SRB’s Bedside Clinics in Surgery Sriram Bhat M
INDEX
A
Abdomen examination 143
Abdominal aneurysms 66
Abdominal compartment syndrome 33
Abdominal incisions 540
Abrahamson nylon darning 23
Abscess drainage 513
Abscess in special locations 513
Absorbable 491
Acinic cell tumour 265
Acquired AVF 234
Acrocyanosis 69
Acute arterial occlusion 62
Additional problems in large incisional hernia 33
Adenoid cystic carcinoma 265
Adenolymphoma 265
Adenoma of colon 297
Adrenal mass 206
Adson's test 42
Advanced CT methods 432
Advanced laparoscopic 539
Advanced ultrasound techniques 430
Ainhum 72
Air embolism 64
Airway 496
Allen's test 43
Allis' tissue holding forceps 453
Allison's lung retractor 462
Ambulatory venous pressure 79
Ameloblastoma 258
Amoeboma 208
Anaemia 4
Anaplastic carcinoma 168
Andrew's operation 23
Aneurysm needle 468
Aneurysms 65
Angiograms 426
Angiography 51
Annular type 306
Anterior tibial artery 44
Anthracycline regimes 112
Antibioma 130
Anticoagulants 89
Antisepsis 504
Antithyroid drugs 159
Antithyroid drugs 160
Aortic aneurysm 205
Appendicectomy 538
Appendicular abscess 207
Appendicular mass 207
Arm-foot venous pressure 79
Arterial diseases 40
Arterial/venous grafts 58
Arteriovenous fistula 233
Artery forceps 450
Ascending urethrogram 419
Asepsis 504
Assessment of voice change 134
Atherectomy 57
Auchincloss operation 113
Axillary abscess 514
Axillary artery 46
Axillary dissection 111
Axillary dissection/axillary clearance 111
Axillary nodes 111
Axillary sampling 108
B
Babcock's forceps 454
Backhaus' towel clip 449
Bacteria causing abscess 513
Bairnsdale ulcer 228
Bake's dilator 471
Ballet's sign 146
Bard parker's handle
Barium enema x-ray 407
Barium meal x-ray 403
Barium meal x-ray in duodenal ulcer 404
Barium meal x-ray of carcinoma stomach 405
Barium swallow x-ray achalasia cardia 398
Barium swallow x-ray of pharyngeal pouch 397
Basal cell carcinoma 242
Basic laparoscopic surgeries 537
Basic pattern of case sheet writing 2
Bassini's herniorrhaphy 21
Bassini's repair 19
Bassini's stitch 21
Bazin's disease 229
Bendavid classification 18
Benign gastric ulcer 291
Berliner modified shouldice repair 23
Berry's aneurysms 66
Bickford's bronchial clamp 464
Biological behaviour of carcinoma cheek 249
Bisgaard method 84
Bladder mass 208
Bladder neck retractor 461
Bladder sound 485
Bladder stone 348
Bladder tumours 354
Blood pressure 6
Blood spread in melanoma 345
Bone cutting forceps 497
Bone elevator/bone lever 498
Bone nibbler 498
Bone secondaries in carcinoma breast 122
Boomerang needle 485
Boston's sign 146
Bowel occlusion clamps 469
Branchial cyst 270
Branchial fistula 270
Branham's/nicoladoni's sign 43
Breast 91
Breast abscess 514
Breast conservative surgery 109
Breast implants 125
Breast reconstruction 123
Breslow's classification 244
Broder's classification 241
Brodie's fistula director 490
Brodie-trendelenburg test 74
Bronchoscopy 525
Buerger's disease 52
Buerger's postural test 41
Buerger's postural test 43
Bulldog clamp 451
Burkitt's lymphoma 239
Bursae 221
Buschke-lowenstein tumour 287
C
C shaped retractor 458
Caecostomy 530
Calculus of kidney 353
Calf musculovenous pump 87
Capillary filling time 42
Capillary haemangioma 231
Carbimazole 159
Carcinoid tumour 338
Carcinoma breast 104
Carcinoma breast classified 122
Carcinoma breast in pregnancy 123
Carcinoma breast in pregnant woman 123
Carcinoma caecum 207
Carcinoma cheek 249
Carcinoma colon 306
Carcinoma lip 252
Carcinoma of male breast 125
Carcinoma penis 285
Carcinoma stomach 293
Carcinoma thyroid 162
Cardiac tamponade 526
Cardiovascular system 142
Carotid body tumour 272
Carotid pulsation 141
Cat's paw 457
Catheter introducer 482
Catheters 479
Cavernous haemangioma 231
Ceap classification 86
Cell carcinoma of bladder 353
Cervical rib 269
Cervical sympathectomy 59
Cheatle's forceps 448
Cheatle's gallstone scoop
Cheek retractor 461
Chemical agents 504
Chemical sympathectomy 60
Chisel 499
Choice therapies 161
Cholangiography 424
Cholecystectomy 537
Cholecystectomy forceps 472
Circle of death 30
Circulating nurse 508
Circumcision 520
Cirsoid aneurysm 232
Clamp 472
Clip/forceps 449
Closed loop obstruction 364
Closure of colostomy 532
Clubbing 5
Clutton's dilator 484
Cold abscess 273
Cold abscess 515
Cold and warm water test 43
Colonic mass 205
Colostomy 531
Colostomy care 532
Columbia classification (haagsen, cooley and stout) 103
Common carotid artery 46
Compartment syndrome 62
Compound palmar ganglion 230
Compression 407
Condition age treatment 161
Confirmation of retrosternal extension 140
Congenital AVF 233
Congenital epulis 257
Conservative breast surgeries 115
Conservative treatment 79
Contraindication for surgery 82
Contrast agents 432
Cooper's ligament repair 24
Costoclavicular compression manoeuvre 42
Coumarin derivatives 90
Course of the disease 331
Courvoisier's law 199
Cowen‘s sign 145
Cricoid hook 475
Crile's method of palpation of gland 139
Critical limb ischaemia 50
Crossed-leg test 43
Crushing clamps 470
Cryosurgery 534
Cyanosis 5
Cyst of the epididymis 284
Cystadenocarcinoma 203
Cystic hygroma 271
Cystic swellings 100
Cysts 216
Czerney's retractor 457
D
Dalrymple‘s sign 145
Darning 23
De bakey's vascular clamp 452
Deaver's retractor 459
Deep vein thrombosis 87
Dental cyst 259
Dentigerous cyst 258
Depezzer's catheter 482
De-quervain's subacute granulomatous thyroiditis 171
Dermal flares 86
Dermatofibroma 239
Dermatofibrosarcoma protuberans 240
Dermoids 217
Diabetic foot and diabetic gangrene 71
Diabetic ulcer 228
Diagnostic laparoscopy 539
Diathermy 535
Differences between dental cyst and dentigerous cyst 259
Differences between paget's disease and eczema of nipple 101
Different abdominal incisions 540
Difficulties and complications in tep repair 30
Diffuse hyperplastic goitre 153
Diffuse toxic goiter 161
Digital subtraction angiography 52
Disappearing pulse syndrome 43
Diseases of the arteries 52
Disinfection 504
Disinfection 504
Disposable staplers 535
Dissecting aneurysm 68
Dissecting forceps 455
Dorsal slit of prepuce 522
Dorsalis pedis artery 44
Double hernia 36
Doyen's mouth gag 496
Doyen's retractor 459
Doyen's rib rasparatory 463
Doyen's towel clip 449
Drains 477
Dry gangrene 50
Duct carcinoma in-situ 121
Duct ectasia 130
Duct papilloma 130
Ductal lavage 107
Ductography 109
Duplex scan 78
Duplication of renal pelvis 421
Dupuytren's enterotome 490
Duties of circulating nurse 508
Dyshormonogenesis 179
E
Echosclerotherapy 80
Ectopic thyroid 179
Eczema 101
Edge biopsy 108
Elevated arm stress test 42
Embolectomy 63
Embolism 62
Endarterectomy 57
Endoscopic sympathectomy 59
Endotracheal tube 475
Endo-venous laser ablation 82
Enlarged spleen 205
Enroth sign 145
Enteroclysis 407
Epulis 257
Erythroplakia 248
Estrogen receptor study 107
Excision of the swelling 522
Exophthalmos 146
Eye signs only 147
F
Facial artery 46
Familial adenomatous polyp 297
Faraboeuf's rasparatory 463
Fat embolism 64
Fegan's technique 79
Fegan's test 77
Femoral artery 45
Femoral hernia 38
Fibroadenoma 125
Fibrocystadenosis 126
Fibrous epulis 257
Field block method 19
Filarial hydrocele and chylocele 282
Filiform bougies 484
Fisch nerve hook 457
Fistula 229
Fistula bistoury 489
Flatus tube 487
FNAC 106
Foam sclerotherapy 80
Fogarty catheter 63
Follicular carcinoma 165
Fontaine classification of limb ischaemia 50
Forceps 454
Forceps/lion forceps 498
Frey's syndrome 268
Frostbite 72
Frozen section biopsy 107
Fruchaud's myopectineal orifice 17
Fuchsig's test 43
Further treatment 167
G
Gaiter's zone 84
Galactocoele 128
Galactorrhoea 131
Gallstone probe 472
Ganglion 220
Gangrene 40
Gas under diaphragm 358
Gastrectomy 542
Gastric ulcer 403
Gastrointestinal stromal tumours 340
Gastrointestinal system 156
Gastrostomy 541
Genitourinary system 156
Gibbon's catheter 482
Gifford‘s sign 145
Gigli's saw 499
Gilbert classification 18
Gilbert mesh repair 27
Goldzieher's sign 146
Granulation tissue 225
Grave signs 103
Griffith's sign 146
Groin hernia 17
Grove's sign 146
Guttering of vein 44
Gynaecomastia 131
H
Haemangioma 231
Halsted radical mastectomy 114
Halsted test 42
Hamartomata 230
Harvey's venous refilling test 42
Hashimoto's thyroiditis 170
Heparin 89
Heparin antagonist 89
Herceptin 118
Hereditary nonpolyposis colonic cancer 308
Hernia 7
Hernia bistoury 487
Hernia director 488
Hernia retractor 457
Hernioplasty 24
Herniotomy 20
Hesselbach's triangle 16
History taking 91
Hodgkin's lymphoma 236
Holding forceps 454
Homan's test 77
Hook phlebectomy 82
Hormone therapy in carcinoma breast 118
Humby's knife 497
Hydrocele 280
Hydronephrosis 205
Hyperabduction manoeuvre 42
I
Ian-Aird test 77
Ideal stoma appliance 529
Ileal urinary conduit 530
Ileocaecal tuberculosis 207
Ileocaecal tuberculosis 298
Ileostomy 530
Implantation dermoid 218
Incision 522
Incisional hernia 31
Incisional hernia surgery 33
Indandione derivative: 90
Infant feeding tube 487
Inguinal hernia 7
Injection sclerotherapy 79
Inlay mesh repair 25
Insertion of a nasogastric
In-situ saphenous vein graft 57
Intercostal drainage tube 478
Intercostal tube drainage 524
Intermittent claudication 49
Interpreting the films 393
Interstitial cell tumour 351
Intraarterial thrombolysis using fibrinolysins 63
Intraluminal stent placement 57
Intramammary mastitis 129
Intravenous urogram 413
Intussusception 206
Ischiorectal abscess 514
Isotope lymphoscintigraphy 235
J
Jaundice 4
Jaw tumours 256
Jejunostomy 542
Jellinek‘s sign 145
Jening's mouth gag 496
Joffroy‘s sign 145
Joll's thyroid retractor 460
K
Keel's operation 33
Kehr's tube 473
Keratoacanthoma 240
Keyland's retractor 459
Kidney hilum retractor 462
Kidney shadow 393
Knie‘s sign 145
Kocher‘s sign 146
Kocher's forceps 453
Kocher's test 139
Kocher's thyroid dissector 455
Kuntz nerve 59
Kuntz‘operation 23
L
Lahey's method of examination 139
Laparoscopic surgery 536
Laryngocele 271
Lasers in surgery 534
Left sided adrenal mass 205
Left sided colonic mass 205
Leriche's syndrome 49
Letrozole 117
Leucoplakia 248
Levels of the axillary nodes 100
Lid lag sign 144
Lid retraction 146
Life saving procedures 71
Limb saving methods 70
Line of demarcation 50
Lingual thyroid 179
Lipodermatosclerosis 86
Lipoma 213
Lister's urethral dilator 484
Loewi‘s sign 145
Lotheissen's repair 38
Low molecular weight heparin 89
Ludwig's angina 514
Lugol‘s iodine 160
Lumbar sympathectomy 59
Lupus vulgaris 228
Lymph node biopsy 522
Lymph nodes 5
Lymphadenitis 353
Lymphangiographic classification 235
Lymphangiography 235
Lymphoedema 235
Lymphomas 236
Lytle's repair 21
M
Macvay operation 24
Magill's forceps 476
Malecot's catheter 480
Malignant lymphoma 170
Malignant neoplasms of small bowel 338
Mallet 499
Mammography 105
Management of malignant 266
Management of ruptured aneurysm 67
Manchester staging 103
Marjolin's ulcer 241
Martorelle's ulcer 227
Mass, epigastrium 201
Mass, hypogastrium 208
Mass, left hypochondrium 205
Mass, left iliac fossa 208
Mass, lumbar region 205
Mass, right hypochondrium 196
Mass, right iliac fossa 207
Mass, umbilical region 206
Mastalgia 131
Mastitis 100
Maydl's hernia 37
Mayo's operation 34
Mayo's towel clip 448
Mean's sign 146
Medullary carcinoma of breast 121
Medullary carcinoma of thyroid 169
Meggitt's classification 71
Meigster's/lahey's 451
Melanoma 244
Meleney's ulcer 228
Menstrual history 133
Mesenteric cyst 206
Mesh repair 27
Mesh repair for incisional hernia 33
Metal catheters 483
Metastatic carcinoma of breast 118
Methimazole 159
Microsclerotherapy 80
Micturating cystourethrography 418
Minor salivary gland tumours 267
Mitchel's clip device 494
Modified radical mastectomy 113
Moebius sign 145
Moebius sign 147
Mollison's mastoid 460
Mondor's disease 130
Morris kidney retractor 462
Morris' retractor 458
Moynihan's glass tube 490
Moynihan's occlusion clamp 469
Moynihan's tissue forceps 454
Mucoepidermoid tumour 265
Multiple air-fluid levels 361
Mycotic aneurysm 65
Myelomatous epulis 258
Myer's vein stripper 497
N
Naffziger's sign 145
Nasogastric tube 486
Nasopharyngeal carcinoma 255
Necrosis 50
Needle holder 466
Negus artery forceps 450
Neoplasm of lip 252
Nerve block method 19
Neurilemmoma 220
Neurofibroma 219
Neurogenic claudication 49
Neuromuscular system 156
Nipple deviation 95
Nipple discharge 91
Nodular goitre 153
Nonabsorbable suture materials 492
Non-hodgkin's lymphoma 238
Nottingham prognostic index 121
Nuttall's operation 33
Nyhus classification 18
Nyhus pre-peritoneal mesh repair 25
O
Oedema 5
Omental cyst 206
Omentoplasty 60
Onlay mesh repair 25
Operation theatre room 506
Oral anticoagulants 90
Oral submucosal fibrosis 248
Order of appearance of signs 146
Oschner's Mahoner's test 76
Osteotome 499
Ovarian mass 208
P
Paget's disease 101
Pain 40
Palliative treatment 402
Palpable gallbladder in right hypochondrium 197
Palpable kidney mass 205
Palpable left lobe of the liver 201
Pancreatography 425
Pantaloon hernia 27
Papillary carcinoma 163
Papilloma 215
Para-aortic lymph node mass 205
Paraphimosis 521
Paraumbilical hernia 33
Parotid abscess 513
Parotidectomy 268
Patey's modified radical mastectomy 115
Patey's operation 113
Paul's drainage tube 478
Pedicle clamps 452
Perforator and burr 491
Perforators 86
Peripheral aneurysms 68
Peritoneal tap 526
Peritoneal tuberculosis 301
Per-operative cholangiograms 425
Perthes' test 77
Peutz-jegher's polyp 297
Pfannensteil incision 27
Pharyngeal pouch 271
Phimosis 521
Phlegmasia alba dolens 87
Phlegmasia caerulea dolens 88
Phylloides tumour 127
Physical agents 504
Physical examination 3
Physiologic changes due to 537
Pigmentation 73
Pile holding forceps 490
Pizzillo's method of palpation 139
Plain non-toothed dissecting forceps 455
Plain x-ray abdomen showing gallstones 372
Pleural effusion 122
Pleural tap 523
Pneumoperitoneum 537
Point block 19
Polycystic kidney 205
Popliteal aneurysm 68
Popliteal artery 45
Portal hypertension 201
Posterior tibial artery 44
Pratt's test 77
Pregangrene 50
Pregnancy epulis 258
Premalignant conditions 249
Premedication 503
Proctoscope 488
Profundaplasty 57
Proper plain x-ray abdomen 358
Propranolol 159
Propylthiouracil 159
Pseudocyst of the pancreas 203
Psoas abscess 208
Psoas shadow 393
Psychiatry 156
Pugh's modification 201
Pulse 6
Pyonephrosis 205
Pyonephrosis 324
Q
Quadrants of breast 96
Quart therapy 110
R
Radioactive iodine 180
Radiofrequency ablation method 82
Radioiodine therapy 160
Radioisotope bone scan 107
Radioisotope imaging 444
Radiotherapy in carcinoma breast 119
Ranula 256
Raynaud's disease 56
Raynaud's phenomenon 55
Raynaud's syndrome 56
Reactive hyperaemia time test 44
Recanalisation procedure 527
Reconstruction after surgery 251
Reisman's sign 146
Renal angiogram 418
Renal cell carcinoma 205
Repair 27
Respiration 6
Respiratory system examination 143
Rest pain 50
Reticular varices 86
Retractor 459
Retrocaval ureter 421
Retrograde pyelography 417
Retromolar trigone 249
Retroperitoneal cysts 206
Retroperitoneal tumours 206
Retroperitoneoscopy 539
Reverse saphenous vein graft 57
Rib approximator 464
Rib retractor 463
Rib shear 463
Richter's hernia 35
Riedel's thyroidis 171
Right angle retractor 458
Ring occlusion test 12
Rive's stoppa's mesh placement 32
Rives preperitoneal mesh repair 25
Robbin's modifications 18
Rochin's sign 146
Romberg hernia 36
Roos test 42
Rosenbach‘s sign 145
Routine investigations 79
Russian forceps 456
S
S shaped retractor 458
Saddle embolus 63
Saddle hernia 36
Saint mark's anal dilator 489
Sainton's sign 146
Salivary neoplasms 260
Salivary tumours 266
Satinsky vascular clamp 452
Scanlon's operation 113
Scapula retractor 462
Schwartz test 77
Scissors 468
Sclerosants 79
Sebaceous cyst 218
Secondary hydrocele 282
Selective estrogen antagonists 117
Seminoma testis 350
Sentinel node biopsy 108
Septic operation theatre 510
Sequestration dermoid 217
Sequestrum holding forceps 498
Severe exophthalmos 147
Shianoya's criteria 53
Shouldice method 19
Shouldice repair 21
Sigmoid volvulus 367
Simple red rubber catheter 481
Single hook retractor 457
Sinus 229
Sinus forceps 456
Skeletal system 156
Skin adnexal tumours 239
Skin excoriation 529
Skin sparing mastectomy 110
Sliding hernia 36
Slough 50
Small bowel swellings 206
Snellen/donder's sign 146
Solitary thyroid nodule 151
Specimen, carcinoma oesophagus 341
Specimen, hydatid cyst of liver 330
Specimen, intestinal gangrene 335
Specimen, intestine with intussusception 335
Specimen, jejunal diverticula 335
Specimen, kidney with renal cell carcinoma 326
Specimen, lipoma 342
Specimen, meckel's diverticulum 334
Specimen, melanoma 343
Specimen, papilloma 342
Specimen, pilonidal sinus 348
Specimen, renal abscess/carbuncle 326
Specimen, renal tuberculosis 330
Specimen, roundworms 348
Specimen, thyroid 347
Specimens, small bowel tumours 337
Spermatocele 284
Spigot 491
Squamous cell carcinoma 240
Stages of tuberculous lymphadenitis 353
Staplers in surgery 535
Stellwag‘s sign 145
Sterilisation 504
Sternomastoid tumour 273
Stoma appliances 529
Stoma care 528
Stones 369
Stoppa's giant prosthesis reinforcement 26
Strangulated hernia 36
Stricture urethra 419
Stripping of vein 81
Struma lymphomatosa 170
Subareolar mastitis 128
Subclavian artery 46
Subclavian steal syndrome 61
Subfascial endoscopic perforator ligation surgery 82
Sublingual dermoids 256
Submandibular salivary gland tumours 266
Subtotal thyroidectomy 155
Suction instruments 473
Suker's sign 146
Superficial temporal artery 46
Superior border of the isthmus 141
Suprapubic cystostomy 481
Surgical blades 467
Surgical jaundice 199
Surgical needles 464
Surgical principles and procedures 535
Suture materials 491
Swelling 91
Syringes 495
T
Tamoxifen 116
Tanner's slide operation 23
Taxanes 112
Taxis 16
Tenotomy knife 468
Teratoma 351
Teratomatous dermoid 218
Theatre plan 506
Therapeutic embolisation 65
Therapeutic uses 180
Thermography 109
Thoracocentesis 523
Thread veins 86
Thrombectomy 57
Thromboangiitis obliterans 52
Thyrocardiac 161
Thyroglossal cyst 176
Thyroglossal fistula 179
Thyroid cyst 155
Thyroid disorders 132
Thyroid function tests 159
Thyroid ophthalmopathy in grave's disease 147
Thyroidectomy 171
Thyroidectomy 532
Thyrotoxicosis and hyperthyroidism 155
Tiemann catheter 483
Toilet mastectomy 115
Tomography 445
Tongue depressor 496
Toomy syringe 496
Toothed-dissecting forceps 455
Total mastectomy 111
Tourniquet test 76
Toxic nodule 158
Toxic thyroid in children 161
Toxic thyroid in pregnancy 161
Tracheal hook 475
Tracheostomy 517
Tracheostomy care 518
Tracheostomy tube 474
Transabdominal preperitoneal mesh repair 28
Transitional cell carcinoma 354
Transtuzumab 118
Transurethral resection of prostate 27
Traumatic acute arterial occlusion 62
Traumatic fat necrosis 128
Trendelenburg operation 80
Trendelenburg test 74
Triangle of pain 30
Triple assessment 108
Trivex method 82
Trocar and cannula 488
Trophic ulcer 227
Trousseau's/Payne's sign 146
Trucut biopsy 107
True papilloma 342
Tube 512
Tuberculous lymphadenitis 515
Tuberculous mesenteric lymphadenitis 301
Tubulodermoids 218
Tumour 349
Tumour markers for melanoma 346
U
Ulcer 222
Ulcer due to chilblains 227
Ulcer due to frostbite 227
Ulceration 40
Ulcerative type 307
Ulnar artery 45
Umbilical hernia 35
Ureteric catheter 483
Ureteric line 393
Ureterocele 421
Urethral dilators 483
Urinary catheterisation 511
Uterine mass 208
V
Van dyke's modification 147
Van nuy's prognostic index for dcis 121
Varicocele 284
Varicose veins 73
Varients 241
Vascular diseases 40
Vasectomy 527
Vaso-vasostomy 527
Venography 78
Venous doppler 78
Venous refilling time 42
Venous return 87
Venous ulcer 83
Verrucous carcinoma 249
Vigourox's sign 146
Virchow's triad 87
Von Graefe‘s sign 144
W
Warfarin sodium 90
Wayne‘s diagnostic indices 157
Well's arterial clamp 451
Werner’ abridged classification 147
Wet gangrene 50
White cell trapping theory 86
Wilder sign 146
Wolf-chaikoff effect 156
X
Xeromammography 106
X-ray bones 375
X-ray spine or mri spine/pelvis 107
Y
Young's gland forceps 455
Z
Zieman's test 13
×
Chapter Notes

Save Clear


Surgical Long CasesSection 1

2
 
INTRODUCTION AND WRITING CASE SHEETS OF SURGICAL CASES (BASIC PATTERN OF CASE SHEET WRITING)
A case sheet comprises a detailed history of a particular patient admitted to the hospital, has to be written carefully and neatly without any spelling mistakes.
Two important aspects of a case sheet are—
  • Detailed history.
  • Physical examination.
 
