Operative surgery

TONY 2010 MBBS 1

Contents

• Cholecystectomy

• Circumcision

• Thyroidectomy

• Appendicectomy

• Tracheostomy

• hydrocele repair

• Hernia repair

• Varicocele repair

• Varicose vein repair

• Parotidectomy

• Mastectomy

• Neck dissection

• Incision & drainage of abscess

• Excision of lipoma

• Excision of sebaceous cyst

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Cholecystectomy

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Cholecystectomy

• Indications • Cholelithiasis with complications

• Biliary colic a/c & c/c cholecystitis,empyema ,mucocele

• Cholelithiasis in a • DM ,immunosuppressed

• Hemolytic anemia

• Young individuals

• Carcinoma

• Choledochal cyst

• Ca head of pancreas in whipples

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• Anaesthesia• GA

• Position • Supine trendelenberg position

• Pillow under the right lumbar & tilt to the left

• Skin preparation: • Prepare the skin from nipple line to mid-thigh, drape to expose the right

upper quadrants

• Incision • Kochers right subcostal Incision (muscle cutting incision)

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Other less common incisions

• Midline incision• Muscle is not cut

• ↓bld supply improper healing

• Paramedian incision

• Right upper quadrant transverse incision• Heal easier

• Mayo robson incision• Combination of medial half of kochers +paramedian incision

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2 methods

• Conventional /classic /retrograde(commonly done)• From cystic duct to fundus

• Fundus first method • From fundus to cystic duct

• Separate GB from liver bed & cover the raw area on liver by thin peritoneum• Injury to CBD & rt hepatic A

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Procedure

• Retract rectus abdominis laterally

• Open peritoneum

• Pack and retract bowel

• Identify GB at the tip of 9th costal cartilage

• Catch hold of fundus with sponge holding forceps

• Identify calots triangle

• Ligate cystic A & cystic duct close to the GB

• Separate the GB from liver

• Drain to prevent Waltmann Walter syndrome

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Complications

• Haemorrhage

• Necrosis of right quadrant of liver (d/t rt hepatic artery is affected in ligature)

• Injury to CBD

• Bile leak – walkmann waters syndrome • May mimic MI

• Tachycardia

• Upper abdominal pain

• Lower chest pain

• Shock

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Circumcision

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Circumcision

• Indications • Religious

• Phimosis paraphimosis

• Differentiated carcinoma prior to radiotherapy

• Cosmetic

• Anaesthesia• LA in adults

• Ring block with out adrenaline

• GA in children

• Position of the Patient: Supine

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Steps

• 2 forceps on either sides of 12 O clock position of foreskin

• Dorsal slit in 12 O clock position halfway to glans

• From there cut downward & laterally on either side till u reach frenulum (6 O clock)

• Tie frenular artery with U stitch cut vessel distal to ligature

• Stitch at 12,3,6& 9 o clock positions

• Ligate all bleeding points

• 4 forceps to hold each of stitches

• Suture b/w • 12 & 3 ,• 3& 6,• 6 & 9, • 9& 12

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4,Ligatting frenular A

2,Dorsal slit

3,Extend the incision

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Complications

• Infection

• Bleeding hematoma

• Injury to glans

• Delayed healing due to tension

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Post op advices

• Handle 4 penis

• Apply ice cubes

• Urinate every 4 hours • Full bladder can compress deep dorsal vein

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Thyroidectomy

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Thyroidectomy

• Indication • Cosmetic

• Pressure symptoms • Dyspnea dysphagia

• Malignancy

• Preparation of the patient • Make the patient euthyroid

• To prevent thyroid storm/crisis

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• Anaesthesia : • GA

• Position • Supine with neck extended with sand bag under shoulder (rose position)

• Clean and drape the area

• Incision • Kochers collar incision

• 2 finger breadths above the suprasternal notch from posterior border of one sternocleidomastoid to another

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• Skin, superficial fascia containing platysma is cut upto investing layer of deep fascia

• Flaps are raised• Upper upto laryngeal prominence • Lower upto suprasternal notch

• Investing layer of deep fascia is incised vertically

• Retract srap muscles laterally• Cut them at upper 1/3rd (to prevent injury to ansa cervicalis)

• If thyroid is too large• Muscles are infiltrated\• Retrosternal extension with impaction

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• Identify the pedicles1. Superior thyroid pedicle (sup throid A (branch of ECA )& V (drains in to IJV))

2. Middle pedicle (middle thyroid V only (drains in t IJV))

3. Inferior pedicle (inferior thyroid A only (thyrocervical branch of 1st part of subclavian A))

• Ligate middle thyroid vein first • Short vein drains into IJV (large vein) if missed torrential hge ))

• Ligate superior throid A & V separately & close to the gland • Separately: If done together AV fistula can occur

• Close to the gland : to prevent injury to external laryngeal nerve

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• Ligate inferior thyroid A close to the gland after identifying & safe guarding recurrent laryngeal nerve• To prevent loss of blood supply to parathyroids

• Sup parathyroid : by sup & inf parathyroid A

• Inf parathyroid : by inf parathyroid A only

• Identification of parathyroid • Yellowish pink (peanut butter appearance) if devascularised become greyish

• Sinks in NS

• Position

• Sup parathgyroid : middle of superior & inferior throid A

• Inferior parathyroid : sup parathyroid & sup mediastinum

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• Identification of RLN

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• Transfix & Ligate thyroidima A,sup thyroid V ,4th thyroid v of kocher

