General Principles

Incisions & Closures

Purpose of incision

·  Access

·  Optimise healing

·  Good cosmesis

Additional considerations:

·  Neurovascular structures below incision line which may be injured

·  Previous wounds which may impede blood supply to wound (parallel linear wounds render separated tissue inschaemic)

·  Relaxed skin tension lines

·  Avoid multiple cuts into fat (risk of fat necrosis)

Specific Incisions

·  Transverse: (1) muscle cutting (2) muscle splitting

·  Midline: "incision of indecision" rapid access, minimal blood loss, easy closure

·  Kochers

·  McBurney/gridiron

·  Lanz

·  Rooftop

·  Paramedian: take longer to form, close, higher risk of blood loss, low complication rate

·  Suprainguinal (Rutherford-Morrison)

·  Inguinal

·  Pfannenstiel

Principles of wound closure

·  Edges should be in good apposition (with slight gaping to allow for swelling)

·  Wound edges should be everted

·  Minimal suture material should be used to secure wound

·  Knots should be secure, to one side of wound and easy to remove

Closure options

  1. Heal by primary intention
  2. Heal by secondary intention +/- VAC, large surface area wounds, large cavitating wounds
  3. Delayed primary closure
  4. Steri-strips
  5. Tissue glue
  6. Skin staples
  7. Sutures

o  Subcuticular - good cosmesis, suitable for clean linear wounds

o  Simple interrupted

o  Vertical mattress

o  Horizontal mattress

Pre-operative preparation

Pre-Induction

·  Identify patient, operation, site, side, starved, allergies

·  Check blood available

·  Check investigations

·  Check imaging

Removal of body hair

·  Remove from operative field

·  Allow for clear surface for application of dressings

·  Perform on morning of surgery

·  Care to avoid cuts/abrasions

Skin preparation

·  Apply to operative field with wide margin (in case need to extend incision)

·  Start at focus and move around

  1. Chlorhexidine (0.5%)
  2. Alcoholic betadine (1% povidine in 70% alcohol)

Field Draping

·  Sterile linen drapes

·  Disposable fabrics (impermeable and waterproof), expensive

·  Polyurethane incisible drapes (clear stuff) used in orthopaedics/vascular, general surgery - limited by cost

Trauma / ATLS

Management of Trauma

Urgent and competent assessment of trauma
Treat life-threatening injuries first
Improve survival and outcome in "golden hour"

  1. Primary Survery

o  Airway

o  Breathing

o  Circulation

o  Disability

o  Exposure, temperature control

  1. Monitoring

o  ECG, Pulse oximetry, BP

o  Urinary catheter (unless contraindicated)

o  NGT

  1. Radiology

o  CXR

o  Lateral C-spine

o  AP Pelvis

  1. AMPLE history -Allergies, Medications, Past medical history, Last meals, Events surrounding injury
  2. Secondary survey

o  Full head-to-toe assessment

o  Can be delayed until all life-threatening injuries have been dealth with

Surgical Equipment

Scalpel Blades

10 - General use
11 - Pointed, for arteriotomy
15 - Smaller minor ops
22 - Big mother
23 - Curved

Scissors

Mayo's: curved dissecting scissors
McIndoe
Pott's (for arteriotomy)

Stitch cutter

Clips

Mosquito
Dunhill
Roberts (big ones)
Spencer-Wells

Forceps
DeBakey's
McIndoe's
Babcock's

Retractors

West self-retaining
Travers
Norfolk & Norwich - Big self-retaining

Langenbeck
Devers retractor

Senn retractor (cat's paw)
Hohmann's

Breast & Endocrine

Adrenalectomy

Indications

·  Phaeochromocytoma

·  Adrenal carcinoma / adenoma

·  Non functioning incidentaloma > 4cm in diameters (risk of malignancy)

·  Failure of medical therapy

Considerations (if for phaeochromocytoma)

- Alpha blockade (doxazosin)
- Beta blockade (atenolol)

Right adrenalectomy

  1. Supine + GA + Prepare/drape
  2. Transverse supra-umbilical incision made with upward convexity
  3. Access adrenal gland

o  Mobilise right colic flexure, retract downwards, retract liver upwards

o  Incise posterior peritoneum above level of upper pole of right kidney

o  Expose IVC, right adrenal gland

  1. Dissect / remove adrenal gland

o  Separate from kidney and perinephric fat / fascia

o  Dissect off IVC

o  ligate vessels

o  Dissect out

  1. Ensure haemostasis
  2. Close wound in layers

Post-operative considerations

·  30mg po hydrocortisone/day

·  Fludrocortisone 0.1mg/day

Breast disorders

Development / anatomy

·  Modified sweat gland

·  2-6 ICS; sternum to AAL

·  2/3 on pectoralis major, 1/3 on serratus anterior (with axillary tail of spence)

