7 Wonders PE in Surgery 1. Breast 2. Thyroid 3. Hernia 4. Stoma 5. Vascular: - Varicose veins - Periphery Artery Ex 6. Lumps n bumps 7. UlcerBreast Examination Introduction, Permission,Positian: 45 degree, Comfort Exposure: Shoulder, axilla , chest up till umbilicus Inspection Both arm relax at the side of body : Look form nipple to areola and the whole breast Call patient to place hands behind head: Nipple line is it parallel? Inspect axillary area for swelling. Comment, Nipple : Retracted, Discharge Areola: Ulcer, Eczematous Breast: Symmetrical, Describe any lump seen ( site, size, colour, uleer, discharge), Surrounding skin ( Peu’d orange, skin dimpling, discoloration) Surgical scars axilla: any lumps Supraclavicular : any lumps Upper limb : lymphedema Palpation: (wear gloves if gat ulcer) Start from normal breast Go by quadrant then examine another breast. If got lump proceed : Site, Size, Shape, Consistency, Margin (well define), Surface ( Smogth/ irregular), Mobility then check fixation. For fixation, call patient to puts hands on hip and press dawn to-contract pec major. (if cannot move oblique after contract then fiz to pec major ; if vertical and oblique both restricted then fix to Pec major and intercostal muscles) Examine both axillary tail. Apical, central, anterior, posterior then change hand feel lateral (Or prefer after palpate left breast palpate left axilla) Palpate Supraclavicular n infraclavi LN Complete my PE with checking signs of Mets: Palpate spine and ribs tenderness Ausculatate n percuss pleural effusion Abd PE - hepatomegalyDiscussion Differential Benign: Fibroadenama Fibroadenacyst Breast cyst. Trauma: fat necrosis, Infection- Abscess, Mastitis If huge: Giant fibroadenoma Phylloides Malignant Breast CA Malignant phylloides Paget;s Dz if nipple eczematous or ulcerated Investigations: A) Tripple assessment 1. Hx PE 2. Imagin: WIS <40 yo Mammogram 40 yo 3. Histopathology FINAC Core biopsy: trucut ( note: good way TRO malignant phylloides with fibroadenoma. Ratio mesenchyme: Epth. Phy more mesenchyme) Incisionat Excisional - if non malignant Punch biopsy of skin- if inflammatory breast CA, B) To Stage CT Thorax and abdomens save cost doing CXR Looks for MetsBREAST EXAMINATION: (VV) _ Exposure+Positioning: Tell the examiner: | would like to undress the patient. -Proper exposure is from the shoulder, axilla, chest and up till umbilicus. Proper positioning: 45degree. (if lie down, pendulous breast may fall sideways) 1, Inspection: Should start fram nipple>areola>whole breast Nipple: Patient's left nipple looked retracted. There is ulceration seen, with some bloody ischarge. The right nipple looked normal. Ask patient to put her hands behind her head: comment on the level of nipple. Eg: the nipple was not located on the same line as the left nipple appeared higher compared to the right. ‘Areola: Both areola looked normal without eczematous changes. (may indicate Paget's dz of breast ‘if presence of eczema) ‘Whole breast: There is a visible lump seen at the lower inner quadrant on the left breast. Measured about 2x2em in size, round shaped. The overlying skin looked tense and bluish discoloration, however no ulceration seen over the lump. Skin retraction was noted. Otherwise, there is na peau d’orange, ne skin dimpling, no skin discoloration, no surgical scar seen ‘over the breasts. -Axilla: There is no visible lump seen in the axilla. ‘Supraclavicular area: No prominent lump seen on the supraclavicular region. UL: No swelling of upper limb. (lympoedema) 2. Palpation: Use one hand to support the breast when palpating. Always start from the normal breast as each person has diff breast consistency, Also don’t want to contaminate the normal breast if the diseased breast was ulcerated. if gat ulceration snust wear glave!! ‘Start from outer upper Qoauter lower Q>inner upper Qoinner lower QoAxillary tail!!! Palpate in circular mation. Then, ask the patient to put hands on hip ta contract Pect Major, to assess for muscle fixation. -Eg; There is a breast (ump palpable at the inner lower quadrant of the left breast. Measured about ‘bcm in size, round shaped, with hard consistency. Surface was irregular, with ill-defined margin. It ‘was fixed to the skin. During contraction of Pect Maj, mass was mobile at all direction(ne fixation) / the mass was able to move vertically but not obliquely/fixed to pect maj)/ mass was fixed at both vertical and oblique directiontinvade into Pect Maj and intereastals ms). 