HISTORY
Particulars of the patient—
  1. Name.
  2. Age.
  3. Sex.
  4. Religion.
  5. Occupation.
  6. Address.
  7. Date of admission.
  8. Hospital number.
 
Chief Complaint
Should be mentioned in brief, and if multiple, in chronological order of appearance
e.g.
  • Pain in the right knee joint—15 days.
  • Swelling in the right knee joint—7 days.
  • Fever since 2 days.
All minor complaints should not be listed; only 2–3 appropriate complaints must be noted.
 
History of Present Illness
Write in detail about the complaints, along with mentioning other minor ailments also.
Begin with an opening statement such as the ‘patient was apparently normal’ (not perfectly or absolutely normal) before this episode of illness, e.g.
If the chief complaint is pain, then write in detail about the site, nature, duration, mode of onset, radiation, shifting of pain, aggravating and relieving factors, its relation to food/sleep/physical activities, whether associated with vomiting.
Then come to the next complaint, if it is swelling, mode of onset, whether there is recent increase in size, pain, its relation to activities, etc. Then the next complaint, if it is fever, mention in detail the type, time of onset, whether associated with chills, sweating.
Once the chief complaints are elaborated, only relevant questions in respect to symptoms pertaining to other systems should be asked and mentioned.
  • GIT: history of haematemesis, melaena, heart burn, flatulence, weight loss, appetite, details of bowel habits, (frequency, nature, bleeding), jaundice.
  • Respiratory system: H/O chest pain, cough, haemoptysis, breathlessness.
  • Cardiovascular system: H/O chest pain, palpitation, breathlessness on exertion
  • Urinary system: Details of urinary habits (frequency, dysuria, urgency, hesitancy), haematuria, burning micturition
  • Neurological: H/O of head ache, vomiting, difficult speech, walk, weakness in limbs, etc.
 
Past History
  • Do not simply mention ‘nothing significant’.
  • History of any other major illness, pulmonary Koch's been treated, epilepsy (treated or on treatment), hypertension, jaundice, diabetes, psychiatric illness, autoimmune disorder.
  • History of surgery in the past, nature of illness, type of surgery, emergency/elective, type of anaesthesia used, mode of recovery, any complication, any blood transfusion given.
 
Personal History
Following aspects must be looked into—
  • Dietary habits.
  • Addiction (alcohol; drugs/cigarettes/tobacco, betel nut chewing).
  • Sleep (disturbed or normal).
    3
  • Bowel habits, micturition (if not mentioned in the h/o presenting complaints).
  • Socioeconomic status, marital status.
  • Menstrual history in females (nature of the cycle, duration of flow, obstetric h/o, LMP, postmenopausal bleeding in old women).
 
Family History
Ask for history of any illness in the parents, siblings, spouse and children.
 
Treatment History
  • History of treatment received for the present illness.
  • History of receiving treatment for any other illness.
 
History of Allergy to Drugs and Food
 
PHYSICAL EXAMINATION
Done under three main categories—
 
General Examination
Level of consciousness, degree of cooperation, build, facies, nutrition decubitus, anaemia, jaundice, cyanosis, clubbing, oedema neck veins, lymph nodes.
Pulse—
Mention the rate, regularity, volume of blood flow, vessel wall, and palpate all the peripheral pulses (radial, brachial, temporal, dorsalis pedis).
Blood pressure—
Respiratory rate—
Temperature—
Pigmentation—
 
Local Examination
Site of disease has to be thoroughly examined in detail under 4 heading (inspection, palpation, percussion, auscultation), e.g.,
  • Examination of inguinal region in hernia.
  • Examination of breast in breast disease.
 
Systemic Examination
All other systems which has not been included in local examination has to be examined and written.
 
Abdomen
 
Inspection:
  • Shape of abdomen (normal/obese scaphoid/distended).
  • Position of umbilicus (central/deviated/pushed up or down).
  • Movements of abdomen.
  • Skin over the abdomen (scar/pigmentation/venous engorgement).
  • Hernial sites (look for expansile impulse on cough).
  • External genitalia.
 
Palpation:
Done for—
  • Swelling, if palpated, its relation to abdominal quadrants has to be mentioned, mobility, tenderness, consistency is noted.
  • Tenderness both deep and superficial is elicited; any rebound tenderness with guarding and rigidity is noted.
  • Liver, spleen, kidneys are palpated for enlargement, their consistency, tenderness, nodularity if any is noted.
 
Percussion:
  • General note all over the abdomen.
  • Shifting dullness.
  • Free fluid thrill.
  • Upper border of liver dullness.
 
Auscultation:
  • Bowel sounds, nature intensity, abnormality is noted.
  • Any added sounds-bruit.
 
Perrectal Examination
 
Pervaginal Examination (in women)
4
 
Respiratory System
Inspection: Shape, movement of chest, respiratory rate is noted.
Palpation: Position of trachea, tenderness over ribs and costochondral junction, vocal fremitus.
Percussion
Auscultation: Breath sounds, any crepitus/rhonchi, vocal resonance.
 
Cardiovascular System
Inspection: Shape of precordium, apex beat, any pulsation.
Palpation: Apex beat, parastenal heave, thrill.
Auscultation: 1st and 2nd heart sound in all the areas.
Murmur
 
Examination of Nervous System
  • Higher functions: Consciousness, speech, alertness, cooperation noted.
  • Gait examined.
  • Cranial nerves examined.
  • Motor system: Tone, power of upper and lower limb muscles must be mentioned.
  • Sensory system: Pain, touch, temperature over arms, chest, back and lower limbs; vibrations and reflexes are checked.
  • Cerebellar sign ± noted.
 
Examination of Cranium and Spine
 
PROVISIONAL DIAGNOSIS
A complete diagnosis has to be given.
e.g—Carcinoma right breast with mobile axillary lymph nodes—T2NIM0.
 
INVESTIGATION SUGGESTED
Base line investigations—
  1. HB%, TC, DC, ESR, blood for sugar, blood urea, creatinine.
  2. Urine routine.
  3. Stool for routine (ova/cyst/parasite).
  4. Chest X-ray.
  5. ECG.
Special investigation—based on clinical findings and provisional diagnosis.
 
DIFFERENTIAL DIAGNOSIS
Can be mentioned in order of significance.
 
IMPORTANT POINTS OF GENERAL PHYSICAL EXAMINATION
 
Anaemia
It is qualitative or quantitative reduction in RBC or HB% in relation to standard age or sex.
It is assessed by presence of pallor at the lower palpebral conjunctiva, tip and dorsum of tongue, nail beds skin over palms and soles.
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Fig. 1.1: Anaemia
 
Jaundice
Yellowish discolouration of sclera, skin and mucous membrane due to excess bilirubin in blood.
Normal serum bilirubin—0.2mg% to 0.8mg%
Jaundice is looked for in day light over sclera by asking the patient to look down and retracting 5the upper eye lid, over soft palate and under surface of tongue, skin over palms and soles.
 
Cyanosis
Bluish discolouration of skin and mucus membrane due to increased amount of reduced Hb in circulation (> 5 gm%).
 
Types
  • Peripheral: Periphery (tip of nose, tips of finger and toes, palms, soles, ear lobule) is blue due to sluggish circulation or vasoconstriction leading to more oxygen desaturation at capillary bed.
  • Central: Excessive oxygen desaturation of central arterial blood (in severe VSD, tetrology of Fallot), looked for in the undersurface of tongue, and inner aspect of lips. Here periphery is also blue.
 
Clubbing
It is increase in anteroposterior and transverse curvature of nail leading to bulbous enlargement of the terminal phalanges. The angle between nail and nail bed is obliterated.
 
Degrees of Clubbing
1st: Increased fluctuation of nail bed (looked for at the base of the nail with two index fingers).
2nd: Fluctuation associated with increased anteroposterior and transverse curvatures.
3rd: Above changes associated with increased pulp tissue in terminal phalanges producing parrot beak or drum stick appearance.
4th: In addition to above changes there is hypertrophic osteoarthropathy (subperiosteal thickening of wrist and ankle bones).
 
Oedema
  • Due to excessive of fluid collection in extra-vascular compartment.
  • In ambulant patient, medial surface of tibia, 2.5 cm above the ankle is pressed for 5–10 seconds.
  • Pitting on pressure becomes evident only when the circumference of limb increases by 10%.
  • In non-ambulant patient, it is checked by pressing over the sacrum.
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Fig. 1.2: Oedema should be looked for in both feet
 
Lymph Nodes
 
Cervical Lymph Nodes
Level 1: Submental group in submental triangle; submandibular group in submandibular triangle—
Palpated with pulp of fingers after flexing the neck to the same side.
Level 2: Upper jugular group, situated along the upper third of the internal jugular from carotid bifurcation to base of skull.
Level 3: Middle jugular group, situated along the middle third of internal jugular.
Level 4: Lower jugular group, situated along the lower third of internal jugular.
Level 2, 3, 4 are palpated along the jugular with the pulp of finger.6
Level 5: Posterior triangle group palpated in posterior triangle, and also includes supraclavicular group which is palpated in supraclavicular fossa by asking the patient to shrug the shoulder.
Level 6: Anterior compartment, includes perilaryngeal, pericricoid, peritracheal nodes from hyoid bone above to suprasternal notch below and to medial border of sternomastoid laterally.
The number of nodes, consistency, mobility/fixity to underlying structures, tenderness, has to be noted.
 
Axillary Group of Nodes
Pectoral group: Situated behind the anterior fold of axilla, palpated with pulp of fingers of right hand for left side, with examiners fingers insinuated behind the pectoralis major, and with patient's arm made to rest over the examiners forearm.
Brachial group: Lies on the lateral wall of axilla along the cephalic vein, left hand is used for left side, with palm directed laterally towards the upper end of humerus.
Subscapular group: Lies along the posterior fold of axilla, palpated standing behind the patient, keeping the arm in semi-flexed position.
Central group: This group is palpated in the apex of the axilla, left side with examiners right hand.
Apical group: This group is palpated higher than the above nodes.
 
Inguinal Group
Both horizontal and vertical group must be examined.
 
Pulse
  • It is lateral expansion of arterial wall by a column of blood forced by the contraction of heart into the peripheral circulation.
  • Radial artery is ideally and conveniently used to palpate for pulse against the lower end of radius above the wrist joint.
Normal pulse rate: 60–100/minute; < 60/mt—bradycardia; > 100/mt—tachycardia.
Not only rate-noting the rhythm is also important. Rhythm is appearance of successive pulse wave with time, regular if successive pulse beat appears at definite interval, irregular if it is not appearing at regular interval.
 
Respiration
Normal respiration is abdominothoracic, normal rate 18–20/min.
 
Temperature
Normal body temperature: 98–99 degree Farenheit.
Pyrexia: >99° Farenheit
Hyperpyrexia: >106° Farenheit.
Pyrexia of unknown origin (PUO): It is fever of >101° Farenheit persisting for more than 2 weeks with cause remaining obscure in spite of intensive investigation.
 
Blood Pressure
Recorded is done in lying down supine position and sitting position, with sphygmomanometer cuff tied firmly around the left arm, one inch above the elbow joint. The cuff is inflated till the radial pulse disappears. The diaphragm of stethoscope is placed over the brachial artery. The pressure reading at which there is a clear tapping sound on deflating the cuff is the systolic blood pressure and the reading which corresponds to complete disappearance of sound is the diastolic pressure.
 
Pigmentations
Looked in face, oral cavity, tongue, palmar creases and general body skin.7
HERNIA
Hernia is an important clinical topic for undergraduate as well as postgraduate students in surgery. It is a long case for undergraduate student and a short case for postgraduate students in surgery. It is the one of the commonest surgical entity that surgeons come across and so detail knowledge of the subject is mandatory to both undergraduates and postgraduates.
Writing a case sheet for hernia is important as a long case.
 
METHOD OF WRITING A CASE SHEET FOR INGUINAL HERNIA
Patient's name.
Age.
Sex.
Occupation.
Elderly people are more prone for hernia. Men with strain full occupation like manual labourer, sportsmen, weight lifters, etc. are more prone for hernia.
 
Chief Complaints
  • Swelling in the groin, right or left or both sided for….durations; or swelling in right/left/both inguinoscrotal region for….durations.
  • Pain over the swelling for….durations.
 
History
 
History of Present Illness
 
Swelling
  • Duration of the swelling.
  • Mode of onset of the swelling—spontaneous or on straining.
  • Site of the first appearance of the swelling in the groin or in the scrotum.
  • Progress and extent of the swelling, whether it limits only to the groin or extends to the scrotum.
  • Any changes in the size and extent of the swelling on standing/walking/straining/lying down.
  • Whether swelling is reducible on lying down/partially reducible or irreducible on lying down or needs any manoeuvre to reduce it. History of gurgling sound in the scrotum signifies enterocele.
  • If swelling is irreducible, then whether it is painful or any abdominal distension vomiting should be asked.
 
Pain
  • Site of pain—whether it is in the groin or in the scrotum.
  • Duration of pain.
  • Severity of the pain, type of pain—dull aching or severe pricking type.
  • Aggravating or relieving factors. Aggravated by straining/walking/weight lifting; relieved by lying down.
 
History Relevant to Precipitating Factors
  • Chronic cough, tuberculosis, bronchial asthma or other respiratory diseases.
  • Constipation, altered bowel habits, tenesmus, bloody stool—in relation to anorectal stricture/carcinoma.
  • Dysuria/urgency/hesitancy/altered stream/night frequency/retention of urine/burning urine/haematuria—in relation to benign prostatic hyperplasia/urethral stricture.
 
Past History
  • Past history of hernia surgery—same side/opposite side. Type of surgery whether mesh used or repair done.
  • History of appendicectomy earlier and if so detail about the surgery (can cause right direct hernia).
  • Past history suggestive of irreducibility/obstruction and treatment for that conservative/surgical.
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Personal History
  • Smoking- duration, number per day, whether beedi or cigarette. Pan chewing/alcohol intake.
  • Appetite and altered weight.
 
Treatment History
Any previous treatment given.
 
General examination
Examine for general built and nutritional status, pallor, clubbing, cyanosis, jaundice, lympha-denopathy, oedema feet, pulse and blood pressure.
 
Local Examination
Inguinoscrotal region should be examined in standing position as swelling commonly reduces and disappears in lying down position.
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Fig. 1.3: All hernias should be inspected initially on standing
 
Inspection
Inspection in standing position—
  • Mention the side of the swelling.
  • Extent of the swelling is important. Incomplete indirect inguinal hernia and usually direct inguinal hernias are in inguinal region. Complete indirect inguinal hernia (rarely complete direct inguinal hernia) is inguinoscrotal extending down into the bottom of the scrotum. Swelling extends from the proximal part of the inguinal canal towards the scrotum below.
  • Both transverse and vertical dimensions of the size should be mentioned.
  • Shape of the swelling is pyriform in indirect inguinal hernia and globular in direct inguinal hernia.
  • Expansile impulse on coughing over the swelling is diagnostic. It is better seen than felt.
  • Surface smooth/uneven.
  • Margin—well-defined/ill-defined.
  • Visible peristalsis over the swelling should be noted if present. It means it could be enterocele.
  • Scar/dilated veins/discolouration/redness over the swelling.
  • On inspection, whether testis is seen sepa-rately from the swelling or covered by the swelling all over.
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Figs 1.4A and B: Expansile impulse on coughing is better seen than felt. It should be inspected with patient standing and examiner sitting beside the patient.
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Fig. 1.5: Inguinal hernia is reduced in lying down position with elevation of scrotum and flexion and rotation of the hip—taxis.
 
Palpation
  • Temperature and tenderness over the swelling
  • Whether get above the swelling is possible or not- purely scrotal swelling one can get above the swelling but in inguinoscrotal swelling one can not get above the swelling.
  • Position and extent of the swelling.
  • Size in vertical and transverse directions.
  • Margin well defined or ill-defined.
  • Surface smooth/lobular/tense.
  • Consistency is soft and elastic in enterocele; doughy in omentocele.
  • Location of the swelling—swelling is above and medial to pubic tubercle in inguinal hernia and below and lateral to pubic tubercle in femoral hernia.
  • Reducibility of the swelling is checked by different methods.
    Whether it is reducible spontaneously while lying down and gets reduced completely or partially.
    In enterocele, it is difficult to reduce the first part but last part gets reduced easily. In omentocele it is difficult to reduce the last part but first part gets reduced easily.
  • Whether swelling needs any manipulation to get reduced like taxis. Taxis is gradual reduction of contents of the scrotum by gentle manipulation by flexion and rotation of hip join.
  • Zieman's test is done to find out over which finger cough impulse is felt and so which type of hernia it could be whether femoral/direct inguinal or indirect inguinal.
  • Deep ring occlusion test: When deep ring is occluded, if impulse on coughing is absent then it is indirect inguinal hernia; if impulse on coughing is still present then it is direct inguinal hernia.
  • Finger invagination test: Size of the superficial ring is noted and site of the impulse felt is observed whether it is in the tip of the finger or on the pulp.
  • Palpation of testis, epididymis and spermatic cord should be done without fail. Relation of swelling to testis also should be noted.
  • Bulbar urethra is palpated by lifting the scrotum and feeling in the midline. (To look for thickening and button like depression-a feature of stricture urethra).
  • Opposite inguinal region, opposite testis, epididymis and spermatic cord should be examined. Presence or absence of impulse on coughing on opposite side should be mentioned.
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Fig. 1.6: Bulbar urethra should be palpated by raising the scrotum in midline posteriorly. Any stricture urethra is felt as thickening/button like depression. Gonococcal urethritis and trauma are the commonest causes of stricture urethra. Bulbar urethra is the commonest site of stricture urethra.
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Percussion
Without reducing contents of the swelling, percussion is done over the surface. If it is resonant, it is enterocele. If it is dull on percussion, then it is omentocele.
 
Auscultation
Bowel sounds may be heard over the swelling if it is enterocele.
Perabdomen examination
  • Abdomen muscle tone should be checked by head raising test, leg raising test and Valsalva manoeuvre. It should be inspected for Malgaigne bulging and should be palpated to check whether the tone is adequate (firm) or inadequate (supple).
  • Any scar over the abdomen (appendicectomy scar may cause right-sided direct inguinal hernia); ascites or mass per abdomen should be mentioned.
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Figs 1.7A and B: Head raising and valsalva manoeuvre tests are needed to check the tone of abdominal muscle in hernia.
 
Digital Examination of the Rectum
Digital examination of the rectum (P/R) must be done in all hernia cases to look for prostate enlargement in elderly and rectal/anorectal strictures.
 
Examination of Respiratory System
Examination of respiratory system for altered breath sounds (rhonchi, bronchial breathing), effusion, etc. to find out any precipitating causes.
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Fig. 1.8: Clinically per-rectal examination is a must in hernia to look for prostate enlargement, and rectal stricture which are precipitating factors.
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Fig. 1.9: Respiratory system should be examined to find out the precipitating causes for hernia like bronchitis, tuberculosis or asthma.
 
Other Systems
Cardiovascular system, nervous system including spine and cranium for any neurological problems are examined for management of hernia.
 
Diagnosis
Diagnosis should be written complete with mentioning of side, type, whether complicated or not.
For example, left sided indirect incomplete uncomplicated inguinal hernia-enterocele.
 
Investigations
  • All case sheets for long case should mention the investigations required for that particular case.
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  • Relevant investigations required for inguinal hernia are chest X-ray, haematocrit, blood sugar, serum creatinine, ultrasound abdomen depending on the age/suspected cause of the hernia.
Note: Presentation of the case should be in order as mentioned above. One cannot alter the order of presentation like presenting percussion first and later palpation or likewise in a haphazard manner.
Students should strictly follow the proper order of presentation in clinical methods.
 
Discussion
In examination, discussion is usually in question and answers method. A provisional discussion often done after a presentation is given here.
 
Why clinically it is inguinal hernia?
Patient presented with swelling in the left groin, gradually increased in size which often descends into the scrotum and gets reduced on lying down. It increases on straining, coughing or walking. Expansile impulse on coughing is present and reduces on lying down or by taxis.
 
Why it is indirect inguinal hernia?
It is pyriform in shape. It descends obliquely in the groin. On occluding the internal ring in ring occlusion test, swelling does not appear later on coughing. On ring invagination test, impulse is felt at the tip of the invaginating finger. Zieman's test confirms the impulse over the index finger.
 
If it is direct inguinal hernia, then what are the differentiating features?
Direct inguinal hernia is globular in shape. After occluding the deep ring, swelling still appears on coughing on the medial side of the inguinal region. Impulse is felt on the pulp of the finger in invagination test and over the middle finger in Zieman's test.
 
How expansile impulse on coughing is clinically demonstrated?
Expansile impulse on coughing is seen on inspection when patient is asked to cough. Expansile impulse on coughing is also felt by placing the thumb in front, middle and index fingers behind the root of the scrotum and asking the patient to cough.
 
When in a hernia impulse on coughing will not be there?
Strangulated hernia will not show impulse on coughing.
 
What is the meaning of the ‘get above the swelling’?
Root of the scrotum is palpated between the thumb in front, index and middle fingers behind. In purely scrotal swelling like vaginal hydrocele, fingers and thumb meet each other well without any additional structure other than cord in between (one can get above the swelling). In case of inguinoscrotal swelling thumb and fingers do not meet each other properly because of the descent of hernial contents down (one cannot get above the swelling). It occurs in funicular and complete type of inguinal hernia not in bubonocele.
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Figs 1.10A and B: In inguinoscrotal swelling one cannot get above the swelling.
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Fig. 1.11: Ring occlusion test is done to find out whether hernia is direct or indirect. If after occluding the ring swelling appears on the medial side, it is direct hernia. If swelling does not appear on occlusion and coughing it is indirect hernia.
 
What is ring occlusion test?
It is the most important test in inguinal hernia. Deep/internal ring is located 1.25 cm above the mid-inguinal point. Mid-inguinal point is midpoint between the anterior superior iliac spine and pubic symphysis. (Note: Mid point of the inguinal ligament is center point between anterior superior iliac spine and pubic tubercle). Patient is asked to lie down to reduce the hernial contents. Thumb is placed over the mid-inguinal point. Patient is asked to cough. If there is expansile impulse on coughing on the medial side of the thumb, in spite after deep ring occlusion, it is then direct inguinal hernia. If there is no impulse on coughing then patient is asked to stand with thumb occluding the deep ring. Patient is once again asked to cough; impulse on the medial side of the occluded thumb is looked for to rule out the direct inguinal hernia. If there is no impulse even on standing, it is indirect inguinal hernia. The occluded thumb is removed and patient is asked to cough to show the swelling and impulse due to indirect inguinal hernia.
 