·  Condensation of fibrous tissue forms suspensory ligament of cooper (supportive framework)

·  Blood supply

  1. Axillary artery (2nd part, lateral thoracic arter)
  2. Internal thoracic artery
  3. Intercostal arteries

·  Nerve supply

  1. Intercostal nerves T4-T6

·  Lymph drainage

Axillary nodes - 75%

  1. Level 1: lateral to pectoralis minor (14 nodes)
  2. Level 2: posterior to pectoralis minor (5 nodes)
  3. Level 3: Medial to pectoralis minor (2-3 nodes)

Internal mammary - 25%

[Anatomy of axilla]

Congenital / Developmental disroders

·  Athelia / Polytheli: absence / many nipples

·  Amastia: Absence of breast

·  Polymastia: accessory breast

·  Amazia: Absent of breast with nipple present = hypoplasia of breast (90% associated absent/hypoplastic pectoral muscles; ~Poland syndrome)

Gynaecomastia

·  Abnormal breast enlargement

  1. Female
  2. Male

o  Physiological: neonatal, pubertal hormone imbalance

o  Pathological: hypogonadism, neoplasms, drugs - cimetidine, spironalactone, ketoconazole, digitalis, oestrogens

Aberrations of normal breast development and involution (ANDI)

Tumour / Pathology / Features / Management
Fibroadenoma / ·  Aberation of development; 15-25 years
·  Develops from single lobule of breast (rather than single cell)
·  Hormone dependance (lactating during pregnancy, involuting in peri-menopausal period) / ·  Well circumscribed smooth firm lump
·  May be multiple/bilateral / ·  FNA/Biopsy
·  Mammography / ultrasonography
·  Rx: Reassure / remove if large >2cm on request
Phylloides Tumour / ·  Arise from peri-stromal tissue
·  40-50 years
·  More common in African countries / ·  FNA / Biopsy
·  Rx: Complete excision - risk of recurrence
Cystic disease / ·  Common 35-55 years
·  Macrocysts ~7% women in West
·  Unknown cause / ·  Discreet, smooth lump, may be fluctuant (like all cysts) / ·  Aspirate fluid
·  Mammography if > 35years
·  Rx: Excision biopsy
Sclerosing leions / ·  Aberration of involution - sclerosing adenosis, papillomatosis, duct adenoma / ·  Radial scars present via screening
·  Potential underlying breast cancer / ·  Mammography + excision biopsy
Epithelial hyperplasia / ·  Epithelial cell increase in terminal duct lobular unit
·  Common pre-menopausal women
·  If atypia plus hyperplasia increased risk of breast cancer
·  Atypical ductal or lobular cells x4-5 greater risk of breast cancer / ·  breast lump / ·  FNA / NCB
·  Rx: Excision biopsy + screening (increased risk of breast cancer)

Breast pain / inflammatory lesions

Pathology / Features / Treatment
Mastalgia / Cyclical Mastaliga
·  Young women (Any age up to menopause)
·  3-7 days pre menstrual cycle
·  Improves at menstruation
·  Usually lateral part of breast affected / ·  Weight loss
·  Supportive bra
·  Evening primrose oil
·  NSAIDs
Non-Cyclical Mastalgia
·  Older women (45+) / ·  Supporting bra
·  Weight loss
Breast abscess / Lactating
·  Mastitis neonatorum - first few weeks of life
·  Infected enlarged breast bud
·  Caused by s.aureus / e.coli / ·  Rx: Antibiotics / I&D
Non-Lactating
1.  Peri-areolar
o  Complication of periductal mastitis
o  More common than lactating breast abscess
o  35yrs
2.  Peripheral
o  Ass: DM, RA, Steroids, trauma
3.  Periductal mastitis
o  Bacterial / cigarette smoking / AI basis
Complications of Abscess
1.  Duct ectasia: dilatation without inflammation
2.  Duct fistula: - / ·  Nipple discharg
·  Breast pain
·  Retraction / inversion / ·  Antibiotics
·  Aspiration
·  I&DS