3. Axillary lymph node palpation-check for apical grp, central grp, anterior erp, posterior erp and lateral erp. “Lateral grp is located at the starting point of forearm, 4. Supraclavicular & infraclavicular LN palpation ‘Sit up the patient, then stand behind the patient. Ask pt to shrug her shoulder, then palpate for supraclavicular LM Comment on size of LN and fixation 5. Complete examination palpation for spine & ribs tenderness{bone mets) -auscultate lungs for pleural effusion -abd examination for hepatomegaly Provisional diagnosis: Malignant left breast tumor, most possibly Invasive Ductal Carcinoma. DDx: Invasive Lobular Carcinoma, Paget's disease of the breast, malignant phylleides tumor lnvasive tobuilar Caz -usually presented as multiple Lumps. in 1 breast or multiple Lumps in both breasts Paget's disease of the breast ‘Histology: intraductal carcinoma in stu, usually starts under the nipple and tumor spread upwards Management: Triple assessment 1. Clinical: History & PE : Mammogram or ultrasound nt is 60yo, mammogram is better as less dense breast tissue so can visualize lumps 3. Histopathology: FNAC To look at cytology and progesterone/ estrogen receptors and c-erb. Other than FNAC, what other options for this patient? Incisional biopsy of the nipple: bez nipple appear ulcerated, suspect Pagets! will only app as scattered microcalcification under the nipple. Punch biapsy af the ski if inflammatory breast Ca Core biopsy: TRO malignant Phylloides tumor(FNAC not accurate to calculate ratio of mesenchymal cells vs glandular tissue. Phylloides is confirmed by mare mesenchyme compared to glandular) “core biopsy also dane in advanced breast Ca when there is a need to start negadjuvant before surgery, $0 need to determine the receptor status to decide whether can give hormonal therapy.‘Staging: 1. CXR: to look for pleural effusion, cannon ball lesion, osteolytic lesien an ribs/spine. 2. CT of abdomen For this patient: T4 NO Mx (bez tumor fixed to muscle, no LN affected, we didn’t know distant mets yet bcz haven't done cxr or ct scan) Management 1. Surgery {is the mainstay!!!) Depends on staging of the patient: size of Ca, affected LN. Gold standard: Modified radical mastectomy with level 2 axillary clearance. Modified radical mastectomy(Preserve both Pect maj and pect minor} -Patey mastectomy(preservation of Pect Major, remove Pect Minor) Halsted mastectomy(no preservation of Pect Major or Pect minor) Simple mastectomy(only remove breast tissue).Indications: giant fibroadenoma, phylloides tumor, male gynecomastia. Lumpectemy: enly remove the breast lump. -Wide local excision: remove the lump with at least cm rim of healthy tissue. “However, for phylloides tumor mz remove 3em rim of healthy tissue bez of pseudopads, high risk of recurrence. 2. Chemotherapy for systemic destruction of Ca cells if there is mets FAC: 5-fluorouracil,adriamycin,cyclophosphamide -or TAC: docetaxel, adriamycin, cyclophosphamide 3. Radiotherapy To destroy local remaining Ca cells. Done after BCS, hence if C/I far radiotherapy also cannat do BCS. Hormonal therapy +2 types: SERM or aromatase inhibiter SERM (eg Tamoxifen) for premenopoausal “act locally at breast,x affect estrogen production and action on other place -aromatase inhibitor(eg aromasin/arimidex/femara) for postmenopausal “act systemically to block conversion frm androgen to estrogen 5. Biological therapy -Eg Herceptin® { Transtuzumab) ‘only works when breast ca cantains ¢-erb3 components : 1. Neck 2. Peripheral - Thyroid status 3. Metastasis if necessary, Introduction Permission. Sitting position. Exposure. Comfortability Prepare a cup of water if possible. Inspection Inspect from infront, ask patient to swallow and protrude tongue. However if diffuse huge swelling, unlikely ta be thyroglossal cyst. Hence better skip tongue protrusion if get Dr KH. Comment is it Solitary ¢ Multinodular f Diffuse swelling Located at ..anterior part of neck Extending from ..left to right SCM Moves on swallowing/ protrusion of tongue ‘Any surgical scar - collar incision Skin discoloration Dilatation of veins Ulcer Palpation: walk to the back of patient, Stabilize on the left side and palpate the right side. Drink water and swallow on instruc Palpation the other side. Go in front of patient to measure the size and palpate the trachea. Comment: Temperature tenderness Single Multiple swelling palpated Diffuse/MN/Solitary at anterior part of neck Extension from.. . Size of cm. Moved on swallowing Consistency: hard firm, soft Margin -well demarcated? Border- able to get abv and below MobilityFixation Palpate Lmph node: Submental - submandibular - pre-suricular - postauricular - occipital - jugular nodes - anterior and posterior - supraclavicular Papate Carotid Pulse (Never palpate both together ) Berry’s sign posititive if unable to felt carotid pulse AN 3 direction even if lower border is felt as it can be a dumb bell shape/ Thyrothymic tumour Pereu: Ausculatation: either d2 atherosclerosis or infiltration. Area of carotid pulse for bri 1. Voice any hoarseness er changes 2. Patient look irritable? Anxious? 3. Palm- sweaty/warm 4. Pulse» Tachy, AF 5. Tremor - place paper 6. Check proximal myopathy - shoulder abd 7. Biceps reflex Eye signs: Lidlag Lid retraction Opthalmaplegia Exopthalmos. Diplopia Lower limb- pretibial myxedema Part Il; Mets: Check if gat signs of malignancy- Lymphadenopathy, hoarseness Spine tenderness- palpate along vet spine using thumb til upper Lumbar. Ribcage tenderness. Lung Abd PE- hepatomegalyDifferential Diagnosis Multinodular goiter can no need differential Diffuse: Physiology : Pregnancy, Puberty Grave's Dz - Dermato, Opthalmo. Thyrotoxicosis, Hashimoto Thyroiditis Solitary: Thyroid adenoma Simple thyroid cyst Dominant nodule of MNG Colloid’ Hyperplastic goiter Thyroid CA lovestigations: Blood: TFT : T4, TSH {if abnormal only do-T3) Imaging: UJS - calcification, hyperechoic Neck Xray » AP and Lateral view. Look for trachea deviation, retrosternal extension FINAC [ grave’s na need) Indirect laryngoscopy - check vocal cord status b4 op. CT scan - If Multiple LN, If stridor ( Long term compression will lead to tracheomalacia- may need tracheostomy after thyroid removal) Thyroid radionucleotide an rarely used: unless solitary ‘Treatment: Pharmac Antithyroid drug: Carbimazole, PTU 6-blocker Block and replace regime Surgical Total thyroidectamy Hemi-thyroidectomy SubtotalLobectomy Radigactive iodine therapy lndicotions of surgery: Malignant - hard nodule, Berry sign +ve, cervical lymphadenopathy Obstructive Sx- Dysphagia, Strider Grave's that failed medical therapy Cosmetic Surgery of choice: Total - Malignant ( must total only can do future radioactive therapy), MNG Semi - if FNAC result is follicular lesion then do a hemi-thy to look for vascular and capsular invasion. If got then is follicular CA need Total thy. If is benign then still got half left. Complications: Early: Haemorthage Laryngeal edema Thyrotoxicosis Late: HypoPTH- HypeCA- Troussier;s and Chovtek's sign External/ Recurrent laryngeal nerve damage : Temporary or permemnent Long term: HypoTH Recurrent thyrotoxicosis Motes: HypoCa Temporary: < 6 months due to devascularize or denervation to parathyroid gland Permanent Hoarseness of voice Temporary: Laryngeal edema ( first few days}, Neurapraxia { 6 months} Permanent; Total transaction of nerve Take note: Papillary CA- tends to spread to LN Follicular CA. Thru haematogenous to bone, lung, liver { Fram Dr IKH teachine. Octaher 2092)(FROM Dr inte TEBCring, UCKODEr SUES) Hernia Examination Ques: Examine the groin of this patient Intro, permission, position( supine first if already obvious ) , Exposure, Comfort, Wear glove Inspection Describe any swelling seen : L/R, site( above or below crease of groin if can see) , shape, extend to scrotum Flip up scrotum to look at ventral surface. Skin disceloration, ulcers, dilated veins( more prominent on standing) Ask patient look to side and cough Palpation: Feel normal side first. Feel for scrotum content Feel the swelling Temp( if