Yas'er

presents

Surgery
Theoritical Curriculum

th

year

SKIN & SUBCUTANEOUS TISSUES

SEBACEOUS (EPIDERMOID) CYST
Definition : blockage of a sebaceous gland duct ----> retention of sebaceous secretion Retention cyst. Microscopic picture : lining
st. sq. epithelium

content
white material

composed of foul smelling

Keratin epithelial cells granular debris

Clinical features :
slowly growing rarely seen before adolescence * most commonly seen in :Scalp, Face, Neck or Scrotum. * occurs anywhere except palm or sole of foot which are devoid of sebaceous glands cyst characters * small * well-defined * cystic * usually att. to skin at one pt which is duct site * a punctum may be seen mobile over deep structures sometimes it may attain large size may be solitary or multiple

Complications :

infected cyst may undergo ulceration

Infection
commonest * 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 wall curetted * makes cyst more difficult to excise as it becomes more adherent to surrounding SC tissue

Sebaceous horn

Ulceration
rare

Localized alopecia

* contents come out slowly & become inspissated in successive layers over the base

*raised edges *overgrowing granulations * may be mistaken for carcinoma Cocks Peculiar tumor

Treatment : * COMPLETE EXCISION with an elipse overlying skin containing punctum is done to avoid recurrence * if small cyst ----> local anaesthesia. Definition : cyst Types :
POC lined by st. sq. epithelium contains sebaceous material hairs or sebaceous glands may grow from wall of cyst

DERMOID CYST
Tubulodermoids
D. due to distention of remnants of embryonic ducts

Sequesteration Dermoids
D. due to SC inclusion of portions of surface epith. along lines of fusion of cut. dermatomes during fetal life * well-defined , globular & cystic * not att. to skin * underlying bone may be hollowed out * a pedicle may conncet its deep aspect to dura mater * Although since birth , appears clinically after few yrs for cyst to distend
*outer eye angle ext. angular *root of nose *around ear *along body midline

Inclusion Dermoids
D. due to inclusion of epidermis during closure of a cavity

Teratomatous Dermoids
benign forms of teratomas

Implantation Dermoids
D. 2ry to punctured wounds displacing some epith. into SC tissues *displaced cells retain viability and form dermoid cyst * small & tense * overlying skin sometimes scarred

Def.

Features

* cyst lined by sq. epithelium * BUT contains teeth, hairs, bone, cartilage or glands.

Site

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

*sublingual *suprasternal *intra-cranial & spinal

*mostly ovary *occasionally testis or post, mediastin.

*mainly fingers, palm or sole

Treatment : * SURGICAL EXCISION only. cysts may communicate with dura.

*In childeren with D. cyst in scalp --> wait till closure of sutures because some *since dermoid cyst is deeper than sebaceous cyst ---> surgery is more difficult.

Lipoma
benign tumor composed of fatty areolar tissue arranged in lobules enclosed in a thin fibrous capsule but can be enucleated easily from within this capsule may contain
excess angiomatous myxomatous fibrous tissue tissue tissue angiolipoma myxolipoma fibrolipoma

grows very slowly & its common to find a pt who has the tumor for 10 or more yrs

Lipoma Presentations
Solitary well-defined swelling
Multiple Lipomatosis
esp. in DD of limbs or multiple trunks swellings
patients with myxoedema have supraclavicular fatty deposits

Diffuse lipomatous deposits

e.g. elderly persons may develop deposits below chin females may develop painful fatty deposits in thigh Dercums Disease

classified according to site of origin into

Subcutaneous lipomata

Intermuscular Submucous Parosteal Extradural Intra-articular Subfascial lipomata lipomata lipomata lipomata lipomata under lipomata deep fascia masked by arise in not att. to skin commonest Respiratory arise in may be larynx overlying ms & no slippery obstruction relation found characters stomach difficult to to cranial within edge diagnose intestine bones soft spinal painless fixed deeply slowly initiate canal consistency & not and become has to be intussusception erosion growing BUT some , esp. in warm diff. from of bones tender more paraplegia in SC weather , give intestinal prominent fibrosarcoma tissues pseudofluctuation, this is obstruction if they are hard & due to mobility of tumor pushed out lobulated grows in its bed & because fat at of ms or rapidly surface & may disappear warm temp. may undergo be attached to if they are liquefaction, so trial of skin at multiple drawn into aspiration fails points ms when it contracts well-defined slippery mobile over edge due to deep structures movement of tumor inside its capsule

Gross picture :

*false capsule

*lobulated surface

* yellowish color

Complications : rare

Degenerative changes ---> liquefaction & calcification Malignant transformation (very rare) BUT may occur in retroperitoneal lipoma

Treatment : * lipoma is a very innocent tumor & does not cause any problem EXCEPT in Submucous lipoma in intestine certain situations
Extradural lipoma in spinal canal

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

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+ skin pigmentation Definition : proliferative condition of endoneurium of nerves --> tumor formation _ Varieties : 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

Neurofibromatosis

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

Solitary Neurofibroma (NF)

spine mediastinum viscera

cerebrospinal nerves nerve roots within the cranial cavity and spinal canal Gross : * widespread affection of nerve fibers in the skin, muscles & bones * affected nerves are diffusely and irregularly thickened + formation of tumor-like swellings Microscopic : 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 incomplete removal Clinical features : * Aetiology : often familial * Onset : usually in adolescence * Characters : - commonly preceded with localized areas of pigmentation in the skin Cafe-au-lait patches grow slowly to form fusiform swellings with the - multiple tumors appear allover the body long diameter in the axis of affected nerve - affected nerves may or may not be vary greatly in size : the largest usually lying in papably thickened BUT pain is absent relation to the plexuses at roots of limbs - when a spinal nerve root is affected
firm or soft in consistency movable in lateral direction BUT not in line of may grow into may grow into sometimes it nerve spinal canal with mediastinum with enlarges in both pain signs of intra- or signs of directions as a NB : Malignant change anaesthesia extradural tumor mediastinal tumor dumb-bell tumor is associated with paralysis Treatment : * Excision of all tumors is impossible progressive increase in territory of nerve large tumors * Operation only indicated for in size of lesion painful tumors * tumors should be completely tumors producing pressure symptoms

Generalized Neurofibromatosis (NFs) von Recklinghausens disease

resected

POC Characters

Cutaneous NFs (Molluscum fibrosum) - Multiple soft fibrous swellings - arise in connection with terminal filaments of cut. nerves - vary in size from pins head to a lemon size or larger and may be sessile or pedunculated

Plexiform NF - diffuse fibromatous thickening of branches of nerve forming beaded swelling under skin - in more than 1/2 cases manifestations of generalized NF exist

Elephantiasis Neuromatosa - related to & may coexist with cut. NFs - appears in childhood - affected part gradually increase in size & till being enormous - skin & SC tissues are greatly thickened - variable no of tumors may exist - usually one of extremeties esp. lower - skin may be pigmented and hairy

Acoustic Neuroma - in rare cases NF is associated with acoustic n. tumors -striking familial incidence - associated with tumors of dura & choroid plexus

Neurofibrosarcoma - de novo in normal nerve or as malignant degeneration of NF - spindle-cell or myxosarcomatous - painful & rapidly growing

Site

- Scalp, limbs, abdomen & back - palms & soles escape - skin is the seat of pigmentation Cafe-au-lait patches or Frank Melanomata Large & unsightly tumors are excised

- SC tissues of head & neck - large nerves of limbs - autonomic plexuses of abdomen - overlying skin is pigmented & thickened & hang as pendulous folds Pachydermatocele

- invade surround. tissues --> anaesthesia & paralysis & forms distant metastases
Localised wide excision BUT amputation in extensive and postop. recurrent tumors

Treatment

vascular anomalies
Capillary malformation Venous malformation Arterial Arteriovenous

Current nomenclature is biologically based, and includes two major classes Low flow lesions High flow lesions Lymphatic malformations Vascular malformations Hemangioma

Definition : benign proliferative neoplasm of endothelial lining of vascular spaces Synonym : strawberry mark 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 :
Onset
shortly after birth at end of 1st year

Hemangioma
a) Proliferation stage b) Involution phase

Character
*pale or reddish patch *increases in size over next months *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 & telengectasia

peri-orbital hemangioma encroach on visual field amblyopia

parotid gland hemangioma auditory canal obstruction

c) Involuted phase large cutaneous or visceral Hemangiomata congestive cardiac failure large visceral Hemangiomata

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entrapment of platelets

thrombocytopenia

Treatment : 1) Reassurance of parents + Observation --> as skin appearance after involution may be better Oral or intra-lesional corticosteroids than scar following excision 2) If it is necessary to interfere , the following are helpful Laser photocoagulation

Aetiology : embryological error --> sructural abnormality in blood vessels Onset : at birth but Growth nature : grow proportionately with the child & do not regress or involute often noticed later Diagnostic imaging : Doppler Ultrasound MRI &/or Magnetic Resonance Angiography (MRA) Angiography
differntiate high-flow from low-flow lesions POC Characters most useful study for assessing extent of lesion & degree of involvement of surrounding structures useful in some cases

vascular malformations

Surgical debulking

Comparison between types of low-flow lesions :

Capillary Malformation ( Port wine stain ) Venous malformation

* present since birth & does not undergo involution * it does not undergo involution like * dark purble in color & not raised above surface hemangioma, as it is a malformation * Pressure causes btanchlng but the color returns * similar to hemangioma in C/P but immediately after release of pressure usually appears later * 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) 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 & edema b) percutaneous sclerosis via hypertonic saline, 100% alcohol or Na Tetradecyl sulfate BUT with high recurrence rate & multiple sessions c) surgical excision with preoperative embolization or sclerosis to facilitate intraoerative. hemostasis d) interstitial laser coagulation

Treatment

stenosis -represent abnormal development of arterial structures including hypoplasia temporal region duplication -Site : Most commonly in scalp esp. occipital region tortousity & may involve underlying bone -Character : soft - compressible - pulsating + marked bruit -Complication : ulceration of overlying skin --> serious hge ,since its arterial bleeding -Treatment : - DIFFICULT , bec. swelling is supplied by multiple feeding arteries that need ligation - preliminary embolization of feeding vessels may be tried

Arterial malformation (CIRSOID ANEURYSM)

Arterial venous Malformations(AVMs)

HIGH FLOW LESIONS

-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 -Treatment : - ligation or embolization of feeding vessels --> rapid enlargement of collateral vessels ----> increasing size of lesion - Excision Preoperative angiography & embolization of feeding arteries + excision next day + extensive coverage by a free-flap may be needed -N.B. : Hereditary Hgic telengectasia : - autosomal dominant disease - characterized by multiple cutaneous,visceral & mucosal AVMs

Lymphatic Malformations (LMs)

-classified as Microcystic or Macrocystic + may have component of venous malformation -Site : Head & Neck or Axilla in majority of cases -Complications : * Neck masses --> may extend into mediastinum or prepectoral area congnital macroglossia * LMs are the most common cause of macrocheilia (lip enlargement) * Skeletal involvement ---> distortion macrotia : 1) Percutaneous aspiration followed by Sclerosis --> short term improvement -Treatment 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

ABDOMINAL WALL & HERNIA

abdominal incisions

Requirements : SEGA : Safety - Extensibility - Good cosmetic result - Accessibility Accessibility Extensibility Safety Good cosmetic result
incision should provide good exposure of the diseased area should be possible to enlarge the incision, if needed, to give more exposure should inflict the minimal damage to muscles, blood vessels and nerves e.g. : Muscle splitting incisions are preferable than muscle cutting ones e.g. : a transverse suprapubic incision is better looking than a low mid line incision

Types :

Vertical incisions 1) Vertical incisions POC

or

Transverse incisions

or

Oblique incisions Paramedian transrectal incision

Midline incision
-incision passes through the linea alba and the two recti are retracted apart -incision in the linea alba should be closed by a non-absorbable suture material as prolene to avoid incisional hernia and burst abdomen

Paramedian incision

technique

-upper or lower, right or left -similar to classical paramedian -skin incision is one inch from incision BUT rectus muscle is split the middle line longitudinally in the same line -anterior rectus sheath is incised of incision in the anterior rectus vertically, and the rectus muscle sheath is displaced laterally to preserve the vessels and nerves supplying the rectus muscle from lateral side - posterior rectus sheath and peritoneum are incised as one layer - quick , therefore, not recommended in emergencies. - most useful in children because atrophy is compensated for during growth -scar is not as strong as that of the paramedian incision due to devitalization of the medial part of the rectus muscle

advantages

-safe and the healing power is -good exploratory incision allowing access to both sides of strong the abdomen -readily extensible and can give -quick and can be enlarged freely exposure to any abdominal organ -time consuming , therefore, not recommended in emergencies

disadvantages

POC
Characters & Technique

2) Transverse incisions
-Upper transverse epigastric and low transverse suprapubic (Pfannenstiel) -in Pfannenstiel incision, anterior rectus sheath is cut transversely, and then the two recti are separated -finally the peritoneum is opened

3) Oblique incisions a- Subcostal incision b- McBurneys incision

- it is called Kochers incision if on right side - a muscle cutting incision , one inch below & parallel to costal margin -Medially, rectus muscle and the anterior and posterior rectus sheaths are divided -Laterally, the three abdominal muscles may be divided -a muscle splitting incision, usually used for appendicectomy -5-6 cm and perpendicular to a line passing from the A.S.I.S to the umbilicus at the junction of its outer 1/3 with the inner 2/3 -external oblique aponeurosis is opened in the same direction of the skin incision -internal oblique and transversus abdominis muscles are split in the direction of their fibres
-good exposure to caecum & appendix -safe incision -cosmetic esp. with transverse skin incision ( Lanz incision ) -not exploratory -not recommended if appendicitis diagnosis is not sure -if extended up or down it will be a ms cutting incision

advantages

-scar is cosmetic as wound lies in Langers lines - minimal ms tension on suture & so pt can cough safely postop. -excessive bleeding

-good exposure to the biliary apparatus or the spleen esp. in obese patients with wide costal angle -ms cutting -not exploratory -not extensible -injury to 8th,9th or 10th intercostal n. --> hyposthesia or partial abdominal wall paralysis

disadvantages -time consuming

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Precautions during closure of an abdominal incision Complications of abdominal incisions

1. A non-absorbable monofilamentous suture material, 1. Haematoma : may be due to a bleeding tendency e.g., polypropylene (prolene) is used in the patient but far more commonly due to careless 2. - Sound closure of the strongest layer ( linea alba or the surgical haemostasis anterior rectus sheath ) is essential for safety of wound - causes dull aching pain in the wound which is closure indurated and may be discoloured. - Wide bites (1 cm) are taken from the edge of the fascial - If small --> left for spontaneous absorption incision - If enlarging or large --> evacuated to avoid - Suture length to the wound length should be 4:1 secondary infection 3. Sutures should not be under tension to avoid ischaemia of 2. Infection the wound 3. Wound disruption (burst abdomen) : a serious 4. If there is a peritoneal defect, leave it as the peritoneum will complication which may lead to an incisional hernia regenerate in a few days or may even cause mortality 4. 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 period 5. Desmoid Tumor