What is the prerequisite to do ring-occlusion test?
Hernia should be reduced completely prior to do deep ring occlusion test. One cannot do deep ring occlusion test/invagination test/Zieman's test if hernia is irreducible.
 
How is finger invagination test done?
Patient is asked to lie down. Contents are reduced completely. Using the little finger, scrotal skin is invaginated from below upwards near upper part of the testis. Finger is reached towards the superficial inguinal ring/external ring. Normally external ring does not admit the tip of the little finger. Finger is rotated inwards so that nail is towards the cord side. Patient is asked to cough. If the impulse is felt on the tip of the finger, then it is indirect inguinal hernia. If impulse is felt on the pulp then it is direct inguinal hernia. In case of complete inguinal hernia or funicular hernia external ring is patulous which can be very well-assessed by invagination test. Index finger can also be used for the test.
Invagination test should be done very gently, otherwise it will be very painful. It cannot be done in children.
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Figs 1.12A and B: Ring or little finger is used to do invagination test.
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How is Zieman's test done?
Reduce the hernial contents. Index ring is placed over the deep ring. Middle finger is placed over the superficial ring and ring finger over the femoral ring. Patient is asked to cough.
If impulse touches—
  • Index finger it is indirect inguinal hernia
  • Middle finger it is direct inguinal hernia
  • Ring finger it is femoral hernia.
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Figs 1.13A and B: Zieman's test—done on both sides. Three fingers are used to do Zieman's test.
 
How inguinal hernia is differentiated from femoral hernia?
Inguinal hernia is above and medial to the pubic tubercle. Femoral hernia is below and lateral to the pubic tubercle.
 
What are the boundaries of the inguinal canal?
 
Boundaries
In front: External oblique aponeurosis and conjoint muscle laterally.
Behind: Inferior epigastric artery, fascia transversalis and conjoint tendon medially.
Above: Conjoint muscle (Arched fibres of internal oblique).
Below: Inguinal ligament.
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Fig. 1.14: Anatomy of the inguinal canal. IL—Inguinal Ligament. SIR—Superficial Inguinal Ring. DIR—Deep Inguinal Ring. CT—Conjoint Tendon. ASIS—Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery.
 
What is inguinal defence mechanism?
It is the natural mechanism to maintain the strength of the inguinal canal.
It is by
  • Obliquity of the inguinal canal.
  • Arched conjoined tendon.
  • Shutter mechanism of internal oblique.
  • Ball valve mechanism of the cremaster.
  • Slit valve mechanism of the intercrural fibres of the superficial inguinal ring.
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What are the differences between indirect inguinal and direct inguinal hernias?
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Fig. 1.15: Diagrammatic representations of direct and indirect sacs.
 
How clinically is enterocele and omentocele differentiated?
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Fig. 1.16: Bilateral direct hernia. Note the medial location of the hernia. Direct hernia occurs through Hesselbach's triangle.
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Fig. 1.17: Large bilateral direct hernias. Note, on right side it has descended into the scrotum to become complete. Usually direct hernia will not descend into the scrotum but long standing direct hernia can descend down and become complete.
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Fig. 1.18: Direct sac on table during surgery.
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Fig. 1.19: Irreducible hernia with bowel as well as omentum as contents. Note the change in colour of the bowel.
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Figs 1.20A and B: Hernial sac with small bowel (enterocele) as content.
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What is Hesselbach's triangle?
It is bounded by inferior epigastric artery laterally, lateral border of rectus muscle medially and inguinal ligament below. Direct hernia protrudes out through this triangle.
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Figs 1.21A and B: Direct hernia aries through Hesselbach's triangle
 
What is taxis?
Taxis is a method used to reduce the complete inguinal hernia. Hip and knee are flexed and thigh is adducted. One hand held near the fundus of the sac in the bottom of the scrotum, other hand adjacent to external ring, contents are gently reduced towards the proximal side. Often patient himself does this technique in a better way. It is contraindicated in obstructed/strangulated hernia or femoral hernia or Maydl's hernia. Taxis should be done very gently.
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Fig. 1.22: Anatomy of Hesselbach's triangle. LUL—Lateral Umbilical Ligament. CT—Conjoint Tendon. ASIS—Anterior Superior Iliac Spine. IEA—Inferior Epigastric Artery.
 
How is tone of abdominal muscle checked and why?
Abdominal muscle tone is checked by head rising (without supporting the elbows) or leg rising tests. It is initially inspected for any bulges in the abdominal wall which signifies Malgaigne bulgings. Later abdomen should also be palpated for muscle tone. Firmness signifies adequate tone whereas suppleness signifies poor muscle tone. Poor muscle tone indicates that patient needs hernioplasty using mesh. Abdominal muscle tone is also checked by Valsalva manoeuvre.
 
Use five fingers of the hand to complete all tests for hernia'
  • Thumb for deep ring occlusion test.
  • Index, middle and ring fingers for Zieman's test.
  • Little finger for superficial ring invagination test.
 
Rules of hernia examination
  • Never forget to check expansile impulse on coughing and reducibility.
  • Never forget to examine opposite side.
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  • Never forget to do perrectal examination.
  • Never forget to examine bulbar urethra.
  • Never forget to check abdominal muscle tone.
 
What are the differential diagnoses for groin swelling?
  • Indirect/direct inguinal hernia.
  • Hydrocele—vaginal/encysted.
  • Femoral hernia.
  • Lipoma of the cord.
  • Inguinal lymphadenopathy.
  • Groin abscess.
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Fig. 1.23: Parts of hernia—neck, body and fundus.
 
What is groin hernia?
It is hernia occurring through a myopectineal orifice. It can be indirect inguinal hernia/direct inguinal hernia or femoral hernia.
 
What is Fruchaud's myopectineal orifice?
It is an osseomyoaponeurotic tunnel.
It is bounded—
  • medially by lateral border of rectus sheath.
  • above by the arched fibres of internal oblique and transverse abdominis muscle.
  • laterally by the iliopsoas muscle.
  • below by the pectin pubis and fascia covering it.
It is through this tunnel all groin hernias occur.
 
What are the types of indirect inguinal hernia?
It can be incomplete wherein sac does not reach to the bottom of the scrotum. It can be complete wherein sac descends completely up to the bottom of the scrotum. Incomplete type can be bubonocele where hernia limits to inguinal region without passing through the superficial inguinal ring or can be funicular where sac reaches up to the level of the upper part of the testis into the scrotum across the external ring.
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Figs 1.24A to C: Types of indirect inguinal hernia. (A) Bubonocele (B) funicular (C) Complete
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Fig. 1.25: Complete inguinal hernia is one where hernia descends completely into the scrotum.
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Figs 1.26A to C: Diagram and photos of indirect inguinal hernial sac. IL—Inguinal Ligament. SIR—Superficial Inguinal Ring. DIR—Deep Inguinal Ring. ASIS—Anterior Superior Iliac Spine. IEA—Inferior Epigastric artery
 
What are the newer classifications of groin hernias?
 
Gilbert classification(1987)
Type I: Hernia has got snug internal ring through which a peritoneal sac passes out as indirect sac.
Type II: Hernia has a moderately enlarged internal ring which admits one finger but lesser than two finger breadth. Once reduced it protrude during coughing or straining.
Type III: Hernia has got large internal ring with defect more than two fingerbreadth. Hernia descends into the scrotum or with sliding hernia. Once reduced it immediately protrudes out without any straining.
Type IV: It is direct hernia with large full blow out of the posterior wall of the inguinal canal. The internal ring is intact.
Type V: It is a direct hernia protruding out through punched out hole/defect in the transversalis fascia. The internal ring is intact.
Type VI: Pantaloon/double hernia.
Type VII: Femoral hernia.
Type VI and VII are Robbin's modifications.
 
Nyhus classification
Type I: Indirect hernia with normal deep ring.
Type II: Indirect hernia with dilated (patulous) deep ring.
Type III: Posterior wall defect.
  1. Direct hernia, sliding hernia.
  2. Pantaloon hernia.
  3. Femoral hernia.
Type IV: Recurrent hernia.
 
Bendavid classification
Type I: Anterolateral defect (indirect).
Type II: Antero medial (direct).
Type III: Posteromedial (Femoral).
Type IV: Posteriorprevascular hernia.
Type V: Anteroposterior defect (Inguino-femoral hernia).19
 
What are the precipitating causes for inguinal hernia?
  • Smoking.
  • Obesity.
  • Respiratory causes like bronchial asthma, tuberculosis, bronchitis.
  • Ascites.
  • Previous surgery like appendicectomy which causes direct inguinal hernia.
  • Chronic constipation due to anorectal strictures. Rectal stricture may be due to chronic proctitis (amoebic), tuberculosis of anorectum, previous anorectal surgery, rectal carcinoma or stricture due lymphogranuloma venereum.
  • Urinary problems like benign prostatic hyperplasia (BPH), urethral stricture.
  • Straining.
  • Multiple pregnancies.
 
How patient with hernia is evaluated for treatment?
  • Routine investigations like haemoglobin, total count, blood urea, serum creatinine.
  • Blood sugar
  • Specific investigations like chest X-ray, U/S abdomen to confirm BPH.
 
What is the treatment?
  • Initially precipitating causes should be treated. Asthma, tuberculosis and bronchiec-tasis are treated by proper drugs, broncho-dilators, respiratory physiotherapy.
  • Later definitive surgical treatment is under-taken.
  • Commonly used procedure at present is hernioplasty using prolene mesh. Modified Bassini's repair is done in young individual with indirect hernia. Shouldice repair is also used in some centers.
 
What is the anaesthesia used for inguinal hernia repair?
General/spinal/epidural or local anaesthesia can be used to do inguinal hernia repair.
 
How local anaesthesia is given for inguinal hernia surgery?
Around 50–60 ml of xylocaine 0.5% is used. Plain xylocaine 0.5% or xylocaine 0.5% with adrenaline can be used. Plain xylocaine dose is 2 mg/kg body weight. Xylocaine with adrenaline is 7 mg/kg body weight.
Two methods are used—
  1. Nerve block method (point block)
    • 10 ml of xylocaine is infiltrated 2 cm above and medial to anterior superior iliac spine to block the iliohypogastric nerve.
    • Midinguinal point is infiltrated with 10 ml xylocaine.
    • Pubic tubercle place is infiltrated with 10 ml xylocaine.
    • 10 ml of xylocaine is infiltrated just below the inguinal ligament lateral to femoral artery to block the genital branch of genitofemoral artery.
    • Line of skin incision is infiltrated with 10 ml of xylocaine.
    • Later neck of the hernial sac is infiltrated with 10 ml of xylocaine.
  2. Field block method (Shouldice method)
    • Skin of around 4 cm wide area is infiltrated into the subcutaneous plane as first layer from anterior superior iliac spine to pubic symphysis. Skin, subcutaneous and two layers of superficial fascia (Camper and Scarpa's) are incised.
    • Area deep to external oblique aponeurosis is infiltrated with 10 ml of xylocaine. External oblique aponeurosis is incised.
    • Exposed inguinal canal and hernial sac is infiltrated with 10 ml of xylocaine to continue with the dissection.
 
What is modified Bassini's repair?
It is strengthening of the posterior wall of the inguinal canal by approximation of the conjoint tendon to inguinal ligament using monofilament nonabsorbable suture material. Absorbable suture material like catgut should not be used as 50% of the tensile strength will be lost in 207 days. It takes 6 months to achieve more than 80% of tensile strength in repaired hernial wound; and so non-absorbable suture material has to be used here to maintain the same adequate tensile strength in these period. Multifilament suture material like silk may precipitate infection because of the crevices in the suture material and tensile strength is not as good as monofilament suture material. Commonly used suture material is either polypropelene (prolene (blue in colour)) or polyethylene (ethylon (black in colour)). Continuous sutures compromise the blood supply and interfere with proper healing; and strength will not be as adequate as interrupted sutures. So always interrupted sutures are used.
Earlier, commonest surgery done for groin inguinal hernia is modified Bassini's repair. But now hernioplasty is the commonly done procedure for both direct and indirect sac. In direct hernia, sac is usually not opened but in indirect hernia, sac is always opened.
 
What is herniotomy?
Herniotomy is done for indirect sac, where the sac is dissected, neck of the sac is ligated and redundant sac is excised.
 
What are the steps in inguinal hernia surgery? What are the different modifications?
 
1. Herniotomy
Procedure
After cleaning and draping, skin is incised 1.25 cm above and parallel to the medial two/third of inguinal ligament. Two layers of superficial fascia (outer Camper's fascia and inner Scarpa's fascia) are incised. External oblique aponeurosis is incised. Upper leaf is reflected above and lower leaf is reflected downwards to visualise and expose the inguinal ligament. Ilioinguinal nerve is safeguarded. Cremasteric muscle is opened. Cord structures are dissected. Sac which is anterior and lateral to cord is identified and is pearly white in colour.
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Fig. 1.27: Cord holding forceps is used to hold cords in inguinal hernia surgery.
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Fig. 1.28: Twisting the sac after exposing and dissecting the indirect sac. Sac should be twisted after opening so as to avoid any content from coming back into the sac during transfixation of the sac.
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Fig. 1.29: Bassini's repair
Dissection is usually started from the fundus and extended towards the neck which is identified by extraperitoneal fat. The neck is narrow and is lateral to the inferior epigastric artery. Sac is opened at the fundus. Finger is passed to release any adhesions. Sac is twisted so has to prevent the contents from coming back. It is transfixed using absorbable suture material (vicryl or chromic catgut 2–0) and is excised distally.
 
2. Modified Bassini's herniorrhaphy
Conjoint tendon and inguinal ligament are approximated using interrupted nonabsorbable monofilament sutures [polypropylene (prolene, blue in color)]; medial most stitch is taken from the periosteum of pubic tubercle (called as key or Bassini's stitch); external oblique is closed and other layers are closed. 1–0 polypropylene suture material is used for repair.
 
Lytle's repair
Often internal ring is narrowed by placing interrupted sutures over the medial side of the ring to the transversalis fascia using either thread or silk (To narrow the ring and push the cord laterally).
 
Shouldice repair
Eventhough transversalis fascia is thin, it is a tough layer and so double breasting of this fascia using continuous sutures (with nonabsorbable material) strengthens the posterior wall of the inguinal wall.
It is a multilayered repair. It was originated at Shouldice clinic in Toronto where it was usually done under local anaesthesia.
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Figs 1.30A to F: On table pictures of inguinal hernia surgery from cleaning, incision, exposure of external oblique, opening of external oblique and identification of the cord before dissecting the sac.
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Figs 1.31A to J: Steps in herniorrhaphy (modified Bassini's repair) identification of sac, dissection of sac, opening of the sac, herniotomy, exposure of conjoint tendon and inguinal ligament, placing interrupted, approximating sutures between conjoint tendon and inguinal ligament and putting the knots of repair.
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Fig. 1.32: Lytle's repair
After doing herniotomy as in any other inguinal hernia, transversalis fascia is incised along the line of the wound from deep ring to pubic tubercle. Lower flap of fascia is sutured to posterior part of the upper flap. Upper flap is sutured to the inguinal ligament. It causes double-breasting of the transversalis fascia. Then conjoint tendon and inguinal ligament is further approximated by two layers of continuous sutures. External oblique aponeurosis is sutured in two layers (double-breasting) in front of the cord. Hence the original Shouldice repair is 6 layered procedure. First two layers of transversalis fascia, next two layers of conjoint tendon and last two layers of external oblique aponeurosis. Suture material used here is fine steel wire 34 gauge (in original Shouldice repair) or polypropylene or polyethylene. Recurrence rate is 1%.
Berliner modified shouldice repair: Involves double-breasting of the transversalis fascia like in Shouldice repair and single layer closure of the external oblique aponeurosis without any additional two-layered repair of conjoint tendon to inguinal ligament.
 
Tanner's slide operation
To reduce the tension in the repair area, relaxing incision is placed over the lower rectus sheath so that conjoint tendon is allowed to slide downward.
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Fig. 1.33: Tanner's slide operation—relaxing incision placed over the lower medial aspect of the rectus sheath to reduce the tension after modified Bassini's repair.
 
Darning (Abrahamson nylon darning)
Continuous intervening network of non- absorbable sutures are placed between conjoint tendon and inguinal ligament to give good support to posterior wall inguinal wall.
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Fig. 1.34: Darning of the posterior wall of inguinal canal using nonabsorbable suture material either polypropylene/polyethylene.
 
Kuntz'operation
In old people after taking consent, orchidectomy is done along with removal of full cord, testis and total closure of posterior inguinal wall by repair so as to reduce the recurrence.
 
Removal of cord at inguinal region
Cord is removed from the inguinal canal by ligating both at external and internal ring. But testis is retained (for psychological reason) and closure of inguinal canal by repair is done.
 
Andrew's operation
Overlapping the external oblique aponeurosis.24
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Figs 1.35A and B: Hernia truss. Note the position where sac is supported. It is not commonly used now as it may precipitate strangulation.
 
Macvay operation (Cooper's ligament repair)
Suturing the conjoined tendon to Cooper's ligament.
 
What are the complications of the inguinal hernia surgery?
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Fig. 1.36: Bilateral inguinal hernia-operated. Postoperative wound infection has occurred on left side.
 
What is hernioplasty?
It is strengthening of the posterior wall of the inguinal canal using synthetic material like prolene mesh, or Dacron. Earlier natural materials like tensor fascia lata, temporal fascia were being used. Now prolene mesh is commonly used. It is placed in front of the conjoint tendon between conjoint tendon and inguinal ligament. It is sutured using nonabsorbable suture material below to the inguinal ligament and above to the conjoined tendon. Prolene suture material is white in colour.
Size of the mesh should be 1.5 cm wider than the defect. Adequate haemostasis and prevention of infection is important. Mesh should overlap over pubic tubercle adequately.25
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Fig. 1.37: Mesh repair. Prolene mesh is reinforced between conjoint tendon and inguinal ligament.
 
What are the different types of hernioplasty?
Hernioplasty is becoming the prime treatment for inguinal hernia.
 
Different types are
  • Onlay mesh repair by placing mesh in front.
  • Inlay mesh repair by placing mesh deep to conjoint tendon.
  • Lichtenstein tension free mesh repair (1993) with encircling the cord with mesh which is often done under local anaesthesia.
  • Nyhus pre-peritoneal mesh repair. It is done through suprainguinal horizontal incision. Mesh is placed in the preperitoneal space deep to the cord, conjoined tendon, and transversalis fascia. Below, it is folded deep to the iliopectineal ligament of Cooper and sutured to it using two or three interrupted non-absorbable sutures. It is sutured to transverse abdominis above and transversalis fascia from deep.
  • Rives preperitoneal mesh repair is pre-peritoneal mesh repair through transinguinal approach. Here mesh is folded and sutured below to iliopectineal ligament, above to the transverse abdominis in deeper plane. Often transversalis fascia opened earlier is sutured back using nonabsorbable suture material in front of the placed mesh.
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    Figs 1.38A to F: Hernial sac should be dissected up to the neck of the sac. It is then twisted and transfixed using catgut or vicryl and redundant sac is excised.
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    Figs 1.39A to G: Placement of prolene mesh in inguinal hernia repair. i.e Inlay-Lichtenstein mesh repair.
  • Stoppa's giant prosthesis reinforcement of visceral sac (GPRVS). It is done in large hernias, hernias in elderly, bilateral hernias, recurrent and re-recurrent hernias, hernia with very lax abdomen. Horizontal length (size) of the mesh is 2 cm less than distance between two anterior superior iliac spines and vertical length (size) is distance between the umbilicus and pubic symphysis. Large mesh is placed between peritoneum and lateral, inferior, anterior abdominal wall which stretches in the lower abdomen and pelvis. It is done through lower midline or Pfannensteil incision.
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    Fig. 1.40: Mesh after hernioplasty got infected with wound Dehiscence. It needs removal of mesh.
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    Usually such large mesh is placed without any anchorage.
  • Gilbert mesh repair: after herniotomy, internal ring is plugged by cone-shaped piece of prolene mesh. Later onlay/inlay mesh repair of posterior wall of the inguinal canal is done.
  • Transabdominal preperitoneal laparoscopic mesh repair (TAPP repair): becoming popular.
  • Totally extraperitoneal laparoscopic mesh repair (TEP): becoming popular.
 
Case
A 65 years old male patient presents with bilateral direct inguinal hernia with features of prostatism with night frequency, burning micturition, and incomplete urination.
 
How will you manage the case?
Patient is having bilateral inguinal hernia with benign prostatic hyperplasia (BPH). Digital examination of the rectum (P/R) should be done. Patient is evaluated with ultrasound examination, serum acid phosphatase and PSA (Prostate specific antigen). Residual urine should be assessed. Normal value is 30 ml. More than 50 ml is abnormal. More than 200 ml signifies severe obstructive uropathy which needs surgical intervention.
 
What surgery is done to this patient?
TURP (Transurethral Resection of Prostate) with hernioplasty either Lichtenstein or preperitoneal mesh repair should be done. Both surgeries are done at single sitting usually under spinal anaesthesia.
 
If TURP facility is not available what other options are there?
Open prostatectomy, either transvesical or retropubic can be done, which also can be com-bined with hernioplasty. But many advocate hernioplasty 12 weeks after open prostatectomy. Incidence of open prostatectomy has drastically come down because of advent of TURP. It is done only in case of nonavailability of TURP or very large BPH.
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Fig. 1.41: Left-sided complete inguinal hernia in a patient with Benign Prostatic Hyperplasia (BPH) who is on Foley's catheter. He needs trans urethral résection of prostate (TURP) with hernioplasty.
 
Recurrent Hernia
 
What are the causes of recurrent hernia?
  • Infection—most common—50%.
  • Haematoma in the wound.
  • Early straining.
  • Retained indirect sac, after repair of a direct sac (Pantaloon hernia).
  • Smoking, constipation, obstructive uropathy, old age, nutritional deficiencies.
  • Altered tension in repair site. Altered collagen synthesis.
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Fig. 1.42: Recurrent hernia on table. Note the defect on the medial aspect.
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Fig. 1.43: Sac in a case of recurrent hernia.
 
What are the types of recurrent hernias?
True or false recurrence—based on type of recurrence—whether inguinal recurrence after inguinal hernia repair (true)/femoral hernia or obturator or other rare types after inguinal hernia repair (false). But presently hernia is classified grossly as groin hernias and so all recurrences are true recurrences.
 
How is patient with recurrent hernia investigated?
Patient is investigated by chest X-ray, pulmonary function tests, U/S abdomen for BPH, uroflow-metry, etc.
 
How such patient is treated?
Treatment is always by surgery—always by hernioplasty. Ideally preperitoneal mesh repair is done either Rives or Nyhus or giant prosthetic reinforcement of visceral sac (Stoppa's GPRVS). Technically dissection is difficult because of the distorted anatomy of the inguinal canal and scarring. Orchidectomy may be added in old people only after taking formal consent.
 