wear glove no need comment), tenderness Can or cannot get above Feel scrotum content. Is the swelling separate from the testis, Extension, Shape, Size, consistency Cough Impulse again. Look and feel Reducibility: Ask patient to reduced the hernia. If cannot may ask permission to reduced it. One way is by flexing the hip. If able to reduced - Deep ring Occlusion test (1.25 cm above mid inguinal ligament) Translucency test ( depends) Standing-Can ask permission to stand up with purpose of: 1, To make the hernia more prominent so as to know the true extension 2. To look for varicocele 3. To look far Contralateral hernt (no need if on catheter or inconvenient for pt) Percussion As it may cause discomfort and pain to pt ask examiner can we skip and do auscultation as this can also determined is it a bowel Auscultation Complete Ex DRE: lock for enlarged prostate ‘Abd PE: look for scars, palpate for mass that may cause increase intrabd pressure Respi: Signs of COPDDiscussion: Differential Diagnosis Inguinoscrotal swelling 1. Inguinal hernia 2, Lipoma of the cord 3. Hydrocele of the cord Scrotal swelling 1. Feel scrotum content 2. Translumination test 3. Tenderness. Testis, epididymis not definable Testis, epididymis not definable Opaque: Translucent Opaque Translucent Tender: Tender: Test torsion Vaginal Hydrocele | - Acute Epididymo- Cyst of epididymis Severe epididyma- ochitis ochitis Acute haematocele Non tender: ~ TB epididymis Not tender: + Test Tumour Chronic haematocele » Tumour Gumma Notes: ‘Mid Inguinal ligament iid point between ASIS and p.tubercle Mid inguinal point :Mid point between ASIS p symphysis Complications hernia : Strangulation causing bowel ischemia, obstruction - e imbalance Complications of surgery: Early : scratla haematoma, Wound infection Late: Recurrence, chornic groin pain, testicular atrophy, injured iliginguinal nerve ‘Type surgery : ( Solve or remove the risk factors first) herniotomy( excise sac alone), hernioplasty(mesh patch to strengthen past wall of inguinal canal by forming fibrosis) , herniorrhaphy (suturing edges of healthy msc tissue together to repair weak spot.) Incisional hernia examination is the same. Scars that are more than 1 cm only need to check for cough impulse. Strongest structure when cutting midline laparatomy and strongest structure on appendicectomy- checkIn paeds the laparatomy is done transverse as their abdomen if open midline is smaller. Proportion of abd is different in children.‘Stoma Examination It is a part of abdominal PE. IPPEC same for abdomen PE. inspection: Same as abdomen then comment : I can see a stoma bag situated at which quadrant It isa transparent bag able to see a stama behind The stoma is flush to skin or sprout from skin Content of bag - Fluid, semisolid, solid fecal material Skin around: red,excoriation Others like skin, how many lumen# bleeding point can be examine after bag opened. Inspect n Palpation { Wear glove and open the drainage bag, prepare gauze n yellow bag) Inspection again and comment. Palpate from outward to inward te prevent irritative fluid from bowel to skin. Called patient cough to check parastoma hernia. 2 types reveal and consealed. Reveal is protrude even without coughing. Concealed is expulsion see nen coughing. Insert little finger with Lubricant gel and put inside lumen. Is it single/ double. If 2 lumen try ta seperate them. If cannot it is a loop ( HUSM didn’t do nowadays) / if can separate is a double barrel. Any stenosis. Comment, Inspection : stoma complications ‘Skin erythema/ irritation “Stora prolapsediprotruded bowel) “Stoma retraction Parastomal hernia(ask pt to cough: either concealed/revealed) Parastomal abscess. Fistula Tenderness - parastomal abscess Stoma mucosa- No contact bleed How many lumen - if 2 lumen can be double or loop colestomy, if one Lumen - endcolastomy. Percuss: NIL Ausculatate bawel sounds. Complete the examination with * Digital rectal examination: -If end colostomy for post-APR: absence of anusee If Hartman's procedure: anus still patent If paediatric patient: assess anal tone(Hirschsprung's dz) and anal patency(imperforate anus) * Look at urine I/O chart, BUSE: to prevent fluid electrolyte imbalance. Discussion Ini functonin: 1. Presence of vapour / distended with gas 2. Content 3. Bowel sound present? Common Causes of stoma Paeds: ( All belows are temporary) 1. Hirshprung 2. Imperforated anus 3. Anorectal swelling 4, TB colitis lead to TB peritonitis as anastomosis cannot be done immediately 1. Hartmann procedure 2. 