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