Predisposing factors :
Pre-operative factors
1. Obesity 2. Factors causing poor healing as malnutrition, cirrhosis, DM, jaundice & corticosteroid intake 3. Patients with respiratory problems as chronic bronchitis, bronchial asthma and chronic obstructive lung disease

Burst ABdomen
Operative factors Post-operative factors
1. Poor recovery from anaesthesia leading to strong coughing 2. Persistent increase in intra-abdominal pressure due to repeated coughing, vomiting, hiccough or abdominal distension 3. Haematoma of the wound 4. Surgical site infection is the most important factor , tissues become friable due to collagen lysis allowing the sutures to cut through them

1. Ms cutting incisions Ms splitting ones 2. Vertical incisions Transverse incisions 3. Rough surgical technique with excessiye trauma to the muscles, blood vessels & nerves 4. Use of absorbable sutures in the closure of the aponeurotic layer of an abdominal wound , so, non-absorbable ry sutures as polypropylene are 4. The nature of the 1 disease for recommended & good bites should be which the operation was performed, taken on either side of this layer e.g., patients with abdominal 5. Insertion of drainage tubes through the malignancy are usually malnourished main wound and patients with peritonitis will have abdominal distension and wound sepsis

Types :
Partial deep layers burst but the skin is intact incisional hernia Complete Evisceration if the intestine prolapses out of the wound Dehiscence if the intestine is retained inside the abdomen

Clinical features :
Red sign
th

Onset
th

Symptoms
- patient often feels as if something gives way - Symptoms of intestinal obstruction may be present

- warning sign to the occurrence of burst 6 to the 8 - serosanguinous discharge soaks the dressing day post- due to straqgulation of a piece of omentum or a loop of bowel operatively which is prolapsed through a defect in the muscles

1- Cover the prolapsed bowel by a sterile dressing 2- Insert a nasogastric tube and start an IV infusion 3- using general anaesthesia, wash protruding loops with saline & return them to abdominal cavity, omentum is spread over intestine, abdominal wall is closed as one layer by through-and-through sutures, using strong non-absorbable polypropylene Retention sutures as they are retained for at least three weeks + Care should be taken not to puncture a loop of bowel 4- Antibiotics are prescribed and an abdominal binder is recommended

Treatment : Urgent surgical closure

Minimal Access surgery

- many operations can now be performed through

natural body orifices via fibre-optic endoscopy fine stabs for introducing rigid endoscopes into
peritoneum pleura joint cavities

laparoscopy

for abdominal surgery

Frequently performed Iaparoscopic operations: 1- Cholecystectomy 2- Appendicectomy 3- Inguinal hernia repair 4-Bariatric surgery Tubal ligation 5- Fundoplication for gastro-oesophageal reflux 6- Gynaecologic operations : Tubal adhesiolysis Steps : 1- General anaesthesia 2- Insufflation of peritoneal cavity with CO2 using 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 instruments 3- 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 cavity 4- Inspection of peritoneal cavity 5- Insertion of other ports under direct vision through abdominal wall to allow introduction of instruments for dissection , coagulation , retraction & cutting Advantages
1. Minimal postoperative pain 2. Minimal impairment of pulmonary functions 3. Fast recovery and early return to normal activities 4. Ability to visualize and explore the whole abdominal and pelvic organs 5. Video recording of the operative procedures with obvious educational advantages 6. Better appearance and decreased wound problems as dehiscence or infection

Drawbacks
1. Need for well-trained surgeons 2. High cost of the equipment 3. Postoperative shoulder pain, which is caused by irritation and stretching of the diaphragm by CO2

Conversion of laparoscopic surgery --> conventional open surgery in the following situations : 1- Equipment failure considering the safety of patient is the absolute priority 2- Dense adhesions or anatomical abnormalities precluding safe performance of procedure 3- Uncontrolled bleeding 4- Accedintal injuries reqiring open repair Diagnostic laparoscopy : rapidly gaining popularity in certain situations to determine cause of acute lower abdominal pain , e.g. : acute pelvic appencicits or torsion of an ovarian cyst to determine extent of malignant disease , e.g. : small liver secondaries or peritoneal nodules to detect the exact injuries in blunt abdominal trauma

Diseases of umbilicus 7 : fistula - sinus - stone - polyp - granuloma - hernia - tumors

Umbilical fistula
1- Faecal fistula : - congenital from patent vitello-intestinal duct -traumatic -inflammatory from TB of small intestine -malignant from carcinoma of transverse colon that ulcerates 2- Urinary fistula : -congenital from patent urachus -rarely acquired 3-Biliary fistula : -very rare - due to operative bile duct injury in cholecystectomy

Diseases of abdominal wall

Umbilical sinus
- discharges pus - due to abdominal wall abscess or umbilical infection - Pilonidal sinus of umbilicus is rare --> persistent discharge

Umbilical stone
- due to chronic inflammation of umbilicus or from umbilical granuloma - should be removed - granuloma is excised by diathermy & antiseptics applied

- due to persistence of the umbilical extremity - mass of granulation tissue of the vitello- intestinal duct which becomes due to chronic infection of everted outwards umbilical scar - irritative hyperplasia of epithelial - should be curetted & surface from friction --> polypoidal then cauterized by silver mass at bottom of umbilicus nitrate - should be excised

Umbilical Hernia

Umbilical polyp

Umbilical granuloma

Umbilical Tumors
1. SCC : rare & gives metastasis to axillary & inguinal lymph nodes on both sides 2. 2ry carcinoma nodules :may be present at umbilicus due to spread from carcinoma of stomach , pancreas, liver or breast

Desmoid Tumor
Pathology : -nature is not exactly known & may be considered as locally malignant fibrosarcoma -it arises from the anterior or less commonly the posterior rectus sheath , or from the anterior abdominal wall muscles -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 Clinical features : -usually affects females about age of 40 years -patient presents by : painless - hard - ill-defined - slowly growing mass of abdominal wall with nodular surface Treatment : EXCISION with safety margin of at least one inch & RECONSTRUCTION of defect by flaps of fascia or synthetic mesh BUT recurrence is very common if not adequately excised

Hematoma of rectus sheath

Clinical features : - pain - tenderness - swelling over rectus muscle Treatment : -if large --> evacuation of hematoma & ligation of epigastric vessels

due to trauma --> rupture of inferior epigastric vessels

General principles of external abdominal hernias

Definition : protrusion of a viscus or part of it ,usually within a peritoneal sac, through an abdominal wall defect Aetiology : Congenital (preformed) sac Acquired causes
- unobliterated processus vaginalis --> congenital inguinal - Raised intra-abdominal pressure due to : chronic cough, hernia straining at micturition or stools , heavy work, obesity or huge abdominal swelling (splenomegaly or pregnant uterus) - unobliterated physiological umbilical hernia of fetus --> - Weak abdominal wall due to : obesity , senility , debility , congenital umbilical hernia (exomphalos) pregnancy , weak scar & damaged n. supply of muscles

Components : Sac
-peritoneal pouch which bulges out through abdominal wall defect -it has a neck (junction with peritoneum), body & fundus

Contents
-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 peritoneal cavity while empty sac remains in place

Coverings
-structures that are stretched over the sac

Special Contents Richters hernia

-content is part of bowel circumference - common in femoral hernia

Littres hernia
-content is Meckels diverticulum

Maydls (W) hernia

-contains 2 loops of intestine while an intermediate loop lies in peritoneal cavity

Urinary bladder (Sliding hernia)

-part of it may protrude into inguinal or femoral hernia -usually protrudes along inner side of sac lying outside it forming a SLIDING HERNIA

Diagnosis : when a clinical diagnosis of hernia is suspected , 7 questions need to be answered : a) present at one of anatomical sites e.g. : inguinal, 1- Is this swelling a hernia ? hernia is characterized by femoral, umbilical, epigastric or incisional exact site 2- Which type ? depends on special features b) has an expansile impulse on cough EXCEPT if special tests 3- What are the contents ? strangulated
POC Consistency Gurgling ease of reduction Percussion Intestine (enterocele) soft during reduction 1st part is more difficult to reduce than last may be resonant Omentum (omentocele) doughy none last part is more difficult to reduce dull

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

-History & examination for the following before surgery

-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 b) Divarication of recti cardiac complications c) bulge of lower abd. on straining respiratory complications (Malgaigne bulge) HTN & DM

4- Is it Complicated ? 5- Is there any causes for intra-abdominal P or weak abdominal wall ?

c) reducible EXCEPT if (irreducible-obstructedstrangulated) d) opaque by transillumination EXCEPT in infants

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avoid complications of hernia Treatment : 1- Operation is always advised to prevent its progressive enlargement which widens the - Uncomplicated hernias are defect & weakens musculoaponeurotic layers around it repaired by elective surgery after eradication of predisposing factors 2- It is better to avoid truss to control herniation BUT may be used for extremely unfit patients Herniotomy (herniectomy)
-excision of sac -done alone or as part of herniorrhaphy or hernioplasty

Herniorrhaphy
-entails herniotomy & repair of defect by approximation of local tissues

Hernioplasty
-entails herniotomy & closure of defect without tension using imported material ,which are not from the vicinty of the defect -this material may be tissues from distant parts of the body, e.g., fascia lata or 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 the lowest incidence of hernia recurrence

Complications : N.B. : hernia complications are those of contents Irreducibility

- 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

6 complications as follows : Inflammation

-uncommon & means inflammation of contents -causes: rough taxis - ill-fitting truss - spont. inf. of contents (appendix-fallopian tube-ovary) -clinical features: tenderness BUT NOT tense & overlying skin is red & oedematous -ttt : operation is essential as strangulation cant be excluded

Obstruction
-occurs in irreducible hernias due to occlusion of intest. lumen from without or from within -if purely obst. --> bl. supply is unaffected -symptoms of intest. obst. are vomiting-distention-colics & constipation -picture simulates strangul. but less severe -locally, hernia becomes distended, irreducble BUT still soft -Distinction between it & strangulation may be difficult so its safer to ttt it as strang. & performing an early surgery

Strangulation

Hydrocele of the hernia sac

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

Torsion of the omentum

Strangulated hernia

most serious hernia complication

Definition : contriction of contents --> interruption of their bl. supply & if not relieved --> gangrene within hrs Incidence : - varies according to type of hernia 2-4% : inguinal - Strangulation may occur at any age 3-5% : incisional - Although its higher in femoral hernias , & is commoner after prolonged use 15-20% : paraumbilical yet, strangulated inguinal hernias account of a truss 25-30% : femoral for 50% of all strangulated ext. hernias Causes : 1- Straining --> extrusion of new contents 2- Repeated reduction attempts --> Oedema superficial inguinal ring Pathology : constricting agent may be a resistant structure outside sac as deep inguinal ring
neck of the sac bands of adhesion within sac Gimbernats ligament

Consequences : if contents are intestine proximal intestine

-Obstructed -progressive Distention -Hyperperistalsis

Strangulated loop
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 sac 2- Later, Impaired arterial supply & devitalized intestine exudes its content(fluid-bloodbacteria) through its wall to sac and so it contains dark highly toxic fluid 3- Finally, Gangrene occurs : starts at constriction ring --> affects antimesenteric border (convexity) of loop --> perforation may occur at these sites & later gangrene affects whole loop & its mesentery 4- Peritonitis is the terminal event , as there is infection spread from sac to peritoneum --> septic shock & dehydration in neglected cases --> death

distal intestine -collapsed

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Clinical Features : Symptoms
1- Acute pain in the hernia 2- Sudden enlargement --> bigger hernia 3- Irreducibility (hernia which used to disappear on lying down or by pressing it ) now fails to reduce , sometimes a hernia presents for the 1st time by strangulation 4- 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

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Signs General examination Local examination

-usually shows no abnormality except -Hernia is : in neglected cases where shock a) Tense (hypovolemic or even septic) exists b) Tender c) Irreducible d) No impulse on cough

Treatment : URGENT SURGERY Preoperative preparation Postoperative management

-as any case of intestinal obstruction 1- Nasogastric tube suction & IV fluids continued until intestinal 1- Nasogastric tube suction sounds are audible 2- IV infusion of lactated Ringers solution to correct hypovolemia 2- Prophylactic antibiotics 3- IV broad spectrum antibiotics to guard against septicaemic shock 3- Drains removed when they stop discharging (usually 5-7 days)

STEPS 1. incision should 2. fundus of sac st be planned to is opened at 1 3. constricting ring is divided expose the to evacuate toxic & a grooved director or left fundus of sac fluid that is full of finger inserted inside ring organisms & its coverings are divided from outside till constriction is relieved viable intestine
1.Normal Luster 2.Pink 3.Pulsating mesenteric arteries 4.Bleeds if injured 5.Firm 6.Contracts if pinched

non-viable intestine
1.Lusturless 2.Grey or Black 3.NOT Pulsating 4.Does not bleed 5.Flabby & thin 6.No response

4. contents are pulled out & examined, that is important so as not to miss a strangulated Maydls hernia

5. Dealing with contents

7. SC drains are usually needed

6. repair of hernia defects via polypropylene sutures which are inert with no inflammatory reaction

a) omentum always excised

c) resection & b) viable ry 1 anastomosis intestine of gangrenous returned to small intestine abdomen

d) resection of gangrenous segment of colon and clostomy BUT anastomosis of unprepared colon is better avoided,in such cases elective anastomosis after colon preparation is done after few weeks

e) if suspicious intestine, apply warm packs and give pt oxygen for few minutes , then decision is taken whether intestine is viable or gangrenous

Sliding Hernia
Definition : a hernia where a viscus forms a part of wall of sac , commonest are Clinical Features : - usually a longstanding hernia in an obese elderly man
- hernia is usually complete oblique inguinal

bladder & caecum sigmoid colon

common in

- 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

old-standing hernias males old age

Treatment :

- 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

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Surgical anatomy of inguinal region

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

Superficial fascia
-composed of a superficial faty layer ( Camper fascia ) & a deep membraneous layer ( Scarpas fascia ) which allows free gliding of fat over the muscles -superficial fascia of the abdomen does not communicate with the corresponding layer of thigh due to the presence of an inguinal crease where skin is attached to deep fascia, one inch below inguinal ligament -No deep fascia is abdominal wall to allow for free respiratory movements , gastric fullness & pregnancy

Transversalis fascia
-thin but strong fascial layer that lies in front of the peritoneum -most important defense against hernia formation -its lower part is thickened forming the iliopubic tract which runs just above and parallel to the inguinal ligament -its upper part is thickened forming the arch of the transversus abdominis which lies at the lower border of the transversus muscle

External oblique muscle

-origin : arises by fleshy digitations from the lower 8 ribs

Internal oblique muscle

Transversus abdorninis

-origin : arises by fleshy digitations -origin : lower part arises by from lateral half (or two thirds) of fleshy fibres from the reflected surface of the the lateral third of inguinal ligament the ing. ligament -course: run downwards and forwards, and -course & insertion: -course & insertion : become aponeurotic from the level of - its lower border covers the deep - arches horizontally the umbilicus down to its free lower inguinal ring and the beginning of higher than the internal border which is infolded & thick and the spermatic cord oblique to be inserted is called inguinal (Pouparts) ligament - It arches horizontal!y above the through the conjoint cord and fuses with the lowest fibres tendon in the pubic -inguinal (Pouparts) ligament : of transversus muscle to form the tubercle & iliopectineal - stretches between the pubic tubercle conjoint tendon which, passes line medially & the A.S.I.S laterally vertically downwards behind the - its free posterior margin fuses with cord to be inserted into the pubic lower ends of fascia transversalis and iliaca tubercle & iliopectineal line - in its medial fourth, its infolded part is thick and is attached to the iliopectineal line 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)

Inguinal canal

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

Dimensions and site : - in adults the canal is 1.5 inches (4cm) long

-course : extends obliquely downwards, medially and forwards in the lower and lateral part of the anterior abdominal wall from the deep to the superficial inguinal rings (above the medial half of the inguinal ligament) Contents : -sperrnatic cord (round ligament in female) -ilioinguinal nerve

Inguinal rings : Deep inguinal ring.

