local examination

-usually shows no abnormality except

in neglected cases where shock(hypovolemic or even septic) exists

-Hernia is :

a) Tense b) Tender c) Irreducible

d) No impulse on cough

URGENT SURGERY

STEPS1. incision shouldbe planned to

expose thefundus of sac

2. fundus of sacis opened at 1st

to evacuate toxicfluid that is full of

organisms

3. constricting ring is divided& a grooved director or leftfinger inserted inside ring& its coverings are divided

from outside till constriction

is relieved

4. contents arepulled out &

examined, thatis important soas not to miss a

strangulatedMaydls hernia

5. Dealing withcontents

7. SC drainsare usually

needed

Preoperative preparation Postoperative management

-as any case of intestinal obstruction1- Nasogastric tube suction2- IV infusion of lactated Ringers solution to correct hypovolemia3- IV broad spectrum antibiotics to guard against septicaemic shock

1- Nasogastric tube suction & IV fluids continued until intestinalsounds are audible

2- Prophylactic antibiotics3- Drains removed when they stop discharging (usually 5-7 days)

viable intestine non-viable intestine

1.Normal Luster2.Pink3.Pulsating mesenteric arteries4.Bleeds if injured5.Firm6.Contracts if pinched

1.Lusturless2.Grey or Black3.NOT Pulsating4.Does not bleed5.Flabby & thin6.No response

a) omentumalways excised

b) viableintestine

returned toabdomen

c) resection &1ryanastomosisof gangrenoussmall intestine e) if suspicious intestine,

apply warm packs andgive pt oxygen for few

minutes , then decision istaken whether intestine is

viable or gangrenous

6. repair of herniadefects via

polypropylene

sutures whichare inert with

no inflammatoryreaction

d) resection of gangrenous segment of colon andclostomy BUT anastomosis of unprepared colon isbetter avoided,in such cases elective anastomosis

after colon preparation is done after few weeks

Sliding HerniaDefinition : a hernia where a viscus forms a part of wall of sac , commonest are & common in

bladder

old-standing hernias

malesold age

caecumsigmoid colon

- usually a longstanding hernia in an obese elderly man

- DO NOT try to dissect sliding viscus from sac --> devascularization or injury of viscus- FREE the sliding sac & viscus from surrounding structures & push them back behind transversalis fascia + repair

of transversalis fascia + strong repair to inguinal canal using mesh if required

- hernia is usually complete oblique inguinal

- hernia is partially reducible , after reduction of contents there is still fullness at site of hernia

- Urinary symptoms are present e.g. : pressing hernia --> desire to void - double micturition - reduction of hernia size after micturition


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12 :

Surgical anatomy of inguinal region

layers of abdominal wall in inguinal region

Inguinal canal

-They are 6 layers (from superficial to deep as follows) : 1-Skin 2-Superficial fascia 3-External oblique muscle 4-Internal oblique muscle 5-Transversus abdorninis 6-Transversalis fascia

Superficial fascia Transversalis fascia

-composed of a superficial faty layer ( Camper fascia ) & adeep membraneous layer ( Scarpas fascia ) which allowsfree gliding of fat over the muscles

-superficial fascia of the abdomen does not communicatewith the corresponding layer of thigh due to the presenceof an inguinal crease where skin is attached to deep fascia,

one inch below inguinal ligament-No deep fascia is abdominal wall to allow for freerespiratory movements , gastric fullness & pregnancy

-thin but strong fascial layer that lies in front of theperitoneum-most important defense against hernia formation-its lower part is thickened forming the iliopubic tractwhich runs just above and parallel to the inguinalligament

-its upper part is thickened forming the arch of thetransversus abdominis which lies at the lower border ofthe transversus muscle

Deep inguinal ring. Superficial inguinal ring

-opening in the transversalis fascia 1/2 inch abovemidinguinal point (midway between the symphysis pubisand the A.S.I.S

-inferior eigastric vessels run medial to it-covered anteriorly by the lower border of the internal

oblique muscle

-triangular opening in the external oblique aponeurosisthat is situated half an inch above & medial to the pubictubercle

-bounded by the pubic crest below and the medial andlateral crura which are joined by intercrural fibres

-normally it does not admit the tip of the little finger-it is an exit for the spermatic cord and the ilioinguinalnerve-it is backed by the conjoint tendon

External oblique muscle Internal oblique muscle Transversus abdorninis

-origin : arises by fleshy digitations from thelower 8 ribs

-course: run downwards and forwards, andbecome aponeurotic from the level ofthe umbilicus down to its free lowerborder which is infolded & thick andis called inguinal (Pouparts) ligament

-inguinal (Pouparts) ligament : - stretches between the pubic tubercle

medially & the A.S.I.S laterally - its free posterior margin fuses with lower ends of fascia transversalis and iliaca - in its medial fourth, its infolded part is

thick and is attached to the iliopectinealline of the pubic bone to form the lacunar(Gimbernats) ligament

-thus, the infolded surface of the inguinal & lacunar ligaments makes a floor for the

spermatic cord -it is convex downwards, being attached to the deep fascia of the thigh (fascia lata)

-origin : arises by fleshy digitationsfrom lateral half (or two thirds) ofthe reflected surface of theinguinal ligament