• Thyroidectomy proper • Total

• Subtotal

• Neartotal

• Wound closure:• Reapproximate strap muscles and platysma

• Skin closure with subcuticular stitch

• Dressing

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Complications

• Complications of anaesthesia

• Complications of Sx• Hge• injury to adjacent structures (trachea esophagus )• Injury to RLN,ext LN,Sup LN parathyroid

• Postoperative • Early

• Hematoma reactionary hge

• Late• Recurrence• Hypothyroidism• Tetany

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Appendicectomy

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Appendicectomy

• Indications • a/c appendicitis • Recurrent appendicitis • Carcinoid at the tip of appendix

• Contraindications • Appendicular mass faecal fistula

• Position• Supine

• Anaesthesia• GA• Spinal/epidural

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• Preparation • Cleaned with iodine & spirit

• Incision • Muscle splitting incision

• McBurneys grid iron • Most popular • 6-8cm long at McBurneys point perpendicular to spinoumbilical line

• Lanz incision • Curved transverse incision cosmetically better

• Right paramedian incision • When diagnosis is doubtful

• Bikini incision • Very low & very cosmetic • Part of pfannensteil incision rt part

• Muscle cutting • Rutherford Morrison incision

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• Layers opened:• skin

• two layers of subcutaneous tissue: Camper's, Scampa's..

• external oblique aponeurosis running downwards and medially.it is incised in the direction of the fibres

• Internal and transverse abdominal muscles are split

• Peritoneum is opened

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• Locate appendix using taenia coli

• Surgical procedure• Appendix is gently held at mesoappendix by using Babcock's forceps and

blood vessels in the mesoappendix are divided.These include appendicular artery, branch of ileocolic artery.Once the appendix is freed upto the base (caecum), a purse string suture is applied all round appendix, taking bites from caecum , using 2-0 atraumatic silk.

• Appendix is crushed at the base and is held 1cm above the crush. A tight silk ligature is applied at the crushed site and appendix is cut in between.Stump is cleaned with spirit.invaginated and purse string is tightened.This is called burial of the stump (to prevent adhesions of exposed mucosa)

• Perfect haemostasis is obtained.

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• Closure• Peritoneum -continous 2-0 catgut/vicryl

• Split muscles -sutured together by a few interrupted suteres using chromic catgut/vicryl

• External oblique is sutured with silk

• Subcutaneous fat is sutured with vicryl

• Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used more often nowadays.

• Corrugated red rubber drain is not kept routinely unless there is gangrenous appendicitis or a lot of pus in the peritoneal

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• Postoperative• Ryles tube aspn for 2 days

• IV fluids

• Appropriate Abx

• Suture removal 7-10 days

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Complications

• Peritonitis • From spread of infection

• Wound infection

• Intra abdominal abscess

• Fecal fistula formation

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Tracheostomy

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• Indication:• Emergency:

• choking, stridor• Coma severe barbiturate poisoning• Foreign body

• Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency

• Contraindications:• Anaplastic carcinoma thyroid patients presenting with stridor due to infiltration of

growth into trachea.

• Anaesthesia: LA

• Position

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Procedure:

• Incision: • Tranverse curved incision 3-4cm at the level of 2nd tracheal ring.(horizontal)• Vertical in emergency

• Dissection: Skin , subcutaneous tissue and deep fascia are incised.Isthmus of thyroid is separated.

• Procedure:

• A transversed curved cut is made at the level of 2nd tracheal ring, its edge is held by Allis forceps and a small cuff of cartilage is removed. Cricoid hook can be used to stabilise the trachea (found more usefull in children).

• Ligate anterr jugular vein ,isthmus of thyroid ,thyroidima

• A suitable sized tracheostomy is introduced within.

• The cuff of tracheostomy tube is inflated by using 2-5ml of air and is held in place by passing a tape around the neck.

• Confirm the tube in the trachea not in the subcutaneous plane.

• Confirm air entry into both lungs.

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• Post op Rx• Suction of tracheostomy tube• Regular dressing• Humidification of air• Check for air entry• Inner tube cleaned in 3 hours outer tube in week ly

• Post op complication• wound infection• Air leakage• Improper air entry• cricoid stenosis

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Hydrocele repair

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• Indications• Cosmetic

• Symptomatic

• Very large

• Anaesthesia• LA or spinal

• Incision • Paramedian incision on the side of hydrocele

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• Structures cut • Skin

• Superficial fascia with dartos muscle

• External spermatic fascia

• Dissect all around

• Study the tunica,size of the sac,thickness of the wall

• Make a stab incision & drain the fluid

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Procedures

• Small sized & thin wall • Plication of the sac }lords plication

• Large sac & thick wall• Eversion of sac } jaboulays procedure

• Very large hydrocele• Excision & eversion

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• If the sac is small, thin and contains clear fluid, either • Lord’s plication, i.e. tunica is bunched into a “ruff” by placing series of multiple

interrupted chromic catgut sutures so as to make the sac form a fibrous tissue which is relatively avasular and so haematoma will not occur, or

• Evacuation and eversion of the sac behind the testis (after eversion, everted sac is sutured with chromic catgut by continuous sutures) is done.