10 to divert fecal 3. Rest bowel after dissection ( defunctioning) 4. Perineal injury: perianal abscess, severe pelvic fractures 5. Permenant stoma : APR Why sometime ileostoma can be at LIF: As don’t want to cross a midline laparatomy sear If there are lots of adhesion at te right side Why transverse colostomy done at Right hypechondriac region? As.there are anchoring from hepatic flexure, can prevent protrusion of stoma. (less impact by peristaltic movement as fram flexure to stoma not too long. The longer it is the more changes of protrusion of stoma?) When can we anatomose immediately withaut a defunctioning stoma? If large bowel anastomose to large bowel then in HUSM will do covering/defunctioning stoma . As blood spupply to Large intestine not as good as small int. so give time for healing to occur. Loopegram done to look at anastomotic site. See any stricture. If healthy can close back/ reverse the stoma. If ileum to colon then no need, Criteria of where to bring out the stoma:1, Away from bony prominence: ex ASIS 2. Able to seen by pat nt esp in obese pt- mark stoma site on patient lying and standing 3. Away from waist line or belt area in male 4. Avoid surgical scar 5. Avoid skin crease STOMA EXAMINATION (YW) 1. Inspection Location: Right hypochondriac(proximal transverse colostamy) Right iliac fossa(ileostomy/ileal conduit post-cystectomy) Left iliac fossa(end colostomy /Hartmann’s procedure /sigmoid loop colostomy) Content inside the stoma bag: Yellowish fluid(ileostomy) Semi-solid feces(colostomy) } indicate stoma +stoma bag is distended with gas & v4 is functioning! ‘If stoma located at left iliac fossa, but spouting of mucosa, with a laparotomy scar: ‘t can stile an ileostomy! Because patient may have adhesions post-Iaparatomy, causing difficulty te bring out and create the ‘leostamy on RIF, thus mobilize the bowel and do it an LI. 2. Offer to examiner that you would like to open the stoma bag Ask for: gloves, yellow bag, gauze. Describe what you see: Presence of spout(ileastomy) Bowel mucosa is flushed with overlying skin(colastomy) Number of Lumen: Single lumen(end calostomy), Double lumen (Loop or Double Barrel) If presence of 2 lumens, try to slide 1 finger between the 2 lumen: Continuity(Loop} Discontinuation of bowel(Double-barrel) Look for complications of stoma: Skin erythema/irritation Stoma prolapsed{pratruded bowel) Stoma retraction -Parastomal hernia(ask pt to cough: either concealed/revealed} Parastomal abscess. “Fistula‘Stoma stenosis(insert your gloved finger into the lumens to access for opening} 3. Complete the examination wit * Digital rectal examination: -If end colostomy for post-APR: absence of anus If Hartmann’s procedure: anus still patent, -If paediatric patient: assess anal tone(Hirschsprung's dz) and anal patency(imperforate anus) * Look at urine 1/0 chart, BUSE: ta prevent fluid electrolyte imbalance. NOTES ON STOMA. 1. Def: Stoma is a surgically created opening that connects a hollow organ to the outer skin 2. Indications: 1 Temporary: “Emergency procedure (Eg: Hart mann’s procedure done in the case of Rectosigmaid Ca presented with intestinal obstruction.) Defunctioning aka Covering stoma (Eg: Trephine transverse colostomy done after left hemicolectomy+primary end to end anastomosis in the case of colorectal Ca) Bowel rest (Eg: Laop colostomy done in the case of perianal abscess/pelvic fracture) Diversion (Eg: in acute 10 due to advanced rectal Ca, trephine sigmoid colostomy done to divert feces, then arrange patient for radiotherapy to shrink tumor, then only subject patient for surgery) ““Trephine colostamy is a type af loop colostomy. Need not to be dane as open laparotomy. Is minimally invasive procedure done only in emergency situation. Commonty created as proximal trephine transverse colostamy or trephine sigmoid