-opening in the transversalis fascia 1/2 inch above midinguinal point (midway between the symphysis pubis and the A.S.I.S -inferior eigastric vessels run medial to it -covered anteriorly by the lower border of the internal oblique muscle

Superficial inguinal ring

-triangular opening in the external oblique aponeurosis that is situated half an inch above & medial to the pubic tubercle -bounded by the pubic crest below and the medial and lateral 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 ilioinguinal nerve -it is backed by the conjoint tendon

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Boundaries : Posteriorly
constitute the relations of the spermatic cord

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Anteriorly

Superiorly
-conjoint muscles ( int. oblique & transversus)

Inferiorly
-infolded surface of ing. lig. with the upper surface of lacunar lig. medially

-fascia transversalis -external oblique aponeurosis -inferior epigastric vs laterally -lower part of internal oblique ms -conjoint tendon medially laterally

Spermatic cord
Course
-begins just deep to the deep inguinal ring by gathering of its constituents -enters the deep ring ,traverses the inguinal canal and exits from the superficial ring -then passes down in front of the pubic bone, crosses the scrotal neck and enters the scrotum where it is attached to the top and back of the testis

Constituents
1. Vas deferens 2. Testicular artery 3. Pampiniform plexus of veins (testicular veins) 4. Artery of the vas 5. Testicular lymphatics 6. Genital branch of genito-femoral nerve 7. Testicular autonomic nerves 8. Vestige (remnant) of processus vaginalis, which is anterolateral to the vas and the vessels N.B. :All the structures of the cord are embedded in loose fat and areolar tissue

Coverings
-has three coverings which are derived from the penetrated layers of the abdominal wall during testicular descent -they surround the testis & cord like 3 sockets 1. internal spermatic fascia: derived from transversalis fascia at the deep ring 2. cremasteric muscle and fascia : derived from the lower border of the internal oblique muscle as it overlies the deep ring & cremasteric muscle is supplied by the genital branch of genitofemoral nerve and it acts to elevate the testis 3. external spermatic fascia: derived from the external oblique aponeurosis at the superficial ring

Anatomical basis of inguinal hernia

Causes of weaknes of anterior abdominal wall
1. Muscles of the abdominal wall in the inguinal region are aponeurotic & therefore, this area is weaker than the fleshy parts of the abdomen. 2. Internal oblique and transversus abdominis muscles arch up to form the roof of inguinal canal 3. Spermatic cord passes between the muscles and adds more weakness to the inguinal area

Protective mechanisms
1. Obliquity of the inguinal canal 2. Transversalis fascia although thin, is a strong layer that supports the posterior wall 3. Weak parts of the canal are supported by strong structure: - deep inguinal ring is reinforced by condensation of the transversalis fascia and by the fleshy fibres of lower part of internal oblique in front of it - superficial inguinal ring is supported by the conjoint tendon posteriorly 4. Shutter mechanism : -During contraction of the abdominal muscles, the lower border of the conjoint tendon straightens & descends downwards toward the inguinal ligament, thus closing the posterior wall 5. Valvular mechanism : -Contraction of the external oblique ms tightens its aponeurosis and narrows the superficial ing. ring 6. Cremasteric mechanism : -Contraction of the cremasteric muscle plugs the superficial inguinal ring and causes bulging of the spermatic cord in the middle third of inguinal canal leading to its obliteration 7. Contraction of the transversus abdominis muscle pulls and tenses the edges of the internal ring
due to the presence of an unobliterated processus vaginalis Congenital (preformed) sac Acquired (pulsion) sac

Oblique (indirect) inguinal hernia

Aetiology : sac of an oblique inguinal hernia is either : Anatomy of oblique inguinal hernia :
1. The hernia defect is the stretched deep ring

due to raised intra-abdominal pressure and weak abdominal wall 2. The hernia sac (congenital or acquired) escapes from deep ring and lies always inside the cord within the coverings, being anterolateral 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 two cord 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 3 cord coverings;external spermatic fascia, cremasteric muscle and fascia and internal spermatic fascia

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Anatomical types : Congenital type Infantile type (operative finding) Adult type

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a. It is due to persistence of - tunica vaginalis extends upwards to the -which may be : the whole processus external ring, so that the sac passes down a. Bubonocele : i. The hernia is limited vaginalis, hernia reaches behind it to the inguinal canal and is seen as a down to the bottom of the - at operation, the tunica is liable to be bulge or a swelling in the groin scrotum (scrotal or complete opened in mistake for the true sac which ii. The processus vaginalis is hernia) will be found behind it (two sacs) obliterated at the superficial inguinal b. The testis lies among the ring contents of the sac, i.e., the b. Funicular hernia : hernia reaches down testis lies within the lower to the neck of the scrotum part of the hernia i. The processus vaginalis is closed c. Although called congenital, it only at its lower end, just above the may appear in adult life epididymis.

ii. The tunica vaqinalis is normal and the sac represents the proximal part of processus vaginalis only iii. The testis can be felt separate from the hernia and below it c. 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 Clinical features : 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 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 scrotum forming an inguino-scrotal swelling (funicular and scrotal types). Inguinal hernias lie above the inguinal ligament, and above and medial to the pubic tubercle. In contrast femoral hernias lie below the inguinal ligament, and below and lateral to the pubic tubercle 4. Direction of descent of contents is downwards, forwards and medially 5. Direction of reduction is obliquely upwards, laterally and backwards 6. Shape: the swelling is oblong with a narrow neck and wide fundus 7. 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 comes directly from posterior wall of inguinal canal Treatment : -Surgery is necessary because of the risk of strangulation -BUT truss is indicated only if there is a contraindication to surgery -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)

Recurrent inguinal hernia

Aetiology : 1. causes leading to incisional hernia
2. 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 end of the repair and will present as a direct inguinal hernia

Treatment :

a. Leaving a part of the original sac, i.e., failure to 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 a Bassinis repair in a patient with a weak conjoint tendon or doing the repair under tension.

1. Correction of any predisposing factors. A truss may be applied until the patient is fit for surgery 2. Hernioplasty by a synthetic mesh is usually performed

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inguinal hernia in infants & children

1. Hernia is always due to presence of preformed sac 2. always of the oblique type 3. operation can be done at any age provided a skilled anaesthetist is available 4. 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 neck 6. If strangulation is neglected, testicular atrophy may occur

Herniotomy
-excisron of the sac only and is pertormed in cases of hernias in infants and children -Technique : 1. Anaesthesia: General, spinal or local 2. Inguinal incision is made half an inch above and parallel to medial two thirds of the inguinal ligament. The two layers of the superficial fascia are incised 3. The external oblique aponeurosis is incised in the direction of its fibres and the superficial ring is slit open. The spermatic cord is seen lying in the canal with the conjoint tendon arching over it. The ilioinguinal nerve traverses the canal in front of the cord and comes out through the superficial ring. In infants, the inguinal canal is short and the superficial ring lies opposite the deep ring. There is no need to open the external oblique because the surgeon can easily reach the neck of the sac without opening 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 inguinal ligament 5. The cord or the round ligament is elevated to clear the posterior wall of the canal ( transversalis fascia 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 is identified by its opaque pearly white colour, definite edges and crescentic fundus. It lies anterolateral to the vas and vessels. The sac is dissected up to its neck which is identified by the presence of the inferior epigastric vessels at its medial side, by being the narrowest part of sac and by the presence of extra peritoneal fat 7. The sac is opened at its fundus and explored. Adherent intestine is separated and returned to the abdomen. Adherent omentum is excised. A finger is passed in the sac to explore for the presence of a direct or femoral hernia 8. A transfixation ligature is applied to the neck. The sac is divided leaving a half inch stump distal to the ligature to avoid its slipping. The stump retracts up to lie flush with peritoneum 9. The cord is returned back in place and its coverings are stitched 10. The external oblique aponeurosis is closed. Medially, it is sutured comfortably around cord thus narrowing external ring if wide 11. Skin closure by silk

Herniorrhaphy
-indicated for hernias of adults -The idea is to strengthen the posterior wall of the ing. canal -Excision of the sac (herniotomy) should be done first -As a rule, repair of any hernia defect (hemiorrhaphy) should be performed by nonabsorbable suture material as prolene -In all patients , plication of the fascia transversalis & reconstruction of the internal ring with lateral displacement of the cord are performed , placating sutures pass through the arch of transversus abdominis superiorly and the iliopubic tract inferiorly, then an additional procedure is added, and in any of them the repair should not be under tension

Hernioplasty
-means obliteration of the hernia defect using tissues which are not from the vicinity of the hernia -generally indicated whenever the defect is very wide (any repair under tension is doomed to failure) or When the musculoaponeurotic boundaries are too weak to hold sutures. Currently hernioplasty is gaining popularity for the treatment of all adult inguinal hernias because it is not associated with tissue tension and consequently has the lowest recurrence rate -Onlay mesh hernioplasty.: After excision of the sac a mesh which is made of synthetic material is placed behind the spermatic cord, and is fixed to the transversus abdominis and its aponeurotic arch superiorly, and to the iliopubic tract and the inguinal ligament inferiorly. The interstices of the mesh will be impregnated with a dense sheet of fibrous tissue. This operation is called Lichtenstein tension free mesh repair

-Bassinis repair : the ing. lig. is sutured to the aponeurotic part of the conjoint tendon behind the spermatic cord, to be successful, the gap between the two -Preperitoneal hernioplasty : In this case structures should not be wide and the mesh is placed between the the conjoint tendon should be peritoneum and the fascia transversalis. strong This can be achieved either by open or -This operation is performed for by laparoscopic surgery young patients -Previous operations as shouldice or McVays repair are not commonly performed now

incisional hernia
-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

Treatment :
-If the patient is unfit for surgery and provided the hernia is reducible ---> an abdominal 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 just pushed 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 a synthetic mesh

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direct inguinal hernia

Aetiology : common in elderly males - often the patient has weakness of the lower abdominal muscles with chronic
cough or straining due to urinary problems. -Injury of the ilioinguinal nerve during appendicectomy --> paralysis .of conjoint tendon --> direct ing. hernia Pathology : 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.

Clinical features : -usually affects old males

POC Age Side Shape Direction of Descent Direction of reduction Descent to scrotum Size Complications Internal ring test relation of sac neck to inf. epigast. a. at operation

-bilaterality is commom Olique Any age uni or bilateral oblong

-complications are unusual Direct Elderly commonly bilateral hemispherical forwards backwards very rare usually small rare hernia protrudes medial to artery

downwards-forwards-medially upwards-backwards-laterally may occur may attain large size liable to occur hernia does not protrude lateral to artery

Treatment: ESSENTIALLY SURGICAL

1. Removal of the cause of straining e.g.: In an elderly male with senile enlargement of the prostate, prostatectomy should 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 indicated 3. truss may be indicated if the patient is not fit for surgery

Femoral hernia
Surgical anatomy of the femoral canal :

it is the most medial compartment of femoral sheath the intermediate compartment is occupied by the femoral vein and the lateral one by the femoral artery it is about 1/2 inch long

Its function is to give a space for expansion of the femoral vein

Contents of femoral canal are fat, lymphatics and one lymph node of Cloquet

Femoral hernia components: Sac

-proceeds downwards in the femoral canal then forwards stretching the cribriform fascia then upwards and laterally towards inguinal ligament -The neck of the sac is narrow, therefore femoral hernia is liable to irreducibility and strangulation which are common

it is cone shaped, its mouth (femoral ring) is open upwards behind the inguinal ligament & its apex is below & is formed by fusion of the medial border of femoral sheath and the septum between the femoral canal and the femoral vein Anteriorly : ing. ligament Posteriorly : pectineal fascia & lig. Relations of the femoral ring : Laterally : femoral vein Medially : lacunar ligament

Contents
-femoral hernia usually contains omentum,bowel of only part of the circumference of bowel (Richters hernia)

Coverings
1. Stretched femoral septum 2. Transversalis fascia from the anterior wall of the canal 3. Cribriform fascia 4. Superficial fascia. 5. Skin

Clinical features : -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 -direction of reduction is downwards then backwards and finally upwards -Pressure on the saphenous opening obliterates the impulse and prevents descent of the hernia, BUT pressure on the internal inguinal ring fails to do so -femoral hernia may present for the first time with strangulation ---> acutely painful groin swelling and sometimes features of intestinal obstruction & the hernia is tense, tender, irreducible with no impulse on cough

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Differential Diagnosis : Reducible femoral hernia
1- Inguinal hernia 2- Saphena varix 3- Aneurysm of the femoral artery 4- Psoas abscess

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Irreducible femoral hernia

1. Irreducible inguinal hernia 2. Lipoma 3. Inguinal lymphadenopathy 4. Iliopsoas bursa -Surgery is the only line of treatment

Treatment : -A truss is contraindicated due to the possibility of strarngulation Approach :

3 approaches for the repair

low approach
-incision is 1/2 inch below and parallel to the inguinal lig. -The sac is transfixed as high as possible and the femoral ring is closed by suturing the ing. to Coopers ligament

high approach (Lotheissens operation)