• If the sac is thick, in large hydrocele and chylocele, • subtotal excision of the sac is done (as tunica vaginalis is reflected on to the cord

structures and epididymis posteriorly, total excision of the sac leads to orchidectomywith division of cord). Often the sac is excised partially and eversion is done, which is called as Jabouley’s operation.

• After evacuation, the sac with the testis is placed in a newly created pocket between the fascial layers of the scrotum (Sharma and Jhawer’stechnique).

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Lords plication

• Lord’s Plication is done for a Small Hydrocele.

• Done under Spinal Anaesthesia.

• Vertical Para median incision is made.

• Layers of Scrotum are divided along the line of the incision.

• Tunica vaginalis ( TV ) sac is identified.

• Tunica vaginalis Sac is opened and the Hydrocele Fluid is drained out.

• Plicating sutures are placed around the cut opened Tunica vaginalis sac.

• Achieve complete haemostasis.

• A suction drain is placed.

• Wound is closed in layers.

• Scrotal suspensory bandage is given

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• Incision:• Vertical Paramedian Procedure parallel to the median raphe of the scrotum

• Incision deepened and the Hydrocele Sac Isolated

• Hydrocele Fluid drained and Excess sac excised.

• Eversion of TV Sac ( Tunica Vaginalis sac).

• Wound is closed in layers after achieving complete hemostasis.

• Scrotal suspensory bandage applied ( Scrotal Support )

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• Closure • Drain is kept

• Suture scrotal wound

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• Complication• Injury to testis & epididymis

• Scrotal hematoma

• Recurrence

• infection

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Hernia repair

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Hernia repair

• Hernioplasty when herniotomy is combined with a reinforced repair of the posterior inguinal canal with autogenous (patient’s own tissue) or heterogenous material such as prolene mesh.

• Herniorraphy is somewhat like hernioplasty only that no autogenousor heterogenous material is used for reinforcement.

• Herniotomy is a surgical operation where the hernia sac is removed without any repair of the inguinal canal.

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• Indications • All hernia require Sx unless they are eldely /unfit for Sx

• Due to risk of complications of hernia

• Preparation• Treat the predisposing cause

• c/c cough constipation BPH

• Anaesthesia• General

• Spinal

• Local } point block field block } anaesthesia of choice

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• Position• Supine

• Cleaning & draping the area

• Incision• ½ ‘’ above & parallel to medial to 2/3rd of inguinal ligament

• Structures cut • skin • 2 layers of superficial fascia • Ligate superficial epigastric & superficialexternal pudendal• External oblique along the direction of fibres directed towards apex of superficial

inguinal ring • Ilioinguinal nerve is thus identified and preserved

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Herniotomy

• Search for sac (pearly white in colour)• Indirect – inside the spermatic cord anterolateral to it• Direct– outside the cord & posteromedial to it (therefore spermatic cord is not

opened)

• Incase of indirect hernia Incise cremasteric fascia & inrenal spermatic fascia • Expose the sac from fundus to neck separate from spermatic cord • Divide the fundus of the sac in the inguinal canal and reduce the contents

by opening it and with fingers • Identify the neck with

• Constriction /narrowness• Inferior epigastric A• Presence of extraperitoneal fat

Alone is sufficient in childrens

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• Transfix and ligate the neck by needle passing technique through the tissue to prevent slipping

• Excise the redundant sac

• Closure of the wound

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Herniorraphy *(repair of posterior wall)

• Indication for In children only when there is collagen vascular disease,severe anemia,severe malnutrition,CRF

• bassini’s repair • The conjoined muscle of the transversus abdominis and the internal oblique

muscles is sutured to the inguinal ligament by 3-5 interrupted sutures (non absorbable suture)

• Drawbacks • Undue tension to relieve it tanners slide operation (transverse incision on rectus sheath)

• Recurrence due to approximation of muscle to a ligament & thick distant bites

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• Modified bassini’s repair• Conjoint tendon to inguinal ligament with continuous sutures

• shouldice repair • 6 layers

• 1st &2nd } double breasting of fascia transversalis• 3rd & 4th } approximate conjoint tendon to inguinal ligament in 2 layers • 5th & 6th } double breast external oblique aponeurosis

• Spermatic cord is superficial more chance of trauma

• Modified shouldice• Only 4 layers

• 1st &2nd } double breasting of fascia transversalis• 3rd } approximate conjoint tendon to inguinal ligament in 1 layer

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• Coopers ligament repair/mc vays repair

• inguinal and femoral canal defects

• The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

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Hernioplasty

• Lichenstein tension free mesh repair

• Rives repair• Preperitoneal mesh is kept with out suturing by incising transversalis fascia

• GPRVS/giant prosthetic reinforcement of visceral sac/stoppas repair• By pfannensteil incision/midline vertical

• Size of mesh • Breadth = distance B/W 2 ASIS -2cm

• Length = b/w umbilicus to pubic symphysis

• Desaradas technique• Dynamic repair

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• Closure• External oblique is sutured with chromic catgut or silk.• Subcutaneous fat absorbable catgut suture.• Skin with silk.

• Post -op• NPO fro 6-8 hours, oral fluids and soft diet later.• Analgesics• Antibiotics• Scrotal support if the dissection is more(complete hernia)• Suture removal after 7-10days.

• Post-op complications• Haematoma• Wound infection• Severe peritonitis pubis• nerve entrapment causing pain.