-course & insertion:- its lower border covers the deep

inguinal ring and the beginning ofthe spermatic cord

- It arches horizontal!y above the cord and fuses with the lowest fibres

of transversus muscle to form theconjoint tendon which, passes

vertically downwards behind the cord to be inserted into the pubic

tubercle & iliopectineal line

-origin : lower part arises byfleshy fibres fromthe lateral third ofthe ing. ligament

-course & insertion : - arches horizontally

higher than the internaloblique to be insertedthrough the conjointtendon in the pubictubercle & iliopectinealline

Development :

Dimensions and site :

Contents :

Inguinal rings :

by the passage of the testis from the abdomen to the scrotum

- in adults the canal is 1.5 inches (4cm) long

-sperrnatic cord (round ligament in female) -ilioinguinal nerve

-course : extends obliquely downwards, medially and forwards in the lower and lateral part of the anterior abdominalwall from the deep to the superficial inguinal rings (above the medial half of the inguinal ligament)


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13 :

Boundaries :

Aetiology :Anatomy of oblique inguinal hernia :

constitute the relations of the spermatic cord

Posteriorly Anteriorly Superiorly Inferiorly

-fascia transversalis-inferior epigastric vs laterally-conjoint tendon medially

-external oblique aponeurosis-lower part of internal oblique mslaterally

-conjoint muscles( int. oblique &

transversus)

-infolded surface of ing. lig.with the upper surface oflacunar lig. medially

Course Constituents Coverings

-begins just deep to the deepinguinal ring by gathering ofits constituents

-enters the deep ring ,traversesthe inguinal canal and exitsfrom the superficial ring

-then passes down in front ofthe pubic bone, crosses thescrotal neck and enters the

scrotum where it is attached tothe top and back of the testis

1. Vas deferens2. Testicular artery3. Pampiniform plexus of veins (testicular

veins)4. Artery of the vas5. Testicular lymphatics6. Genital branch of genito-femoral nerve7. Testicular autonomic nerves8. Vestige (remnant) of processus vaginalis,

which is anterolateral to the vas and the vessels

N.B. :All the structures of the cord areembedded in loose fat and areolar tissue

-has three coverings which are derivedfrom the penetrated layers of theabdominal wall during testicular descent

-they surround the testis & cord like3 sockets

1. internal spermatic fascia: derived fromtransversalis fascia at the deep ring

2. cremasteric muscle and fascia : derivedfrom the lower border of the internal

oblique muscle as it overlies the deepring & cremasteric muscle is suppliedby the genital branch of genitofemoralnerve and it acts to elevate the testis

3. external spermatic fascia: derived fromthe external oblique aponeurosis atthe superficial ring

Causes of weaknes of anterior abdominal wall Protective mechanisms

1. Muscles of the abdominal wall in the inguinal

region are aponeurotic & therefore, this area isweaker than the fleshy parts of the abdomen.

2. Internal oblique and transversus abdominismuscles arch up to form the roof of inguinalcanal

3. Spermatic cord passes between the muscles and adds more weakness to the inguinal area

1. Obliquity of the inguinal canal

2. Transversalis fascia although thin, is a strong layer that supports the posterior wall3. Weak parts of the canal are supported by strong structure:

- deep inguinal ring is reinforced by condensation of thetransversalis fascia and by the fleshy fibres of lower part ofinternal oblique in front of it

- superficial inguinal ring is supported by the conjoint tendonposteriorly

4. Shutter mechanism : -During contraction of the abdominalmuscles, the lower border of the conjoint tendon straightens& descends downwards toward the inguinal ligament, thusclosing the posterior wall

5. Valvular mechanism : -Contraction of the external oblique mstightens its aponeurosis and narrows the superficial ing. ring

6. Cremasteric mechanism : -Contraction of the cremastericmuscle plugs the superficial inguinal ring and causes bulgingof the spermatic cord in the middle third of inguinal canalleading to its obliteration

7. Contraction of the transversus abdominis muscle pulls andtenses the edges of the internal ring

Spermatic cord

Anatomical basis of inguinal hernia

Oblique (indirect) inguinal herniasac of an oblique inguinal hernia is either : Congenital (preformed) sac

Acquired (pulsion) sac

due to the presence of anunobliterated processus vaginalis

due to raised intra-abdominalpressure and weak abdominal wall1. The hernia defect is the stretched deep ring

2. The hernia sac (congenital or acquired) escapes from deep ring and lies always inside the cord within the coverings, beinganterolateral to the vas and vessels 3. The contents are usually small intestine, omentum or both

4. Coverings : a. In the inguinal region the coverings include the skin, superficial fascia, external oblique aponeurosis, then the twocord coverings in this region; cremasteric muscle and fascia and internal spermatic fascia

b. In the scrotum the coverings include the skin, non fatty superficial fascia containing the dartos muscle then the 3cord coverings;external spermatic fascia, cremasteric muscle and fascia and internal spermatic fascia


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14 :

Anatomical types :

Clinical features :

Treatment :

Aetiology :

Treatment :

Congenital type Infantile type (operative finding) Adult type

a. It is due to persistence ofthe whole processus

vaginalis, hernia reaches

down to the bottom of thescrotum (scrotal or completehernia)

b. The testis lies among thecontents of the sac, i.e., thetestis lies within the lowerpart of the hernia

c. Although called congenital, itmay appear in adult life

- tunica vaginalis extends upwards to theexternal ring, so that the sac passes downbehind it