-incision is made above and parallel to the medial 2/3 of the inguinal ligament (similar to that of inguinal hernia) -The external oblique aponeurosis is incised so that the inguinal canal is opened and the cord is isolated upwards -Transversalis fascia in the floor of inguinal canal is incised medial to the inferior epigastric vessels exposing the peritoneum and the neck of the sac as it enters the femoral canal

preperitoneal approach
-suitable for both the uncomplicated and the complicted femoral hernias. -It is either done through a lower midline incision or a pararectal incision (McEvedys operation) at the outer border of the lower part of the rectus abdominis. The latter is extended down to beyond the inguinal lig. in case of strangulation, to empty the sac of its toxic contents before releasing the strangulation agent -The abdominal incision is deepened dividing the fascia transversalis till the peritoneum and the protruding sac are exposed Suturing the inguinal ligament (anterior border of femoral ring) to Coopers lig. (posterior border of femoral ring) by interrupted polypropylene sutures

-sac is excised

-defect (femoral ring) is obliterated by either

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

Synthetic mesh as for inguinal hernia -Strangulation is common because the neck of the sac is narrow and the constricting agent which is the crescentic edge of Gimbernats ligament is sharp. N.B. : Intestinal obstruction is absent if the content of the sac is omentum, Meckels diverticulum (littres hernia) or part of the circumference of bowel (Richters hernia).

strangulated Femoral hernia

-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 urinary bladder on the medial side

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

1. Congenital UH (exomphalos) : Exornphalos minor
- small defect (less than 5 cm) is present at the umbilicus through which a small peritoneal sac protrudes - contents are usually intestine or Meckels diverticulum - coverings are a thin layer of Whartons jelly and a layer of amniotic membrane -Treatment : contents are reduced & returned to abdomen, the sac is excised & defect is repaired in layers

Exornphalos major
- 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 the liver - 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 skin flaps 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 : Aetiology
-weakness of the umbilical scar from infection of the umbilical cord stump -Increased intra-abdominal pressure from coughing or abdominal distension

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Pathology
-defect is exactly at the umbilicus -umbilical scar is stretched & is present at the top of the hernia -neck of the sac is wide and the coverings are extraperitoneal fat and umbilical scar

Clinical features
-there is umbilical protrusion which inc. with cough or crying -the edge of the defect can be palpated as a firm ring -Obst. & strangulation are rare below the age of 3 yrs -this type occasionally affects adults

Treatment
-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 or when the hernia persists after the age of two years - A semicircular incision is done below the umbilicus, and a skin flap is turned upwards - sac is transfixed and excised, and the defect in linea alba is closed with few stitches of prolene

2. Adult UH : principles of the treatment are the same as paraumbilical hernia

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

Surgical pathology :
-para-UH defects lie in linea alba & in most cases it lies above umbilicus bec. linea alba is thinner & broader above than below 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 at the fundus, rendering the hernia irreducible -Complications as strangulation and irreducibility are very common due to the narrow neck, sharp edge and adhesions inside the sac Clinical features : -painless swelling above the umbilicus --> expansile impulse on cough -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 Treatment : - Surgery is the only method of treatment -truss is not satisfactory because the hernia is usually irreducible & its use carries high risk of strangulation -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 upwards and downwards - sac is exposed and dissected down to the neck then sac is opened at its neck-because adhesions are 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 as a protrusion of the extraperitoneal fat through a defect in the EPIGASTRIC hernia -starts supraumbilical part of the linea aiba and is called fatty hernia of linea alba -As the protrusion enlarges the fat pulls through the defect a small peritoneal pouch which may contain intestine or omentum, and is called epigastric hernia Clinical features : -may be symptomless -it may cause local pain or cause dyspepsia due to traction on stomach -a swelling in the epigastrium which is soft, frequently irreducible & gives expansible impulse on cough -Occasionally there are multiple hernias

Treatment : -If there is pain, the surgeon should be sure that it is not due to an underlying disease, e.g. peptic ulcer or
gallstones -Operation is performed by excision of the protruding extraperitoneal fat and the hernia sac followed by simple closure of the linea alba defect BUT if the defect is large ---> prolene mesh hernioplasty

Divarication of recti

Clinical features : -common in middle aged females with repeated pregnancies and pts with ascites and splenomegaly
-if abdomen is relaxed --> nothing is visible BUT on raising the shoulders --> the linea alba bulges as a longitudinal ridge and the fingers can be dipped into the abdomen between the two recti Treatment : -abdominal belt is satisfactory in most cases -Surgical repair is likely to fail until the cause of high intra-abdominal pressure is treated

-separation of recti due to stretching of the linea alba by a chronically raised intra-abdominal pressure

THE BREAST

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surgical anatomy
Development - breast = modified sweat gland
ridges extend from the axillae to the groins middle part of the upper 1/3 of each ridge persists to form the breast while the rest of the line disappears (in humans only) - 2 ectodermal thickenings (Rt & Lt)

develop into mammary glands known as the mammary ridges

Position & extent

-breasts lie between the skin and the pectoral fascia to which they are loosely attached
-apparently, adult female breast overlies the area from the 2nd to 6th ribs & from the lateral border of the sternum to the anterior axillary line -in anatomical studies, however, a thin rim of glandular tissue of the breast has been observed to extend outside the apparent 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 -the actual extent of the breast is Upwards : to the clavicle
Downwards : to below the costal margin Medially : to the middle line Laterally : to the posterior axillary line

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

Breast components adult female breast has two components

Epithelial elements
-responsible for milk secretion and transport -Each breast consists of 15-20 radially-arranged lobes, and each is drained by a lactiferous duct -ducts converge at the nipple -A lobe is made up of 20-40 lobules, each of which consists of 10-100 alveoli -It is of clinical importance to recognize that the main ducts lie behind the areola, while the lobules occupy the more peripheral part of the breast -alveoli and ducts are lined by a single layer of epithelium, and the ducts are surrounded by contractile myoepithelial cells which are stimulated by oxytocin and move milk towards the nipple

Supporting tissue
-Fibrous septa (Coopers ligaments) extend from the pectoral fascia to the skin, and are responsible for division of the parenchyma into lobes -shape of the female breast is due to the fat contained between the fibrous septa -In adolescents and young adults, breast is firm and prominent -With age the glandular and fibrous elements atrophy, the skin stretches, and the breast sags

Blood supply
Arteries Veins
-arterial supply comes from the following arteries in order of their -venous return is primarily through the axillary and internal contribution : mammary veins 1. Internal mammary artery : through branches that perforate the -The intercostal veins are clinically important as they drain into intercostal spaces and the pectoralis major muscle the azygos system and communicate with the valveless -these branches are encountered in the operation of mastectomy, vertebral venous plexus, This communication could explain the and should be ligated or clamped before their division, tendency of breast cancer deposits to affect the axial skeleton otherwise the cut end of the artery retracts and bleeds in the mediastinum and is difficult to control 2. Lateral thoracic artery : a branch of the axillary 3. The pectoral branch of the acromiothoracic artery 4. The intercostal perforators

Lymphatic drainage
1- Axillary nodes :

-This is most important in cases of breast cancer. An extensive lymphatic plexus drains 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 breast lymph -average 35 lymph nodes in the axilla that are arranged into : a- Anteromedial (pectoral) group b- Posterior (subscapular) group c-Lateral group d- Interpectoral (Rotter) e- Central group f- Apical group

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Anteromedial (pectoral) gp Posterior (subscapular) gp
-along the lateral thoracic vessels -at the lower border of the pectoralis minor muscle -along the subscapular vessels

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Interpectoral (Rotter)
-few lymph nodes between the pectoralis major and minor muscles

Central group
-embedded in the axillary fat behind pectoralis minor (Level II)

Lateral group
-along the axillary vein -the posterior and lateral lymph nodes have numerous connections with the anterior chain -Though they do not directly drain the breast, they are potential sits of breast cancer spread through the mentioned connections

Apical group
-lying between the pectoralis minor muscle and the clavicle, and situated behind the clavipectoral fascia -the apical group receives lymph from all other groups, and are in continuity with the lower posterior deep cervical nodes that ultimately drain into the subclavian lymph trunk -Lymphatics from the upper lateral part of the breast may drain directly into the apical group (Level III )

N.B. : For the purpose of determining the prognosis after mastectomy, the axillary lymph nodes are divided by the pectoralis minor muscle into three levels :
Level I
-nodes are located low in the axilla below the muscle

Level II
-nodes are located behind the pectoralis minor muscle

Level III
-nodes are located above the muscle in the apex of the axilla

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.
2- Internal mammary nodes : - 3 or 4 internal mammary iyrnph nodes on each side - lying along the internal mammary vessels in the first three intercostal spaces 3- Further lymphatic spread : - they receive part of the lymph from the medial half of the breast - 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 two pectoral muscles ( interpectoral lymph nodes of Rotter ) and pass along the intercostal bundles to reach the posterior intercostal lymph nodes - Lymph channels from the breast do not cross the midline BUT they do cross the diaphragm, where they communicate with 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

physiology of the breast

Hormonal control
- 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

Physiological changes
*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 -At puberty : * The breast remains dormant until puberty

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Congenital anomalies
Anomalies of Nipple Anomalies of breast
1. Athelia : -Absence of a nipple is very rare 1. Amazia : -Absence of the breast -usually unilateral -usually associated with absence of the breast (Amazia) -is often associated with absence of the sternal 2. Polythelia : -Supernumerary nipples occur anywhere along portion of the pectoralis major either or both the mammary ridges (mammary lines) 2. Polymazia : -Supernumerary breasts are due to persistence of which extend from the axillae to the groins extra mammary portions of the mammary ridge -An accessory nipple may be mistaken for a mole -They may occur in axilla (accessory breast), groin, or a wart or even the thigh -They may function during lactation 3. Infantile gynaecomastia : -Diffuse enlargement of the male breast which may be unilateral or bilateral -caused by the effect of circulating maternal sex hormones -usually reversible within six months, thereforerequires no ttt

- 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 Breast haernatorna
-If there is no external bruising , a deeply seated old haematoma may form a hard mass that greatly resembles a carcinoma. -A biopsy will settle the issue

Breast Trauma

Traumatic fat necrosis

-Blunt breast trauma may cause death of some of the fat cells --> liberated fatty acids + calcium --> calcium soaps ---> one of two forms : a) A cyst : that contains thick oily fluid b) 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 gritty texture of carcinoma

inflammations of breast
Acute lactational mastitis and breast abscess
-Acute bacterial mastitis is most common during lactation Aetiology : - coagulase positive Staphylococcus aureus --- > induce clotting of milk in the ducts, producing obstruction and stasis -Organisms from the mouth of the suckling infant gain access through nipple cracks and the openings of the lactiferous ducts a ) inspissated milk + epithelial debris -Much less common is the blood-born infection --> Milk engorgement ---> blocks the ducts Predisposing factors : b) poor hygiene Pathology : c) Abrasions to the nipples caused by suckling - Infection affects any part of the breast and is at first diffuse & retracted nipple is more likely to be - The disease usually starts by milk engorgement, which if not properly injured by the baby who tries to get hold of it treated ---> acute mastitis - Staphylococci ---> necrosis and pus formation ---> multilocular abscess Clinical features : Stage of milk engorgement Stage of acute mastitis
- 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 induration of the breast BUT there are no physical signs of inflammation - pain gets worse and there is continuous higher pyrexia - Examination reveals diffuse swelling, redness, induration and tenderness

Stage of acute abscess

-Suppuration is diagnosed if : * Pain is throbbing * Temperature is hectic * Physical signs get localized in breast * Pitting oedema is elicited in the area of the skin overlying abscess * Persistence of local signs of inf. for more than 5 days or of severe systemic upset for more than 2 days after full antibiotic ttt * Breast abscess is one of the sites where surgeon should not wait for fluctuation to diagnose it

Stage of chronic breast abscess

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Treatment : N.B. : The treatment of pus anywhere in the body is by DRAINAGE Before the development of an abscess
-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 by squeezing and by a breast pump. After resolution of infection the baby can be refed by both sides

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Abscess formation
-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 which is 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.

Non lactational mastitis

- 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 - Spontaneous or surgical drainage of such an abscess may be followed by the development of a mammilary fistula at the margin of the areola & these fistulae require surgical excision

Chronic inflammatory conditions of the breast

POC Aetiology Mammary duct ectasia (plasma cell mastitis)
not known

Chronic pyogenic breast abscess

-improper ttt of an acute abscess of the breast. where instead of adequate surgical incision, the abscess had been treated by prolonged use of antibiotics or was drained by a small incision -This type of chronic abscess is termed antibiorna. The bacteria are killed, yet the pus remains in the breast with excess fibrous tissue formation - breast becomes chronically thickened and honey combed with pus - There may be nipple retraction or skin puckering, and so the condition may simulate carcinoma - However, a chronic breast abscess is more painful and is accompanied by a low grade pyrexia - Ultrasound examination and needle aspiration are helpful to differentiate both conditions

Tuberculosis of the breast

- rare disease - always associated with active pulmonary TB, or is secondary to tuberculous cervical lymphadenitis

Pathology

- dilatation of the major ducts, which fill with pultaceous creamy secretion - associated with periductal inflammatory reaction in which round cell infiltration predominates

Cl. features -may be asymptomatic, or may present with

one of the following : 1. Nipple discharge : from one or more ducts, it may be blood stained, serous, creamy white, or yellow 2. Retraction of the nipple : due to ducts shortening 3. Acute inflammation 4. Recurrent and .chronlc inflammation and breast abscess : near the areola - Because of the predominance of plasma cells, it ts termed plasma cell mastitis -The affected area is hard and may be associated with skin dimpling & nipple retraction simulating a carcinoma -surgically by excision of the major ducts through a circumareolar incision -Nipple inversion is also corrected

- presents as multiple cold abscesses and sinuses, or as multiple nodules in the breast substance - axillary nodes are enlarged and matted - manifestations of tuberculous toxaemia are present - diagnosis rests on finding the characteristic tuberculous granuloma on histological examination of a biopsy specimen

Treatment

-chronic breast abscess is - by antituberculous drugs surrounded by thick fibrous wall and - Mastectomy is reserved for the proper treatment is excision, not patients with resistant infection only simple incision

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Fibrocystic disease of the breast

- the most frequent disorder of the breast - Synonyms : mammary dysplasia, ANDI, fibroadenosis, and chronic interstitial mastitis (a misnomer as no evidence of inf.) Aetiology : - the exact cause is not known - prevalence of the disorder in women aged 30-50 years - its rarity after the menopause suggests that it is related to ovarian activity - disease is thought to represent a variation or aberration of the normal changes that take place in a healthy breast with the menstrual cycles, pregnancy, lactation, and menopausal involution - The acronym ANDI stands for Aberrations of Normal Development and Involution Pathology
- The upper outer quadrant is the commonest site of affection - The changes which take place include a mixture of the following with a variable proportion : 1. Adenosis : non-neoplastic glandular hyperplasia --> multiplication of acini 2. Epitheliosis: solid epithelial hyperplasia within the small ducts -When extensive it forms intraductal papillary growths and is termed papillomatosis -in rare cases thereis atypical epithelial hyperplasia which is accompanied by a higher possibility of developing breast cancer 3. Fibrosis : the replacement of elastic and fatty tissue by fibrous tissue -When fibrosis is extensive it clinically resembles scirrhous carcinoma, and is called sclerosing adenosis 4. Cyst formation : - cysts may be small (microcysts), or large (macrocysts) - They are lined with epithelium and are filled with clear yellow, or sometimes brownish fluid - Cysts are aberrations of involution and are, therefore, most frequent in late premenopausal and menopausal women - Abnormal involution of the supporting CT in the lobules allows the acini to dilate - Obstruction of the ducts by papillomatosis and by the surrounding fibrosis aid in the formation of the cysts