What are the recent approaches for inguinal/groin hernias?
Transabdominal preperitoneal mesh repair (TAPP) using laparoscope. This is used in large indirect hernia or irreducible inguinal hernia. 10 mm umbilical port is used for laparoscope. 5 mm ports on pararectal point at the or above the level of the umbilicus one on each side so that to achieve adequate triangulation.
Contents of the hernia are reduced. Hernial sac is dissected in preperitoneal plane after making horizontal incision at the upper part of the sac opening. Vas, gonadal vessels, pubic bone, inferior epigastric vessels are identified. Once sac is dissected and excised, a prolene/vipro/ultrapro mesh of 15 × 10 cm sized is placed in preperitoneal space. It is fixed to pubic bone using tacks. Peritoneum is closed with continuous prolene sutures.
Totally extra peritoneal repair (TEP repair) using laparoscope—This technique is gaining more popularity than TAPP. Through subumbilical incision (10 mm) extraperitoneal space is reached. After CO2 insufflation, another 5 mm port is inserted 4 cm below the first port in the midline. Third 5 mm port is inserted in the same line 4 cm below or in the right iliac fossa. Dissection is carried out downwards carefully, then medially up to the pubic tubercle, iliopectineal ligament, laterally to iliac vessels, inferior epigastric vessels. Once adequate space is dissected 15 × 15 cm mesh is placed and spread. Care should be taken not to have any folding in the mesh. Mesh may be sutured to iliopectineal ligament. Displacement of mesh is not common. Other side also can be done together.
 
Anatomical Considerations
Preperitoneal space is a potential space in front of the peritoneum and behind the transversalis fascia and anterior rectus muscle. Below in front of the urinary bladder it is called as space of Retzius (medially), laterally it is called as space of Bogros. Median umbilical fold is formed by urachus in the midline. Medial umbilical 29ligament is formed by obliterated umbilical arteries. Lateral umbilical fold by inferior epigastric vessels. Three fossae are lying in relation to these folds—supravesical and medial fossae are medial to lateral umbilical fold which are sites of direct hernia whereas lateral fossa is lateral to lateral umbilical ligament is site of indirect hernia.
In 1956, Fruchaud described his myopectineal orifice bounded medially by the lateral border of rectus abdominis, laterally by iliopsoas, superiorly by conjoined tendon and inferiorly by pectin pubis. This area is the site of groin hernia which should be covered by mesh of adequate size to strengthen the defect and to prevent the recurrence. Iliopubic tract is analogue of the inguinal ligament extends from Cooper's ligament to anterior superior iliac spine which divides endoscopic view of preperitoneal space into superior compartment (contains inferior epigastric artery, Hesselbach's triangle, cord structures and site of indirect inguinal hernia) and inferior compartment (contains femoral canal, iliac vessels, iliopsoas muscle, genitofemoral nerve, lateral femoral cutaneous nerve).
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Fig. 1.44: Ports used for TEP (red colour) and for TAPP (yellow colour).
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Fig. 1.45: Diagrammatic representations of TEP and TAPP.
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External iliac vessels lie in a triangle formed by gonadal vessels laterally, vas deferens medially and peritoneal reflection inferiorly (triangle of doom).
Aberrant obturator artery which is an occasional branch of inferior epigastric artery replacing its pubic branch travels across Cooper's ligament, which during fixation of mesh can cause torrential haemorrhage—circle of death. Triangle of pain is formed by gonadal vessels medially, iliopubic tract laterally and peritoneal reflection below. Genitofemoral nerve and lateral cutaneous nerve of thigh traverse this triangle. Injury to these nerves either by dissection or by tacks cause postoperative pain. Tacks/staplers should not be placed in this triangle.
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INCISIONAL HERNIA
  • Incisional hernia is a hernia occurring through a weak scar.
  • Writing case sheets, taking detailed history is similar to inguinal hernia.
 
 
 
Additional history to be collected in history of present illness—
  • Details of surgery patient has undergone earlier. After how long incisional hernia has occurred?
  • History of wound infection, wound dehiscence, whether surgery done was an emergency or elective, and tension sutures placed or not.
  • History of pain, irreducibility and details of precipitating factors to be asked.
  • Other precipitating factors similar to inguinal hernia like smoking, urinary/respiratory/abdominal symptoms.
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Fig. 1.46: Lower abdominal incisional hernia adherent to skin.
 
Local Examination (Abdomen)
 
Inspection
Scar, its extent and location, whether healed primarily or secondarily, skin over the scar and swelling is noted. Details of the swelling with expansile impulse on coughing and examination both in lying down and standing are done.
 
Palpation
Palpation is like for inguinal hernia. Size, extent, impulse on coughing must be confirmed; scar and skin should be palpated. The defect in the abdominal wall must be assessed. It is done after reducing the hernial content with patient in lying down position. Fingers are placed horizontally over the hernial defect and patient is asked to raise the head with arms folded over the chest (to contract the abdominal wall muscles) so that the defect is felt clearly. Its size, extent can be assessed well. Assessment can also be done by raising the legs instead of head.
Gap cannot be assessed in an irreducible hernia.
 
Factors Responsible for Development of Incisional Hernia
  • Vertical incision has got higher chances of incisional hernia than horizontal incision.
  • Layered closure of the abdomen has got higher chance than single layer.
  • Continuous closure has got higher chances than interrupted closure.
  • Use of absorbable suture material has got higher chances of hernia than nonabsorbable sutures.
  • Emergency surgical wound has higher chances than elective surgical wound.
  • Laparotomy for peritonitis, acute abdomen, and trauma can commonly cause incisional hernia.
  • Drainage through the main laparotomy wound may precipitate formation of incisional hernia.
  • Chronic cough, smoking, obstructive uro-pathy, constipation can precipitate incisional hernia.
  • Diabetes, old age, malnutrition, malignancy, anaemia, hypoproteinaemia, jaundice, ascites, liver disease, uraemia, steroid therapy, immunosuppressive diseases are other precipitating factors.
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Treatment Strategy for Incisional Hernia
  • When the defect is less than 3 cm, and if the patient is having adequate abdominal muscle tone then layer by layer anatomical repair is done using monofilament non-absorbable suture material like polypropylene/polyethylene with ideally interrupted sutures. Sac should be dissected, ligated and excised prior to repair. Peritoneum and posterior rectus sheath is apposed as first layer and anterior rectus sheath as second layer.
  • Double breasting of the rectus sheath using interrupted nonabsorbable sutures using monofilament suture material. It is over-lapping the rectus sheath in two layers with two rows of sutures.
  • Mesh repair of the incisional hernia defect is always better and ideal with less chances of recurrence. Adequate sized mesh is placed either outer to peritoneum (inlay), or outer to musculoaponeurotic abdominal layer (onlay/overlay), or occasionally combined inlay and onlay mesh placement, both deep to peritoneum and outer to musculoaponeurotic layer. Rive's Stoppa's mesh placement for incisional hernia is placing mesh between posterior rectus sheath and rectus muscle. Commonly polypropylene mesh is used. Other materials used are Dacron, polytetrafluroethylene (PTFE) mesh, polyglycolic mesh (vicryl mesh) or combined polypropylene and polyglycolic acid mesh (vipro mesh). Drain (suction drain) must be placed after surgery.
  • Laparoscopic mesh repair is done for incisional hernia by placing a mesh under the defect laparoscopically in intraperitoneal plane. The only problem of this underlay placement is chances of adhesion and GI fistula formation but it is found to be safer. Laparoscopic preperitoneal mesh placement also done for smaller defects. Now dual mesh (PTFE) or four layered mesh are available. In this mesh is placed under the peritoneum deep to the defect after reducing the contents. Mesh is fixed with sutures and tacks. In four layer mesh, deepest 1st layer is absorbable cellulose which allows new peritoneum to creep underneath. Second layer is PDS mesh 3rd layer is polypropylene mesh last 4th layer is again PDS mesh. It is ideal but costly.
  • Keel's operation is done in large defect. Scar is excised and sac is dissected beyond the margin of the defect. Sac is never opened unless there is obstruction of the content. Sac in inverted using continuous/interrupted inverting nonabsorbable sutures, layer-by-layer until the defect margins are apposed together which is then again sutured with interrupted sutures. Keel is inverted beam of the ship.
  • Nuttall's operation is done for lower midline incisional hernia. Recti attachments are detached from the pubic bones and are crossed over to fix to opposite pubic bones so as to create a firm abdominal wall support by crossed recti muscles.
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Figs 1.47A and B: (A) Keel's operation is inverting rectus sheath layer by layer using nonabsorbable monofilament suture material so as to appose the defect. (Keel of a ship). (B) Nuttall's operation—rectus muscle detached from its attachment from the pubic bone and sutured to opposite pubic bone.
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Preoperative Preparations for Incisional Hernia Surgery
  • Reduction in weight and control of obesity.
  • Nutrition, control of anaemia.
  • Treatment for diabetes, hypertension, cardiac diseases, respiratory problems.
  • Treating the precipitating causes.
  • Chest X-ray, U/S abdomen to be done.
  • Massive incisional hernia after reduction might cause IVC compression, paralytic ileus and diaphragmatic elevation with respiratory embarrassment (abdominal compartment syndrome). It is prevented by prior increasing the capacity of peritoneal cavity by creating the pneumoperitoneum using CO2 so as to increase the peritoneal pressure by 12–15 cm of H2O, daily for 3–6 weeks. Later definitive surgery is done.
 
Different Types of Mesh Repair for Incisional Hernia
  • Outer to peritoneum is ideal method. Large-sized mesh is placed in preperitoneum. It need not be fixed as abdominal pressure keeps it in position.
  • Under the peritoneum, directly over the content. Now it is accepted but there are chances of adhesions/fistula formation. It is used in laparoscopic repair.
  • Overlay mesh placed outer to musculoaponeurotic layer.
  • Combined inlay and overlay with two layers of mesh.
  • Rive's Stoppa's method of placing mesh between posterior rectus sheath and rectus muscle.
 
Additional Problems in Large Incisional Hernia
  • While reducing the bulky contents like bowel and omentum, inadequate intra-abdominal capacity leads to increased intra-abdominal pressure causing IVC compression, mesenteric oedema following stasis of splanchnic bed, paralytic ileus, diaphragmatic elevation and respiratory distress (abdominal compartment syndrome), urinary and bowel disturbances. Abdominal capacity can be raised by regular pneumoperitoneum over the period of 3–6 weeks.
  • Lordosis and back pain may be presenting feature.
  • Sac and contents may get adherent to the thin skin over the summit of the hernia leading to skin ulceration and occasionally fistula formation.
  • Often might need resection of the adherent bowel segment.
  • Large mesh placement is required.
 
What is paraumbilical hernia?
It is midline herniation above or below the umbilicus. It often attains large size and sags downwards. Neck may be narrow with omen-tum/small bowel as contents. Obstruction/strangulation tend to occur. It is commonly associated with obesity and multiple pregnancies. It is common in females. Swelling, impulse on coughing, dragging pain and reducibility are usual presentations. It is common with flabby, pendulous abdomen.34
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Figs 1.48A to D: Epigastric hernia. It is fatty hernia through a gap in the decussation of the linea alba. Initially, it is sacless but later develops peritoneal sac with contents. Pain is the common feature of the epigastric hernia. Condition may be associated with peptic ulcer and so gastroscopy should be done. Treatment is surgical repair. Large mesh should be used to correct the hernia (in preperitoneal position).
 
How is paraumbilical hernia treated?
It is treated by transverse elliptical incision, dissection and ligation of sac followed by closure of defect with interrupted nonabsorbable sutures when it is less than 4 cm size; mesh repair should be done using polypropylene mesh if the defect is large. Additional lipectomy (panniculectomy) may be done in case of pendulous abdomen.
 
What is Mayo's operation?
It is done for umbilical and paraumbilical hernia. Once lower flap or umbilicus is raised above, sac is identified, dissected and opened.35
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Fig. 1.49: Paraumbilical hernia.
After reducing the contents sac is transfixed using vicryl. Rectus sheath is repaired with double breasting using nonabsorbable sutures. Skin flap is closed often with a drain. Infection, recurrences are known complications.
 
What is umbilical hernia?
It is herniation through a weak umbilical cicatrix. It is common in infants and children. It is hemispherical in shape with defect felt during crying. It can cause obstruction and strangulation. 95% of umbilical hernias disappear in 2 years. If it persists beyond 2 tears, and if the defect is more than 2 cm in size or presence of complications are indications for surgery. It is operated through an infraumbilical incision; defect is closed with interrupted sutures after ligating the sac.
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Fig. 1.50: Umbilical hernia
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Fig. 1.51: Incision for umbilical hernia
 
What is Richter's hernia?
It is herniation of a portion of circumference of intestine usually small bowel leading into gangrenous change. But patient presents with features mimicking gastroenteritis without any signs of intestinal obstruction. Eventually it leads to perforation and peritonitis. It is common in femoral hernia. It is treated by resection and anastomosis and repair.
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Fig. 1.52: Richter's hernia.
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Fig. 1.53: Richter's hernia with gangrene of part of the circumference of the bowel with perforation in a case of femoral hernia.
 
What is sliding hernia?
Posterior wall of the sac is formed by parietal peritoneum and also by sigmoid colon/caecum/urinary bladder. It occurs exclusively in males and common on left side. It attains large size and its content is usually small bowel. Posterior wall should not be separated from the sac. Sac is excised only partially and then is pushed into peritoneal cavity. Mesh repair is done afterwards.
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Fig. 1.54: Sliding hernia.
 
What is pantaloon hernia?
Inguinal hernia containing both direct and indirect sacs is called as pantaloon hernia but it presents as direct hernia. It is also called as double hernia, saddle hernia or Romberg hernia. So in all cases of direct hernia, indirect sac should be looked for. Condition is one of the causes for recurrence.
 
What are the problems of strangulated hernia?
It is due to compromised blood supply of the contents of the hernia like bowel/omentum causing toxicity, tenderness at the site. There is no impulse on coughing, and is irreducible and tense. Features of intestinal obstruction are present if the content is bowel. Narrow neck and adhesions are the causes of strangulation. It is treated by emergency surgery. Exploration is done through groin incision. Contents are not allowed to spill or to get reduced. Toxic fluid is removed using suction. Bowel is checked for viability. If not viable resection and anastomosis is done. Groin is repaired by herniorrhaphy. Mesh is not used in strangulated hernia. Drain is kept to the wound. Adequate antibiotic coverage is a must.
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Fig. 1.55: In strangulated hernia, if the content is stran-gulated omentum, then omentum is excised and repair is done. Mesh is usually not used in strangulated hernia.
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Figs 1.56A and B: Strangulated enterocele with irreducibility, absence of impulse on coughing, signs of acute inflammation, tense and tender with features of intestinal obstruction. Bowel strangulation is obvious during surgery.
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Fig. 1.57: Incision used for strangulated inguinal hernia. It is placed in the inguinal region extending into the scrotum downwards.
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Fig. 1.58: Strangulated hernia with toxic fluid and site of obstruction.
 
What is Maydl's hernia?
Here bowel loop in the form of ‘W’ lies in the hernial sac and centre of the portion of the W is strangulated. It may get reduced ‘en-masse’. Strangulation of centre part is common.
 
What is ‘taxis’?
Taxis is reducing hernia by flexing and medially rotating the hip. It is done in case of partially reducible or irreducible hernia. Patient himself does it properly. It is dangerous in case of obstructed hernia, Maydl's hernia, femoral hernia, strangulated hernia and sliding hernia.
 
What are the clinical features of femoral hernia?
Femoral hernia is herniation through the femoral ring over medial most part of the femoral canal.38
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Fig. 1.59: Maydl's ‘W’ hernia.
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Fig. 1.60: Anatomical locations of femoral and inguinal hernia. Inguinal hernia is above and medial to pubic tubercle. Femoral hernia is below and lateral to pubic tubercle. Also note the location of the obturator hernia below in Scarpa's triangle.
Femoral ring is bounded by inguinal ligament, iliopectineal ligament, lacunar ligament and septum separating femoral vein. It is retort-shaped hernia, more prone for strangulation. It is common in females and it is bilateral in 20% cases. It is below and lateral to pubic tubercle whereas inguinal hernia is above and medial to pubic tubercle. Impulse on coughing, pain, reducibility are the usual features. It should be differentiated from inguinal hernia, lymph node mass, lipoma, psoas bursa, femoral aneurysm and saphena varix.
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Figs 1.61A and B: Femoral hernia is common in females. It occurs below and lateral to pubic tubercle. Herniation occurs through femoral ring- medial most part of the femoral canal.
 
How is femoral hernia treated?
It is treated by surgical approach. Different approaches like Lockwood-low approach, McEvedy-High vertical approach (for strangulated femoral hernia), Lotheissen's inguinal approach or suprapubic approach are used. After sac dissection and ligation, repair is done by approximating inguinal ligament to iliopectineal ligament or by approximating conjoint tendon to ilio-pectineal line (Lotheissen's repair). Polypropylene mesh can be buttressed into the femoral canal to close the defect. A K Henry's approach is suprapubic transverse extra peritoneal approach for bilateral femoral hernias. Laparoscopic mesh repair of femoral hernia is also a good method which is done using large mesh like TAPP/TEP.39
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Fig. 1.62: Diagramatic representation of location of inguinal, femoral and obturator hernias. Obturator hernia occurs through obturator canal, commonly presenting with features of intestinal obstruction. Often radiating pain to knee joint through geniculate branch of the obturator nerve called as Howship-Romberg sign may be the presentation. Obturator hernia is common in elderly females.
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Fig. 1.63: Femoral hernia repair. Repair of femoral hernia is done either by approximating inguinal ligament to ilio-pectineal ligament or by approximating conjoint tendon to iliopectineal ligament or by plugging the mesh to femoral opening.
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Fig. 1.64: Different approaches for femoral hernia. 1. Lockwood low approach is below the inguinal ligament parallel to it. 2. McEvedy high approach is vertical incision extending above and below the inguinal ligament. It is used in strangulated femoral hernia. 3. Lotheissen's approach is inguinal approach through inguinal canal. 4. A K Henry's approach is horizontal lower abdominal approach for bilateral femoral hernia repair with extra-peritoneal approach.
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Fig. 1.65: Right-sided hernia in a child. Only herniotomy is done for inguinal hernia in children. Repair/mesh are not used. Herniotomy is also done for hydrocele in children through inguinal approach. Hydrocele in children is due to patent processus vaginalis.
40
VASCULAR DISEASES
 
EXAMINATION OF A CASE OF ARTERIAL DISEASES
Arterial diseases can occur in lower limb commonly and also occasionally upper limb. Often both lower and upper limbs may get involved.
It is often classified as lower limb ischaemia and upper limb ischaemia. But wherever the disease detailed examination of both lower limb and upper limb vessels is required in all patients.
Name:
Age:
Sex:
Occupation:
Address:
Atherosclerosis occurs in old age usually. Thromboangiitis obliterans (Buerger's disease) occurs in young males. Raynaud's disease is common in young/middle-aged females.
 
Chief Complaints
  • Pain in the limb right/left/both—its duration.
  • Intermittent claudication—its duration.
  • Blackish discoloration/ulceration.
 
History
 
History of Present Illness
 
Pain
  • Site of pain, type of pain—severe burning/aching/deep persisting.
    Whether pain radiates or not.
  • Intermittent claudication—duration, grade/distance how much patient can walk/whether pain subsides after stopping walk or after continuous walk/whether patient is able to walk in spite of pain/change in the claudication distance eventually/site of claudication—foot/leg/thigh/buttock.
  • Presence of rest pain—its location/severity/whether patient has to hold the limb/foot/leg/toes to relieve pain little bit (probably by transmission of temperature from holding hand into the part) or to hang the leg down to relieve the pain or by applying the warmth.
    zoom view
    Fig. 1.66: Rest pain in a TAO patient. Observe the way patient holding the foot to relieve the pain.
  • Pain, discomfort, colour changes when exposed to cold.
 
Ulceration
  • Whether precipitated by trauma/spontaneously.
  • Pain in the ulcer/type/duration/aggravating or relieving factors.
  • Discharge-type—serous-purulent-bloody.
  • Progression.
 
Gangrene
  • Site of gangrene/its onset/progression/pain.
  • History of difficulty in walking/altered gait.
  • Mode of onset—in atherosclerosis/Buerger's disease process is spontaneous and gradual. Gangrene due to embolism is sudden in onset, rapidly progressive.
  • History of fever.
    41
  • History of impotence—its duration.
  • History of tingling/numbness/weakness in the limbs.
  • History of syncope/blackouts/loss of consciousness/blurred vision.
  • History of chest pain/cough or cardiac related symptoms.
  • History of abdominal pain/bloody diarr-hoea/abdominal angina.
  • History of paraesthesia over the skin.
  • History suggestive of superficial thrombophlebitis like swelling/redness/pain along the line of superficial vein.
 
Past History and Treatment History
  • Similar history earlier.
  • History of drug intake earlier for similar conditions like vasodilators/drugs to increase the perfusion.
  • History of earlier surgery like/sympathectomy/omentoplasty/their results or effects.
 
Personal History
History of smoking—beedi or cigarettes/duration/number per day/stopped now or continuing/since when stopped smoking.
 
Family History
Any family history suggestive of atherosclerosis or vascular diseases.
 
General Examination
  • Pulse-rate/rhythm/character/condition of vessel wall.
  • Blood pressure of both arms and if possible of both lower limbs.
  • Attitude of limbs.
 
Local Examination
 
Inspection
  • Inspect both lower limbs keeping side-by-side as comparison is needed during clinical examination.
  • Change in colour is very important sign of ischaemia.
  • Colour proximal to gangrene area/ischaemic area (usually ischaemic area is pallor).
  • Limb deformity.
  • Gangrene of toe/toes/foot/leg: Its extent, discharge from area, type of gangrene—dry or wet, line of demarcation—type/level/depth, colour of gangrenous area—black/purple/greenish black (in gas gangrene).
  • Ulceration if any—its extent/discharge/size/shape/floor/surrounding area.
  • Patchy ulcers proximal to gangrenous areaskip lesions which are usually black patchy lesions.
  • Muscle wasting in the foot/leg/thigh should be observed. It should be compared and also should be measured using a tape from a fixed bony point keeping equal distance in both limbs.
  • Features of ischaemia—shiny thin skin/loss of subcutaneous fat/hair loss- its extent/nail changes—brittle nail/transverse ridges in the nail.
  • Plantar aspect of the foot for infective focus/abscess/callosities/skin changes/superficial ulcers in heel/malleoli/toes.
  • Buerger's postural test: Patient in supine position is asked to raise his legs one after other with knee keeping straight. In normal limb even after 90° elevation limb remains pink without any palor. Diseased limb after elevation shows marked palor (overfoot) with empty-guttered veins. The angle with which palor develops (between limb and ground) is called as Buerger's vascular angle of insufficiency. In severe ischaemia, this angle will be less than 30°. If foot does not become palor or doubtful, then repeated ankle flexion and extension is done until it becomes palor empty-guttered veins on the dorsum of foot and after lowering the foot cyanotic congestion appears in the foot.
  • Oedema in the foot/feet/legs.
  • Status of the superficial veins—normally filled veins or pale/discoloured/guttered veins as seen in ischaemic limb.
    42
  • Capillary filling time: Initially elevated limbs are made to hang down the bed. Limb will remain normal pink in elevated as well as down position because of rapid capillary filling time. In ischaemia, limb becomes palor in elevation and only gradually becomes purple-red and then pink in more than 20 seconds. Purple pink colour is due to deoxygenated blood. Prolonged capillary time signifies severe ischaemia.
  • Venous refilling time: Elevated limb when laid horizontal in the bed normal venous refilling occurs within 5 seconds. It is delayed in ischaemic limb.
 