- at operation, the tunica is liable to beopened in mistake for the true sac which

will be found behind it (two sacs)

-which may be :a. Bubonocele : i. The hernia is limited

to the inguinal canal and is seen as a

bulge or a swelling in the groin ii. The processus vaginalis is

obliterated at the superficial inguinalring

b. Funicular hernia : hernia reaches down to the neck of the scrotum i. The processus vaginalis is closed

only at its lower end, just above the epididymis.

ii. The tunica vaqinalis is normaland the sac represents theproximal part of processus

vaginalis only iii. The testis can be felt separate

from the hernia and below itc. Complete (scrotal) hernia : i. The hernia descends to the

bottom of the scrotum ii. The testis is behind the hernia

and is difficult to locate

1. Painless inguinal or inquino-scrotal swelling , sometimes there is mild groin pain in early stages. The presence of severe acute pain indicates a complication

-Surgery is necessary because of the risk of strangulation-BUT truss is indicated only if there is a contraindication to surgery

a. Leaving a part of the original sac, i.e., failureto ligate the sac at the proper neck

b. Missing of a direct hernia sac which was present in addition to the oblique one

c. Failure to do the proper repair, e.q. doing aBassinis repair in a patient with a weak conjointtendon or doing the repair under tension.

1. causes leading to incisional hernia2. specific causes

N.B. : In most of the patients with a recurrence after a repair of an

oblique inguinal hernia, the recurrence will be in the medial endof the repair and will present as a direct inguinal hernia

1. Correction of any predisposing factors. A truss may be applied until the patient is fit for surgery2. Hernioplasty by a synthetic mesh is usually performed

-Preoperative preparation : Treat any cause of increased intra-abdominal pressure as difficulty in micturition, bronchitis,ascites, abdominal swellings, or obesity.

-Types of surgery : A. Herniotomy B. Herniorrhaphy C. Hernioplasty (see table next page)

2. Swelling shows an expansile impulse on cough and is reducible

3. Site: it may be limited to the inguinal canal forming an inguinal swelling (bubonocele) or it may extend to the scrotumforming an inguino-scrotal swelling (funicular and scrotal types). Inguinal hernias lie above the inguinal ligament, andabove and medial to the pubic tubercle. In contrast femoral hernias lie below the inguinal ligament, and below andlateral to the pubic tubercle

4. Direction of descent of contents is downwards, forwards and medially5. Direction of reduction is obliquely upwards, laterally and backwards6. Shape: the swelling is oblong with a narrow neck and wide fundus7. Internal ring test to differentiate oblique from direct hernia. This test is not needed if the hernia is scrotal as in such

case it is sure to be of the oblique variety : a. The patient lies down and flexes the knees to relax the abdominal ms b. The hernia is reduced by grasping it by one hand, and squeezing it upwards and laterally, while other hand

manipulates at the external ring to push the contents backwards c. The deep ring is determined. It lies half an inch above the mid inguinal point d. The deep ring is pressed by the thumb and the patient stands up and coughs; an oblique hernia does not come out

except after release of the thumb while a direct hernia comes out despite occluding the internal ring, as it comesdirectly from posterior wall of inguinal canal

Recurrent inguinal hernia


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15 :

inguinal hernia in infants & children1. Hernia is always due to presence of preformed sac 2. always of the oblique type3. operation can be done at any age provided a skilled anaesthetist is available4. Herniotomy alone is performed. In infants the operation can be performed through the external ring without the need

to open the inguinal canal

5. Recurrence is rare and is due to failure to ligate the sac at the proper neck6. If strangulation is neglected, testicular atrophy may occur

Herniotomy Herniorrhaphy Hernioplasty

-excisron of the sac only and is pertormed in casesof hernias in infants and children-Technique :1. Anaesthesia: General, spinal or local2. Inguinal incision is made half an inch above

and parallel to medial two thirds of the inguinalligament. The two layers of the superficial fasciaare incised

3. The external oblique aponeurosis is incised in

the direction of its fibres and the superficial ringis slit open. The spermatic cord is seen lying inthe canal with the conjoint tendon arching overit. The ilioinguinal nerve traverses the canal infront of the cord and comes out through thesuperficial ring. In infants, the inguinal canal isshort and the superficial ring lies opposite thedeep ring. There is no need to open theexternal oblique because the surgeon caneasily reach the neck of the sac withoutopening the inguinal canal

4. The upper flap of the external oblique aponeurosis is dissected up to expose the conjoint tendon. The lower flap is dissected

down to expose the infolded surface of inguinalligament

5. The cord or the round ligament is elevated toclear the posterior wall of the canal ( transversalisfascia and the conjoint tendon medially)6. The coverings of the cord (cremasteric muscle

and fascia then the internal spermatic fascia)are opened longitudinally. The hernia sac isidentified by its opaque pearly white colour,definite edges and crescentic fundus. It liesanterolateral to the vas and vessels. The sac isdissected up to its neck which is identified bythe presence of the inferior epigastric vessels atits medial side, by being the narrowest part ofsac and by the presence of extra peritoneal fat

7. The sac is opened at its fundus and explored.Adherent intestine is separated and returned tothe abdomen. Adherent omentum is excised.