Clinical features
1. Fibrocystic changes may be completely asymptomatic 2. The affected lady may present because of an accidentally felt lump, may be caused by a prominent cyst, aggregation of small cysts, or by the scierosing adenosis - A palpable thickening may disappear when the patient is re-examined one week after the menstrual cycle - The differentiation from carcinoma is discussed under the differential diagnosis of breast cancer 3. The most frequent complaint is of multiple, sometimes painful, small lumps that may be unilateral or bilateral (painful nodularity) & lady usually observes this in relation to her cycles 4. Mastalgia (breast pain) is a common presentation - This is usually a cyclical mastalgia which is an exacerbation of the premenstrual tension - The pain typically occurs few days premenstrually and is accompanied by enlargement and increased nodularity of the breasts 5. Nipple discharge is usually clear or yellow, but sometimes brown or green

Investigations
- usually not required, but the following are indicated to rule out breast cancer in suspected cases : 1. Ultrasound, and mammography show the cysts 2. A cyst is fully aspirated & It is considered benign if the fluid is not blood-stained, the mass disappears completely after aspiration, and does not recur within two weeks - Cytology of the fluid may be performed to exclude malignancy, but the results are not conclusive 3. A solid mass is aspirated for cytology 4. Open biopsy is indicated when experience in interpreting cytology is not available, or if its result is not conclusive

Treatment
-Treatment is individualized -Exclusion of malignancy and reassurance of the patient are most important -Accidentally discovered cases deserve no treatment -Cysts are treated by aspiration -A recurring cyst is excised for biopsy -Mastalgia: a) In mild cases reassurance and wearing (night and day) a brassiere that gives good support and protection are usually enough b) Giving up caffeine consumption (coffee, tea, and chocolate) may be useful c) Prolactin inhibitor as bromocriptine 2.5 mg b.d. gives gratifying results in many patients d) Danazol, which is a synthetic androgen, is effective in controlling cyclic pain & dose is 100-200 mg twice daily orally BUT its androgenic effects, as acne and hirsutism, limit its use to the unusual severe cases -Cases with atypical epithelial hyperplasia, discovered by biopsy, should be instructed to perform a monthly breast self examination -Meanwhile, regular medical follow-up examinations aranged

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Cysts of the breast

-usually arise from the duct system (acinar cysts), and occasionally they occur in the stroma (interacinar cysts) Acinar cysts
1. Retention cysts : due to blockage of the secreting mechanism, either by fibrosis from without or by obstruction from within the lumen - They account for more than 75% of cysts of the breast and are really a manifestation of fibroadenosis - cyst is often solitary, and varies from one quarter to two inches in diameter. The fluid content may be clear and serous, thick and greenish, or creamy in colour and consistence - Large cysts distended with clear fluid may have a curious blue green colour (blue- domed cysts of Bloodgood) - Occasionally, the whole breast is occupied by large cystic spaces 2. Galactocele (milk cyst) : develops during or shortly after lactation, probably from obstruction to one of the principal ducts - At first, the content is thin and milky and the cyst is tense & thin-walled, but gradually the milk becomes inspissated and the wall thickened and fibrous - The cyst forms a solitary painless swelling situated close to the nipple and dating from lactation - Sometimes a little milky fluid may be expressed from the nipple by pressure on the cyst 3. Intracystic papilliferous carcinoma

Interacinar cysts
-Cysts arising in the stroma are rare and include : 1. Dermoid cysts 2. Lymph cysts 3. Blood cysts : arise either as traumatic haematomas or as other types of cyst with bleeding into them 4. Sebaceous cysts : arise in the skin near the nipple in relation to one of the tubercles of Montgomery

Treatment : 1. Aspiration : About 2/3 of retention cysts are cured by aspiration and provided the diagnosis is certain aspiration should always be tried 2. Excision : Retention cysts which recur after aspiration and all other cysts should be excised. Superficial cysts are readily excised through a radial incision in the overlying skin

Fibroadenoma
- commonest breast mass of young women Pathology : Microscopic Picture - usual age is between 15 and 30 years. Gross Picture

- benign neoplasm of the breast which affects both the fibrous - tumour may be solitary or multiple - firm - smooth surface that may be lobulated in big lesions and the glandular tissues, but the fibromatous element - well circumscribed and is never attached to surrounding predominates tissue - Histologically there are two types : - cut surface reveals lobules of whorled white fibrous tissue a) Pericanalicular (hard) fibroadenomata : the usual form which bulges out of its capsule *These tumours are formed mainly of fibrous tissue that surrounds a few small tubular glands *They tend to be small b) Intracanalicular (soft) fibroadenomata :contain more glands *They are usually larger and softer than the pericanalicular type Clinical features : - Hard fibroadenoma occurs commonly in young women 20-30 years of age - Soft fibroadenoma occurs between the ages of 30-50 - The patient always presents with a painless lump (or lumps) that is accidentally discovered - A fibroadenoma is usually small (few centimeters), nontender, spherical, firm, well circumscribed, and with smooth surface that may be bosselated - The characteristic feature, however, is its high mobility within the breast that gained it the name breast mouse Investigations : - Soft tissue mammography reveals a well-circumscribed lesion Treatment : -Excision + histological confirmation of the diagnosis Cystosarcoma phylloides :
- highly cellular type of fibroadenoma that tends to grow rapidly - named by Brodie who used the term phylloides because the cut surface resembles a leaf or fern - term cystosarcomais a misnomer as many are not cystic, and it is rarely malignant. It is, therefore, better termed Phylloides tumour - they tend to enlarge slowly and to reach a large size, 20-30 cm in diameter - A big tumour may ulcerate - there are branching like projections of the tumour tissue into the cystic cavities of the neoplasm - In spite of its huge size and skin ulceration, the tumour is not attached to the skin - Treatment : wide local excision to prevent recurrence BUT if the tumour infiltrates the whole breast, simple mastectomy is indicated

THE THYROID GLAND

EMBRYOLOGY

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* Appears by 3rd week of life * Appears as a proliferation of epithelial cells in the floor of developing pharynx ( Thyroglossal duct ) at a point indicated by Formaen cecum ( depression at base of tongue) * Thyroid primordium descends & unites with the ultimo-branchial body ( arises from a diverticulum of the 4th pharyngeal pouch , on either side ) * Para-follicular cells C-cells (derived from neural crest ) reach the thyroid via the ultimo-branchial body * After thyroid reaching its definitive location in lower neck , the connecting thyroglossal duct undergoes obliteration

General features & position

Anatomy

* Color : brownish red (highly vascular) * Composition : endocrine gland of two lobes connected across midline by an isthmus * Extensions : a- lobes : Superiorly till oblique line of thyroid carilage & Inferiorly to 4th or 5th tracheal rings b- isthmus : overlies 2nd & 3rd tracheal rings at puberty * Weight : 20-25 gm in adult --> enlarges (physiologically) during menstruation

Relations
Medially Superficially *each lobe moulded *gland covered by over larynx & trachea 3 muscles : 1-Sternothyroid 2-Sternohyoid 3-Sternomastoid (its anterior border) [inferiorly}

during pregnancy

Superiorly *gland overlies cricothyroid muscle *External branch of Superior laryngeal nerve passes deep to upper pole of gland on its way to supply this muscle

Postero-medially *lobe is related to tracheo-esophageal groove *Recurrent laryngeal nerve runs in this groove

Postero-laterally *thyroid in contact with carotid sheath *Parathyroid glands usually related to the poetero-lateral surface of thyroid

**Pretracheal Fascia : - in which thyroid is enclosed - attached above to the arch of cricoid & oblique line of thyroid cartilage (thats why it moves with larynx in all directions)

blood supply & lymphatic drainage

Arteries
1-Superior thyroid arteries (branches of External carotid arteries) 2-Inferior thyroid arteries (from thyrocervical trunks of subclavian arteries) *N.B.: Recurrent laryngeal nerve comes into direct relationship with terminal branches of inferior thyroid artery being posterior BUT may pass anterior or between arterial branches 3-Thyroidae ima artery (from innominate artery or the aortic arch ) *minimal blood supply *variable in size *ascends upwards anterior to trachea reaching lower pole of gland 4-Esophageal arteries

Veins

Lymphatic drainage

1-Superior thyroid vein *subcapsular plexus --> juxta-thyroid *drains into Internal Jugular lymph nodes (pre-laryngeal & vein coursing with the pre-tracheal lymph nodes along the corresponding artery recurrent laryngeal nerve) --> deep 2-Middle thyroid vein cervical & mediastinal lymph nodes *passes as well defined trunk *some lymphatics pass directly to deep *drains into Int. Jugular vein cervical lymph nodes *its short if gland is enlarged 3-Inferior thyroid vein *from lower pole of each lobe *course to left brachio-cephalic trunk (innominate vein)

Physiology
*The functioning unit of the thyroid gland is the LOBULE : - supplied by single arteriole - consists of 20-40 follicles lined by cubical epithelium - the resting follicle contains colloid in which thyroglobulin is stored - The normal thyroid gland is able to concentrate iodide from the blood at a rate of about 2 ug per hour. - Once within the thyroid follicular cells, the iodides are incorporated into the synthesis of the hormones Triiodo-thyronine (T3) and thyroxine (T4), the process being controlled by several enzymes in distinct steps.

Thyroid hormone synthesis

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Step
1- Trapping of inorganic iodide from blood 2- Oxidation of iodide into iodine 3- Binding of iodine with tyrosine 4- Coupling of mono-iodotryosines and di-iodotyrosines

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dependent on
ATP (Active process) Peroxidase enzyme Tyrosinase enzyme -----------

N.B.
----------------------Mono and Di-iodotyrosines are formed (Organification) - T3 and T4 are formed ----> unite with thyroglobulin ----> stored in the follicles - Major fraction of T3 and T4 in the blood is bound to plasma proteins (albumin, prealbumin and thyroid binding globulins) - Minute fraction of T3 and T4 is present in a free form and this represents the functionally active fraction - (Free T4 = 0.03-0.04% & free T3=02-0.5% of the total circulating hormones respectively) - T3 is the quick acting, physiologically important hormone, being also produced by peripheral conversion from T4 - Released iodine is reused in thyroid hormone synthesis instead of being wasted

5- Release of T3 and T4 into the circulation upon need

-----------

6- Few mono and diiodotyrosines are deiodinated ( not coupled to form T3 or T4)

Dehalogenase enzyme

Hypothalamo-pituitary-thyroid axis
* Synthesis and liberation of thyroid hormones are controlled by the thyroid stimulating hormone (TSH) : - produced by the anterior pituitary - its level assumes an inversely proportional relation to the level of circulating thyroid hormones (feed back mechanism) - Thyrotropin releasing hormone (TRH) produced by the hypothalamus is a further stimulant to its production

Tests of thyroid function

Test
1- Measurement of serum TSH

Method & Results

- test is routinely performed with a normal range of 0.5-5 Mu/l - it is now possible to do ultrasensitive TSH ( most sensitive for assessment of the thyroid function ) - Elevated level is the earliest test to diagnose hypothyroidism

Hormone
2- Measurement of serum thyroid hormones

Total serum thyroxine (T4) 55-150 nmol/l

Free serum thyroxine (T4) 8-26 pmol/l

Total Tri-iodo thyronine (T3) 1.2-3.1 nmoL/l

Free serum Tri-iodo thyroxine (T3) 3-9 pmol/l

Normal value

- Total serum T4 and T3 are no reflection of the free active hormones - affected by fluctuations in the levels of the thyroxine binding proteins (thyroid binding globulin & pre-albumin) - False elevated levels of total serum T3 or T4 accompany pregnancy and oral contraceptive intake - On the other hand false low results occur with hypoproteinaemia, e.g. nephrotic syndrome - Intravenous 500 ug TRH is administered and the level of TSH is measured and compared to the baseline level - This test is sometimes used to assess patients with borderline hyperthyroidism - raised in Hashimotos thyroidits and Graves disease a. Radioactive iodine uptake test : - Following an oral dose of 5 uCi, the percentage of uptake of radioactive material by the thyroid gland is measured at 4 hours (The normal uptake is 11-55%) - Level of radioactive thyroxine bound to plasma proteins in blood is measured at 24 & 48 hours - In hyperthyroidism a high counting rate is detectable over the thyroid gland after 4 hours, followed by an elevated plasma protein 123 I at 24 or 48 hours b. Thyroid scanning : - After a tracer dose of 123 I or Technetlum 99 pertechnetate (99m Tc) a scan of the thyroid gland is obtained - It allows evaluation of the functional activity of the different areas of the gland, whether normal (warm) or hyperactive (hot) or non functionlnq (cold) - The principal value is inidentifying an autonomous toxic nodule whether solitary or a part of toxic multinodular goitre - Risk of malignancy in cold nodules is 15-20%

3- Thyrotropin releasing hormone (TRH) 4- Thyroid antibodies

5- Tests using radioactive 123 I

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Thyroid - Developmental anomalies

Anomaly
Aetiology & Pathology

Thyroglossal cyst
- midline tubulodermoid cyst arising in thyroglossal duct remnant - thyroglossal duct can assume a variable relationship to the hyoid bone; behind or in front or passing through the body of the bone - may occur at any level from the foramen caecum of tongue to the suprasternal notch, usually in the midline just below the hyoid bone except at the level of the thyroid cartilage, where it is displaced usually to the left

Thyroglossal fistula
- Acquired fistula caused either by : a) Infection of a thyroglossal cyst ---> rupture b) Inadequate removal of the cyst - track is lined by columnar epithelium - discharges mucus - presents with recurrent inflammation

Lingual thyroid
- Failure of descent of the thyroid ---> an intralingual development of the gland

Clinical features - may present at any age, but is most

- the opening of the fistula is common during childhood near the midline on the left side with a crescentic fold - appears as a painless cystic swelling that moves up and down on swallowing and on - A track can usually be protrusion of the tongue (due to its palpated extending from this relation to the hyoid bone) opening upwards to the hyoid bone - there may be a palpable track extending from the hyoid bone upwards towards the tongue - the wall of the cyst is rich in lymphatics which may communicate with the cervical lymph nodes, so infection may be the presenting symptom & ---> fistula formation when an infected thyroglossal cyst ruptures or is incised