colostomy. “Ileo-eolic anastamosis usually won't need covering stoma because small bowel has rich blood supply>faster heating» less risk of anastomotic risk. Hawever, anastomosis btw large bowel usually needs covering stoma because large bowel has poor blood supply. Permanent: -End colostomy (after Abdominal Perineal Resection follows rectal Ca or anal Ca) -End lleostomy(after panproctocolectomy follows Familial Adenomatous Polyposis)3. Criteria of stoma creation: i ii, iti iv vw ‘Away from surgical incision(risk of wound contamination+infection) ‘Away from bony prominencetpredisposes to leakage) Away from old surgical scars(risk of hernia) Easily accessible by patient(not hidden by abdominal fat} Avoid waist line(cause difficulty to patient to wear pants) Must have enough bowel mobilization(to prevent tension over the stoma>decreased vascularity stoma necrosis}By Dr Ikhwan 1. Inspection Usually starts when pt is in tying position, must property expose the patient from grain to whole lower limbs, -Tortuosity of vein in medial aspect of R/L leg. Healed sear along the course of varicose vein(indicate healed venous ulcer). “Any venous stars, ulcer, bleeding Inform your examiner that you would like to do inspection while patient stands. Then, ask your patient to stand up. Varicosity becomes more prominent, which extends from medial aspect of right foot, passing anteriorly to medial malleolus, ascends in medial aspect of leg, anterior aspect of upper thigh. ‘Ask pt ta cough: Look for cough impulse at saphenofemoral jxn(evidence of saphenous varix). 2. Palpation Any tenderness along the vein (indicate superficial thrombophlebitis) -Press the calf for tenderness(indicate DVT). Palpate along the vein for any blow-out{indicate the exit of perforators which connect the superficial vein ta the deep vein). 3. Percussion Venaus tap(you may skip this because doesn’t carry any significance). 4. Special test a) Single Tourniquet Test It’s similar as Tredetenburg Test, except in Tredelenburg we use our thumb to occlude saphenofemoral jxn(SFJ), but for single tourniquet we use a tourniquet to tie on upper 1/3 of thigh(just below the SFJ). Tredelenburg is less practical and harder to perform than Single Tourniquet Test because we need to locate the SFJ and difficult to acclude it by thumb. First step of Single Tourniquet test: ask pt to lie down. Then, elevate the leg to squeeze and empty the vein. With the leg elevated, tie the tourniquet at upper 1/3 of thigh. -Next, stand up the patient.Inspect: Any filling of vein when pt stand upz(indicate valve incompetency of perforatars) In this case, can proceed to Multiple Tourniquet Test to check which perforator is involved. -If the wein is empty even when patient stand up, try to release the tourniquet. Inspect: Any filling of vein from above to below?(indicate SFJ valve incompetency) b) Multiple Tourniquet Test -Will not ask you to perform, but may ask you to explain the technique and principle of this test. Similar as Single Tourniquet test, except we tie at 4 places: Upper thigh, above knee, below knee, above ankle. Ask pt to stand up, look at which column of vein is filled up. (indicate which perforator is involved). c) Perthes’ Test -Lie dawn pt, elevate leg, empty vein, then tie a tourniquet at upper thigh. Stand up the pt, then ask pt te walk in tip-toe for 3min, if patient feel pain over the leg, indicative of DVT. 5. Complete the examination with: Abdominal examination: TRO abdominal mass. Notes: Names of perforators: Hunter's perforator: mid-thigh Dodd's perforator: distal thigh Boyd's perforator: knee Cockett’s perforator: distal medial calf May's perforator: ankle (mneumonic: Hunter Destray Boy's Cock in May) Indications of surgical repair of varicose vein 1. Cosmesis 2, Complications: varicose ulcer/ bleeding 3. Symptomatic: feeling of heaviness over the affected leg Name of surgery: High saphenous vein ligation & stripping & multiple stab avulsion (HSVL+S+MSA) Things to rule out before surgery: DVT! Perthes" test should be negative, meaning no DVT. Because if pt has DVT, even after you repair the vein, blood still cannot drain upwards. Colour Doppler USG of deep vein, TRO DVT.