A finger is passed in the sac to explore for thepresence of a direct or femoral hernia

8. A transfixation ligature is applied to the neck.The sac is divided leaving a half inch stumpdistal to the ligature to avoid its slipping. Thestump retracts up to lie flush with peritoneum

9. The cord is returned back in place and itscoverings are stitched

10. The external oblique aponeurosis is closed.

Medially, it is sutured comfortably around cordthus narrowing external ring if wide11. Skin closure by silk

-indicated for hernias of adults-The idea is to strengthen theposterior wall of the ing. canal

-Excision of the sac (herniotomy)should be done first-As a rule, repair of any herniadefect (hemiorrhaphy) should beperformed by nonabsorbablesuture material as prolene

-In all patients , plication of thefascia transversalis &reconstruction of the internal ring

with lateral displacement of thecord are performed , placatingsutures pass through the arch oftransversus abdominis superiorlyand the iliopubic tract inferiorly,

then an additional procedure is added, and in any of them therepair should not be undertension

-Bassinis repair : the ing. lig. is

sutured to the aponeurotic part ofthe conjoint tendon behind thespermatic cord, to be successful,the gap between the twostructures should not be wide and

the conjoint tendon should bestrong

-This operation is performed foryoung patients-Previous operations as shouldiceor McVays repair are not commonlyperformed now

-means obliteration of the hernia defectusing tissues which are not from the

vicinity of the hernia-generally indicated whenever the defect

is very wide (any repair under tension isdoomed to failure) or When themusculoaponeurotic boundaries are too

weak to hold sutures. Currentlyhernioplasty is gaining popularity for the

treatment of all adult inguinal hernias because it is not associated with tissue

tension and consequently has the lowestrecurrence rate

-Onlay mesh hernioplasty.: After excisionof the sac a mesh which is made ofsynthetic material is placed behind thespermatic cord, and is fixed to thetransversus abdominis and itsaponeurotic arch superiorly, and to theiliopubic tract and the inguinal ligamentinferiorly. The interstices of the mesh willbe impregnated with a dense sheet of

fibrous tissue. This operation is calledLichtenstein tension free mesh repair

-Preperitoneal hernioplasty : In this casethe mesh is placed between theperitoneum and the fascia transversalis.

This can be achieved either by open orby laparoscopic surgery

Treatment :-If the patient is unfit for surgery and provided the hernia is reducible ---> anabdominal binder will keep hernia reduced

-Surgery offers the only definitive cure-Many operation are available, but it is to be stressed that any repair under

tension is doomed to failure 1. Anatomical repair : The idea is to expose the hernia defect, remove sac

and then repair the abdominal wall in layers according to the site of the

incision. If the sac has a wide neck it is not necessary to excise. It is justpushed inside and is covered by the repair. 2. Hemioplasty : If the hernia defect is wide or the musculoaponeurotic

edges are weak, it is recommended to perform hernioplasty using asynthetic mesh

-hernia that develops at the site of a previous abdominal incision-the aetiology and clinical picture have been discussed before-the commonest cause is surgical site infection

incisional hernia


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16 :

direct inguinal hernia

Femoral hernia

Aetiology :

Pathology :

Clinical features :

Treatment:

Surgical anatomy of the femoral canal :

Femoral hernia components:

Clinical features :

common in elderly males - often the patient has weakness of the lower abdominal muscles with chroniccough or straining due to urinary problems.

-Injury of the ilioinguinal nerve during appendicectomy --> paralysis .of conjoint tendon --> direct ing. hernia

Direct inguinal hernia protrudes through Hasselbachs triangle which is bounded medially by lateral border

of rectus muscle, laterally by the inferior epigastric vessels and inferriorly by the medial half of the ing. lig.

1. Removal of the cause of straining e.g.: In an elderly male with senile enlargement of the prostate, prostatectomyshould precede hernia repair

2. Operation: Herniotomy is not usually needed as the sac is small and is composed mainly of extraperitoneal fat.Repair of the weak posterior wall of the inguinal canal by plication of the fascia transversalis and mesh hernioplasty

is indicated3. truss may be indicated if the patient is not fit for surgery

ESSENTIALLY SURGICAL

it is the most medial compartment of femoral sheath

the intermediate compartment is occupied by the femoralvein and the lateral one by the femoral artery

it is about 1/2inch long

Anteriorly : ing. ligament

Posteriorly : pectineal fascia & lig.

Medially : lacunar ligament

Laterally : femoral vein

Contents of femoralcanal are fat, lymphaticsand one lymph node ofCloquet

Its function is togive a space forexpansion of thefemoral vein

-more common in females especially after repeated pregnancies -gives an expansile impulse on cough

-presents as a rounded swelling, below the medial part of inguinal ligament, and below and lateral to the pubic tubercle

-Pressure on the saphenous opening obliterates the impulse and prevents descent of the hernia, BUT pressure on the internalinguinal ring fails to do so

-femoral hernia may present for the first time with strangulation ---> acutely painful groin swelling and sometimes features of intestinalobstruction & the hernia is tense, tender, irreducible with no impulse on cough

-direction of reduction is downwards then backwards and finally upwards

it is cone shaped, its mouth (femoral ring) is open upwards behind theinguinal ligament & its apex is below & is formed by fusion of the medialborder of femoral sheath and the septum between the femoral canal andthe femoral vein