Palpation
  • Temperature of the skin is important factor in ischaemic limb. Extent of cold and proxi-mally where exactly limb/part become warmer also should be assessed.
  • Tenderness: Site/extent/severity should be assessed.
  • Gangrenous area to be palpated for extent/whether it is dry and shriveled or whether it is wet and oedematous. Crepitus in gangrenous present or not should be checked.
  • Limb above the gangrenous area should be palpated.
  • Capillary filling: Tip of the nail or pulp of the finger or toe is pressed to blanch it and pressure is released (in 2 seconds) to make it to become pink. Time taken from blanched area to turn into pink is capillary filling time. It is prolonged in ischaemic limb.
  • Harvey's venous refilling test: Two fingers are placed over the vein. Pressure is elicited over the vein. Proximal finger is moved proximally for about 5 cm without releasing the pressure. Vein between the fingers gets emptied completely and becomes flat. Distal finger is released now to see the flow of the blood and its refilling is observed whether it is good or poor. It is poor in ischaemic limb.
  • Elevated arm stress test (EAST): Both shoulders are abducted 90° with arms fully externally rotated. Patient will open and close the hands rapidly for 5 minutes. Normal individual can do this without any discomfort and pain. Patient with thoracic outlet syndrome develops pain, fatigue, paraesthesia of forearm with tingling and numbness of fingers. Patient will not be able to complete the test for 5 minutes. This test can also differentiate thoracic outlet syndrome from cervical disc prolapse disease.
  • Roos test: Patient is asked elevate and abduct the shoulders 90° with external rotation of arms to keep it for 5 minutes. Patient feels fatigue in the diseased side.
  • Costoclavicular compression manoeuvre: While feeling radial pulse of the patient, he is asked to place his shoulder backwards and downwards (exaggerated military position) causing absence/feeble radial pulse and while auscultating the supraclavicular region a bruit may be heard. This is due to com-pression of subclavian artery between clavicle and first rib.
  • Hyperabduction manoeuvre (Halsted test): While palpating the radial pulse, arm on the diseased side is passively hyperabducted causing feeble or absence of radial pulse. This is due to compression of artery by pectoralis minor tendon (pectoralis minor syndrome). An axillary bruit may be heard on auscul-tation.
  • Adson's test: While feeling the radial pulse of the affected side of the patient, patient is asked to take deep breath and to turn his neck/head towards the same side so as to compress the thoracoaxillary channel. Pulse becomes feeble or absent in positive Adson's test in thoracic outlet syndrome/scalenus anticus syndrome. While taking deep breath thoracic cage moves upwards and narrows the space causing aggravation of compression of subclavian artery by scalenus anterior muscle. Contraction of scalenus anterior further aggravates the feature (by turning neck towards same side).43
    zoom view
    Figs 1.67A and B: Adson's test
  • Branham's/Nicoladoni's sign: In arteriovenous fistula, pressure over the artery proximal to fistula will cause reduction in pulse-rate and size of the swelling with pulse pressure becoming normal and disappearance of bruit.
  • Allen's test: It is used in hand to find out the patency of radial and ulnar arteries. Both radial and ulnar arteries of the patient is felt and pressed firmly at the wrist. Patient clinches his hand firmly (often repeated clinching) and holds it tightly. After 1 minute, clinch is released to open the palm of the hand which looks pale. Pressure on the radial artery in wrist is released to see area of distribution of the radial artery. Normally, it becomes flushed with pink colour. If there is radial artery block area will remain white. Test is repeated again. This time pressure on the ulnar artery is released to check the patency of ulnar artery. Area will be pale and blanched after releasing in case of ulnar artery block. Otherwise in normal individual it becomes pink after release.
  • Cold and warm water test: It is commonly done to confirm Raynaud's phenomena. Patient is asked to dip hands in cold water to precipitate the vasospasm and Raynaud's syndrome.
  • Crossed-leg test (Fuchsig's test): Patient is asked to sit with the legs-crossed one above the other so that the popliteal fossa of one leg will lie against the knee of other leg. Oscillatory movements of foot can be observed synchronous with the popliteal artery pulsation. If the popliteal artery is blocked oscillatory movements will be absent.
  • Disappearing pulse syndrome: Exercise the limb after feeling the pulse. Pulse will disappear once patient develops claudication. It is because of vasodilatation and increased vascular space occurring due to exercise wherein arterial tension can not be kept adequately and so pulse will disappear (unmasking the arterial obstruction).
  • Buerger's postural test: Patient lying down on his back is asked to raise the leg forward for two minutes.
    zoom view
    Figs 1.68A to D: Allen's test
    44
    zoom view
    Figs 1.69A and B: Crossed-leg test—checking oscillatory movements.
    In normal individuals, limb (plantar aspect of foot) will remain pink even after raising to 90°. Ischaemic limb, when elevated shows marked pallor and empty veins. The angle in which pallor develops is called as Buerger's angle of vascular insuffi-ciency. Less than 30° angle indicates severe ischaemia. Ischaemic height of the heel in relation to the sternal angle where palor develops in heel signifies the severity of the disease. This height in centimeter is equal to the arterial pressure in the foot in mmHg. After that patient is asked to keep the legs below the bed to fill the vessels. Time taken to become leg pink colour is capillary filling time. Filling time more than 30 seconds suggests severe limb ischaemia.
  • Guttering of vein while raising the leg for 15° is observed in ischaemic limb due to complete collapse of the veins whereas in normal individual veins are only partially collapsed while raising the leg.
  • Reactive hyperaemia time test: Inflate the sphygmomanometer cuff around the limb up to 250 mmHg for 5 minutes to appear palor significantly. Release and assess the time of appearing of red flush in skin which signifies the reactive hyperaemia time. Normal time is 2 seconds. It is delayed in ischaemia.
 
Palpation of Blood Vessels
Dorsalis pedis artery is felt just lateral to the extensor hallucis longus tendon at the proximal end of first web space, felt against the navicular and middle cuneiform bones. It is absent in 10% cases.
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Fig. 1.70: Palpation of dorsalis pedis artery pulsation.
Posterior tibial artery is felt against the calcaneus just behind the medial malleolus midway between it and tendo-Achilles.
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Fig. 1.71: Palpation of posterior tibial artery.
Anterior tibial artery is felt in the midway anteriorly between the two malleoli against the 45lower end of tibia just above the ankle joint lateral to extensor hallucis longus tendon.
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Fig. 1.72: Palpation of anterior tibial artery
Popliteal artery is difficult to feel. It is palpated better in prone position with knee flexed about 90–130° to relax popliteal fascia. It is felt in the lower part of the fossa over the flat posterior surface of upper end of tibia. In upper end of the fossa, artery is not felt as bony area in intercondylar region is not present. It can also be felt in supine position with knee flexed 90–130° to relax the popliteal fossa so as to feel the pulsation against tibial condyles.
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Figs 1.73A and B: Palpation of popliteal artery both in supine and prone positions. Prone position is better.
Femoral artery in the groin is felt just below the inguinal ligament midway between anterior superior iliac spine and pubic symphysis (mid-inguinal point). Often hip has to be flexed for about 10–15° to feel it properly.
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Fig. 1.74: Palpation of femoral artery.
Radial artery is felt at the wrist on the lateral aspect against lower end of the front of radius.
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Fig. 1.75: Palpation of radial artery
Ulnar artery is felt at the wrist on the medial end against lower end of the front of ulna.
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Fig. 1.76: Palpation of ulnar artery.
46
Brachial artery is felt in front of the elbow just medial to biceps brachii tendon.
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Fig. 1.77: Palpation of brachial artery.
Axillary artery is felt in lateral aspect of the axilla against upper end of the shaft of the humerus with raised and elevated arm.
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Fig. 1.78: Palpation of axillary artery.
Subclavian artery is felt against first rib just above the middle of the clavicle in supraclavicular fossa while patient is lifting the shoulder to relax deep fascia.
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Fig. 1.79: Palpation of subclavian artery.
Common carotid artery is felt medial to sternomastoid muscle at the level of thyroid cartilage against carotid tubercle (Chaissagne tubercle) of transverse process of 6th cervical vertebra (in carotid triangle).
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Fig. 1.80: Palpation of common carotid artery.
Facial artery is felt against body of mandible at the insertion of masseter.
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Fig. 1.81: Palpation of facial artery.
Superficial temporal artery is felt just in front of the tragus of the ear against zygomatic bone.
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Fig. 1.82: Palpation of superficial temporal artery.
47
All pulsations should be written in a tabular form right and left side.
Condition of the vessel wall, thrill and any tenderness on the artery should be mentioned.
Ulcer if present should be examined for different features like tenderness/mobility/fixity/base/induration.
Limb muscle wasting assessment is important to find out the severity of the ischaemia. It is done by inspection of muscle bulk; prominent bony prominences; by measurement of the limb girth (circumference is measured using a tape, 15 cm away from the bony point).
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Figs 1.83A and B: Measurement of girth is important to find out the wasting. It should be compared to opposite side and measured at a specific distance from a bony prominence.
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Fig. 1.84: Muscle power should be checked against resistance to find out the grade.
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Fig. 1.85: Wasting of muscles of right hand because of ischaemia. Note also colour difference between two hands.
48
Muscle power is also should be checked and graded as—Grade 0—complete paralysis; Grade 1—flicker of contraction, no movement; Grade 2—movement with the elimination of gravity; Grade 3—movement against gravity, not against resistance; Grade 4—movement against partial resistance; Grade 5—normal movement against full resistance.
 
Auscultation
Auscultation over the artery for bruit is done using bell of the stethoscope placing gently over the artery. It signifies localised stenosis causing turbulence flow. Machinery bruit/murmur also heard in AV malformations/fistulas.
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Figs 1.86A to C: Auscultation over the major vessel like femoral/carotid for bruit is important. It signifies stenosis and turbulence flow of blood.
 
Neurological Examination
Muscle tone/power at ankle, knee and hip, sensory examination for touch, pain and temperature, reflexes at ankle and knee and plantar response should be checked when associated neurological conditions are suspected (like tabes dorsalis, syringomyelia, hemiplegia, transverse myelitis).
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Fig. 1.87: Sensation should be checked for neurological deficit especially in upper limb (cervical rib).
 
Systemic Examination
Abdomen should be examined for the presence of abdominal aortic aneurysms. It presents as pulsatile mass above the umbilicus, vertically placed, smooth, soft, nonmobile, not moving with respiration, resonant on percussion. Expansile pulsation is confirmed by placing the patient in knee-elbow position.
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Fig. 1.88: Examination of abdomen for aortic pulsation/aneurysm; old sympathectomy scar are important.
49
Cardiovascular system: CVS is essential part of the arterial system for any associated or causative causes to find out. There may be embolic focus in heart like fibrillation/endocarditis, etc.
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Fig. 1.89: Cardiovascular system examination is also equally important for mitral stenosis/endocarditis, etc.
Other systems like skeletal and respiratory systems should be examined in detail.
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Fig. 1.90: Palpation of abdominal aortic pulsation in epigastrium, above the umbilicus, midline.
 
Intermittent Claudication
Claudio means ‘I limp’ a Latin word. It is a crampy pain in the muscle seen in the limbs. Due to arterial occlusion, metabolites like lactic acid and substance P accumulate in the muscle and cause pain.
The site of pain depends on site of arterial occlusion.
  • Commonest site is calf muscles.
  • Pain in foot is due to block in lower tibial and plantar vessels.
  • Pain in the calf is due to block in femoropopliteal site.
  • Pain in the thigh is due to block in the superficial femoral artery.
  • Pain in the buttock is due to block in the common iliac or aortoiliac segment, often associated with impotence and is called as Leriche's syndrome.
Pain commonly develops when the muscles are exercising. Cause for pain is accumulation of substance ‘P’ and metabolites. During exercise increased perfusion and increased opening of collaterals wash the metabolites.
Neurogenic claudication is pain in the leg during walking due neurological causes. It often mimics vascular claudication but arterial pulses are normal in this. It is common in spinal cord stenosis.
Claudication distance is distance at which claudication appears. It is better assessed using a treadmill.
Claudication is not that common in upper limb but can occur during writing or any upper limb exercise.50
 
Rest Pain
It is continuous aching in calf or feet and toes or in the region depending on site obstruction. It is ‘cry of dying nerves’ due to ischaemia of the somatic nerves. It signifies severe decompensated ischaemia. Pain gets aggravated by elevation and is relieved in dependant position of the limb. Pain is more in the distal part like toes and feet. It gets aggravated with movements and pressure. Hyperaesthesia is common association with rest pain. Rest pain is more during night time as there is reduced heart-rate and blood pressure during night (sleeping time).
 
Critical Limb Ischaemia
It is persistently recurring ischaemic rest pain or ulceration or gangrene of the foot or toes with an ankle systolic pressure < 50 mmHg or toe systolic pressure < 30 mmHg.
 
Pregangrene
It is the changes in tissue which indicates that blood supply is inadequate to keep the tissues alive and presents with rest pain, colour changes, oedema, hyperaesthesia with or without ischaemic ulceration.
 
Gangrene
It is macroscopic death of tissue in situ with or without putrefaction.
 
Dry Gangrene
It is dry, dessicated, mummified tissue caused by gradual slowing of blood stream. There is a line of demarcation and is localised.
 
Wet Gangrene
It is due to both arterial and venous block with superadded putrefaction and infection. It spreads proximally and there is no line of demarcation. It spreads faster.
Organs in which gangrene can develop are appendix, bowel, gall bladder, testis and pancreas.
 
Necrosis
It is microscopic cell death.
 
Sequestrum
Sequestrum is dead bone in situ.
 
Slough
Slough is dead soft tissue.
 
Line of Demarcation
It is a line between viable and dying tissue indicated by a band of hyperaemia. It also indicates that disease is well-localised. Final separation between healthy and gangrenous tissue occurs by development of a layer of granulation tissue in between. It is hyperaesthetic due to exposed nerve endings.
 
Type of separation
  • Separation by aseptic ulceration-seen in dry gangrene.
  • Separation by septic ulceration-seen in infected cases and wet gangrene.
51
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Fig. 1.91: Ischaemic ulcers in both upper and lower limbs
Aortoiliac block causes claudication in both buttocks, thighs, and calves; absence of femoral and distal pulses; bruit over aortoiliac region. Impotence occurs due to defective perfusion through internal iliac arteries and so into the penis causing erectile dysfunction (Leriche's syndrome).
Iliac artery obstruction causes claudication in thigh and calf; bruit over iliac arteries with absence of femoral and distal pulses.
Femoropopliteal obstruction causes claudication in calf with absence of distal pulses but with palpable femoral.
Distal obstruction shows absence of ankle pulses with palpable femoral and popliteal pulses.
 
INVESTIGATIONS FOR ARTERIAL DISEASES
  • Blood tests: Hb%, blood sugar, lipid profile, peripheral smear, platelet count.
  • Doppler to find out the site of block.
  • Duplex scan: It is combination of B mode ultrasound and Doppler study. Difference in transmitted beam of the ultrasound and reflected beam is called as Doppler shift which is assessed and converted into audible signals. To study the site, extent, severity of block, and also about collaterals. Audible sound—with normal flow and sound is important. Turbulence is heard with stenosed partially blocked artery. Audible sound will be absent, if there is complete block. Using Doppler probe blood pressure at various levels can be assessed. Pulse wave tracing along the artery is also important.
  • Plethysmography.
  • Ankle-brachial pressure index (ABPI):
Normally, it is 1. If it is less than 0.9, it means ischaemia is present. If it becomes 0.3 or below then it signifies severe ischaemia with gangrene. It may be normal at rest in early mild ischaemia but alters (reduces) during exercises.
 
Angiography
Retrograde transfemoral Seldinger angiography: It is commonly done. It is done only when femorals are felt. If femoral pulsation is not felt, then angiogram is done either transbrachially (left brachial artery), or transaortic.
Other angiograms are carotid angiogram, celiac angiogram, superior mesenteric angiogram, coronary angiogram.
Femoral artery is cannulated with a guide wire. Through that Seldinger arterial catheter is passed proximally in retrograde direction and 52water soluble iodine dye (Sodium diatrizoate) is injected. X-rays are taken to see the block, its extent in the affected limb. In TAO cork screw appearance is characteristic. Distal run off through collaterals is also important. If catheter is passed still proximally angiogram of opposite side is possible. Seldinger technique can also be used (to study) to do renal angiogram, renal artery stenosis, renal carcinomas, renal anomalies (vascular).
  • Direct aortic angiogram, practiced earlier, is discouraged at present because of the risk of aortic dissection and paraplegia due to blockage of anterior spinal artery.
 
Digital Subtraction Angiography (DSA)
  • Here vessel (artery) is delineated in a better way by eliminating other tissues through computer system. A-V fistulas, haemangio-mas, lesion in circle of Willis, vascular tumours, other vascular anomalies are well-made out.
  • Dye is injected either to an artery or vein. Injecting into a vein is technically easier but larger dose of dye is required. Injecting into an artery is technically difficult but small dose of dye is sufficient.
  • Advantages: Only vascular system is visualised; other systems are eliminated by computer subtraction. Small lesion, its location and details are better observed with greater clarity.
  • Disadvantages: Cost factor and availability.
  • Complications: Anaphylaxis, bleeding, thrombosis.
 
U/S abdomen
To see abdominal aneurysm or nature of aorta and other vessels.
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Figs 1.92A and B: DSA showing aortoiliac block left- sided. Second film is DSA after balloon angioplasty causing adequate dilatation of the left-sided aortoiliac segment.
 
DISEASES OF THE ARTERIES
  1. Atherosclerosis:
  1. Thromboangiitis obliterans. TAO: (Buerger's disease.)
  2. Raynaud's disease.
  3. Conditions causing Raynaud's phenomenon: Like Scleroderma, Rheumatoid arthritis, SLE, Granulomatosis, vasculitis of other causes.
  4. Embolus.
  5. Aneurysms.
 
Thromboangiitis Obliterans (TAO)
syn. Buerger's disease - Leo Buerger, 1908 (Professor of Urology, 1879–1943).
It is a disease exclusively seen in males of young age group (Not seen in females due to genetic reason).53
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Figs 1.93A and B: X-ray abdomen AP and lateral view showing calcified aorta.
It is seen only in smokers and tobacco users. Always starts in lower limb, may start on one side and later on the other side. Upper limb involvement occurs only after lower limb is diseased. It is a panvasculitis.
 
Pathogenesis
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Once blockage occurs, plenty of collaterals open up depending on the site of blockage either around knee joint or around buttock.
Once collaterals open up, through these collaterals, blood supply is maintained to the ischaemic area.
It is called as compensatory peripheral vascular disease.
If patient continues to smoke, disease progresses into the collaterals, blocking them eventually, leading to severe ischaemia and is called as decompensatory peripheral vascular disease.
It is presently called as critical limb ischaemia. It causes rest pain, ulceration and gangrene.
 
Investigations
  • Hb%. Blood sugar.
  • Arterial Doppler and Duplex scan (Doppler + B mode U/S).
  • Transfemoral retrograde angiogram through Seldinger technique—
    • Shows blockage—sites, extent, severity.
    • Cork screw appearance of the vessel due to dilatation of vasa vasorum.
    • Inverted tree/spider leg collaterals.
    • Severe vasospasm causing corrugated/rippled artery.54
      zoom view
      Figs 1.94A to H: Different types of ischaemic ulcers. Also note wasting, loss of hair, shininess and other features of ischaemia.
      55
      • Distal run off is amount of dye filling in the main vessel distal to the obstruction through collaterals. If distal run off is good then ischaemia is compensated. If distal run off is poor then ischaemia is decompensated.
  • Transbrachial angiogram: If femorals are not felt, then transbrachial angiogram (Through left side brachial artery—left subclavian artery – and so to descending aorta) should be done.
  • Ultrasound abdomen
  • Vein, artery, nerve biopsies.
 
Treatment
Stop smoking. Opt for either smoke or limb but not both.
 
Drugs
  • Vasodilators, e.g. nifedepine.
  • Pentoxiphylline increases the flexibility of RBC'S and helps them reach the microcirculation in a better way so as to increase the oxygenation.
  • Low dose of aspirin—antithrombin activity
  • Prostacyclins, Ticlopidine, Praxilene.
  • Clopidogrel 75 mg, atorvastatin 10 mg, parvostatin 40 mg
  • Cilostazole 100 mg bid—is a phosphodiesterase inhibitor which improves circulation.
All drugs act at the collateral level than at the diseased vessel.
Buerger's exercise, Buerger's position, heel raise, analgesics, care of feet (Chiropady), proper footwear are advised.
 
Surgery
  1. Lumbar sympathectomy to increase the cutaneous perfusion so as to make the ulcer to heal.
  2. Omentoplasty to revascularise the affected limb.
  3. Profundaplasty is done for blockage in profunda femoris so as to open more collaterals across the knee joint. (It often makes better perfusion to the knee joint and flap of below knee amputation).
  4. Amputations are done at different levels depending on site, severity and extent of vessel occlusion. Usually either below- knee or above—knee amputations are done.
  5. Ilzarov method of bone lengthening helps in improving the rest pain and claudication by creating neoosteogenesis and improving the overall blood supply to the limb.
  6. Gene therapy: Intramuscular injection of vascular endothelial growth factor (VEGF) which is an endothelial cell mitogen which promotes angiogenesis.
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Fig. 1.95: Below-knee amputation stump is still infected in a TAO patient. This patient might require an above- knee amputation.
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Fig. 1.96: Below-knee amputation with long posterior flap.
 
Raynaud's Phenomenon
It is an episodic vasospasm, i.e. arteriolar spasm. It leads to sequence of clinical features called as Raynaud's syndrome.56
 
Causes for Raynaud's Phenomenon
  • Raynaud's disease:
    • It is seen in females, usually bilateral.
    • It occurs in upper limb with normal peripheral pulses.
    • It is due to upper limb (hand) arteriolar spasm due to abnormal sensitivity to cold. Patient develops blanching, cyanosis and later flushing as Raynaud's syndrome. Occasionally, if spasm persists it result in gangrene. Symptoms can be precipitated and observed by placing hands in cold water.
  • Working with vibrating tools: Like pneumatic road drills, chain saws, wood cutting, and fishermen traveling in machine boats.
  • Collagen vascular diseases: Like scleroderma, Rheumatoid diseases causing vasculitis (All autoimmune diseases).
  • Other causes: Cervical rib, Buerger's disease, Scalene syndrome.
It is often associated with CREST syndrome. (Calcinosis cutis, Raynaud's phenomenon, Esophageal defects, Sclerodactyly, Telangiectasia).
 
Types of Raynaud's Phenomenon
Vasospastic.
Obliterative.
Type is identified by angiogram of palm, Doppler, Duplex scan.
Other investigations required are X-ray of the part, specific tests for autoimmune diseases.
 
Treatment
  • Treat the cause.
  • Avoid the precipitating cause.
  • Vasodilators, Pentoxiphylline.
  • Small dose of aspirin (100 mg daily).
  • Cervical sympathectomy.
 
Treatment of Arterial Diseases
 
Medical
 
General measures
  • Stop smoking.
  • Reduction of weight.
  • Change in life style.
  • Exercise.
  • Care of feet.
  • Control of diabetes and hypertension.
  • Buerger's position and exercise—regular graded exercises upto the point of claudication improves the collateral circulation.
Drugs: Nifedepine, praxilene, pentoxiphylline, small dose of aspirin, prostacycline, dipyridamole, ticlopidine, atorvastatin, cilostazol 100 mg.
 