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Varicocele repair

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INDICATIONS FOR SURGERY

• A palpable varicocele.

• Symptomatic • Pain

• Sub fertility.

• Jobs like army

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• VARICOCELECTOMY-

The most common approaches are• Palomo’s operation /high approach

• suprainguinal extraperitonial

• Classical / inguinal (groin)• easier and safer.

• Scrotal approach-• grade 4 varicocele

• Anaesthesia • Spinal /LA/GA

• Position • Supine

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Classical

• Incision• As in inguinal hernia

• Dissect out spermatic cord

• All the coverings are split open

• The vas deferens with its artery 2 veins are separated from the main mass of varicocele

• The affected veins are ligated proximally & distally and 2 inches of dilated veins are removed

• The ends of ligature are tied together to raise the testis up

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Postoperative advice

• Avoid strenuous exercise for 2 days after surgery.

• Abx,NSAIDs

• Apply scrotal support.

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Complications

• 20% chance of recurrence.

• 5% chance of hydrocele

• Damage to testicular artery.

• Infection.

• hematoma

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Varicose vein repair

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Varicose vein repair

• Trendelenburg operation

• Ligation & stripping

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Trendelenburg operation

• Indication – Sapheno Femoral Valve incompence (trendelengurg test +ve)

• Anesthesia : • Spinal

• Position: • Supine

• Incision: • Oblique incision at the level of saphenous opening ( 4 cm below& lateral to

pubic tubercle) starting from femoral artery pulsation to 5 cm medially

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• Skin flaps reflected

• Long Saphenous Vein identified in the Superficial fascia

• All the tributaries of long saphenous vein at the SFJ are ligated and divided(superficial epigastric, superficial external pudendal,superficial circumflex iliac,medial & lateral accessory V).

• Long saphenous vein flush ligated close to femoral vein(juxa femoral flush ligation)

• Another ligature distal to flush ligature & divide b/w 2 ligatures

• Long saphenous vein excised maximum up to upper calf to avoid injury to sural nerve• The conventional way of removing the saphenous vein is with a Babcock stripper. This consists of a

flexible wire which is passed down the long saphenous vein. The end is identified in the upper third of the calf and a 2-mm incision is made to retrieve the stripper. An olive about 8 mm in diameter is attached to the upper end and the saphenous vein is removed by firm traction on the wire in the calf.

• Haemostasis achieved and skin closed & Elastocrepe bandage applied.• Steps 2, 3 and 4 form the components of Trendelenburg Surgery

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• Complications• Haematoma

• Recurrence (up to 20%)

• Saphenous nerve injury - loss of sensation medial thigh

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Parotidectomy

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• 1. Superficial parotidectomy: • It is the removal of superficial lobe of the parotid (superficial to facial nerve.).

It is done in case of benign diseases of superficial lobe of the parotid.

• 2. Total conservative parotidectomy: • It is done in benign diseases of parotid involving either only deep lobe or both

superficial and deep lobes. Here both lobes are removed with preservation of facial nerve.

• 3. Radical parotidectomy: • Both lobes of parotid are removed along with facial nerve, fat,fascia, muscles,

and lymph nodes. It is done in case of carcinoma parotid. Later facial nerve reconstruction is done using hypoglossal or

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Superficial parotidectomy

• Indication• Recurrent parotitis

• Benign tumours

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Superficial Parotidectomy

• Oral endotracheal

• Anaesthesia : GA

• Position • Head is extended by elevating the shoulders

• Head rotated to the contralateral side

• Draping the head separately incorporating the endotracheal tube

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Skin incision

Lazy S Incision

From the level of tragus of the

ear ( along the crease), winding

around the lobule towards the

mastoid and curving down

anteriorly 2 inches along the

anterior border of SCM to upper

Cervical crease.

.

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Lazy s incision

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Allis clamps on subcutaneous tissues provide traction of the flaps

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• The incision is carried through skin and subcutaneous tissue,

• Developing the plane between the cartilaginous external canal and the posterior aspect of the gland

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Identify cartilaginous pointer

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Anatomical landmarks For identification of Facial N Trunk

1. The cartilaginous external auditory meatus forms a pointer’ at its anterior, inferior border indicating the direction of the nerve trunk. (Tragal Pointer)

2. Just deep to the cartilaginous pointer is a bony landmark formed by the curve of the bony external meatus & its abutment with the mastoid process. This forms a palpable groove (Tympanomastoid Suture) leading directly to the stylomastoid foramen.

3. The anterior, superior aspect of the posterior belly of the digastric

4. Styloid process itself can be palpated superficial to the stylomastoid foramen & just superior to it. Nerve is always lateral to this plane & passes obliquely across the styloid process.

5. Retrograde Dissection

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The mastoid process palpated to identify the origin of the sternocleidomastoidThe sternomastoid muscle is identified and its anterior border exposed as the tail of the gland is dissected and reflected away from the muscle

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Identify anterior border of posterior belly of digastric

Continues to dissect in this plane, incising attachments to the mastoid, until the posterior belly of the digastric muscle is visualized below the digastric groove

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• When the volar aspect of the fifth finger is placed deeply on the junction of cartilaginous and bony external auditory canal and wedged against the bone cephalad, the main trunk will be found below the inferior border of the finger, a few millimeters above the exposed superior border of the posterior belly of the digastric muscle as it enters its groove in the mastoid bone

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Identify facial nerve trunk

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• Once the facial nerve trunk has been identified the superficial lobe exteriorised by opening up the plane in which the branches of the facial nerve run between the two lobes by blunt dissection

• Small hemostat in the plane superficial to N, elevating the hemostatlaterally, gently spreading the tips, and then incising the tissue between the tips with direct visualization of the N

• Good traction on the reflected parotid

• Clamp is used to elevate and incise the overlying tissue in layers

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After the lateral portion of the gland has been removed, all nerve branches should be exposed.