Relations of the femoral ring :

-usually affects old males -bilaterality is commom -complications are unusual

POC Olique Direct

Age Any age Elderly

Side uni or bilateral commonly bilateral

Shape oblong hemispherical

Direction of Descent downwards-forwards-medially forwards

Direction of reduction upwards-backwards-laterally backwards

Descent to scrotum may occur very rare

Size may attain large size usually small

Complications liable to occur rare

Internal ring test hernia does not protrude hernia protrudes

relation of sac neck to inf. epigast. a.at operation

lateral to artery medial to artery

Sac Contents Coverings

-proceeds downwards in the femoral canal thenforwards stretching the cribriform fascia thenupwards and laterally towards inguinal ligament

-The neck of the sac is narrow, therefore femoralhernia is liable to irreducibility and strangulation

which are common

-femoral hernia usuallycontains omentum,bowel ofonly part of thecircumference of bowel(Richters hernia)

1. Stretched femoral septum2. Transversalis fascia from the anterior wall of

the canal3. Cribriform fascia 4. Superficial fascia. 5. Skin


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17 :

Differential Diagnosis :

Treatment :

Treatment :

Approach :

Reducible femoral hernia Irreducible femoral hernia

1- Inguinal hernia2- Saphena varix3- Aneurysm of the femoral artery4- Psoas abscess

1. Irreducible inguinal hernia2. Lipoma3. Inguinal lymphadenopathy4. Iliopsoas bursa

-A truss is contraindicated due to the possibility of strarngulation -Surgery is the only line of treatment

3 approaches for the repair

-sac is excised -defect (femoral ring) is obliterated by either

- Urgent surgery, preferably by the McEvedys operation is indicated.

3 types : congenital - infantile - adult (seen in ascites patients)

1. Congenital UH (exomphalos) :

-sac is exposed, and the fundus is opened to evacuate the toxic fluid-femoral ring is then exposed from above and the lacunar ligament is incised against the finger within the neck of sac-In dealing with the lacunar ligament, avoid injury of the abnormal obturator artery which is present in 30% of cases-contents are delivered above the inguinal ligament and are dealt with as usual-During repair of a femoral hernia the surgeon should be aware of the femoral vein on the lateral side and of the urinarybladder on the medial side

Suturing the inguinal ligament (anteriorborder of femoral ring) to Coopers lig.(posterior border of femoral ring) byinterrupted polypropylene sutures

Synthetic mesh as for inguinal hernia

low approach high approach (Lotheissens operation) preperitoneal approach

-incision is 1/2 inch below andparallel to the inguinal lig.

-The sac is transfixed as high aspossible and the femoral ringis closed by suturing the ing. toCoopers ligament

-incision is made above and parallel to themedial 2/3 of the inguinal ligament (similar tothat of inguinal hernia)

-The external oblique aponeurosis is incised sothat the inguinal canal is opened and the cord isisolated upwards

-Transversalis fascia in the floor of inguinal canal

is incised medial to the inferior epigastric vesselsexposing the peritoneum and the neck of thesac as it enters the femoral canal

-suitable for both the uncomplicated and thecomplicted femoral hernias.-It is either done through a lower midlineincision or a pararectal incision (McEvedysoperation) at the outer border of the lowerpart of the rectus abdominis. The latter isextended down to beyond the inguinal lig.

in case of strangulation, to empty the sac ofits toxic contents before releasing thestrangulation agent

-The abdominal incision is deepened dividingthe fascia transversalis till the peritoneumand the protruding sac are exposed

strangulated Femoral hernia

umbilical hernia

-Strangulation is common because the neck of the sac is narrow and the constricting agent which is the crescentic edge of Gimbernatsligament is sharp.

N.B. : Intestinal obstruction is absent if the content of the sac is omentum, Meckels diverticulum (littres hernia) or part of thecircumference of bowel (Richters hernia).

Exornphalos minor Exornphalos major

- small defect (less than 5 cm) is present at theumbilicus through which a small peritoneal sacprotrudes

- contents are usually intestine or Meckelsdiverticulum

- coverings are a thin layer of Whartons jelly and alayer of amniotic membrane

-Treatment : contents are reduced & returned toabdomen, the sac is excised & defect is repairedin layers

- large defect (more than 5 cm) in the center of the abdom. wall,usually above the umbilical cord

- contents may include many viscera and occasionally a part of theliver

- covering is only a layer of amniotic membrane- there is a danger of rupture of the sac followed by peritonitis-Treatment : is by urgent operation -Usually there is no room in

the abdomen to accommodate the contents - If the sac is intact, the defect is closed by a synthetic mesh - If the sac has ruptured skin flaps are used

- skin on either sides of the defect is undermined creating skinflaps which are brought together over the sac and sutured

- Release incisions in the flanks are needed -After several months the peritoneum and muscles can be

approximated and closed in layers


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2. Infantile UH :

2. Adult UH :

Aetiology :

Surgical pathology :

Clinical features :

Clinical features :

Clinical features :

Treatment :

Treatment :

Treatment :