Surgery
  1. Transluminal balloon angioplasty/percutaneous transluminal balloon angioplasty/PTA): Through transfemoral Seldinger approach, initially angiogram is done. Then under guidance (fluoro-scopic) stenosed area is approached. Balloon of the angioplasty catheter is inflated at stenosed area for one minute and repeated if required. Catheter is withdrawn. It is useful in cases of localised stenosed areas.
    Complications: Thrombosis, bleeding, sepsis.
    57
  2. Atherectomy: It is removal of atheroma from the wall of the artery either through open surgery or by percutaneous route of medium sized vessels.
  3. Thrombectomy: It is removal of thrombus through an arteriotomy of larger vessels. It is done in aortoiliac, femoropopliteal region.
  4. Endarterectomy: It is removal of thrombus along with diseased intima through an arteriotomy.
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    Fig. 1.97: Endarterectomy technique. Both thrombus and diseased intima are removed through an arteriotomy. Often ring stripper is used to remove the atheromatous plaque.
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    Fig. 1.98: Exposing femoral artery for endarterectomy technique.
  5. Intraluminal stent placement.
  6. Profundaplasty: It is done when there is localised block in opening of profunda femoris (deep femoral). Profunda femoris is opened, thrombus if present, is removed. Opening is widened using either venous or synthetic (Dacron or PTFE) grafts. This procedure allows collaterals across the knee joint through profunda femoris and so gives good blood supply below-knee level and may prevent patient going in for above-knee amputation.
    (May be able to save knee joint with below- knee amputation with better prosthesis).
    zoom view
    Fig. 1.99: Profundaplasty for deep femoral block.
  7. Reverse saphenous vein graft: In case of femoropopliteal block, saphenous vein is dissected out, reversed and sutured above to the femoral artery and below to popliteal segment so as to bypass the blood through reverse saphenous vein graft. Saphenous vein is reversed to nullify the action of valves so as to allow easy flow of blood.
  8. In-situ saphenous vein graft: It is arterialisation of saphenous vein. Saphenous vein intact in same position is sutured above and below the blocked femoropopliteal region to bypass the blood across. Venous valves are removed through valvulotomy instrument so as to allow the blood to pass.
    58
  9. Arterial/venous grafts:
Synthetic:
  • Dacron woven graft.
  • Dacron knitted graft.
  • PTFE—Poly tetra fluoroethylene graft.
Natural:
  • Internal mammary artery.
  • Long saphenous vein either reverse or in situ.
Grafts of different length and size are available.
Different procedures:
  • Aorto-femoral bypass graft.
  • Ileo-femoral bypass graft.
  • Femoro-femoral bypass graft.
  • Femoro-popliteal graft.
  • Femoro-distal graft.
Problems with grafts: Leak, infection, thrombosis, cost factor, availability, re-block.
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Fig. 1.100: Aorto-femoral bypass graft (End to Side).
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Fig. 1.101: On table picture of aorto-femoral arterial graft.
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Fig. 1.102: Femoro-popliteal bypass graft.
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  1. Cervical sympathectomy:
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Figs 1.103A and B: Upper limb ischaemia left-side showing wasting, gangrene of digits.
 
Approaches:
  1. Supraclavicular approach: Through an incision in supraclavicular region, sternomastoid, omohyoid, scalenus anterior muscles are divided. Phrenic nerve is displaced medially; subclavian artery is pushed downwards; suprapleural membrane is depressed, stellate ganglion is identified in the neck of the first rib. All rami communicanting from second and third ganglia are divided and Kuntz nerve is also divided.
    Complications: Bleeding, injury to subclavian artery and nerves, pneumothorax and haemopneumothorax, Horner's syndrome with ptosis, miosis, anhydrosis, enophthalmos.
    zoom view
    Figs 1.104A and B: Patient underwent cervical sym-pathectomy left-side for ischaemic gangrene index finger tip which has healed now. Note the sympathectomy scar. In another patient typical ptosis after sympathectomy is seen.
  2. Transthoracic approach (Hedley Atkins): This gives better visibility and easier removal of rami, lower down compared to supraclavicular approach.
  3. Endoscopic sympathectomy is the choice and popular approach at present.
Advantages are better visibility with magnification, less trauma of access (wound), faster recovery, and precise.
  1. Lumbar sympathectomy
Indications:
  • Peripheral vascular disease like TAO.
  • To promote healing of cutaneous ulcers.
  • To change level of amputation and to make flaps to heal better after amputation.
  • Causalgia of lower limb (it is common in upper limb).
  • Hyperrhidrosis.
Principle: It increases the cutaneous blood supply and so ulcer healing and healing of skin flaps in amputations is better. It will not improve intermittent claudication.
Procedure: Under general or spinal anaesthesia, ganglia are approached through a transverse incision in the loin at the level of umbilicus, through extraperitoneal approach, by dividing external oblique, and splitting internal oblique, and transverse abdominis muscles. Inferior vena cava on right side, aorta on left side are identified. Sympathetic chain is identified by its rami. L2, L3, L4, L5 Ganglia are removed. L2 is identified 60by its size (Larger) and more number of rami. L1 is retained on one side in bilateral cases. It is under the crus of the diaphragm. L4 is under iliac vessels. Sympathetic chain is deeply placed in front of the vertebra with firm tense cord like feeling with ganglia at different levels. After removal, chain should be sent for histology. Chain may be missed for genitofemoral nerve. Lymphatics and lymph nodes are also can be missed for sympathetic chain. Chain has got grey rami communicantes from spinal cord to the chain and ganglia; and white rami communicantes begins at ganglia and enters the peripheral nerves. If it is removed it will lead on to failure of ejaculation and so sterility.
Complications:
  1. Injury to IVC or aorta.
  2. Bleeding lumbar veins.
  3. Spinal vessel spasm and so ischaemia of spinal cord and paraplegia.
  4. Injury to bowel and ureter.
  5. Wound infection and abscess formation.
Its effects are only temporary (3–4 wks). Long term results are doubtful. It can be combined with omentoplasty.
It can also be done along with below- knee amputation to increase the blood supply of skin flap so as to have better healing.
Limb will become warmer immediately after sympathectomy.
  1. Chemical sympathectomy
    It is done in lateral position using a long spinal needle under local anaesthesia. Position is confirmed by injecting dye under fluoroscopy. Later 5 ml of phenol in water or absolute alcohol (1: 16) is injected lateral to the vertebral bodies of second and fourth lumbar vertebrae. Care should be taken to see that the needle does not enter IVC or Aorta. Procedure is contraindicated in patients with bleeding disorders and in patients who are on anticoagulants.
  2. Omentoplasty.
    Indications:
    1. Peripheral vascular disease—To improve circulation.
    2. For lymphoedema it helps by providing lymphatics and so to drain lymph from the limb.
    3. It is also tried for revascularisation of pharynx, cranial cavity.
      Omentum is supplied by omental vessels.
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Four layers of omentum have got omental arcades of vessels. Omentum is also rich in lymphatics. It has got adhesive property. By retaining one of the pedicles, omentum can be mobilised so as to reach the limb to maintain the circulation. It can also be mobilised up to the ankle. It promotes ulcer healing, reduces the pain, and controls the features of ischaemia. It can be used in upper limb ischaemia. But if patient continues to smoke, disease spreads to these omental vessels also. Often it can be used for both limbs.
Complications of omentoplasty:
  • Abdominal sepsis.
  • Incisional hernia, where omental pedicle is tunneled into the limb from the abdomen.
  • Adhesions and intestinal obstruction.
Procedure:
Under general anaesthesia, abdomen is opened with upper midline incision. Omental vessels are identified. Omentum with its blood supply is carefully mobilised to get a adequate length. Lengthened, mobilised omentum is brought into the subcutaneous plane through abdominal wall, lateral to the lower part of rectus muscle. Later this pedicle is mobilised in the subcutaneous tunnel across the leg, burried in the deep fascia.61
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Figs 1.105A to G: Omentoplasty technique. Mobilization of greater omentum with its arterial arcade and bringing down to the limb up to the ankle.
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Fig. 1.106: Incisional hernia in omentoplasty patient. Patient also has failure of omentoplasty and underwent above knee amputation because of gangrene.
Other treatment methods:
Amputations at different levels depending on extent of gangrene, site of block, amount of collaterals.
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Fig. 1.107: Amputated 2nd toe (ray amputation)—healing well-done for toe gangrene. It was dry gangrene.
 
Subclavian Steal Syndrome
Following obstruction of the first part of subclavian artery, vertebral artery provides collateral circulation to the arm by reversing its blood flow. This causes cerebral ischaemia with syncopal attacks.
Visual disturbances, diminished blood pressure in the affected limb.62
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Fig. 1.108: Forefoot amputation – it is not an ideal procedure for vascular disease. In this patient wound is granulating well after amputation. It is probably due to good number of opened collaterals in the foot.
Symptoms will be aggravated by arm exercise.
Investigations: Duplex scan and angiogram. DSA is useful.
Treatment: Transluminal balloon angioplasty/endarterectomy or bypass graft.
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Fig. 1.109: Subclavian steal syndrome.
 
Acute Arterial Occlusion
Causes
  1. Trauma.
  2. Embolism.
 
Traumatic Acute Arterial Occlusion
Causes
  1. Thrombus due to trauma.
  2. Subintimal haematoma.
  3. Acute compartment syndrome.
  4. During femoral or brachial arterial catheterisation, either diagnostic or therapeutic procedures.
Clinical features: H/o trauma, pain, swelling at the site, pallor, pulselessness, cold limb
Investigation: Duplex scan, angiogram.
Treatment: Wound is explored and tear in the artery is identified. It is sutured using nonabsorbable monofilament material, polypropylene 6–0. Often venous or dacron graft is required for interposition.
Proper antibiotics and heparin are required to prevent thrombosis of the vessel. Later patient is advised to take oral warfarin for maintenance.
Compartment syndrome: Is common in anterior compartment leg and in front of forearm. Here because of the closed compartment, pressure increases following fracture, haematoma which compresses over the vessel. It leads to blockade of vessel causing acute ischaemia of the limb presenting with severe pain, pallor, pulselessness.
Treatment: Immediate decompression by longitudinal fasciotomy, is the treatment of choice, where in deep fascia is cut adequately to relieve the compression. Otherwise limb may go for severe ischaemia, gangrene and may land with amputation.
Associated fractures, haematoma, vessel tear has to be managed accordingly.
 
Embolism
It is due to a solid material which is floating and traveling in the blood stream, eventually blocking the vessel on its pathway.
Arterial emboli: Source-due to mural thrombus following—
  • Myocardial infarction.
  • Mitral stenosis.
  • Atrial fibrillation.
  • Aortic aneurysms.
    63
  • Cervical rib causing poststenotic dilatation of subclavian artery.
Venous emboli are due to DVT causing pulmonary embolism.
  • Fat embolism.
  • Air embolism.
 
Effects of Arterial Embolism
  • Brain: Blockage at middle cerebral artery causes hemiplegia, transient ischaemic attacks (TIA), visual disturbances.
  • Blockage at central retinal artery causes amaurosis fugax, or permanent blindness.
  • Blockage at mesenteric vessels causes intestinal gangrene.
  • Blockage at renal artery lead to haematuria, loin pain.
  • Blockage at limb vessels causes pain, pallor, pulseless, paraesthesia, paresis, ulceration, gangrene.
Commonest site of arterial emboli is common femoral artery.
 
Investigations for Arterial Embolism
  • Emergency Doppler, ECG and echocardiography, angiogram.
  • Relevant tests for origin of emboli.
 
Treatment
  1. Embolectomy: It is done as early as possible as an emergency operation. Under fluoroscopic guidance, Fogarty catheter (interventional radiology) is passed beyond the embolus and balloon is opened. Catheter is pulled out gently with embolus. Procedure has to be repeated until embolectomy is completed and bleeding occurs. Angiogram is repeated to confirm the free flow. Postoperatively initially heparin and later oral anticoagulant are used. Procedure is done under general anaesthesia.
    Open arteriotomy and embolectomy can be done by direct approach and later the arteriotomy has to be sutured. Postoperatively, anticoagulants, antibiotics should be given.
  2. Intraarterial thrombolysis using fibrinolysins: After passing arterial catheter, angiogram is done and agents are injected intraarterially through the arterial catheter.
Drugs used are:
  • Streptokinase (here lysis occurs in 48 hours).
  • Urokinase.
  • Tissue plasminogen activator. (TPA)— Here lysis occurs in 24 hours.
  • TPA pulse- spray method – here lysis occurs in 6 hours.
Contraindications for thrombolysis: Stroke, bleeding diathesis, pregnancy.
Heparin should not be used concomitantly with fibrinolysins.
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Fig. 1.110: Embolectomy technique.
 
Saddle Embolus
It is an embolus blocking at bifurcation of aorta.
Causes:
  • Mural thrombus after myocardial infarction.
  • Mitral stenosis with atrial fibrillation.
  • Aortic aneurysm.
The embolus which blocks at aortic bifurcation is usually large.64
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Fig. 1.111: Fogarty catheter. It is 80 cm in length with 4 to 7 French size. It is used for embolectomy. Note the inflated balloon at the tip.
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Fig. 1.112: Saddle embolus blocking the bifurcation of abdominal aorta.
Clinical features:
  • Features of ischaemia in both lower limbs.
  • Gangrene of both lower limbs.
  • Associated infection and its features.
Investigations:
  • Arterial Doppler.
  • Aortic angiogram.
  • U/S abdomen.
Treatment:
  • Initially, heparin is given intravenously - 10,000/ units and later 5,000 units/- subcutaneously 8th hourly.
  • Embolectomy can be done using Fogarty catheter.
  • Open arteriotomy and embolectomy can also be tried.
  • Antibiotic prophylaxis has to be given to prevent infection.
 
Fat Embolism
It is commonly seen after fracture femur, tibia, or multiple fractures and occasionally following electro convulsive therapy, usually occurs in 24–72 hours.
It is due to aggregation of chylomicrons, derived from bone marrow, causing fat embolism. It is often a fatal condition.
Features:
  • Cerebral: Drowsy, restless, disoriented, constricted pupils, pyrexia, coma.
  • Pulmonary: Cyanosis, tachypnoea, right heart failure, froth in mouth and nostrils, fat droplets in sputum, eventually respiratory failure.
  • Cutaneous: Petechial haemorrhages in the skin.
  • Retinal artery emboli is the earliest sign to appear, causing striae haemorrhages, fluffy exudates confirmed on fundoscopic examination.
  • Kidney: Blockage in renal arterioles results in fat droplets in urine.
Treatment: Oxygen, heparinisation, low mole-cular weight dextran, ventilator support and ICU management.
 
Air Embolism
Causes:
  • Through venous access like IV cannula.
  • During artificial pneumothorax.
  • During surgeries of neck and axilla.
  • Traumatic opening of major veins sucking air inside, causing embolism.
  • During fallopian tube insufflation.
  • During illegal abortion.
    65
Amount of air required to cause air embolism is 50 ml.
When the air enters the right atrium, it gets churned up forming foam which enters the right ventricle and then blocking the pulmonary artery.
Treatment:
Patient has to be placed in Trendelenburg position. By passing a needle, the air has to be aspirated from the right ventricle. Often requires life saving open thoracotomy to aspirate the excess air causing the block.
 
Therapeutic Embolisation
Indications:
  • Haemangiomas,
  • AV fistulas,
  • Malignancies like renal cell carcinoma, hepatoma,
  • Craniovascular problems.
  • To arrest haemorrhage from GIT, urinary and respiratory tract.
In bleeding duodenal ulcer or gastric ulcer, embolisation is used to occlude gastroduodenal artery or left gastric artery respectively. It also useful in bleeding oesophageal varices, secondaries in liver (mainly due to carcinoids), hepatoma.
 
Aneurysms
It is dilatations of localised segment of arterial system.
  • True aneurysm contains all three layers of artery.
  • False aneurysm contains single layer of fibrous tissue as wall of the sac and it usually occurs after trauma.
 
Types
  • Fusiform
  • Saccular
  • Dissecting
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Fig. 1.113: True and false aneurysms. In true type, all layers are intact. In false type all layers breached with haematoma having a false capsule.
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Fig. 1.114: Fusiform and Saccular types of aneurysms.
 
Causes
  • Atherosclerosis.
  • Syphilis.
  • Traumatic.
  • Collagen diseases like Marfan's syndrome.
 
Mycotic Aneurysm
It is a misnomer. It is not due to fungus but due to bacterial (commonly Staphylococcus, 66Streptococcus) infection. Origin of bacteria may be from any site of infection in the body.
 
Sites:
  • Aorta.
  • Femoral.
  • Popliteal.
  • Subclavian.
  • Cerebral, mesenteric, renal, splenic arteries
  • Commonest is true, fusiform, atherosclerotic, aortic aneurysms.
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Fig. 1.115: Thoracic aortic aneurysm.
Berry's aneurysms are multiple aneurysms occurring in circle of Willis.
 
Clinical features of aneurysms:
  • Swelling at the site which is pulsatile, (expansile), smooth, soft, warm, compressible, with thrill on palpation and bruit on auscul-tation. Swelling reduces in size when pressed proximally.
  • Distal oedema due to venous compression.
  • Altered sensation due to compression of nerves.
  • Erosion into bones, joints, trachea or oesophagus.
  • Aneurysm with thrombosis can throw an embolus causing gangrene of toes, digits, extending often proximally also.
 
Differential diagnosis:
  1. Pyogenic abscess: Abscess has to be always confirmed by aspiration; especially in axilla, popliteal region, groin.
  2. Vascular tumours.
  3. Pulsating tumours: Sarcomas, pulsating secondaries.
  4. Pseudocyst of pancreas mimics aortic aneurysm.
  5. A-V fistula.
 
Investigations:
Doppler study, duplex scan, angiogram, DSA.
Tests relevant for the cause, like blood sugar, lipid profile, echocardiography.
 
Treatment:
  • Reconstruction of artery using arterial grafts.
  • Arterial endoaneurysmorrhaphy—MATA'S.
  • Therapeutic embolisation,
  • Clipping the vessel under guidance (e.g. cranial aneurysms).
 
Abdominal Aneurysms
Abdominal aortic aneurysm is the commonest aortic aneurysm. It has got 2% incidence.
 
Causes:
Atherosclerosis: 95%.
Others: Syphilis, dissecting, traumatic, collagen diseases.
 
Classification I:
  • Infrarenal—Commonest. 95%.
  • Suprarenal 5%.
 
Classification II
  1. Asymptomatic: Found incidentally either on clinical examination or on angiography or on ultrasound. Repair is required if diameter is over 5.5 cm on ultrasound.
  2. Symptomatic without rupture: Present as back pain, abdominal pain, mass abdomen which is smooth, soft, nonmobile, not moving with respiration, vertically placed above the umbilical level, pulsatile both in supine as well as knee-elbow position with same intensity, resonant on percussion. GIT, 67urinary, venous symptoms can also occur. Hypertension, diabetes, cardiac problems should be looked for and dealt with.
 
Investigations:
  • Blood urea, serum creatinine.
  • U/S, aortogram.
  • DSA, CT scan, MRI.
 
Treatment:
If aneurysm is more than 5.5 cm then surgery is the choice.
Options are
  • Open surgical aneurysm repair using PTFE or dacron graft.
  • Endoluminal stent graft procedure using interventional radiology with Seldinger's technique. Adequate amount of blood is required for surgery.
 
Symptomatic Ruptured Aortic Aneurysm
Risk of rupture is 1%, if diameter is within 5.5 cm in size. Risk increases to 20% once the diameter = 7 cm. It may be anterior rupture (20%) into the free peritoneal cavity causing severe shock and death very early; or posterior rupture (80%) with formation of retroperitoneal haematoma of large size causing severe back pain, hypotension, shock, absence of femoral pulses and with palpable mass in the abdomen.
 
Management of ruptured aneurysm:
  • Immediate diagnosis by ultrasound.
  • Resuscitation.
  • Massive blood transfusions (10–15 bottles).
  • Emergency surgery is the only life saving procedure in these cases.
Patient has to be shifted to the operation theatre. Abdomen is opened. Vascular clamps or bull dog clamps are applied to the aorta above and below the aneurysm. Adventitia is opened and the clot is removed. Aneurysm is excised and the arterial graft PTFE (Polytetra fluoroethylene), knitted dacron graft, or woven dacron graft is placed. The graft is sutured to the vessel above and below using monofilament, nonabsorbable suture material, polypropelene 5-zero.
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Fig. 1.116: Chest X-ray showing aortic aneurysm.
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Fig. 1.117: Abdominal aortic aneurysm ultrasound picture.
68
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Fig. 1.118: Infra-renal aortic aneurysm repair. It is the commonest site of aortic aneurysm.
 
Peripheral Aneurysms
 
Popliteal aneurysm
  • Is commonest (70%).
  • 65% are bilateral.
  • 25% cases are associated with abdominal aortic aneurysm.
  • 75% causes complications in 5 years.
Presentations
  • Swelling in popliteal region which is smooth, soft, pulsatile, well localised, warm, and compressible, often with thrill and bruit. It may mimic a pyogenic abscess.
  • Thrombosis and emboli from popliteal aneurysm can cause distal gangrene which may be spreading proximally and may lead to amputation.
  • Rupture may cause torrential haemorrhage.
Investigations
  • Duplex scan, angiogram.
  • CT scan/CT angiogram.
  • MRI/MR angiogram.
Treatment
  • Repair with arterial graft using PTFE, dacron.
  • Endoluminal stenting.
  • Aneurysmorrhaphy.
 
Dissecting aneurysm:
It is the dissection of media of the aorta after splitting through intima creating a channel in the media of the vessel wall.
Causes:
  • Hypertension (It is associated in 80% of dissecting aneurysms).
  • Cystic medial necrosis.
  • Marfan's syndrome and collagen diseases.
  • Trauma.
  • Weakening of the elastic layers of the media due to shear forces.
Features:
  • It is always seen in thoracic aorta, common in ascending aorta. (70%).
  • It is uncommon in other part of aorta or other vessels.
  • It can occur in aortic arch or thoracic descending aorta.
  • This dissected aortic channel gets lined by endothelium, often re-opens distally into the aorta causing double-barreled aorta which in fact prevents complications.
  • It is commonly associated with aortic insufficiency.
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Fig. 1.119: Dissecting aneurysm.
Dissecting aneurysm is a misnomer. It is only aortic dissection.
Atherosclerosis is not a usual cause for dissecting aneurysm.
 
Classification (DeBakey's):
Type I: Dissection begins in ascending aorta extends into descending thoracic aorta (70%).69
Type II: Dissection origins and extends only up to the origin of the major vessels. it is safer type with less complications.
Type III: Dissection begins in the descending thoracic aorta beyond the origin of the left subclavian artery.
Dissecting aneurysm can be
  • Acute.
  • Chronic.
  • Healed dissecting aneurysm which communi-cates distally again to aorta as double barreled aorta.
Complications:
Acute: Rupture into the pericardium or pleura - dangerous type.
Chronic: Blockage of coronary vessels, major vessels like carotid, subclavian arteries with aortic insufficiency.
Clinical features:
  • Pain in the chest, back which is excruciating.
  • Features of ischaemia due to blockage of different vessels.
Investigations:
  • Chest X-ray shows mediastinal widening.
  • Arterial Doppler.
  • Angiogram.
Treatment: Antihypertensives.
Surgery: Using Dacron graft reconstruction of aorta has to be done with cardio-pulmonary by-pass.
Indications for surgery:
  • Progressive disease
  • Significant ischaemia
  • Impending rupture.
 