Benign Neoplasms

Duct papilloma / ·  Common
·  Single / multiple / ·  Usually small, symptomless
·  Bloody discharge if duct involvement / ·  Mammography, ductography
·  Rx: Microdochectomy
Lipoma / ·  Soft lobulated radiolucent lesion

Nipple discharge

  1. White = Milk: lactating breast (physiological / prolactinoma)
  2. Yellow = Exudate: abscess
  3. Green = Cellular debris: duct ectasia
  4. Red = Blood: ductal papilloma or carcinoma

Determine whether single or multiduct (not usually pathological except in hormone producing endocrine tumours)

Mangement

  1. Haemo-stix
  2. Cytology
  3. Mammography / USS
  4. Ductography / ductoscopy (washings can be taken for cytology)

Breast Cancer: Aetiology & Clinical features

Risk factors: OESTROGEN EXPOSURE

  1. Age
  2. Early menarche, late menopause, nulliparity
  3. Diet / obesity (fat turned into oestrogens/phyto-oestrogens)
  4. Drugs: OCP, HRT
  5. Smoking
  6. Family history + Genetics: BrCa1 (17q), BrCa2(13q)

Linear increase with age

Clinical features

  1. From the lesion

o  Painless breast lump +/- lymph node involvment (I-III; relative to pec. minor)

o  Hard lump with poorly defined margins

o  Skin tethering or fixation to underlying structures

o  Pain / skin ulceration "peau d'orange" - due to involvement of suspensory ligaments of cooper

o  Nipple discharge / retraction

  1. Systemic features

o  Weight loss

o  Ascities

  1. Features of spread

o  Bone pain / pathological fractures

  1. Paraneoplastic manifestations

Diagnosis

  1. History (including risk factors)
  2. Examination - "Triple assessment"
  3. Investigations:

o  Blood tests: Tumour markers Ca 15-3 (mucin marker)

o  Imaging: Mammography, Ultrasound (if young pair of titties)

  1. Tissue diagnosis

o  FNA / NCB - 95% pre-operative diagnostic sensitivity

FNA Cytology / NCB Histology
C1 - Inadequate
C2 - Benign
C3 - Equivocal
C4 - Suspicious
C5 - Malignant / H1 - Normal
H2 - Benign
H3 - Equivocal
H4 - Suspicous
H5 - Malignant

o  Excision biopsy

Pathology

  1. Epithelial cell origin
  2. Non-invasive

§  DCIS - cured by total mastectomy

§  LCIS

  1. Invasive

§  Ductal carcinoma: 80-90% (NB Paget's disease of nipple = Ductal carcinoma involving epidermis; starts at nipple with some evidence of destruction)

§  Lobular carcinoma: 1-10%

§  Mucinous 5%

§  Medullary 1-5%

§  Metaplastic

  1. Connective tissue origin

Prognostic indicators

  1. Node positive = <20% survival
  2. High Grade (1-well, 3-poor)
  3. Size
  4. Vascular invasion
  5. Oestrogen receptor: based on H (histochemical score) out of 300

o  H Score > 50: Receptor positive

o  H Score < 50: Receptor negative

Nottingham Prognostic Index (NPI)

NPI = Size (in cm) x 0.2 + Grade (1 - 3) + Stage (Lymph node)

NPI < 3.4 - excellent: 15y 90% survival
NPI > 5.4 - poor: 15 8% survival

Grading

Bloom & Richardson grading system

Based on tubule formation, nuclear pleomorphism ("many different forms"), and mitotic activity

  1. Grade 1: Well differentiated
  2. Grade 2
  3. Grade 3: Poorly differentiated

Tissue Staging

·  TNM system

T - Tumour / N - Node / M - Metastasis
0 / Subclinical / No nodes / No mets
1 / <2cm / Ipsilateral axillary (mobile) / Distant mets
2 / 2-5 / Ipsilateral axillary (fixed)
3 / >5 / Ipsilateral mammary
4 / Any size with (a) chest wall or (b) skin extension

·  Manchester system / Columbia system

TNM / Manchester / Columbia
- T1
- N0-N1 / Stage 1
o  Confined to breast < 5cm
o  With or without skin involvement / Stage A
T2N1b / Stage 2
o  Confined to breast <5cm
o  Nodes involved but not fixed / Stage B
T3-T4
N2-N3 / Stage 3
o  Locally advanced disease >5cm
o  Affects underlying muscle/overlying skin or fixed lymph nodes / Stage C
M1 / Stage 4
o  Distant metastatic disease (lung, liver, brain, bone) / Stage D