Aetiology Pathology Clinical features Treatment

-weakness of the umbilicalscar from infection of the

umbilical cord stump

-Increased intra-abdominalpressure from coughingor abdominal distension

-defect is exactly at theumbilicus

-umbilical scar is stretched

& is present at the top ofthe hernia

-neck of the sac is wideand the coverings are

extraperitoneal fat andumbilical scar

-there is umbilical protrusionwhich inc. with cough orcrying

-the edge of the defect canbe palpated as a firm ring

-Obst. & strangulation arerare below the age of 3 yrs

-this type occasionally affectsadults

-Reassurance of the parents &follow-up are the usual measures

-defect closes spontaneously within

2 yrs in most of cases-Correction of the cause of

straining, if any-Operation is indicated when defect

is more than 2 fingers wide orwhen the hernia persists after theage of two years

- A semicircular incision is donebelow the umbilicus, and a skinflap is turned upwards

- sac is transfixed and excised, andthe defect in linea alba is closedwith few stitches of prolene

principles of the treatment are the same as paraumbilical hernia

-para-UH defects lie in linea alba & in most cases it lies above umbilicus bec. linea alba is thinner & broader above thanbelow the umbilicus -Occasionally the defect is below the umbilicus -It is never lateral to it

-umbilical scar lies below the swelling, it is compressed by the hernia and looks like a crescent-the sac has a narrow neck with a small defect in the linea alba & Adhesions inside the sac are very common especially atthe fundus, rendering the hernia irreducible

-Complications as strangulation and irreducibility are very common due to the narrow neck, sharp edge and adhesionsinside the sac

-painless swelling above the umbilicus --> expansile impulse on cough

-may be symptomless -it may cause local pain or cause dyspepsia due to traction on stomach

-common in middle aged females with repeated pregnancies and pts with ascites and splenomegaly

-abdominal belt is satisfactory in most cases-Surgical repair is likely to fail until the cause of high intra-abdominal pressure is treated

-if abdomen is relaxed --> nothing is visible BUT on raising the shoulders --> the linea alba bulges as a longitudinalridge and the fingers can be dipped into the abdomen between the two recti

-For the obese reduction of weight is advised prior to surgery-An elliptical transverse incision is made over the max. convexity of the hernia and skin flaps are undermined upwardsand downwards - sac is exposed and dissected down to the neck then sac is opened at its neck-because adhesionsare usually present at the fundus -contents are dealt with and reduced into the abdomen -sac is excised at the neck

-defect is then repaired: *If the defect is small --> closed by non-absorbable suture *If the defect is large or the musculoaponeurotic layer is weak ---> a prolene mesh *The previous Mayos repair is not commonly performed nowadays

-Mild dragging pain may be present in a huge hernia BUT Severe acute pain indicates strangulation-frequently found to be irreducible or partially reducible & are liable to strangulation

-a swelling in the epigastrium which is soft, frequently irreducible & gives expansible impulse on cough-Occasionally there are multiple hernias

- Surgery is the only method of treatment-truss is not satisfactory because the hernia is usually irreducible & its use carries high risk of strangulation

-If there is pain, the surgeon should be sure that it is not due to an underlying disease, e.g. peptic ulcer orgallstones

-Operation is performed by excision of the protruding extraperitoneal fat and the hernia sac followed by simple closure ofthe linea alba defect BUT if the defect is large ---> prolene mesh hernioplasty

-more frequent in middle aged females, esp. in obese multiparous women-it is actually paraumbilical and not umbilical hernia

-starts as a protrusion of the extraperitoneal fat through a defect in thesupraumbilical part of the linea aiba and is called fatty hernia of linea alba

-separation of recti due to stretching of the linea alba by a chronically

raised intra-abdominal pressure

-As the protrusion enlarges the fat pulls through the defect a small peritoneal pouch which may contain intestine oromentum, and is called epigastric hernia

paraumbilical hernia

EPIGASTRIC hernia

Divarication of recti


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THE BREAST

surgical anatomyDevelopment

Position & extent

Breast components

Blood supply

Lymphatic drainage

- breast = modified sweat gland

adult female breast has two components

-This is most important in cases of breast cancer. An extensive lymphatic plexusdrains the breast mainly to the axillary and the internal mammary lymph nodes

-constitute the chief draining station of the whole breast, even its medial part & receive about 75% of breastlymph-average 35 lymph nodes in the axilla that are arranged into :a- Anteromedial (pectoral) group b- Posterior (subscapular) group c-Lateral groupd- Interpectoral (Rotter) e- Central group f- Apical group

1- Axillary nodes :

develop into mammary glands

known as the mammary ridges

- 2 ectodermal thickenings (Rt & Lt)

ridges extend from the

axillae to the groins

Upwards : to the clavicleDownwards : to below the costal marginMedially : to the middle lineLaterally : to the posterior axillary line

middle part of the upper 1/3 of eachridge persists to form the breast while

the rest of the line disappears(in humans only)

-breasts lie between the skin and the pectoral fascia to which they are loosely attached-apparently, adult female breast overlies the area from the 2ndto 6thribs & from the lateral border of the sternum to theanterior axillary line

-in anatomical studies, however, a thin rim of glandular tissue of the breast has been observed to extend outside theapparent boundaries of the organ

-the actual extent of the breast is important for the surgeon who aims at removal of the whole organ for malignancy

N.B.: Axillary tail (of Spence) = prolongation of parenchyma that passes deeply through an opening in the deep fascia toblend with the axillary fat