- patients may present with a tongue swelling with obstructive manifestations i.e : dysphagia, difficult breathing or change in the quality of voice or even haemorrhage

Investigations

- Thyroid scans --> absence of thyroid tissue in the normal site in the neck - surgical excision of the cyst and its associated tract entailing removal of the middle third of the body of the hyoid bone (Sistrunks operation) - If the excision is incomplete, recurrence in the form of thyroglossal cyst or fistula may result - excision of the fistula together - full replacement with with the central part of the L-thyroxine to induce hyoid bone reduction in size - If there is an upward extension - surgical extirpation or beyond the hyoid bone it radioactive-iodine ablation should be followed up even to the foramen caecum of the tongue

Treatment

Goitre classification
- Goitre : generalized thyroid enlargement - Based on the aetiological and clinical picture goitre may be classified into :
Inflammatory goitre (Thyroiditis) a. Acute bacterial (rare) b. Subacute thyroiditis (De Quervains disease) c. Chronic, e.g. tuberculosis or syphilis (rare) d. Autoimmune goitre as Hashimotos thyroiditis or Riedels thyroiditis. Toxic goitre thyroid enlargement accompanied by the clinical picture of hyperthyroidism Neoplastic goitre may be benign or malignant Simple goitre - thyroid enlargement, not accompanied by inflammatory, toxic or neoplastic criteria - may be : (a) Simple physiological goiter (b) Simple colloid goiter (c) Simple nodular goitre

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Thyroiditis
Thyroiditis Cause Thyroiditis Acute Pyogenic bacteria, rare Subacute thyroiditis (Granulomatous-thyroiditis) (De Quervains thyroiditis)
controversial BUT most probably a viral infection

Subacute ? Viral

Chronic T.B., rare

Hashimotos Autoimmune

Riedles Autoimmune Riedels thyroiditis

Some consider this disease as autoimmune disorder, others consider it as a collagen disease - rare condition ( 0.5% of goitres ) - presents as hard woody transformation of thyroid tissue due to extensive fibrosis which extends even beyond the gland - may occur in association with retro-peritoneal fibrosis - Hypothyroidism is usually present

Autoimmune thyroiditis (Hashimotos thyroiditis)

supposed to be due to the presence of antibodies to thyroid antigens

Aetiology

Pathology & Clincal features

- moderately abrupt onset, often following an upper respiratory infection - thyroid becomes congested, swollen with a firm irregular pattern and slightly tender - accompanied by neck pain with fever and malaise - characterized by remissions and exacerbations over a period of up to few months

- the most common form of thyroiditis, which usually affects females at menopause - there is infiltration of the thyroid gland by lymphocytes & plasma cells - Eventually the acini are replaced by this infiltrate ---> development of mooedema - exhibits a variable onset being insidious & asymptomatic in some cases or sudden & painful in others - goitre is usually lobulated (flat-topped nodularity) - the condition being diffuse or localized to one lobe - may be large or small, soft, rubbery or firm - Mild hyperthyroidism may be present initially but hypothyroidism is inevitable - Serum titres of antimicrosomal & anti-thyroglobulin antibodies are elevated - Nevertheless, differential diagnosis from nodular goitre or carcinoma may require fine needle or tru-cut needle biopsy

Investigations

- Elevation of ESR with a normal or depressed leucocytic count is a feature - lodine uptake by the gland is depressed in the presence of a slight elevation of serum T4 - usually it is self-limited - rapid response to oral prednisone is diagnostic - a course of the drug may be required for few weeks - In the occasional severe cases, anti-inflammatory drugs are beneficial

- differentiation from anaplastic carcinoma may mandate an open biopsy

Treatment

- Full replacement dosage of thyroxine - open biopsy where a - Surgical treatment may be needed for large-sized wedge of the isthmus is goitres or suspected development of lymphoma removed to free the which is occasionally associated with Hashimotos trachea goitre or develops later in the disease

Simple goitre - endemic or sporadic

Thyroid enlargement not belonging to the inflammatory, thyrotoxic or neoplastic groups an absolute or relative decrease in the circulating thyroid hormones --> elevated levels of TSH --> stimulation of the thyroid 1- Iodine deficiency
- may be absolute or relative - Normal daily requirements of iodine:100-125ug - Simple goitre is endemic in regions with low iodide content of the water and food as in mountainous regions or low-land areas with a soil lacking iodide , e.g. : Egypt oasis - Relative deficiency of iodine occurs during periods of stress : females during the menarche, pregnancy and lactation are susceptible to this problem

Aetiology

2- Enzymatic deficiency
- responsible for many cases of sporadic goitre - often being associated with positive family history, reflecting an underlying genetic defect - Pendreds syndrome is an example being due to deficiency of peroxidase enzyme which transforms inorganic iodides to organic iodine - In this syndrome there is : goitre, deafness & mutism - Patients develop goitre at a young age, sometimes several brothers or sisters are affected - Patient is liable to get recurrent goitre after surgery - Deficiency of dehalogenase enzyme is also responsible for sporadic goitre

3- Goitrogens
- Intake of goitrogens results ultimately in goitre formation - include : a) thiocyanates in cabbages b) drugs as para-amino salicylic acid & antithyroid drugs

 : Stages of goitre formation

A. Diffuse hyperplastic (physiological) goitre 1.* Deficient synthesis of thyroid hormone ---> persistent TSH elevation ---> diffuse homogenous hyperplasia * All follicles are active with uniform iodine uptake * This stage is reversible on cessation of its stimulus i.e. increased TSH : If the iodine requirements are satisfied ---> follicles undergo involution or even hyperinvolution where the follicles are distended with colloid and are lined by flattened epithelium 2. *Repeated cycles of stress and strain ---> repeated fluctuations in the level of TSH ---> heterogeneity of the gland, with areas of active follicles and others with inactive follicle N.B. : * In a single lobule all follicles behave similarly * Active follicles are : small, lined by tall columnar cells * Inactive follicles are : large, lined by flattened epithelium B. Colloid goiter 3.*When the iodine requirements are satisfied ---> follicles undergo hyperinvolution & become large in size, lined by flattened epithelium and full of colloid *Clinically this is the simple colloid goiter C. Nodular goiter

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4. *As a result of recurrent hyperplasia and hypervascularity -- > haemorrhages ---> central necrosis in the lobules *These ultimately coalesce into nodules containing iodine-free colloid or masses of new inactive follicles *The nodules are enclosed in delicate connective tissue, most nodules are inactive, the active follicles being present in the internodular tissue 5. *Other factors different from TSH have also been implicated in the aetiology of nodular goitre, e.g. immunoglobulins. *These by acting on oversensitive cells and/or receptors produce a nodular goitre with marked heterogeneity of structure and function between adjacent follicles

& &

they are empty are full of colloid

Types of simple goitre

N.B : more common in females as they are more liable to repeated stresses due to the menstrual cycles, pregnancy and lactation

1. Simple physiological (diffuse hyperplastic) goitre -Patient presents with a diffuse, soft , homogenous enlargement of the whole gland, which may appear in childhood in endemic regions -In sporadic cases (non-endemic) its appearance corresponds to an increased metabolic demand, e.g. puberty or pregnancy -The condition is reversible upon disappearance of the triggering stimulus

2. Simple colloid goitre - due to hyperinvolution of diffuse hyperplastic goitre., the patient receiving large doses of iodine producing a gland the follicles of which are lined by flattened epithelium and distended with colloid -Clinically the gland is enlarged, the surface is smooth and its consistency is soft - The cut surface of the gland has a glistening surface as the follicles are full of colloid

3. Simple nodular goitre -Usually multiple nodules are grossly present -Sometimes one of he nodules is prominent, while the rest of the nodules are not palpable and the patient is diagnosed as having a solitary thyroid nodule

Complications of simple nodular goitre

1. Tracheal obstruction by compression. : * trachea may be compressed on either side and becomes transformed into anteroposterior slit (scabbard trachea) * it may be compressed anteropostertorly or it may be displaced to one side by marked unilateral enlargement * In long-standing nodular goitre, the tracheal rings undergo chondromalacia and the tracheal rings may collapse post-operatively 2. Secondary thyrotoxicosis : * may occur in up to 30% of cases 3. Malignancy : * occasionally follicular carcinoma may develop * incidence is about 3% 4. Cyst formation 5. Haemorrhage into a nodule 6. Calcification : * occur in longstanding cases 7. Retrostemal extension

 : Clinical picture of simple-nodular goitre

* Onset of Condition : early in endemic regions BUT may be delayed to the third decade or later in sporadic cases * Main complaint : usually cosmetic deformity or some respiratory obstruction * Thyroid gland : firm in consistenty with a nodular surface : nodules are smooth, firm and painless * Euthyroid patient * Complications : - Haemorrhage into a nodule ---> Sudden enlargement with the appearance of pain and tenderness - Calcification ---> hardness and irregularity simulating malignancy

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Investigations of simple nodular goitre

* Assessment of thyroid functions --> to differentiate it from mildly toxic nodular goitre * Assessment of thyroid antibodies titres --> to exclude Hashimotos disease ( sometimes needed )

Prevention and treatment of simple goitre

Prevention use of iodized table salt (potassium iodide 1 part 10.000) has proved successful for prophylaxis in endemic area Treatment of diffuse hyperplastic goitre
- Diffuse hyperplastic goitre is usually reversible by the use of L-thyroxine, usually 0.2 mg/day for several months --> tapered to 0.1 mg/day for several years - Reassurement of patient & regular follow-up

Treatment Treatment of multinodular goitre

- Most authorities agree upon the irreversibility of multinodular goitre, thus surgical excision (thyroidectomy) is indicated for : 1. Evidence of compression manifestations mainly on the trachea 2. Cosmetic reasons - Surgery for multinodular goitre should not be advised age of 25 unless very much indicated as it may be followed by recurrence - Surgery entails removing the nodular parts leaving an equivalent of 8 gm of relatively normal thyroid tissue (size of a normal lobe) on each side if feasible - Sometimes the distribution of the pathology requires removal of a whole lobe and subtotal excision of the other lobe - Postoperatively suppressive doses of L-thyroxine 0.1-0.2 mg/day are advisable to avoid recurrence in the remainder of thyroid tissue if constant iodine dietary supplementation is not continuously ascertained

Retrostern goitre
Pathology
- Retrosternal goitres usually arise in a normally placed thyroid gland - Sternohyoid and sternothyroid muscles prevent forward expansion, and assisted by gravity and the negative intrathoracic pressure, they direct the swelling into the mediastinum - In most cases, the intrathoracic swelling occupies the superior mediastinum - Retrosternal goitre is classified into 3 types :

Plunging goitres

Mediastinal goitres

Intrathoracic goitres

- rise with deglutition - lie wholly in the chest, but are connected - lie wholly in the chest, completely & then descend again with the thyroid by a relatively narrow band separate from the main gland through the thoracic inlet of tissue and derive their blood supply from - probably arise from congenitally misplaced the thyroid vessels thyroid tissue, deriving an independent blood supply from mediastinal vessels

Clinical features
Symptoms Signs
* An intrathoracic goitre is more common in men (particularly short-necked * Inspection : - innominate veins may be obstructed individuals) and because it often remains symptomless for years--> patient --> superficial veins of the upper part of the chest are usually presents after middle age obviously dilated and there may be even cyanosis and oedema of the face and neck. * The goitre displaces and compresses the trachea --> dyspnea ( worse at - lower border of goitre cannot be seen as it lies night, and often spasmodic ) & varies with the patients position behind the sternum ( aggravated by any posture that reduces the thoracic inlet, such as lying down or flexion of the neck, so that many patients prefer to spend the * Palpation : of neck may reveal an enlarged thyroid night in a chair ) while some patients are diagnosed as asthmatics * Percussion : of sternum may reveal retrosternal * Sometimes there is dysphagia dullness

 : Investigations & Treatment

Investigations Treatment

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* - Plain X-ray of the chest ---> a shadow in the superior mediastinum which * Thyroidectomy is the only line of treatment moves vertically with deglutition unless the goitre is firmly wedged between the structures which surround it or is intrathoracic in type * Resection is almost always possible via the cervical - Calcification often occurs in the walls of the goitre, and may be approach, rarely a median sternotomy is required demonstrated radiologically * - Devascularization is done via the neck from which * 99mTc scan ---> reveal the retrosternal extension the restrostemal portion derives its blood-supply - Special care should be exerted to avoid injury of the recurrent laryngeal nerves during delivery of the * CT scan of the thorax ---> reveal the exact level of the retrosternal retrosternal goitre extension and its anatomic relations

Toxic goitre (thyrotoxicosis = hyperthyroidism)

Common Types Incidence Diffuse toxic goitre Toxic nodular goitre (Primary toxic goitre or Graves disease) (Secondary toxic goitre or Plummers disease) 76 % 14 % Toxic nodule 5%

rare causes of hyperthyroidism

1. Thyrotoxicosis factitia 2. Jod-Basedow thyrotoxicosis 3. Subacute thyroiditis (De Quervains disease) 4. Hashitoxicosis 5. A large mass of secondary carcinoma - due to excess intake of L-thyroxine ( 0.3 mg per day) - may occasionally occur in cases of hyperplastic endemic goitre upon the administration of large doses of iodine - condition is temporary and very rarely permanent - Mild manifestations of thyrotoxicosis may occur due to liberation of hormones from destroyed tissue - About 5% of patients with Hashimotos disease may have hyperthyroidism in the early stages of the disease - may be functioning - may occur in newborns of thyrotoxic mothers or of mothers with history of thyrotoxicosis, due to transmission of thyroid antibodies across the placenta - condition subsides in 3-4 weeks upon decline of the titre of the antibodies in the babys serum - secreting TSH

>

6. Neonatal thyrotoxicosis

7. Adenoma of the pituitary gland

Pathology
POC Diffuse toxic goitre (Graves disease) (exophthalmic goitre) Nodular toxic goitre Plummers disease) Autonomous toxic nodule due to a solitary, hyperactive autonomous nodule (not due to thyroid antibodies)

Aetiology & Clinical Picture

- due to the presence of thyroid stimulating antibodies - on top of a long-standing simple which combine with thyroid stimulating hormone nodular goitre, hence affecting middle receptors in the thyroid gland cells ---> release of aged and elderly persons cAMP ---> activation and increased production of T4 - very rarely, if ever, accompanied by - disease affects mainly young females, is usually of extra-thyroidal manifestations, e.g. abrupt onset and is characterized by remissions and advanced exophthalmos exacerbations - onset is insidious and may present with cardiovascular manifestations --------------- usually the internodular tissue that becomes hyperactive, however occasionally one or more nodules become the site of hyperactivity