Managment

  1. Diagnose

o  Triple assessment: high positive predicitive value and prevents erros in diagnosis

  1. Stage disease
  2. Good cosmesis
  1. Surgery

o  WLE / Quadranetectomy / Segementectomy

o  Remove tumour + adequate resection margins (>5mm margins)

o  Adequate skin flaps for cover

o  Breast reconstruction: pedicled flaps, free flaps (DIEP)

  1. Axilla

o  Level II (up to medial border of pec minor) clearance accepted as best balance between adequate staging and morbidity

o  Sentinel node technique - finds first draining node (technetium + blue dye); contra-indicated in pregnancy [NB also has use in melanoma and penile cancer]

o  Morbidity: haematoma, wound infection, seroma, lymphoedema, intercostobrachial neuralgia, injury to thoracodorsal nerve, long thoracic nerve injury, axillary vein injury, brachial plexus injury, post-op frozen shoulder

  1. Hormonal therapy

o  1st Line: Tamoxifen (Selective oEstrogen Receptor Modulator (SERM)) - reduce circulating oestradiol

o  2nd Line: Aromatase inhibitors (Anastrazole[Arimadex], fromenstane, aminogluthethimide) - block oestrogen via aromatase pathway

o  LHRH antagonists (Goserelinp [Zoladex] - prevents oestrogen production by ovaries

o  3rd Line: Progesterone

  1. Chemotherapy
  2. Antimetabolites (impair production of DNA):5-FU, Methotrexate
  3. Vinca alkaloids (inhibit microtubule formation): Vincristine, vinblastine
  4. Alkylating agents (bind to and disrupt DNA): Cyclophosphamide
  5. Platinum-based agents

Radiotherapy

Follow up

  1. Early detection + treatment of recurrence

o  Local recurrence: - single spot,

o  Regional recurrence: axilla, brachial plexus, supraclavicular nodes

o  Distant mets

  1. Early detection of metastatic disease
  2. Psychiatric morbidity

Excision of a breast lump

Indications

·  Benign lump

·  Possibly malignant lump

Procedure

  1. Fix lump between finger and thumb
  2. Incision made circumferentially if close to nipple, radially if placed distally
  3. Grasp lump with forceps and retract out of wound
  4. Expose interior of cavity and diathermy bleeding points
  5. Obliterate cavity +/- suction drain
  6. Close skin with subcuticular stitch

Complications

·  Haematoma

·  Distortion of breast architecture

·  Recurrence of lump

Fine Needle Aspiration (FNA)

Procedure

  1. Explain to patient
  2. Sterile field
  3. 21G needle, syring + 2ml of air (for explusion of contents)
  4. Prepare slides
  5. Fix breast lump
  6. Pass needle through lesion in several directions maintaining suction
  7. Release suction, withdraw needle
  8. Air used to blow out cells to slides
  9. Label slides and send to your friendly histopathologist

Microdochectomy

Indications

Persistent blood-stained discharge from single duct opening on nipple

Procedure

  1. GA/LA
  2. Identify duct

o  Squeeze breast until drop of discharge seen

  1. Cannulate duct

o  Use lacrimal probe and secure in place

  1. Incise skin along line of probe, encircling duct orifice
  2. Dissect skin of areola away from breast tissue (for 1cm)
  3. Excise breast segment
  4. Secure haemostasis with diathermy + approximate breast tissue with interrupted absorbable sutures.

Modified Patey Mastectomy

Indications

Cytologically proven breast carcinoma

Preparation

GA
DVT prophylaxis
Supine position + arm on armboard

Procedure

  1. Mark boundaries for skin incision

o  At least 3cm from tumour

o  Anatomical markers - medially: sternum / laterally: lat dorsi / superiorly: 2cm below clavicle / inferiorly: 1-2cm below infra-mammary fold

o  ?? Excision should include nipple/areolar complex

  1. Dissect lump

o  Incise skin

o  Develop flaps (use clips/retractors) in plane corresponding to Scarpa's fascia between the subcutaneous fat and mammry fat - aim for thickness of 3-4mm medially increasing to 6-8mm laterally

o  Approaching clavicle superiorly, dissect more deeply to pectoral fascia

o  Raise inferior flap

  1. Dissect axilla: - obtains regional control of disease, establishes prognostic information

o  peel breast laterally until border of lat dorsi

o  retract pec major to expose pec minor

o  divide pec minor (close to point of insertion onto coracoid process)