-the actual extent of the breast is

Epithelial elements Supporting tissue

-responsible for milk secretion and transport-Each breast consists of 15-20 radially-arranged lobes, and each isdrained by a lactiferous duct

-ducts converge at the nipple-A lobe is made up of 20-40 lobules, each of which consists of10-100 alveoli

-It is of clinical importance to recognize that the main ducts liebehind the areola, while the lobules occupy the more peripheralpart of the breast

-alveoli and ducts are lined by a single layer of epithelium, andthe ducts are surrounded by contractile myoepithelial cells whichare stimulated by oxytocin and move milk towards the nipple

-Fibrous septa (Coopers ligaments) extend from the pectoralfascia to the skin, and are responsible for division of theparenchyma into lobes

-shape of the female breast is due to the fat containedbetween the fibrous septa

-In adolescents and young adults, breast is firm and prominent-With age the glandular and fibrous elements atrophy, the skinstretches, and the breast sags

Arteries Veins

-arterial supply comes from the following arteries in order of their

contribution :1. Internal mammary artery : through branches that perforate the

intercostal spaces and the pectoralis major muscle -these branches are encountered in the operation of mastectomy,

and should be ligated or clamped before their division,otherwise the cut end of the artery retracts and bleeds in themediastinum and is difficult to control

2. Lateral thoracic artery : a branch of the axillary3. The pectoral branch of the acromiothoracic artery4. The intercostal perforators

-venous return is primarily through the axillary and internal

mammary veins-The intercostal veins are clinically important as they drain intothe azygos system and communicate with the valveless

vertebral venous plexus, This communication could explain thetendency of breast cancer deposits to affect the axial skeleton


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Lateral group Apical group

-along the axillary vein-the posterior and lateral lymph nodes have numerousconnections with the anterior chain

-Though they do not directly drain the breast, they arepotential sits of breast cancer spread through the mentioned

connections

-lying between the pectoralis minor muscle and the clavicle, andsituated behind the clavipectoral fascia

-the apical group receives lymph from all other groups, and are incontinuity with the lower posterior deep cervical nodes thatultimately drain into the subclavian lymph trunk

-Lymphatics from the upper lateral part of the breast may draindirectly into the apical group (Level III )

Anteromedial (pectoral) gp Posterior (subscapular) gp Interpectoral (Rotter) Central group

-along the lateral thoracicvessels-at the lower border of thepectoralis minor muscle

-along the subscapularvessels

-few lymph nodesbetween the pectoralismajor and minormuscles

-embedded in the axillary fat behindpectoralis minor (Level II)

Level I Level II Level III

-nodes are located low in the axilla belowthe muscle

-nodes are located behind the pectora-lis minor muscle

-nodes are located above the muscle in theapex of the axilla

N.B. : For the purpose of determining the prognosis after mastectomy, the axillary lymph nodes are divided bythe pectoralis minor muscle into three levels :

N.B. : - Within the axilla lymph passes from level I to level II and then level III- The level of lymph node involvement is detected by the pathologist who examines the excised specimen.

- 3 or 4 internal mammary iyrnph nodes on each side- lying along the internal mammary vessels in the first three intercostal spaces- they receive part of the lymph from the medial half of the breast

- Breast development is under the control of the following hormones : * Oestrogen, adrenocortical steroids, and growth hormone ----> promote development of ducts * Progesterone ---- > stimulates the growth of lobules * Prolactin is essential for alveolar formation

-At puberty : * The breast remains dormant until puberty *The onset of cyclical hormonal activity stimulates growth,branching of ducts, and formation of ductules

-Menstrual changes : *During the menstrual years the breast undergoes cyclical changes which can cause heaviness,discomfort, and increasing nodularity during the latter part of menstrual cycle

-During pregnancy : * there is marked lobular development * The high level of ovarian and placental oestrogen,however, inhibits lactation

-Lactation : * Followinq delivery, reduction of oestrogens increases sensitivity of mammary epithelium to the lactational

complex (prolactin, growth hormone, and cortisol), and milk is formed* Suckling stimulates the release of prolactin and oxytocin which stimulates the myoepithelial cells to eject

milk into the terminal ducts- These effects are reversed by weaning- After menopause : the lobules gradually disappear

- Lymph passing through either the axillary or the internal mammary nodes --> jugulosubclavian venous confluence, BUT if this is obstructed, the lymph ---- in a retrograde way----> supraclavicular nodes- posterior intercostal lymph nodes lying along the necks of the ribs have a minor share in breast drainage

- few lymphatics pierce the pectoralis major muscle to drain into the occasional lymph nodes that lie between the twopectoral muscles ( interpectoral lymph nodes of Rotter ) and pass along the intercostal bundles to reach the posteriorintercostal lymph nodes

- Lymph channels from the breast do not cross the midline BUT they do cross the diaphragm, where they communicatewith liver lymphatics.