If a clean dissection has been performed, at least a portion of the masseter muscle should be in view

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•The Stensen duct is transected and ligated anteriorly

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Suture & keep drain

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Conservative parotidectomy

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Complications

Intra-operative complications

• Transection of facial nerve

• Rupture of capsule

• Haemorrhage

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Post Operative Complications

Early Late

• Facial N Paralysis

• Hemorrhage

• Hematoma

• Infection

• Skin Flap Necrosis

• Cosmetic Deformity

• Trismus

• Parotid Fistula

• Hypoaesthsia

• Soft Tissue Defect

• Hypertrophic Scar

• Frey’s Syndrome

• Crocodile tear syndromr

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Intra Op Transection OF Facial N

• Immediate nerve repair

• Segments fully mobilized

• Brought together without tension

• Two ends should be sutured together

• With an 8-0 nylon suture

• As an alternative to sutures, fibrin tissue adhesive can be used.

• If the nerve length is inadequate, a nerve graft of the greater auricular

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Mastectomy

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Operative procedures-Mastectomy

1. Simple mastectomy.

2. Modified radical mastectomy.

3. Breast conserving surgery.

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Total or simple mastectomy:

• Removal of the entire breast tissue,

• No dissection of lymph nodes or removal of muscle.

• Sometimes adjacent lymph nodes are removed along

with the breast tissue.

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Which procedure is best ?

• Loco-Regional therapy include:

a. Surgery

b. Radiotherapy

• Systemic therapy:

a. Chemotherapy

b. Hormonal therapy

c. Monoclonal antibodies.

However surgery is important to get rid of gross cancer

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Pre-operative management• Triple assessment.

• Metastatic workup.

• Routine blood investigations.

• Pre-anesthetic evaluation.

• Control of medical conditions like diabetes and hypertension.

• Counseling and written informed consent.

• Parts preparation- neck to mid thigh including pelvic region, axilla

and arm.

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Operative procedure

• Anesthesia

• General anesthesia.

• Position

• The patient is placed in supine position with the arm

abducted < 90 degree.

• Sandbag or folded sheet is placed under the thorax and

shoulder of affected side.

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Operative procedures- Simple Mastectomy

• Indications:

• Stage I and stage IIa carcinoma

• Large cancers that persist after adjuvant therapy

• Multifocal or multicentric CIS.

• Incision:

• Horizontal elliptical incision is marked so as to include the entire

areolar complex.

• Should be 1-2cm away from the tumor margins.

• Skin sparing incision- if breast reconstruction is planned

• Two skin edges should be of equivalent length

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Simple Mastectomy-procedure

• Skin incision is deepened with electro-

cautery.

• A plane between breast fat and the

subcutaneous fat, seen as white fibrous

plane.

• Dissection is carried in this plane and

flaps are raised inferiorly and superiorly.

• Ideally thickness of the flap should be 7-

10mm.

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Simple Mastectomy-procedure

• Extent of dissection:

• Superiorly till clavicle,

• Laterally till P.major lateral border

• Medially to the sternal border, and

• Inferiorly till infra-mammary fold

• Breast tissue along with the pectoral fascia

(controversial) is dissected from the P.major.

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Simple Mastectomy-procedure

• Usually started superiorly and the proceeded clock-wise ending in the axillary region.

• Care must be taken to ligate perforating branches of lateral thoracic and anterior intercostal vessels.

• Lateral branches of the medial pectoral neurovascular bundle is carefully dissected while removing axillary tail.

• Wound irrigated with sterile water to crenate (shrivel or shrink) cancerous cells.

• Subcutaneous tissue is closed using 00 absorbable interrupted sutures.

• Skin closed using 00 non-absorbable mattress sutures or using staples.

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Modified Radical Mastectomy (MRM):

• Removal of breast tissue and axillary lymph nodes.

• No removal of pectoral muscle.

• 3 modifications:

a. Patey’s

b. Scanlon’s.

c. Auchincloss.

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Modified radical Mastectomy-procedure

1. Patey’s procedure:

• The P.minor is removed for better visualization and easy

dissection of level III lymph nodes.

2. Scanlon’s procedure:

• P.minor is retracted to expose level III nodes and dissected out.

3. Auchincloss procedure:

• Level I and II lymph nodes are cleared, level III nodes are left

behind.

TONY 2010 MBBS 118

Operative procedures- Modified radical Mastectomy

• Indications:

• Early breast cancer (most commonly done)

• LABC

• Residual large cancers that persist after adjuvant therapy

• Multifocal or multicentric disease.

• Incision:

• Oblique elliptical incision angled towards axilla.

• Should include the entire areolar complex and previous scars, if present.

• Should be 1-2cm away from the tumor margins.