Acrocyanosis
It is persistent, painless cyanosis seen in fingers and often in legs with paraesthesia and chilblains affecting young females. It is chronic persistent arteriolar constriction with slow rate of blood flow. Trophic changes, ulcerations are not seen. Cyanosis which is persisting may aggravate by exposure to cold. It may be associated with endocrine dysfunction.
Treatment: Vasodilators, cervical sympathectomy (Effective).
 
Gangrene
It is macroscopic death of tissue in situ (in continuity with adjacent viable tissue) with or without putrefaction.
It can occur in—limbs, appendix, bowel, testes, gall bladder.
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Fig. 1.120: Gangrene of toes and ischaemic changes in the foot.
 
Causes
Secondary to arterial obstruction like atherosclerosis, emboli, diabetes, TAO, Raynaud's disease, ergots, etc.
Infective: Boil, carbuncle, gas gangrene, Fournier's gangrene, cancrum oris.
Traumatic: Direct, indirect.
Physical: Burns, scalds, frostbite, chemicals, irradiation, electrical.
Venous gangrene.70
 
Clinical Features
  1. Colour changes: Pallor, greyish, purple, brownish black due to disintegration of haemoglobin to sulphide.
  2. Absence of pulse, loss of sensation, loss of function,
  3. Line of demarcation between viable and dead tissue by a band of hyperaemia and hyperaesthesia with development of a layer of granulation tissue.
    In dry gangrene separation occurs by aseptic ulceration with minimum infection and gangrene is dry, and mummified.
    In moist gangrene separation takes place by septic ulceration. Often demarcation is vague with skip lesions more proximally and so landing with higher level of amputations. Even after amputation skin flap may show die back process, leading to failure of taking up of flap of amputation and so require still higher level of amputation.
  4. Proximal ischaemic features may be present with rest pain, colour changes, hyperaesthesia— pregangrene.
 
Types of Gangrene
Dry gangrene is due to slow gradual loss of blood supply to the part causing dry, desiccated, wrinkled, mummified part with proper line of demarcation.
Wet gangrene is due to infection with put-refaction, causing oedematous, swollen, discolouration, spreading proximally, with vague line of demarcation.
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Fig. 1.121: Dry gangrene of leg. Patient needed above knee amputation.
 
Investigations
  • Hb%, blood sugar.
  • Arterial Doppler, angiogram (Seldinger's technique).
  • U/S abdomen to find out the status of aorta.
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Figs 1.122A and B: Gangrene both in lower and upper limbs. Note all features of gangrene.
 
Treatment
 
Limb saving methods:
  • Drugs: Antibiotics, vasodilators, pentoxiphylline, praxilene, dypyridamole, small dose of aspirin, ticlopidine.
  • Care of feet and toes:
    • The part has to be kept dry.
    • Any injury has to be avoided.
    • Proper footwear is advised (Microcellular rubber footwear, MCR).
    • Measures for pain relief is taken.
    • Nutrition supplementation is done.
    • The limb should not be heated.
    • Pressure areas has to be protected.
    • Localised pus has to be removed.
  • Cause has to be treated.
  • Diabetes has to be controlled.
    71
  • Surgeries to improve the limb perfusion: Lumbar sympathectomy, omentoplasty, profundaplasty, femoropopliteal thrombectomy or endarterectomy, arterial graft bypass are done according to the need.
 
Life saving procedures:
Amputations may have to be done occasionally.
Level of amputation has to be decided on skin changes, temperature, line of demarcation and Doppler study.
  • Below-knee amputation is a better option as BK prosthesis can be fitted better and also the movements of knee joint are retained. There is no need of external support and limp is absent.
  • In above-knee amputation range of movements is less, limp is present and often requires third (stick) support to walk.
  • Different amputations done are Ray ampu-tation, below-knee amputation (Buerges's amputation), Gritti-Stokes transgenial ampu-tation, above-knee amputation.
Lisfranc's, Chopart's, Symes', Modified Symes' amputations are not commonly used in ischaemic limb as flaps will not survive.
 
Diabetic Foot and Diabetic Gangrene
Foot is a complex structure with many layers of muscles, ligaments, joints, arches, fat, thick plantar fascia, vascular arches, neurological system which maintains weight bearing, gravity, normal walk (swing, and stance phases).
 
Problems in Diabetic Foot
  • Callosities, ulceration.
  • Abscess and cellulitis of foot.
  • Osteomyelitis of different bones of foot like metatarsals, cuneiforms, calcaneum.
  • Diabetic gangrene.
  • Arthritis of the joints.
 
Pathogenesis of Diabetic Foot/Gangrene
  • High glucose level in tissues is a good culture media for bacteria. So infection is common.
  • Diabetic microangiopathy causes blockade of microcirculation leading to hypoxia.
  • Diabetic neuropathy: Due to sensory neuropathy, minor injuries are not noticed and so infection occurs. Due to motor neuropathy, dysfunction of muscles, arches of foot and joints, and loss of reflexes of foot occurs causing more prone for trauma, abscess, etc. Due to autonomic neuropathy, skin will be dry, causing defective skin barrier and so more prone for infection.
  • Diabetic atherosclerosis itself reduces the blood supply and causes gangrene. Thrombosis can be precipitated by infection causing infective gangrene. Blockage occurs at plantar, tibial, and dorsalis pedis vessels.
  • Increased glycosylated haemoglobin in blood causes defective oxygen dissociation leading to more hypoxia. At tissue level there will be increased glycosylated tissue proteins, which prevents proper oxygen utilisation and so aggravates hypoxia.
 
Clinical Features
  • Pain in the foot.
  • Ulceration.
  • Absence of sensation.
  • Absence of pulsations in the foot (Posterior tibial and dorsalis pedis arteries).
  • Loss of joint movements.
  • Abscess formation.
  • Change in temperature and colour when gangrene sets in.
 
Investigations
  • Blood sugar, urine ketone bodies.
  • Blood urea and serum creatinine.
  • X-ray of part to see osteomyelitis.
  • Pus for culture and sensitivity.
    72
  • Doppler study of lower limb to assess arterial patency
  • Angiogram to see proximal blockage
  • U/S abdomen to see status of abdominal aorta.
 
Treatment
Foot can be saved only if there is good blood supply.
  • Antibiotics—decided by pus C/S.
  • Regular dressing.
  • Drugs: Vasodilators, pentoxiphylline, dipyridamole, small dose of aspirin.
  • Diabetes has to be controlled by insulin only.
  • Diet control, control of obesity.
  • Surgical debridement of wound.
  • Amputations of the gangrenous area. If blood supply is not present, then below knee or above knee amputation may be required. Level of amputation has to be decided by skin and temperature changes or Doppler study.
  • Care of feet in diabetic:
    • Any injury has to be avoided.
    • MCR foot wears must be used.
    • Feet has to be kept clean and dry, especially the toes and clefts.
    • Hyperkeratosis has to be avoided.
 
Frostbite
  • It is due to exposure to cold wind or high altitude.
  • It is common in old age during cold spells.
  • Damage to vessel wall causes oedema, blistering, gangrene formation.
  • Part is painless and waxy.
  • Treatment: Gradual warming is done. Part should be wrapped with cottonwool and rested. Warm drinks, analgesics, paravertebral injections to sympathetic chain, hyperbaric oxygen are effective.
 
Ainhum
zoom view
Fig. 1.123: Typical Ainhum. Note it is bilateral. Note the constriction ring in the little toe. It may go for autoamputation. It needs Z plasty.
  • Commonly affects males (can also occur in females)
  • Common in blacks, in Negroes.
  • History of running barefoot in childhood is common.
  • Fifth toe is commonly affected. A fissure develops in interphalangeal joint which becomes a fibrous band that encircles the digit causing necrosis. (Gangrene of little toe).
  • Often it is bilateral.
  • Treatment: is early ‘Z’ plasty. Amputation is often required later. Commonly autoamputation occurs.
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VARICOSE VEINS
 
WRITING A CASE SHEET FOR VARICOSE VEINS (LONG CASE)
Name:
Address:
Age:
Occupation: Varicose veins are more common in people who stand for long hours like bus conductors, nurses, doctors, manual labourers, watchmen, traffic policemen, etc.
 
Chief Complaints
  • Pain in the leg/thigh/foot with the duration of pain and side.
  • Swelling/dilated veins in the leg and its duration.
  • Pigmentation/ulceration in the leg with duration.
 
History
 
History of Present Illness
 
Pain
  • Pain in the leg/foot/or thigh with duration. Origin of pain, its severity, nature of onset whether acute or insidious has to be asked.
  • Character of pain: Dull aching or cramping should be asked. Whether pain gets aggravated by walking/standing should be noted. Dull aching pain along the line of the vein is typical and usually aggravates in the evening and gets relieved by lying down. Pain in calf of short duration, may be due to co-existing deep vein thrombosis (DVT).
  • Pain also can be due to ulcer/periostitis/infection.
 
Pigmentation
  • It is due to stasis and release of chemicals and usually occurs around ankle region.
  • It is associated with itching and often ulceration.
 
Ulcer
  • History: Mode of onset, duration, site of onset. Ulcer on the medial aspect of the ankle is due to long saphenous vein varicosity; on the lateral aspect is due to short saphenous vein varicosity.
  • Discharge from ulcer: Its type, smell, quantity signifies the severity of the infection.
  • Itching and bleeding in the ulcer bed are also important.
History of trauma: Often minor trauma precipi-tates ulcer formation in patients with varicose vein.
History of swelling around the ankle.
History of pain/lump in the abdomen.
History of urinary/bowel symptoms.
History of similar complaints on the other leg— Varicose veins are often bilateral.
 
Past History
  • History suggestive of earlier deep vein thrombosis like pain, calf swelling and fever.
  • History of immobilisation, hospitalisation.
  • History of any previous surgery.
 
Treatment History
  • History of previous surgery for varicose vein, drug intake like warfarin for DVT, injection therapy—sclerotherapy, wearing stockings/crepe bandages.
 
Personal History
  • In females, history of pregnancy, delivery and postdelivery period, oral contraceptive intake.
  • Smoking/alcohol/working pattern.
 
Family History
Family history relevant of varicose veins.
  • Often varicose veins are familial, which are bilateral and severe, observed in young individuals. There are absent/defective valves in these patients.
    74
 
Local Examination
Examination of lower limbs—symptomatic limb should be examined first.
 
Inspection
Examination of veins in standing position is the first method in varicose veins.
zoom view
Figs 1.124A and B: Inspection of varicose veins should be done on standing. Long saphenous veins on both sides should be inspected along medial aspect in standing position. Short saphenous vein should also be inspected from behind.
  • Limb is looked for dilated long saphenous vein on the medial side and for short saphenous vein on posterior and lateral side. Other communicating veins are also looked for.
  • Beginning of the varicosity in the foot, later its extent above also should be examined. Great saphenous vein tortuosity often extends into the thigh whereas short saphenous vein varicosity ends at popliteal region.
  • Always limb is looked for skin changes, pigmentation, oedema, ankle flare, and ulcer. Cough impulse at saphenous opening (Morrisey's) may be significant.
  • Extent, size, shape, margin, edge and discharge in an ulcer should be noted.
 
Palpation
  • Ulcer, if present should be described with tenderness, induration, warmness, mobility, fixity to the underlying bone, etc.
    zoom view
    Figs 1.125A and B: Bilateral varicose.
  • Brodie-Trendelenburg test
    Vein is emptied by elevating the limb and milking the vein in lying down position; a tourniquet is tied just below the saphenofemoral junction (or saphenofemoral junction can be occluded using a thumb). Saphenous opening is located 3.5 cm below and lateral to the pubic tubercle. Pubic tubercle is palpated along the adductor longus tendon which is identified by adducting the thigh against resistance. Patient is asked to stand quickly. When tourniquet or thumb is released, rapid filling from above signifies sapheno femoral incompetence. This is Trendelenburg test I.
    In Trendelenburg test II, vein is emptied again in lying down position and tourniquet is applied at sapheno-femoral junction. After standing without releasing the tourniquet, the limb is observed. Filling of blood from below upwards rapidly can be observed within 30–60 seconds. It signifies perforator incompetence.75
    zoom view
    Figs 1.126A and B: Long saphenous vein varicosity. Note the prominent of veins and blow outs. Note the diagrammatic representation of varicose veins.
    zoom view
    Figs 1.127A to C: Emptying of the superficial varicose vein is important in all tourniquet tests for varicose veins. It is done in lying down position with elevating and milking the vein. Emptying is not done in modified Perthes' test. Note the marking of the saphenofemoral junction before applying the tourniquet.
    76
    zoom view
    Figs 1.128A and B: Note the site of applying the tourniquet at sapheno-femoral junction. It is 3.5 cm below and lateral to pubic tubercle.
    zoom view
    Fig. 1.129: Tourniquet test. After emptying the vein by elevating the leg and milking, tourniquet is applied. Patient is asked to stand, tourniquet is released immediately and saphenous vein is observed. Rapid filling of vein from above signifies LSV varicosity with sapheno-femoral incompetence.
  • Three/multiple (Oschner's Mahoner's test) tourniquet test: To find out the site of incompetent perforator, three tourniquets are tied after emptying the vein—
    1. At sapheno-femoral junction.
    2. Above knee level.
    3. Another below knee level.
    4. Additional tourniquets often may be applied at below-knee and above ankle level.
Patient is asked to stand; filling of veins and site of filling is looked for. Then tourniquets are released from below upwards to look again for incompetent perforators. Individual perforators may be tested by repeating the procedure.
zoom view
77
zoom view
Figs 1.130A to H: Note the different phases of multiple tourniquet tests.
  • Schwartz test: In standing position, when lower part of the vein in leg is tapped, impulse is felt at the saphenous junction or at the upper end of the visible part of the vein. It signifies continuous column of blood and valves between two fingers are incompetent due to valvular incompetence. It signifies continuous column of blood and also signifies. Positive test is usually found in gross venous varicosity.
  • Pratt's test: Esmarch bandage is applied to the leg from below upwards with a tourniquet tied at saphenofemoral junction. The bandage is released after that to see the ‘blow outs’ as perforators.
  • Fegan's test: Line of varicose vein is marked. On standing, the site where the perforators enter the deep fascia bulges and these points are also marked. In lying down, button like depressions (crescentric gaps) in the deep fascia are felt at the marked out points which confirms the perforator site.
  • Ian-Aird test: On standing, proximal segment of long saphenous vein is emptied with two fingers. Pressure from proximal finger is released to see the rapid filling from above which confirms saphenofemoral incompetence.
  • Perthes' test: The affected lower limb is wrap-ped with elastic bandage and the patient is asked to walk around and exercise. Development of severe crampy pain in the calf signifies DVT.
  • Modified Perthes' test: Tourniquet is tied just below the sapheno femoral junction without emptying the vein. Patient is asked to do a brisk walk which precipitates bursting pain in the calf and also makes superficial veins more prominent. It signifies DVT.
    DVT is contraindicated for any surgical intervention of superficial varicose veins. It is also contraindicated for sclerosant therapy.
  • Homan's test is dorsiflexion of the foot to elicit pain in the calf and Mose's sign is squeezing the relaxed calf muscles sidewards to elicit pain. Both tests signify deep vein thrombosis (DVT).78
    Point to be remembered is that in case of acute DVT, Homan's/Mose's tests should not be done as it will precipitate the dislodgement of the clot and embolism.
  • Bone thickening in the shin (tibia and ankle) is important which signifies periostitis.
  • Measurement limb length and girth is needed especially in arterio-venous malformation with varicose veins and also to find out deformities.
 
Auscultation
Auscultation of the vein for bruit/venous hum.
 
Other Examinations
Examination of peripheral pulses are important (dorsalis pedis/anterior tibial/posterior tibial/popliteal/femoral).
Regional lymph nodes Vertical inguinal nodes and external iliac nodes (above and medial aspect of the inguinal ligament) are palpated.
Ankle Joint movements (plantar and dorsiflexion) are checked for any restriction.
Examination of the other limb both in standing and lying down position should not be forgotten.
Abdomen should be examined for any mass which might be compressing the inferior vena cava (IVC) or iliac veins causing varicose veins.
Examination of other systems also should be done.
 
INVESTIGATIONS FOR VARICOSE VEINS
 
Specific Investigations
  1. Venous Doppler: With the patient standing; the Doppler probe is placed at saphenofemoral junction and later wherever required. Basically by hearing the changes in sound, venous flow, venous patency, and venous reflux can be very well-identified.
  1. Duplex scan is a highly reliable U/S Doppler imaging technique (Here high resolution B mode ultrasound imaging and Doppler ultrasound is used) which along with direct visualisation of veins, gives the functional and anatomical information, and also colour map. Examination is done in standing and lying down position and also with valsalva maneuver. Hand held Doppler probe is placed over the site and visualised for any block and reversal of flow. DVT is very well- identified by this method.
    zoom view
    Fig. 1.131: Doppler machine used for varicose veins and DVT.
  2. Venography
    • Ascending venography was a very common investigation done earlier to Doppler period.
      A tourniquet is tied above the malleoli and the vein of dorsal venous arch of foot is cannulated.79
      zoom view
      Fig. 1.132: Doppler showing DVT in leg. Deep vein thrombosis is contraindicated for varicose vein surgery.
      zoom view
      Fig. 1.133: U/S showing IVC thrombosis.
      Water soluble dye injected, flows into the deep veins (because of the applied tourniquet). X-rays are taken below and above knee level.
      Any block in deep veins, its extent, perforator status can be made out by this.
      Note: In the presence of Duplex scan ascending venography is not necessary investigation.
      If DVT is present, surgery or sclerotherapy are contraindicated.
    • Descending venogram is done when ascending venogram is not possible and also to visulalise incompetent veins. Here contrast material is injected into the femoral vein through a cannula in standing position. X-ray pictures are taken to visulalise deep veins and incompetent veins.
  3. Plethysmography.
  4. Ambulatory venous pressure.
  5. Arm-foot venous pressure (Foot pressure is not more than 4 mmHg above the arm pressure).
  6. U/S abdomen, peripheral smear, platelet count, and other relevant investigations are done depending on the cause of the varicose veins. If venous ulcer is present, then the discharge is collected for culture and sensitivity, biopsy from ulcer edge is taken to rule out Marjolin's ulcer, plain X-ray of the part is taken to find out periostitis.
 
Routine Investigations
  • Haematocrit, blood urea, serum creatinine, blood sugar.
  • Chest X-ray, ECG.
It is done mainly to prepare the patient for surgery—for anaesthesia purpose.
 
TREATMENT FOR VARICOSE VEINS
 
Conservative Treatment
  1. Elastic crepe bandage application from below upwards or use of pressure stockings to the limb.
  2. Diosmin therapy which increases the venous tone.
  3. Elevation of the limb.
 
Injection sclerotherapy (Fegan's technique)
By injecting sclerosants into the vein, complete sclerosis of the venous walls can be achieved.
80
After emptying a 23 gauge needle is inserted into the vein with the patient sitting down, with the legs kept horizontal. 0.5 ml of sclerosant is injected into the vein and immediately compression is applied on the vein (to prevent the entry of blood which may cause thrombosis, which later gets re-canalised and further worsens the condition) so as to allow the development of sclerosis and proper endothelial apposition.
Usually injection is started at the ankle region and then preceded upwards along the length of veins at different points. Later pressure bandage is applied for three weeks. Often injection may have to be repeated after a week.
Microsclerotherapy: Very dilute solution of sclerosing agent like STDS, Polidocanal is injected into the thread veins and reticular veins followed by application of compression bandage (30 G needle). Dermal flare will disappear well by this method.
zoom view
Fig. 1.134: Note the typical ankle flare—dilated dermal and reticular veins. Microslerotherapy is useful to these veins.
Contraindications
  1. Sapheno-femoral incompetence.
  2. Varicose veins with venous ulcer.
  3. DVT.
Advantages
  1. It can be done as an out patient procedure.
  2. It does not require anaesthesia.
Disadvantage: Inadvertent subcutaneous injection can cause skin necrosis or abscess formation.
Foam sclerotherapy: STD 3% is taken in a syringe and is passed rapidly into another syringe which contains air to form foam. This can be injected into larger area of the vein and also long saphenous or short saphenous veins. Air gets absorbed and endothelial destruction and sclerosis occurs.
Echosclerotherapy: Sclerotherapy is done under ultrasound duplex image guidance.
 
Surgery
  1. Trendelenburg operation: It is juxta-femoral flush ligation of long saphenous vein (i.e. flush with femoral vein), after ligating named (superficial circumflex, superficial external pudendal, superficial epigastric vein) and unnamed tributaries. All tributaries should be ligated otherwise recurrence occurs and retained stump of the vein becomes tortuous and dilated (saphena varix).
    zoom view
    Fig. 1.135: Incision for Trendelenburg operation is on below and medial aspect of the inguinal ligament at the level of the sapheno-femoral junction. Long saphenous vein is identified and ligated flush with femoral vein.
    81
  2. Stripping of vein: Using Myer's stripper vein is stripped off. Stripping from below upwards is technically easier. Immediate application of crepe bandage reduces the chance of bleeding and haematoma formation.
    zoom view
    Figs 1.136A and B: Myer's stripper. Note the stripper and olive tip.
    Complication: Injury to saphenous nerve causing saphenous neuralgia.
    Stripping is not usually done for the veins in the lower part of the leg.
    zoom view
    Figs 1.137A to C: Note the stripper in place inside the vein and stripped vein entangled to stripper.
    zoom view
    Fig. 1.138: Diagrammatic representation of stripping vein.
    82
  3. Subfascial ligation of Cockett and Dodd
    Perforators are marked out by Fegan's method. Perforators are ligated deep to the deep fascia through incisions in antero-medial side of the leg.
  4. Ligation of short saphenous vein at saphenopopliteal junction. Stripping of the short saphenous vein is better. It is done using a rigid stripper.
  5. Removal of superficial varicose veins by hook phlebectomy.
  6. Linton's approach is vertical skin incision approach in the calf to do perforator ligation subfascially.
  7. Contraindication for surgery: Deep vein thrombosis (DVT).
zoom view
Fig. 1.139: Cockett and Dodd operation. Note the multiple small transverse incisions. Perforators are ligated deep to deep fascia.
zoom view
Fig. 1.140: Linton's incision and approach for perforator ligation. It is vertical incision in mid-calf region. Incision is deepened upto the muscle plane by cutting the deep fascia. All perforators are easily identified and ligated.
 
Newer Methods Available for Treating Varicose Vein
  • Radiofrequency ablation (RFA) method (VNUS closure method) (VNUS medical technologies Inc; Sunnyvale, CA, USA) (by Goldman 2000): This procedure is done under general or regional anaesthesia. A RFA catheter is passed into long/short saphenous vein near sapheno-femoral or sapheno-popliteal junction under guidance. 85°C temperature is used for longer period of time to cause endothelial damage, collagen denaturation and venous constriction. Phlebectomy is done while withdrawing the catheter.
  • TRIVEX method—By subcutaneous illumination, a large quantity of fluid is injected percutaneously to identify the superficial veins. Superficial veins are removed using suction.
  • Subfascial endoscopic perforator ligation surgery (SEPS)—is becoming popular.
  • Endo-venous laser ablation (EVLA): It is done as an OP procedure or as day- care surgery. Patient lies supine with diseased leg flexed, hip externally rotated and knee flexed. With aseptic precaution, under U/S guidance LSV is cannulated above the knee and a guide wire is passed beyond SFJ and 5-French catheter is passed over guide wire and tip is placed 1 cm distal to the junction. 200 ml of 0.1 % lignocaine is infiltrated along the length of the LSV. Laser fibre is inserted up to the tip of the catheter and catheter is withdrawn for 2 cm and laser fibre protrudes for 2 cm. Laser fibre is fired step by step using diode laser one second withdrawal in 2 seconds. Once procedure is over catheter is removed and pressure bandage is applied for 2 weeks. Heat produced (729°C at tip) by the laser produces steam bubbles with thermal damage of endothelium leading into occlusion of the vein.
83
zoom view
Fig. 1.141: After any intervention for varicose veins, crepe bandages should be applied for 3–6 weeks.
 