Macroscopic diffuse enlargement of whole thyroid gland -Proliferation of the epithelial lining of the acini which may be arranged in several layers - Cells are columnar, and full of granules - Acini contain less vacuolated colloid or devoid of it - Marked increase in vascularity making surgery, if indicated, difficult - Extensive lymphocytic infiltration is present - Administration of iodine to these patients will diminish the vascularity and leads to storage of colloid

--------------nodule --> suppress TSH secretion with subsequent suppression of the remainder of the thyroid gland which becomes almost atrophic as evident on isotope scanning

Microscopic

 :
- Excess of thyroid hormones ---> state of hypermetabolism that affects the whole body systems - Nervous, metabolic and eye manifestations are more marked than the cardiovascular , however, some of the manifestations of Graves disease are not due to hyperthyroidism, e.g. exophthalmos and pretibial myxoedema ---------------

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---------------

Abnormal Physiology

Clinical features
1. Metabolic

* N.B. : - Most but not all symptoms and signs are due to excess thyroid hormones - Many systems are vulnerable to these hormones

* loss of weight in spite of increased voracious appetite * patient complains of excessive sweating and intolerance to hot weather * hands of the patient are warm due to vasodilation and are moist * Symptoms: patient complains of nervousness, bad temper, insomnia or bad dreams * Signs: patient looks tense and irritable - with tremors in the outstretched hands - reflexes, e.g. the knee jerk are exaggerated * Symptoms: - patient complains of palpitation sometimes even at rest - there may be anginal pains - If there is heart failure, the patient complains of : orthopnea - pain in the right hypochondrium - bilateral oedema of the tower limbs * Signs: (a) Tachycardia with a sleeping pulse more than 90/minute (b) Water hammer pulse : due to high systolic (due to increased cardiac output) and low diastolic blood pressure (due to decreased peripheral resistance) (c) Arrhythmias : All sorts of cardiac arrhythmias except heart block may occur - may be multiple extrasystoles paroxysmal atrial tachycardia - paroxysmal atrial fibrillation or persistent atrial fibrillation not responding to digoxin * usually muscular weakness with rapid exhaustion after minor effort * In severe cases proximal myopathy and muscle atrophy may occur * The proximal muscles as the shoulder and plevic girdle muscles are particularly affected * Patchy pigmentation or vitiligo may occur * Pretibial myoedema presents as multiple orange yellow patches of thickening of the skin over the shin of the tibia ( due to deposition of mucin like substances under the effect of LATS ) * may be diarrhoea * In females: menstrual abnormalities may occur as menorrhagia * In males: abnormal libido, gynaecomastia or impotence * rnay be polyuria or glycosuria S E E N E X T PA G E * *

2. Nervous system

3. Cardiovascular system

4. Muscular

5. Skin 6. GIT 7. Endocrine system 8. Urinary system 9. The eyes

10. Local signs of toxic goitre in the neck

* In diffuse toxic goitre : - the thyroid gland is diffusely enlarged - usually a slight to moderate enlargement - gland is soft but infrequently firm in consistency - thrill and bruit may be detected at the upper pole over the superior thyroid arteries - surface of the gland is smooth and the overlying skin may be warm - gland may show expansible pulsations * In nodular toxic goitre : - thyroid gland is firm in consistency with a nodular surface - size of the gland may be large

Diagnosis * Clinical examination provides adequate basis for the diaqnosis in most cases * Thyrotoxicosis should be suspected in : a) Children with growth spurt, behavioural problems or myopathy b) Elderly persons with unexplained tachycardia or arrhythmia (apathetic hyperthyroidism ) c) Unexplained diarrhoea d) Unexplained loss of weight e) Resistant heart failure (marked thyrotoxicosis)
POC Age Onset & Course Nervous symptoms Metabolic manifestations Cardiovascular manifestations Eye signs Thyroid Graves disease Young O : Abrupt - C : Exacerbations & remissions +++ +++ + exophthalmos Diffuse enlargement soft and vascular +++ usually no exophthalmos Multiple or solitary nodules Toxic nodular goitre Elderly O : Gradual - C : Steady +

 : * * EYE manifestations of thyrotoxicosis

EXOPHTHALMOS
True exophthalmus - implying actual protrusion of the eyeball - characteristic of Graves disease - due to deposition of fluid and round cell infiltrate in the retrobulbar tissues - condition is aggravated by ophthalmic vein compression ---> lid oedema, conjunctival injection and chemosis - Weakness of extra-ocular muscles ---> diplopia - In severe cases papilloedema, corneal ulceration and optic nerve neuropathy may occur - Malignant exophthalmos : the severe progressive form - It is postulated that true exophthalmos is an autoimmune disease due to thyroid stimulating antibodies affecting the ocular muscles - usually self-limiting and may even regress - Sleeping in the propped up position and lateral tarsorrhaphy may help to protect the eyes, but have no effect on progression of the conditions - Hypothyroidism increases the condition - Improvement has been reported with high doses of prednisone; its local administration is however, risky especially in the presence of venous congestion - Thyroid ablation has not proved effective, on the contrary it may aggravate a pre-existing exophthalmos which is only checked by postoperative administration of L-thyroxine - Orbital decompression may be indicated when the eye is endangered - For clinical detection of exophthalmos two methods are available: 1. Naffzigers method : examiner stands behind the patient, with the head tilted backwards. In true exophthalmos the eyeballs protrude beyond the plane of the superciliary ridge 2. Russell Frazers method : examining the patient from the side with the eyes lightly closed, will determine the depth of the groove between the orbital margin and the covered globe (shallow in true exophthalmus) False exophthalmus - due to retraction of the upper eyelids - accompanies both diffuse and nodular toxic goitres - due to contraction of the levator palpebrae superioris (Mullers muscle) pulling the upper eyelids tarsus and superior conjunctival fornix upwards - high level of thyroid hormones sensitizes this unstriated muscle to the effect of circulating catecholamines - usually disappears when the hyperthyroidism is treated - Beta-adrenergic blocking drugs as guanethidine eye drops improve false exophthalmos

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EYE SIGNS (other than exophthalmos)

Dalrymples sign Stellwags sign Von Graefes sign Joffroys sign Moebius sign Appearance of a rim of sclera between upper eyelid and the cornea Staring look with infrequent blinking upper eye lid lags behind the moving eyeball as the patient looks down without moving the head Lack of forehead wrinkling on looking upwards without moving the head Defective convergence due to muscle paresis

Investigations
Test Thyroid function tests T3 , T4 , TSH and 123I uptake test Elevated free T3
123

Value confirm the diagnosis identify T3 thyrotoxicosis diagnose toxic adenoma which shows as a hot nodule with suppression of the uptake of the surrounding thyroid tissue A. Medical Treatment B. Radioactive Iodine C. Surgery

I scanning

Treatment * Comprises 3 options : A. Medical treatment

Medications

Value - blocks iodine binding to tyrosine and decreases antibody titres - initial dose is 10 mg three times daily with a maximum dose of 60 mg daily - a latent interval of 7-14 days before clinical improvement takes place - When the euthyroid state is reached, the dose is gradually reduced to 5 mg two or three times a day, and is maintained for 12-18 months - blocks iodine binding to tyrosine and prevents peripheral conversion of T4 ---> T3 - competitively inhibits iodide uptake by the thyroid

Carbimazole ( most commonly used drug in Egypt )

Propylthiouracil (100 mg t.d.s) Potassium perchlorate

- inhibit the cardiogenic effects of thyroid hormones by beta-blockade Propranolol or other beta-adrenergic blockers - Non selective beta-adrenergic blockers e.g., propranolol must not be used in asthmatic patients. In such cases selective beta-1 blockers as atenolol must be used

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Iodides

- reduce the effect of TSH on the thyroid gland and inhibit iodine binding - also reduce the vascularity of the thyroid gland ---> storage of colloid within acini - effect is only temporary and so they cannot be used for long term control - main use is for preoperative preparation Indications Contraindications 1. Toxic nodular goitre : will ultimately require surgery 2. Retrosternal toxic goitre : will ultimately cause respiratory obstruction Drawbacks

1. Primary thyrotoxicosis 2. Mild thyrotoxicosis 3. Children and young patients because surgery may affect their growth 4. Pre-operative preparation 5. Post-operative recurrence 6. Refusal of surgery 7. Small gland Advantages

1. Avoiding surgical risks 1. No way to accurately predict which patient is liable to pass into remission 2. Avoiding the possible hazards of radioactive materials 2. High relapse rate which amounts to 60% within 2 years from stopping ttt 3. Further enlargement of the gland may occur 4. Adverse effects of the drugs Thiouracil and carbimazole may cause gastrointestinal upset, rashes, arthralgia and reversible bone marrow depression ---> agranulocytosis ( Blood picture should be performed every two weeks )

B. Radioactive Iodine :
Mechanism of action - destroys the thyroid cells thus reducing the mass of functioning thyroid tissue Dose - suggested dose is 160 uCi per 1gm of thyroid tissue - response is usually slow, a substantial improvement is anticipated by 8-12 weeks, if not a second dose or several doses may be required, which is the case in 20-30% of these patients Advantages 1. Avoidance of surgery 2. Avoidance of prolonged medical therapy Possible side effects - has long been blamed for causing genetic damage, leukaemia or damage to the foetus if inadvertently administered in early pregnancy as well as increasing the incidence of thyroid carcinoma in adults 10-15 years after its administration - However, no substantial evidence has been definitely established regarding all these adverse effects and so the minimum age for its use in many centers is now 25 years Disadvantages 1. Progressive destruction of the gland --> thyroid insufficiency in up to 75-80% of cases after 10 years and so an indefinite follow-up is mandatory 2. Inadequate for the treatment of secondary toxic goitre

Indications 1. Diffuse toxic goitre 2. Thyrocardiac patients 3. Refusal of surgery 4. Recurrence after surgery

C. Surgery :
* Aim of surgery : to remove most of the thyroid gland leaving an equivalent of 4-5 gm of thyroid tissue on each side * Solitary toxic nodule Is treated by ipsilateral total lobectomy. * Some surgeons nowadays advocate total thyrodiectomy for the treatment of toxic goitre * Patient should be in a euthyroid status before the operation, otherwise he may develop a post-operative thyroid criris * Preparation by carbimozole and propranolol is usually satisfactory * Some surgeons recommend prescribing iodides (Lugols iodine 10 drops t.d.s.) for 10 days preoperatively to diminish the vascularity of the gland and render it more firm * A sleeping pulse of 80 min is considered as effective preoperative preparation Indications 1. Secondary toxic goitre 2. Severe primary thyrotoxicosis 3. Retrosternal toxic goitre 4. Failure of medical treatment 5. Occurrence of side effects due to medical treatment Advantages Drawbacks

1. Rapid cure 1. Morbidity and mortality : negligible in experienced hands 2. High rate 2. Recurrence rate less than 5% of success 3. Thyroid insufficiency at an incidence of 20-45% 4. Parathyroid insufficiency in less than 0.5% but is a definite risk even in experienced hands because of the high incidence of anatomical variation of the site of the parathyroid glands

Special problems in management

Case Problems - Radioiodine is contraindicated for children - Conventional surgery is either followed by a high recurrence rate, due to high activity of the cells in the young or followed by a hypothyroid state which affects later growth - It is preferable to tide them over by antithyroid drugs until the late teens

Thyrotoxicosis in children

35

Thyrotoxicosis with pregnancy

- Radio-iodine absolutely contraindicated, because destruction of the fetal thyroid would result - Antithyroid drugs at conventional doses would result in foetal hypothyroidism with development of goitre that may obstruct the airway - Minimum doses antithyroid drugs, supported by B-blockers reduce this risk (dose of an antithyroid drug is adjusted according to the serum level of free T4 ) - Surgery after a short course of antithyroid drugs and propranolol proved to be safe during the 2nd or 3rd trimester - During lactation propyl-thiouracil is recommended as it is excreted in a harmless very low concentration in milk - cardiac condition takes priority in management - Thyroidectomy is ideal after control of the cardiac status - If it is not permissible, radioiodine is used followed by antithyroid drugs until the effect of the former appears (6 weeks) - It is not preferable to terminate the toxic status abruptly by surgery or radio-iodine, for fear of the theoretical risk of progressing to malignant exophthalmos - Antithyroid drugs are used until the proptosis been stable for 6 months, after which thyroidectomy is permissible

The thyrocardiac patient Proptosis of recent onset

Hypothyroidism
Aetiology 1. Failure of development of the thyroid gland 2. Dyschromogenesis : congenital deficiency of one of the enzymes necessary for the formation of thyroid hormones, e.g. peroxidase enzyme 3. Failure of secretion of TSH by the anterior pituitary, e.g. in Sheehans syndrome 4. Primary myxoedema is supposed to be an autoimmune disorder BUT it may be associated with Addisons disease 5. Iatrogenic following subtotal thyroidectomy or radioactive iodine treatment particularly for toxic goitre 6. In late stages of Hashimotos thyroiditis
Investigations * T3 and T4 levels are low * TSH is markedly raised Cretinism ( in infants or children)

Clinical Picture
Myxoedema ( in adults - severe cases ) - All the parameters of normal * Symptoms of myxoedema are nearly opposite to development are impaired those of thyrotoxicosis - Infant does not grow properly, * Patient complains of lethargy, weakness, loss of he is stunted, slow to develop appetite, putting on weight and intolerance to cold his teeth or to walk weather * On examination : - Child has an apathetic look - patient looks apathetic with sluggish reactio with depressed nose, thick lips and thick protruding tongue - face is puffy with supraclavicu!ar pads of fat - Abdomen is distended (potbelly) - skin and hairs are dry and there is usually an - hands are cold umbilical hernia - bradycardia with a low volume pulse - voice of the patient is coarse - Pericardial effusion, carpal tunnel syndrome, deafness and ataxia may be present * Complications : - danger of myxoedema is that the diagnosis may be missed and the condition may progress to coronary thrombosis due to hyper-cholesterolaemia - myxoedematous patient if subjected to a stressful situation may develop coma Treatment * Replacement by L. thyroxine 0.2-0.3 mg/day for adults is satisfactory * Very early treatment of cretin infants may save these patients, otherwise the changes are irreversible

Thyroid neoplasms
Classification
* Thyroid gland contains follicular and parafolllcular ( C ) * Tumours of thyroid gland can be classified as follows : Tumours from parafollicular epithelium Medullary carcinoma Tumours from lymphoid elements Malignant lymphoma Infiltration by metastatic deposits or local infiltration from nearby lesion Rarely Tumours arising from follicular epithelium Benign Follicular adenoma Malignant *Differentiated: Papillary , Follicular & Mixed Carcinomas *Undifferentiated: Anaplastic Carcinoma