• Two skin edges should be of equivalent length

TONY 2010 MBBS 119

Modified radical Mastectomy-procedure

• Procedure till approaching axilla is

same as simple mastectomy.

• Extent of dissection:

• Superiorly till clavicle,

• Laterally till anterior margin of

latissimus dorsi.

• Medially to the sternal border, and

• Inferiorly till the costal margin near the

insertion of the rectus sheath.

TONY 2010 MBBS 120

Modified radical Mastectomy-procedure

• The specimen is retracted upwards and laterally to expose

P.minor.

• The dissection is continued to axillary lymph node

clearance.

• Care must be taken not to injure medial pectoral nerve

and vessels.

• The axillary investing fascia is incised to expose the

axillary group of lymph nodes.

TONY 2010 MBBS 121

Modified radical Mastectomy-procedure

• The inter-pectoral (Rotter) group of lymph nodes are removed.

• Then dissection can be done either from medial to lateral or vise-

versa.

• The loose lateral areolar tissue in axillary space is dissected to

expose the axillary vein.

• The investing layer of axillary vessels is cut, the tributaries are

transfixed and cut.

• Dissection is carried out laterally including lateral grp (level I) of

lymph nodes.

TONY 2010 MBBS 122

Modified radical Mastectomy-procedure

• Thoracodorsal neurovascular bundle lies over the lat.dorsi, with

nerve more laterally placed, subscapular (level I) nodes are removed.

• The level II lymph nodes between superior trunk of

intercostobranchial bundle and axillary vein are removed.

• The central grp of lymph nodes are removed carefully separating

from axillary vein and its tributaries.

• While dissecting medially, long thoracic nerve is encountered, which

lies anterior to the subscapular muscle. The dissection carried out

anterior and medial to long thoracic nerve and the specimen

delivered.

TONY 2010 MBBS 123

Modified radical Mastectomy-procedure

• Care must be taken while dissecting in axillary area to preserve,• Medial and lateral pectoral nerve.

• Long thoracic vessels and nerve

• Nerve to latissimus dorsi.

• Axillary vein.

• Wound irrigated with sterile water to shrink/crenate cancerous cells.

• 2 drains, 1 below and other above P.major are secured.

• Subcutaneous tissue is closed using 00 absorbable interrupted sutures.

• Skin closed using 00 non-absorbable mattress sutures or using staples.

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TONY 2010 MBBS 125

Post-operative care

• Wound examined on post-op day 3.

• Drain can be removed when it is < 30ml.

• Any collection is to be aspirated under aseptic precautions.

• Staples can be removed after 10days.

• Arm movements started in the 1st week..

• Active shoulder and upper limb exercises are started from 2

weeks

TONY 2010 MBBS 126

Types of mastectomy

3. Halsted’s Radical Mastectomy:

• Most extensive type.

• Breast tissue, axillary lymph nodes and pectoral muscles are removed.

• Disadvantages:

• Bad scars and unacceptable deformity.

• Reduced range of mobility of shoulder

TONY 2010 MBBS 127

Types of mastectomy

4. Subcutaneous mastectomy:

• Simple mastectomy sparing nipple.

• Rarely done, as a large amount of

breast tissue is left in situ.

5. Skin sparing mastectomy:

– Total/simple mastectomy or

modified radical mastectomy

with preservation of as much

as breast skin as possible

needed for breast

reconstruction.

– Local recurrence is

acceptable, 0-3%.

TONY 2010 MBBS 128

Types of mastectomy

6. Breast conserving surgery:

• Wide local excision/Lumpectomy

• Quadrantectomy.

TONY 2010 MBBS 129

Breast conserving surgery

• Indications:

• Stage 0 (CIS), Stage I,

Stage IIa breast

carcinoma.

• Single lesion.

• Clinically downstaged

LABC (controversial)

• Method:

• Wide local

excision/Lumpectomy or

Quadrantectomy +

axillary lymph node

clearance +

radiotherapy.

TONY 2010 MBBS 130

Types of mastectomy

7. Extended radical

mastectomy:

• Radical mastectomy +

enbloc resection of

internal mammary lymph

nodes + supraclavicular

lymph nodes.

• Obsolete.

8. Toilet mastectomy:

• Done in fungating or

ulcerative growths.

• Palliative simple

mastectomy.

TONY 2010 MBBS 131

Which procedure is suitable for the given patient ?

• Age

• Size of the tumor

• Axillary lymph node status.

• Stage of the malignancy

• Biologic aggressiveness of the

tumor

• Receptor status of the tumor.

• Multicentricity or multifocality

• Menstrual status.

• Size of the breast

• Availability of

radiotherapy.

• Patients choice.

• Prophylactic/therapeutic/

palliative.

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Which procedure is best ?

• When the tumor size is ≥ 1cm, becomes systemic.

• No single method is considered better in terms of

disease free survival or mortality.

• Suitable local therapy + systemic therapy is the most

appropriate approach.

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Breast conserving surgery

• Advantages:

• Maintenance of appearance

and function of breast.

• Disease free interval is same as

MRM.

• Better quality of life and

psychological advantage.

• Contraindications:

• Multicentric tumor.

• Positive margins after excision.

• Size > 4cm (relative).

• Advanced stages.

• No assess to radiation/ poor

patient compliance.

• C/I for radiation: SLE/ Rheumatoid

arthritis/ Scleroderma/ pregnancy/

prior chest radiation.