- Lymphatics from the lower inner quadrant may pierce the rectus sheath to reach the peritoneal lymphatic plexus- Previously much emphasis was mentioned about the importance of the subareolar plexus of Sappey and the pectoral

plexuses in the lymphatic drainage of the breast- It is now realized that lymphatics of the breast and the skin overlying it pass directly to the corresponding nodes

2- Internal mammary nodes :

3- Further lymphatic spread :

physiology of the breastHormonal control

Physiological changes


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Congenital anomalies

Breast Trauma

inflammations of breast

Anomalies of Nipple Anomalies of breast

1. Athelia : -Absence of a nipple is very rare-usually associated with absence of the breast (Amazia)

2. Polythelia : -Supernumerary nipples occur anywhere along

either or both the mammary ridges (mammary lines)which extend from the axillae to the groins

-An accessory nipple may be mistaken for a moleor a wart

1. Amazia : -Absence of the breast -usually unilateral-is often associated with absence of the sternalportion of the pectoralis major

2. Polymazia : -Supernumerary breasts are due to persistence ofextra mammary portions of the mammary ridge

-They may occur in axilla (accessory breast), groin, or even the thigh -They may function during lactation3. Infantile gynaecomastia : -Diffuse enlargement of the male

breast which may be unilateral orbilateral

-caused by the effect of circulating maternal sex hormones -usually reversible within six months, thereforerequires no ttt

Breast haernatorna Traumatic fat necrosis

-If there is no external bruising , a deeply seated oldhaematoma may form a hard mass that greatlyresembles a carcinoma.

-A biopsy will settle the issue

-Blunt breast trauma may cause death of some of the fat cells --> liberatedfatty acids + calcium --> calcium soaps ---> one of two forms :

a) A cyst : that contains thick oily fluidb) A hard mass (less frequently) : resembles a carcinoma

-condition is diagnosed by biopsy-if the lesion is excised, the cut section shows a characteristic

chalky white appearance without the yellow specks and grittytexture of carcinoma

- Blunt trauma to the breast produces two lesions that may be clinically difficult to distinguish from carcinoma, viz,

haematoma, and traumatic fat necrosis- Sometimes it is the trauma that draws the patients attention to an already existing carcinoma of the breast

-Acute bacterial mastitis is most common during lactation

a ) inspissated milk + epithelial debris--> Milk engorgement ---> blocks the ducts

b) poor hygiene

c) Abrasions to the nipples caused by suckling & retracted nipple is more likely to be injured by the baby who tries to get hold of it

- coagulase positive Staphylococcus aureus --- > induce clotting of milk in the ducts, producing obstructionand stasis

-Organisms from the mouth of the suckling infant gain access through nipple cracks and the openings of thelactiferous ducts

-Much less common is the blood-born infection

- Infection affects any part of the breast and is at first diffuse- The disease usually starts by milk engorgement, which if not properly

treated ---> acute mastitis- Staphylococci ---> necrosis and pus formation ---> multilocular abscess

Aetiology :

Predisposing factors :

Pathology :

Clinical features :

Acute lactational mastitis and breast abscess

Stage of milk engorgement Stage of acute mastitis Stage of acute abscess Stage of chronic breast abscess

- may affect the whole or a sector of the breast- The patient complains of a

dull aching pain- There is persistent pyrexia- Examination reveals

enlargement and indurationof the breast BUT there are

no physical signs ofinflammation

- pain gets worse andthereis continuous higher

pyrexia - Examinationreveals diffuseswelling, redness,

indurationand tenderness

-Suppuration is diagnosed if :* Pain is throbbing* Temperature is hectic* Physical signs get localized in

breast* Pitting oedema is elicited in thearea of the skin overlying abscess

* Persistence of local signs of inf. for

more than 5 days or of severesystemic upset for more than 2 daysafter full antibiotic ttt* Breast abscess is one of the siteswhere surgeon should not wait forfluctuation to diagnose it


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Treatment :

Before the development of an abscess Abscess formation

-condition can be medically treated- An antibiotic against staphylococci is administered,e.g. a semisynthetic penicillin as flucloxacillin, a cephalosporin,

or erythromycin,- Support of the breast helps to lessen pain - Local heat- advisability of weaning is controversial, but a reasonable approach is

to : * Advise cessation of breast feeding if the baby has been nursed for more than 9 months & agents in common use are bromocriptine (parlodel) 2.5 mg twice daily, or stilboesterol 1Omg three times a

a day * If the baby is younger, the patient is asked to use the healthy

breast for feeding and to regularly empty the inflamed breast bysqueezing and by a breast pump. After resolution of infection thebaby can be refed by both sides

-treated by incision and drainage- Under general anaesthesia- a radial or the more cosmetic circumferential incision is

made over the most tender area to release the pus whichis sampled for culture and sensitivity

- The surgeons finger breaks down the septa between the loculi to form a single cavity- A drain is brought out through the wound, or at the most dependent part of the breast- Antibiotic therapy may be continued for a few days, and

the drain is removed when the drainage ceases.

N.B. : The treatment of pus anywhere in the body is by DRAINAGE

Non lactational mastitis

Chronic inflammatory conditions of the breast

- commonest type of non lactational mastitis is that which complicates mammary duct ectasia- Inflammation produces a painful, tender, and red periareolar swelling- Anaerobes are commonly responsible for the mastitis, and it is, therefore customary to use metronidazole (400 mg four times per day) with flucloxacillin (250 mg four times daily) for five days for its treatment. If an abscess forms, it needs

surgical drainaqe through a small circumareolar incision- Spo

Yaser..Surgery 5th Year Theoritical Curriculum

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