Follicular Adenoma
- presents as a solitary nodule - main concern is to differentiate it from follicular carcinoma which may have the same clinical picture - the main differentiating point during histopathological examination is to detect evidence of capsular or vascular invasion in carcinoma - That is why fine needle aspiration cytology is not reliable test in this condition - Treatment : Lobectomy of the side of the adenoma plus isthmusectomy - Many authors deny now the existence of papillary adenomas and consider them as carcinoma

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Thyroid Cancer
Predisposing factors
1.External irradiation of head & neck region in children that was previously used for ttt of haemangiomas & thymic gland enlargement 2 Follicular carcinoma : commonest type to develop in endemic goitrous areas, possibly due to continuous stimulation of thyroid by TSH 3. A genetic element may be present as the lesion is more common in certain families 4. Malignant lymphoma may occur on top of Hashimotos disease

Types
POC Incidence Age Sex FM

* Differences between the commonest three types of thyroid carcinoma : Papillary 60% may occur in children & young adults 3.51 Follicular 17% middle age 21 * Thyroid follicles with a vanable degree of differentiation, Solid sheets may be present * Diagnosis depends on finding capsular or vascular invasion or on detecting metastases Rare * Mainly blood spread * Mainly direct invasion * Lymphatic or blood spread * Most patients die within 1-2 years Anaplastic 13% elderly 11.3 * May take the form of spindle cell or large cell type

* Papillary projections formed of connective tissue covered by a single layer of epithelial Microscopic cells with pale empty nuclei Picture * Laminated calcified bodies (Psammoma bodies) are often present Multiplicity Up to 80%. May be due to multicentricity or intrathyroid lymphatic spread * Mainly lymphatic * Blood spread may occur with tumours that extend outside the thyroid 90%

Spread 10-year survival

* Encapsulated 97% * Invasive 70%

*N.B. : If the tumour contains both papillary and follicular elements it is managed as papillary

Medullary Carcinoma
* Accounts for : about 6% of malignant neoplasms * Arises from : parafollicular cells , therefore, considered a part of the apudomas & it secretes calcitonin * May occur alone, or it may be associated ith hyperparathyroidism and pheochromocytoma constituting (MEN Ila) * May be familial and in this case it is more common in children and young adults * Microscopically : the tumour is composed of sheets of neoplastic cells set in a hyaline stroma which may contain amyloid material & mitotic rate of growth is usually low * Spread : to lymph nodes in 50-60% of cases ---> blood borne metastases

Clinical features
* Usual complaint : is that of a thyroid swelling which is enlarging- rapidly over some months * Sometimes, the swelling is painful and the pain may be referred to the ear (referred along the auricular branch of vagus) * If the lesion is advanced, the patient may complain of compression manifestations as dyspnoea or change of voice due to involvement of the recurrent laryngeal nerve * Examination reveals a lump, firm to hard in consistency, occupying a part or the whole of the thyroid gland. There may be some restricted mobility of the thyroid * In anaplastic tumours, the rate of growth will be more rapid and there will be early infiltration of the surrounding structures as the trachea, recurrent larynqaal nerve or the muscles * The examiner should look for lymphatic or blood borne metastases, the latter occur usually in the bones particularly the spine, skull or neck of femur, in the lungs or in the brain * Some low grade differentiated tumours present exactly as benign lesions. Any solitary nodule of the thyroid particularly in young males is suspicious. Medullary carcinoma may produce diarrhoea in 30% of cases due to production of 5 hydroxytryptamine or PGs * Some patients may present, by metastatic lymph nodes in the jugular chain while the primary papillary carcinoma is not palpable. This is called occult carcinoma

Investigations
Test Value - of limited diagnostic significance - Malignant lesions usually appear as cold areas in the scan, but it should be remembered that many benign lesions as cysts or haemorrhage in a cyst or degenerative nodules or thyroiditis appear also as cold areas - can prove whether the lesion is cystic, solid or cystic with solid projection

1. Thyroid isotope scanning

2. Ultrasound examination

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3. Aspiration of a cyst

a. A benign cyst is characterized by: i. The aspirate is dear ii. Complete disappearance of the cyst iii. No reaccumulation of fluid. Iv. Cytological examination is free b. A cystic malignant lesion is suspected when: i. The aspirate is haemorrhagic. ii. A residual lump is present iii. Rapid reaccumulation of fluid in the cyst iv. Cytological examination may be positive for malignant cells - Role of this simple, rapid and inexpensive investigation is becoming increasingly reliable - An experienced pathologist can give an accurate result in about 90% of cases - In follicular carcinoma FNAC may not be very conclusive as the diagnosis of this lesion depends upon demonstration of capsular or blood vessel invasion - detects pulmonary deposits - check the mobility of the vocal cords - Estimation of serum calcitonin is not a routine investigation - It is raised in many patients with medullary carcinoma; and is considered as a tumour marker - Thyroglobulin is a tumour marker for differentiated thyroid carcinoma - the best policy if the diagnosis is still in doubt - recommended to do frozen section, so that complete definitive treatment is performed simultaneously

4. Fine needle aspiration cytology (FNAc) 5. Chest x-ray 6. Indirect laryngoscopy 7. Tumour markers 8. Surgical exploration of the thyroid and complete resection of affected lobe

Popular (most common) Psammoma bodies * The Ps of papillary thyroid cancer : Papillary cancer Positive (excellent) Prognosis Palpable lymph nodes (in one third of cases) * The Fs of fallicular cancer : Follicular cancer Far-away metastases (blood spread, commonly to bones) Female (21 ratio) FNAC not useful Favourable prognosis * With Medullary carcinoma remember MEN II

REMEMBER

treatment
Case Management * Total thyroidectomy is recommended because : 1. There is a high incidence of multicentric lesions in papillary carcinoma 2. Total thyroidectomy ablates all thyroid tissue and makes it possible to detect metastases by scanning and to treat them by radioactive iodine which is not possible in the presence of normal thyroid tissue * Post-operatively : L-thyroxine 0.2 mg/day is prescribed to suppress TSH production as most differentiated carcinomas are TSH dependent 1. If there are no palpable metastatic deposits, only the central lymph nodes are excised 2. If there are metastases in the posterior triangle, a modified block dissection is performed in which the accessory nerve, internal juqular vein and sternomastoid muscle are preserved * Thyroxine is stopped for a few weeks or substituted by tniodothyronine (to raise TSH) and then iodine scan is performed * If there is evidence of local recurrence or metastases, a therapeutic dose of radioactive iodine is prescribed * This tumour does not concentrate radioactive iodine and is not under the control of TSH * Treatment is by total thyroidectomy and resection of metastatic lymph nodes * Unfortunately the majority of these patients are inoperable when first seen and are doomed to a fatal outcome within months * ,The usual treatment is external irradiation and chemotherapy * If there is tracheal compression, the isthmus is resected * Rarely the lesion is operable and an attempt at cure by total thyroidectomy is performed * Radiotherapy and chemotherapy

Differentiated Carcinoma

Lymph node metastases Blood borne metastases Medullary carcinoma Anaplastic carcinoma Malignant lymphoma

Prognosis of differentiated thyroid carcinoma

* Certain factors increase the risk including : 1. Age :Males above 40 and females above 50 years of age 2. Size of the lesion : if more than 5 cm in diameter 3. Presence of capsular or blood vessel invasion

Solitary thyroid nodule

Differential Diagnosis 1. The nodule may be a part of multinodular goitre, other nodules are not clinically palpable (commonest) 2. Toxic nodule 3. Colloid nodule 4. Adenoma. 5. Carcinoma

Findings raising suspicion of malignancy in a solitary nodule 1. History of previous irradiation 2. Young and elderly patients 3. Recent onset, and rapid growth 4. Pain 5. If the nodule is hard, irregular, with limited mobility 6. Presence of local invasion or lymphatic or blood borne metastases

 : Investigations
Test Value

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1. Thyroid function tests and thyroid isotope scan 2. Ultrasound 3. Fine needle aspiration cytology (FNAC)

* performed if there is suspicion of toxicity * value of thyroid scan is : a. May reveal the presence of multinodular goitre b. If the nodule is hot ---> toxic and the possibility of malignancy is nearly excluded c. If the nodule is warm ---> functioning adenoma and the possibility of malignancy is only 3.5% d. If the nodule is cold ---> possibility of malignancy is 10-16% * can differentiate between a cyst and a solid lesion * simple, fast, inexpensive investigation which depends upon cytological examination of nodules 0.5 cm or more by an experienced pathologist * can diagnose most lesions of the thyroid but it cannot differentiate follicular adenoma from carcinoma * False positive results occur in 2% while false negative results occur in 3% of cases * obtains a core of tissue for histological examination of nodules 2 cm or more in diameter * may cause haematoma * surest method of diagnosis is to do lobectomy (not enucleation) of the affected side then perform frozen section histological examination in suspicious cases

4. True cut needle biopsy 5. Excision biopsy

Algorithm for the management of a solitary thyroid nodule Thyroid Nodule

Clinical Evaluation + Thyroid function tests & isotope scan Euthyroid Toxic nodule

U/S Cystic Solid

Surgery

Aspirate

U/S guided FNAC

Benign

Suspecious e.g: follicular neoplasm Lobectomy

Malignant

Observe

Total thyroidectomy

Thyroidectomy operation
Indications
*Simple Nodular goiter *Diffuse toxic goiter *Toxic nodular goiter Subtotal thyroidectomy *Solitary Nodule *Papillary carcinoma *Follicular carcinoma *Medullary carcinoma Total lobectomy Total thyroidectomy *Anaplastic carcinoma

Thyroidectomy if possible or excision of the isthmus to relieve tracheal compression

* Preoperative procedure
- If the patient is toxic ---> control the hyperthyroidism - Indirect laryngoscopy ---> check the mobility of the vocal cords (3% of people have asymptomatic vocal cord paralysis {MLI} )

 :
* Operative procedure
* Anaesthetic - general anaesthesia -patient lies supine on the operating table, which is tilted 15o upwards at the head to decrease venous congestion -a sandbag pillow is placed between the shoulder blades with the neck extended (with care particularly in the elderly), thus making the gland more prominent -a curvilinear skin crease incision extending laterally as far as the stemomastoid muscle is made about 1 inch above the suprasternal notch -Lower skin incisions have a tendency to develop hyperplastic (keloid) scars -flaps of skin, subcutaneous tissue and platysma are raised upwards to the level of the notch of the thyroid cartilage and downwards to the suprasternal notch -the midline raphe between the strap muscles is divided longitudinally -it is preferable to divide strap muscles for adequate exposure -pretracheal fascia is opened -plane of dissection is developed between the strap muscles superficially and the thyroid capsule deeply -Each thyroid lobe, in turn, is mobilized -middle thyroid vein: division between its ligatures -superior thyroid pedicle: ligated within the upper pole to avoid the external laryngeal branch of the superior laryngeal nerve -inferior thyroid veins: ligated and divided -inferior thyroid artery branches: ligated on the surface of the thyroid gland -recurrent laryngeal nerve should be identified in its course in the whole field & it is sought below the level of the inferior thyroid artery as it passes obliquely upwards and forwards, usually behind the inferior thyroid artery or its branches then passes into the larynx behind the inferior cornu of the thyroid cartilage -parathyroids: should be identified before resection of the thyroid gland -Avoid moreover ligatures near the hilum of the parathyroid as well as excessive use of diathermy to limit the risk of devascularization of the gland -Absolute haemostasis: ensured by ligature of individual vessels or suturing the capsule of the remnant to tracheal fascia -pretracheal musdes, if divided, are sutured, as well as the cervical fascia. -wound is closed with suction drainage of the deep cervical space

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* Postoperative Complications
-tension haematoma in the deep cervical space is due to slipped ligature of superior thyroid pedicle, but occasionally the bleeding may be from thyroid remnant or a thyroid vein -Haematoma in this closed space is serious as it may compress the trachea or the carotid vessels -Opening the wound in bed to relieve tension may be needed before transferal of patient to the theatre to control the source -A small subcutaneous haematoma may require evacuation or aspiration -causes include: a. Laryngeal edema: due to trauma by endotracheal tube or secondary to extensive manipulation of the larynx during surgery b. Tension haematoma in deep cervical space c. Bilateral recurrent laryngeal nerve injury d. Tracheal collapse due to tracheomalacia:the problem of respiratory obstruction is that it may pass unnoticed until the patient develops severe progressive hypoxia & cerebral damage,so when obstruction is suspected, an endotracheal tube should be immediately inserted and IV corticosteroids prescribed -unilateral or bilateral, transient or permanent -Permanent paralysis is avoided by proper identification of the nerve during operation -Unilateral paralysis ---> hoarseness of voice & dyspnea on exertion ( voice will improve within six months due to compensation by the other vocal cord ) -Bilateral injury ---> stridor if the abductor fibres are injured (partial injury) or it ---> aphonia if whole fibres are damaged (complete injury)

* Position of the patient

1. Hemorrage

* Incision

* Raising flaps

2. Respiratory obstruction

* Strap muscles

3. Recurrent laryngeal nerve ( RLN ) paralysis

* Devascularization

-incidence should be lower than 0.5% -presents dramatically 2-5 days postoperatively -Delay of appearance of hypocalcaemia to 2-3 weeks is 4. Parathyroid very rare insufficiency -Hypoparathyroidism may be due to removal or devascularization of the parathyroid glands -may be temporary or permanent
-acute exacerbation of hyperthyroidism in the form of hyperthermia, tachycardia, irritability & profuse sweating -follows an operation upon an inadequately prepared patient with thyrotoxicosis, hence it became very rare -Rarely, it may be 1st presentation of undiagnosed thyrotoxicosis in patient exposed to stress, e.g. infection, or a different surgery -ttt: Intravenous fluids - Cooling the patient by ice packs - O2 Digoxin for HF -Sedation - IV hydrocortisone - Carbimazole 15-20 mg/6 hours - Lugols iodine 10 drops/8 hours or Na-or K-iodide intravenously as drip - Propranolol 40 mg/6 hours orally or 1 mg IV as a drip to be repeated if needed N.B : Post-thyroidectomy dyspnoea : 1. Laryngeal oedema 2. Deep neck haematoma : Remove sutures and clot at bedside 3. Bilat. RLN injury 4. Tracheal collapse due to tracheomalacia

5. Thyrotoxic crisis

(Thyroid storm)

* Closure

* Posoperative follow-up
1. Assessment of serum calcium by the 6th week 2. - Follow up every 6-12 month for possible recurrence (5-10%) or development of hypothyroidism - T3, T4 and TSH are performed - Any necessary treatment prescribed

6. Wound infection & stitch granuloma 7. Keloid scar 8.Thyroid insufficiency

-subcutaneous or deep cervical abscess need drainage -granuloma may occur if non-absorbable suture material is used -liable to occur if the incision overlies the sternum, and is usuatly managed by local steroid injections -an insidious process over a period of 2-5 years, at an incidence of 20-45% - Estimation of TSH and T4 be performed regularly.