TONY 2010 MBBS 134

Breast conserving surgery-Procedure

• Incision-circular/ radial/ subareolar incision near to the tumor,

about 3-4cm.

• Excision of the carcinoma tissue with a margin of atlaeast 1cm

of normal breast tissue to get a 2-mm cancer-free margin.

• If tumor is situated superficially then excision of that part of skin.

• If tumor is deep then tumor is excised till pectoralis major.

• Depending on post-surgical defect

• Primary closure or

• Reshaping of breast tissue is done.TONY 2010 MBBS 135

Breast conserving surgery-Lumpectomy• After skin incision, subcutaneous tissue is deepened using electric

cautery.

• While dissecting the breast tissue, better to use scalpel.

• Care must be taken while dissecting to palpate the tumor, so that

entire lesion is excised. Specimen radiography can be done to check

for clear margins.

• Hemoclips are applied along the margins of the cavity.

• Wound closed in 2 layers:

• Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.

• Skin with subcuticular 3-0 absorbable sutures.TONY 2010 MBBS 136

Breast conserving surgery-Procedure

Quadrantectomy:

• Usually done for lesion in the upper outer and inner lower

quadrants.

• Radial incision is taken.

• Entire breast tissue in that quadrant is excised till pectoral fascia.

• Wound closed in multiple layers:

• Breast tissue with interrupted 3-0 absorbable suture.

• Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.

• Skin with subcuticular 3-0 absorbable suture.TONY 2010 MBBS 137

Breast conserving surgery

• Quadrantectomy v/s Lumpectomy.

• Lumpectomy has more local recurrence risk.

• Lumpectomy has better cosmetic outcome.

TONY 2010 MBBS 138

Breast conserving surgery

• After BCS, radiotherapy is essential, otherwise the

local recurrence rate is unacceptably high

• Without radiotherapy, the local recurrence can be as

high as 40%

TONY 2010 MBBS 139

Neck dissection

TONY 2010 MBBS 140

Neck dissection

• Medina classification (1989)

• • Radical neck dissection

• • Extended radical neck dissection

• • Modified radical neck dissection• Type I (XI preserved)• Type II (XI, IJV preserved)• Type III (XI, IJV, and SCM preserved)(Known as Functional neck dissection (Bocca))

• • Selective neck dissection • Supraomohyoid neck dissection• Posterolateral neck dissection• Lateral neck dissection• Anterior neck dissection

TONY 2010 MBBS 141

Radical neck Dissection:

Removes

• Removing all lymphatic tissues in regions I - V

• Spinal Acessory Nerve

• Internal Jugular vein

• Sternocleidomastoid muscle

• Submandibular Salivary gland

• Tail of parotid

• Omohyoid muscle

Preserves

• Posterior auricular

• Suboccipital

• Retropharyngeal

• Periparotid

• Perifacial

• Paratracheal nodes

TONY 2010 MBBS 142

Indications

• Radical Neck Dissection

1. Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN

2. Large metastatic tumor mass or multiple matted in upper part of the neck• Tumor should not be dissected to preserve Structures

Contraindications

• 1. untreatable primary lesion (fixed)

• 2. Involvement of internal / common carotid artery

• 3. Presence of distant metastasis.

• 4. Poor anaesthetic risk patient.

TONY 2010 MBBS 144

Modified radical neck dissection:

• Excision of all lymph nodes removed with RND (Nodal groups I-V)

• with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV• Subtype I: Preserve SAN

• Subtype II: Preserve SAN & IJV

• Subtype III: preserve SAN, IJV and SCM • Known as Functional neck dissection (Bocca)

TONY 2010 MBBS 145

Type l MRND

TONY 2010 MBBS 146

(XI preserved)

Indications– Clinically obvious lymph node metastases

– SAN not involved by tumor–Intraoperative decision

Type ll MRND

TONY 2010 MBBS 147

Preserve SAN

&IJV

• Indications– Rarely planned– Intraoperative tumor found adherent to the SCM, but not IJV & SAN

Type lll MRND/ Functional neck dissection

TONY 2010 MBBS 148

preserve SAN, IJV and SCM

• Neck dissection of choice for N0 neck For treatment of N0 neck nodesIndicated for N1 mobile nodes and not greater than 2.5 – 3.0 cmContra-indicated in the presence of node fixationResult is difficult to interpret because of the use of radiation therap

Extended Neck Dissection

• Definition

• – Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures.

• – Usually performed with N+ necks in MRND or RND when metastases invade structures usually preserved

TONY 2010 MBBS 149

Selective Neck dissection:

• Also known as an elective neck dissection

• Need for post-op RT

• Any type of cervical lymphadenectomy with preservation of one or more lymph node groups

• Four subtype:• Supraomohyoid neck dissection

• Posterolateral neck dissection

• Lateral neck dissection

• Anterior neck dissection

TONY 2010 MBBS 150

Indications

• Selective/elective neck dissection:• For treatment of N0 neck nodes

• For N+ nodes when combined with radiotherapy

• Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread

• Upgrade intra-operatively following positive frozen section

Supraomohyoid neck dissection

• Most commonly performed SND

• Definition

• – En bloc removal of cervical lymph node groups I-III

– Posterior limit is the cervical plexus and posterior border of the SCM

– Inferior limit is the omohyoid muscle overlying the IJV

TONY 2010 MBBS 152

Supraomohyoid neck dissection

TONY 2010 MBBS 153

Indications

Oral cavity carcinoma with N0 neck

• Boundaries – Vermillion border of lips to junction of hard and soft palate, circumvallate papillae

• Subsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone, hard palate, and anterior 2/3s of the tongue and FOM

Lateral Type

• En bloc removal of the jugular lymph nodes including Levels II-IV.

• IndicationsN0 Neck in carcinomas of

• Oropharynx

• Hypopharynx

• Supraglottis

• Glottic Larynx

Posterolateral type

En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular.

• Indications• – Cutaneous malignancies

• • Melanoma

• • Squamous cell carcinoma

• • Merkel cell carcinoma

• – Soft tissue sarcomas of the scalp and neck

TONY 2010 MBBS 155

Anterior neck dissection

• En bloc removal of lymph structures in Level VI• • Perithyroidal nodes• • Pretracheal nodes• • Precricoid nodes (Delphian)• • Paratracheal nodes along recurrent nerves

• Limits of the dissection are the hyoid bone, suprasternal notch and carotid sheaths

• Indications• – Selected cases of thyroid carcinoma• – Parathyroid carcinoma• – Subglottic carcinoma• – Laryngeal carcinoma with subglottic extension• CA of the cervical esophagus

TONY 2010 MBBS 156

Y Incision

3 point intersectionflapnecrosis

McFee Incision

H Incision

J Incision

COMPLICATIONS

• Air embolus

• Pneumothorax

• Chyle leak & Chylus fistula

• Wry Neck (Torticollis Coli)

• Shoulder dysfunction

• Cerebral oedema

Incision and drainage of abscess

TONY 2010 MBBS 164

• Indications• 1. Abscess on the skin which is palpable

• Contraindications • 1.Extremely large abscesses which require extensive incision, debridement, or

irrigation (best done in OR)• 2. Deep abscesses in very sensitive areas (supralevator, ischiorectal,

perirectal) which require a general anesthetic to obtain proper exposure• 3. Palmar space abscesses, or abscesses in the deep plantar spaces• 4. Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a

septic phlebitis)

TONY 2010 MBBS 165

• Preprocedure education• 1. Obtain informed consent• 2. Inform the patient of potential severe complications and their treatment• 3. Explain the steps of the procedure, including the not insignificant pain associated

with anesthetic infiltration• 4. Explain necessity for follow-up, including packing change or removal•

• Procedure• 1. Use universal precautions• 2. Cleanse site over abscess with skin prep• 3. Drape to create a sterile field• 4. Infiltrate local anesthetic, allow 2-3 minutes for anesthetic to take effect• 5. Incise widely over abscess cutting through the skin into the abscess cavity. Follow

skin fold lines whenever able while making the incision

TONY 2010 MBBS 166

• 6.Allow the pus to drain, using the gauzes to soak up drainage and blood. Use culture swab to take culture of abscess contents, swabbing inside the abscess cavity

• 7.Use the hemostat to gently explore the abscess cavity to break up any loculations within the abscess

• 8. Using the packing strip, pack the abscess cavity

• 9. Place gauze dressing over wound, and tape in place

TONY 2010 MBBS 167

TONY 2010 MBBS 168

TONY 2010 MBBS 169

Excision of lipoma

TONY 2010 MBBS 170

• Indication

• Large size (cosmesis/patients wish)

• Recent rapid increase in size (sarcomatous change)

• Symptomatic naevo/neurolipomas

• causing pressure symptoms based on site.

TONY 2010 MBBS 171

• Surgical procedures• Incision: A linear incision over the summit of the swelling is placed and flaps raised

on both sides of the incision.• Layers opened: skin and some part of the subcutaneous tissue till the capsule of the

swelling is encountered.• Dissection : using an artery forceps or a moquito forceps( if a small swelling) , a plane

is created between the raised flaps and the capsule of the swelling.Pressure is given at the base of the swelling to deliver out of lipoma.A small vessel may be encountered as the base is being dissected that should be identified and cauterised or ligated.The specimen should be sent for hisptopathological evaluation.

• Closure• The cavity left after the excision can be closed by few interrupted vicryl sutures to

close the subcutaneous layer. The excess skin is removed. The skin is closed with 2.0 ethilon vertical mattress suture. Sometimes a drain may have to be kept to drain the cavity.Remove suture after 7-10days.

TONY 2010 MBBS 172

Excision of sebaceous cyst

TONY 2010 MBBS 173

• Indication : Infection , cosmesis

• Surgical procedure: • Elliptical incision around the summit of the swelling encircling the punctum.• Layers opened:• Incision should be superficial. Care should be taken not to cut open the cyst wall.• The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of

the surrounding skin around the punctum.• Dissection • A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.• An Allis forceps may be applied to the punctum and the elliptical skin to get a traction. Flaps need

to be raised gradually on either sides of the incision and then deliver the cyst in toto.(huh?)• If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst

wall in piece meal is made.• Closure: Single layer closure of the skin. suture removed after 7-10 days.

TONY 2010 MBBS 174

Thanks to

• Our Teachers • Noufal T B• Wajidha P K• Tintu Rose Thomas• Swathikrishna Babu• Vivek Krishna M S• Tariq Navas• Thomas John • Thouseef Muhammed K M• Umbing Mudang

TONY 2010 MBBS 175