Discussion
 
What are the usual presentations of varicose veins?
  • It is more common in females (10:1). It is much more common in females with a family history.
  • Often it is familial.
  • Familial varicose veins begin in younger age group and are seen bilaterally, involve all veins including deep veins.
  • Visible dilated veins in the leg with pain, distress, nocturnal cramps, feeling of heaviness, pruritus.
  • Pedal oedema, pigmentation, dermatitis, ulceration, tenderness, restricted ankle joint movement.
  • Bleeding, thickening of tibia occurs due to periostitis.
  • Positive cough impulse at the sapheno-femoral junction.
 
What are the aetiologies for varicose veins?
Varicosities are more common in lower limb. Because of erect posture long column of blood has to be supported which can lead to weakness and incompetence of valves leading to varicosities.
  1. Primary varicosities are due to—
    • Congenital incompetence or absence of valves.
    • Weakness or wasting of muscles.
    • Stretching of deep fascia.
  2. Secondary varicosities are due to—
    • Recurrent thrombophlebitis.
    • Occupational—standing for long hours.
    • Obstruction to venous return like abdo-minal tumour, retroperitoneal fibrosis, lymphadenopathy.
    • Pregnancy (due to progesterone hormone).
    • A-V malformations—congenital or acquired.
    • IVC/Iliac vein thrombosis.
 
What is the definition of the varicose veins?
It is dilated, tortuous and elongated superficial vein with reversal of blood flow due to incompetence of valves.
 
What are the sites where varicosities can occur?
 
Venous Ulcer
It is the complication of varicose veins or deep vein thrombosis.
zoom view
Fig. 1.142: Venous ulcer—typical site around the ankle.
84
 
Pathogenesis of Venous Ulcer
Varicose veins or DVT which are recanalised, eventually causes chronic venous hypertension around ankle.
zoom view
  • Area where venous ulcer commonly develops is around and above the medial malleoli because of presence of large number of perforators which transmit pressure changes directly into superficial system. This area is called as Gaiter's zone. It can be seen on both malleoli.
  • Ulcer is often large, nonhealing, tender, recurrent with secondary infection. Vertical group of inguinal lymph nodes are usually enlarged and tender.
  • Often it leads to scarring, ankylosis, Marjolin's ulcer formation. Slough from the ulcer bed may give way causing venous haemorrhage.
  • Periostitis is common which also prevents ulcer from healing.
  • Due to regular walking on toes so as to get relief from pain causes contraction and extra-articular fibrosis of Achilles tendon. Proper exercise is the remedy – talipes equino varus.
 
Investigations
  • Discharge from the ulcer for C/S.
  • X-ray of the area to look for periostitis.
  • Biopsy from the ulcer edge to rule out Marjolin's ulcer.
 
Treatment
  • Pressure bandage (crepe bandage). Multilayered (four) pressure bandage with pressure of 45 mmHg is also very useful. This optimum pressure promotes the ulcer healing without injuring the leg.
  • Care of ulcer by regular cleaning with povidone iodine, H2O2.
  • Dressing with EUSOL. (EUSOL is Edinburgh university solution of lime containing boric acid, hypochlorite, and calcium hydroxide).
  • Antibiotics depending on C/S of the dis-charge.
  • Once ulcer bed granulates well, split skin graft (SSG, Thiersch graft) is placed.
  • Specific treatment for varicose veins should be undertaken—Trendelenburg's operation, stripping of veins, perforator ligation.
Note:
50% of venous ulcer occurs as a result of recanalisation of DVT, and the leg is commonly called as post phlebitic limb (leg). It presents with all complications of venous diseases like eczema, ulceration, lipodermatosclerosis, and venous ulcers.
Here surgery for superficial varicose veins is contraindicated. Venous valve repair (Kistner's valvuloplasty) or drugs like Stanazolol which reduces the fibrous tissue in turn increases the oxygenation are beneficial.85
zoom view
Figs 1.143A and B: Typical site of venous ulcer. When ulcer granulates well-split skin grafting is done. Definitive treatment for varicose veins should be done.
zoom view
Fig. 1.144: Stockings should be worn for 3 months after therapy. It should be worn from toes to knee joint.
 
What are the types of varicose veins?
  1. Long saphenous vein varicosity.
  2. Short saphenous vein varicosity.
  3. Varicose veins due to perforator incompetence.
    zoom view
    Figs 1.145A and B: Tortuous, elongated dilated long saphenous vein.
    zoom view
    Figs 1.146A and B: Photo of short saphenous vein varicosity and its diagrammatic location.
    86
  4. Thread veins (dermal flares): Are small varices in the skin usually around ankle which look like dilated, red or purple network of veins. <3 mm in size.
  5. Reticular varices: Are slightly larger than thread veins located in subcutaneous region. >3 mm in size.
  6. Combinations of any of above.
 
What is lipodermatosclerosis? What are the theories of the problems of varicose veins?
Fibrin deposition, scarring and tissue hypoxia due to chronic venous hypertension around ankle joint is called as lipodermatosclerosis. It is irreversible change in the soft tissue which eventually leads into ulceration.
zoom view
Inappropriate activation of trapped leucocytes release proteolytic enzymes which cause cell destruction and ulceration—White cell trapping theory.
 
What are different types of perforators?
  • Ankle perforators (May or kuster).
  • Lower leg perforators I, II, III (of Cockett).
  • Gastrocnemius perforators (of Boyd).
  • Mid thigh perforators (Dodd).
  • Hunter's perforator in the thigh.
 
What is CEAP classification?
It is the classification used for lower extremity venous diseases.
 
Physiology of Venous Blood Flow in Lower Limb
Veins are thin walled vessels with collapsible walls that assume an elliptical configuration in collapsed state and circular configuration in the filled state.87
Venous valves are abundant in the distal lower extremity and the number of valves decreases proximally, with no valves in superior and inferior vena cava.
 
Venous Return
  1. Arterial pressure across the capillary increases the pumping action of vein.
  2. Calf musculovenous pump: During contraction phase of walking, pressure in the calf muscles increases to 200–300 mmHg. This pumps the blood towards the heart. During relaxation phase of walking, pressure in the calf falls and so it allows blood to flow from superficial to deep veins through perforators. Normally while walking, pressure in the superficial system at the level of ankle is 20 mmHg.
  3. During walking, foot pump mechanism propels blood from plantar veins into the leg.
  4. Gravity.
 
Deep Vein Thrombosis (DVT)
 
Aetiology
Factors—
Virchow's triad:
  • Stasis.
  • Hypercoagulability.
  • Vein wall injury.
 
Causes
  1. Following childbirth.
  2. Trauma.
  3. Muscular violence.
  4. Immobility.
  5. Debilitating illness, obesity, bed rest, pregnancy, puerperium, oral contraceptives, and estrogens.
  6. Postoperative thrombosis: Common after the age of 40 years. Incidence following surgeries is 30%. In 30% of cases both legs are affected. Usually seen after prostate surgery, hip surgery, major abdominal sur-geries, gynaec surgeries, cancer surgeries. Bedridden for more than 3 days in the postoperative period increases the risk of DVT.
  7. Spontaneous thrombosis is common in visceral neoplasm like carcinoma pancreas or carcinoma stomach. It is often migrating type.
  8. Thrombus may start in a venous tributary which eventually may extend into the main vein causing DVT.
  9. Axillary vein thrombosis can occur spontaneously, following compression by cervical rib, by various causes of thoracic inlet syndrome, or arm being in the hyper abduction state for prolonged period (e.g painting the ceiling), after axillary lymph node block dissection, after radiotherapy to axilla, occasionally as a complication of venous cannulation.
  10. Polycythaemia vera, thrombocytosis.
  11. Deficiencies of antithrombin III, protein C, protein S.
 
Sites
  1. Pelvic veins: Common.
  2. Leg veins: Common in femoral and popliteal veins—(Common on left side).
  3. Upper limb veins: Not uncommon (Axillary vein thrombosis).
 
Phlegmasia alba dolens:
It is DVT of femoral vein (deep femoral vein commonly) causing painful congestion and oedema of leg, with lymphangitis, which further increases the oedema and worsens the situation. (White leg).
 
Phlegmasia caerulea dolens:
It is extensive DVT of iliac and pelvic veins causing blue leg with either venous gangrene or areas of infarction.88
 
Clinical Features
  • Fever—earliest and common symptom.
  • Pain and swelling in the calf and thigh (often). Commonly associated with fever. Pain is often so severe that the patient finds difficult to flex (or move) the leg.
  • Leg is tense, tender, warm, pale or bluish with stretched and shiny skin.
  • Positive Homan's sign: Passive forceful dorsiflexion of the foot with extended knee will cause tenderness in the calf.
  • Mose's sign: Gentle squeezing of lower part of the calf from side to side is painful. Gentleness is very important otherwise it may dislodge a thrombus to form an embolus.
  • Neuhof's sign: Thickening and deep tenderness is elicited while palpating deep in calf muscles.
  • Most often, DVT is asymptomatic and presents suddenly with features of pulmonary embolism like chest pain, breathlessness and haemoptysis.
 
Investigations
  1. Venous Doppler.
  2. Duplex scanning.
  3. Venogram.
  4. Radioactive I125 fibrinogen study.
  5. Haemogram with platelet count.
 
Treatment
  1. Rest, elevation of limb, bandaging the whole limb with crepe bandage.
  2. Anticoagulants: Heparin, warfarin, phenindione.
  3. For fixed thrombus: Initially high dose of heparin of 25,000 units/day for 7 days has to be given. Later patient is advised to continue with warfarin for 6 months. Low molecular heparin can also be used. Dose is controlled by assessing Activated Partial Thromboplastin Time (APTT). Duration of heparin treatment is usually for 5 days.
  4. For free thrombus: Fibrinolysins-Strepto- kinase or urokinase or tissue plasminogen activator are used to dissolve thrombus (It should not be given when patient is on heparin).
  5. Venous thrombectomy is done using Fogarty venous balloon catheter.
  6. Thrombotic emboli is prevented from reaching the heart by filtering it at IVC level using Kim ray Greenfield filter, suture sieve plication, stapler plication, vena caval ligation, Mobin Uddin umbrella filter.
  7. Palma operation: In iliofemoral thrombosis, common femoral vein below the block is communicated to opposite femoral vein through opposite long saphenous vein.
  8. May-Husni operation: When blockage is in popliteal vein, popliteal vein below the block is anastomosed to long saphenous vein (end to end) so as to by pass the blood across popliteal block.
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Fig. 1.147: Palma operation.
 
Prevention of DVT
  1. Care has to be taken to see for proper positioning of legs with no pressure on the calf muscles.
    89
  2. Pressure bandage to the legs has to be applied during major surgeries, laparoscopic surgeries. During postoperative period, elevation, massaging, pressure bandage, early ambulation, maintaining hydration are essential measures.
  3. Low dose heparin is given in suspected cases, in major surgeries and continued during post operative period till the patient is ambulated. 5000 units is given subcutaneously 2 hours before surgery.
  4. Various measures like graduated static compression, elastic stockings, electrical stimulation of calf muscles, pneumatic compression are used to prevent sluggish flow of blood.
  5. Intravenous dextran 70, 500 ml during surgery and another 500 ml postoperative period in 24 hours can also be used to prevent DVT.
 
Anticoagulants
 
Heparin
  • It is a natural anticoagulant, a mucopolysaccharide.
  • It prevents clotting of blood both in vivo and in vitro by acting on all three stages of coagulation. It prolongs clotting time and activated thromboplastin time in specific (by 1.5–2.0 times the control).
  • Heparin also causes hyperkalaemia.
  • Commercial heparin is derived from lung and intestinal mucosa of pigs and cattle.
  • The onset of action is immediate after administration and lasts for 4 hours.
  • It is metabolised in the liver by heparinase.
  • It does not cross placental barrier and not secreted in breast milk.
 
Indications
  • As prophylaxis in major surgeries, post- operative period, puerperium.
  • As therapy in DVT.
 
Dose
  • For prophylaxis: 5,000 units/SC ly. 8th hourly.
  • For therapy: 10,000 units/IV ly. 6th or 8th hourly. Later change to subcutaneous dose.
  • In severe cases, 5000 units to 20,000 units is given daily through IV infusion at a rate of 1000 units per hour. Daily dose should not exceed 25,000 units.
Note: Heparin should not be given intramuscularly and should not be combined with streptokinase or urokinase.
Heparin is not given orally.
Heparin administration should always be monitored with APTT.
 
Complications
Allergy, bleeding, thrombocytopenia.
 
Low Molecular Weight Heparin (LMWH)
It is a commercially prepared heparin with a molecular weight of 4000 to 6500.
 
Advantages
  • They are absorbed more completely.
  • Have a longer duration of action.
  • Have a better anticoagulant effect.
  • Less interaction with platelets.
  • Less antigenic.
  • Usage is easier and acceptable.
Disadvantages: They are expensive.
Presently LMWH are becoming very popular. Enoxaparin, dalteparin, parnaparin, reviparin.
 
Heparin Antagonist
50 mg of 1% protamine sulphate solution is given slow intravenous.90
 
Oral Anticoagulants
They are given orally and are slow acting.
 
Types
  1. Coumarin derivatives: Bishydroxycoumarin (Dicoumarol)— First coumarin drug derived from sweet clover.
    Warfarin sodium: Commonest oral anticoagulant used.
  2. Indandione derivative:
    • Phenindione.
    • Anisindione.
 
Mode of Action of Oral Anticoagulant Therapy
  • By suppressing synthesis of prothrombin, factors VII, IX, and X.
  • By inhibiting carboxylation of glutamic acid through vitamin K.
 
Features
  • Oral anticoagulant does not have in vitro action.
  • They are slow acting, and long acting.
  • Control of oral anticoagulant therapy is by monitoring prothrombin time.
  • PT comes to normal only 7 days after cessation of the drug.
  • They cross placental barrier and known to cause teratogenicity when given in 1st trimester.
  • They are secreted in breast milk.
 
Indication
  • In DVT, for maintenance therapy after cessation of heparin.
  • After valve replacement surgery.
 
Side Effects
  1. Bleeding: It may require blood transfusion to control.
  2. Cutaneous gangrene.
  3. Fetal haemorrhage and teratogenicity.
  4. Alopecia, urticaria, dermatitis.
  5. Drug interactions: With NSAIDs, cimetidine, omeprazole, metronidazole, cotrimoxazole, erythromycins, barbiturates, rifampicin, griseofulvin.
 
Warfarin Sodium
Warfarin Sodium (Wiskonian Alumini Research Foundation + coumARIN derivative) is the commonest drug used. It has got lesser side effects. It has got cumulative action and so given in tapering dose.
Dose is 5 mg once a day.
It should be discontinued 7 days before any surgery like tooth extraction and prothrombin time should return to normal level. During surgery if excess bleeding occurs, blood transfusion may be given.91
BREAST
 
WRITING A CASE SHEET IN A CASE OF BREAST LUMP
 
History Taking
 
Chief Complaints
  • Swelling in the right/left breast/both breasts; its time duration.
  • Pain in the breast with duration.
  • Ulceration in the breast with duration.
  • Discharge from nipple.
  • Ulceration over the breast/swelling.
  • Swelling in the axilla/neck.
 
History of Present Illness
Swelling: Duration, its progression whether slowly increasing in size or rapidly increasing has to be asked for. Swellings of short duration are most probably due to carcinoma. But most often, after noticing the swelling the patient immediately consults a doctor for opinion and so duration may not be clearly obtained. Swelling in the opposite breast is also important. In 2 % of cases, breast carcinomas are bilateral; and fibrocystadenosis is commonly bilateral.
Pain: In the breast, it is often called as mastalgia. It is common in fibrocystadenosis and acute mastitis. There will be associated fever in mastitis. Carcinoma breast is painless to begin with but eventually becomes painful following infiltration or development of tumour necrosis or skin ulceration/fungation. Pain in fibroadenosis is more prior to menstruation (cyclical), and may disappear during pregnancy and after menopause. Duration of pain, type, timing, site and relation to menstruation has to be noted.
Nipple discharge: Duration of discharge, its type whether serous/purulent/bloody/serosanguinous/milky/greenish has to be asked for and noted. Bloody discharge is often seen in duct papilloma, carcinoma. Serous and greenish discharge is seen in fibroadenosis.
History of changes in nipple: Like retraction (depression), deviation, destruction, displacement, discolouration, duplication and discharge is noted. Recent history of changes signifies carcinoma. Often retraction may be congenital, since birth.
History of alteration in size and symmetry of the breasts with duration.
History related to swelling in the axilla/neck and their details like duration, progress, pain, ulceration, etc. is noted.
History related to respiratory problems has to be asked like chest pain/breathlessness/cough/haemoptysis—signifies the secondaries in lung from carcinoma breast.
History of abdominal pain, loss of appetite, decreased weight, jaundice, abdominal distension which signifies liver secondaries has to be asked for.
History related to bone secondaries:Like bone pain, low back pain, altered sensation like sense of position and vibration, lower limb weakness, features of paraplegia, loss of control over urination and defaecation is asked for.
History of convulsions, loss of consciousness, vomiting, limb weakness, headache, visual disturbances, behavioural changes (psychological like features) and localisation changes.
 
Past History
Past history of any surgeries of breast (recurrence can occur after excision of fibroadenoma, conservative breast surgery may cause recurrent carcinoma breast) or drug therapies like for fibroadenosis.
 
Menstrual History, Obstetric History and Family History
This is important in breast diseases. Family history of carcinoma of breast (in mother, grandmother, 92aunt, cousins, 1st and 2nd degree relatives), ovarian tumour or other tumours has to be noted. Breast carcinoma can be familial. Often multiple tumours can occur. History of menarche, menstrual cycles, number of pregnancies, breast feeding, lactation, menopause, last child birth and usage of contraceptives/postmenopausal HRT are very important.
 
Personal History and Treatment History
History of smoking, alcohol intake, dietary habits is noted. History of any drug intake at present is important.
 
General Examination
Like for any other long case, patient should be examined for palor, jaundice, oedema feet, clubbing. Pulse and blood pressure should be checked.
 
Local Examination of Breasts
 
Inspection
For proper inspection, both breasts should be exposed properly including axillae. Initially examination is carried out with the patient sitting with 45° semi recumbent position. Later examination is done in lying down position. During inspection, the clinician should stand in front and later on the side of the patient. Usually normal breast should be first examined.
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Fig. 1.148: Accessory nipple is not an uncommon condition.
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Figs 1.149A and B: Examination of breast is done in sitting position with arms beside.
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Figs 1.150A and B: Examination with both arms raised above the shoulder and with leaning forward.
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Fig. 1.151: Examination with 45° semi-recumbent position
Inspect both breasts: Note the size, shape and symmetry. Asymmetry can be seen in breast lumps. Inspect both breasts while leaning forward to see whether both breasts fall forward or not. In carcinoma, if the breast is fixed to underlying chest wall, it will not fall forward. Both breasts should be inspected while the arms are raised upwards to see whether breast is/breasts are adherent to chest wall.
Inspection of nipple: Look for symmetry/asymmetry, pushed up/down, displacement, retraction, size/shape of nipple, discharge/ulceration in the nipple, discolouration, duplication, cracks/fissures. Many of these changes occur in carcinoma. Fissuring and cracks can occur in breast feeding mothers during lactation. Nipple retraction may be due to infiltration of lactiferous duct by carcinoma.
Areola should be inspected for any changes in color, size, ulceration, eczema/eczema like changes. Both areolas should be inspected. Areola is pink in colour in young girls, dark coloured in adults, brownish during pregnancy and lactation. Ulceration of nipple can occur in carcinoma and Paget's disease of breast, a localised type of carcinoma breast. It should be differentiated from eczema. Eczema is commonly bilateral without any nodule underneath, associated with itching and vesicles, with normal nipple. It is common during lactation. Paget's disease of breast is unilateral, without vesicles and itching, with a hard lump underneath, often with destruction of nipple.
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Figs 1.152A and B: Nipple deviation and retraction should be looked for in breast lumps.
Skin over the breast is inspected for retraction, pigmentation, redness/shining, dimpling, puckering, Peau d' orange, nodules, ulceration, fungation, and scar. Any dilated veins over the skin and cancer-en-cuirasse is looked for. Involvement of the ligament of Cooper causes dimpling and puckering of skin over the breast. Oedema of skin is due to blockade of cutaneous lymphatics causing burial of sweat glands and hair follicles giving the appearance of orange peel (Peau d' orange). When ulcer is present, its position, size, shape, margin, floor, edge should be noted. Cancer-en-cuirasse is extensive involvement of the skin over the breast and chest wall with multiple nodules and ulceration by the carcinoma. It looks like armor coat.
Swelling in the breast is an important finding to be inspected. Its location in relation to the 94quadrants of the breast, extent, size, shape, margin, surface, skin over it should be examined.
 
Palpation
Normal breast should be palpated first. Palpation should be done by the palmar aspect of the fingers. During palpation one should look for raise in temperature over the breast (observed in mastitis but also can occur in vascular tumours like medullary carcinoma and sarcoma), tenderness, nature of the swelling—its size, shape, extent, surface, margin, consistency (carcinoma is hard/stony hard and irregular), fixity to breast tissue (swelling will not have independent/differential mobility), fixity to skin (by pinching the skin), fixity to pectoral fascia (by tethering), fixity to pectoralis major muscle/serratus anterior muscle/latissimus dorsi muscle. Palpate ulcer—look for tenderness, its edge and base for induration, bleeding on palpation. Nipple and areola should be palpated for tenderness, eversion, induration and discharge.
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Fig. 1.153: Normal breast should be palpated first. It should be palpated for mass, its location, shape, size, surface, consistency, mobility and fixity.
Examination of ipsilateral, regional axillary lymph nodes. Anterior/pectoral, central/medial, posterior, lateral, apical lymph nodes should be examined.
Supraclavicular lymph nodes should be examined.
Opposite axillary nodes are also examined. It may get involved through retrograde spread from internal mammary nodes or through cutaneous lymphatics.
Examination of arms for venous oedema or lymphoedema. Venous oedema may be due to axillary vein compression by nodal mass. Lymphoedema may be due to lymphatic block following nodal involvement. Lymphoedema is mainly distal. It is gradual in onset and progressive. Venous oedema is sudden in onset, with bluish discolouration over the skin, uniform in both distal and proximal aspect of the upper limb (forearm and arm).
Examination for mediastinal node involvement—it is done by percussion. Initially percus for liver dullness. Then percussion is done one space above from lateral to medial, to widened mediastinal border. Mediastinal nodes are common in middle mediastinum.
Examination of respiratory system for secondaries— altered breath sounds, features of consolidation or pleural effusion are looked for.
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Fig. 1.54: Look for pleural effusion and altered breath sounds for secondaries in lungs.
Examination of abdomen—to look for palpable nodular liver, Krukenberg ovaries in menstruating age group, and ascites. It is completed with digital examination of rectum (P/R), and per vaginal examination.95
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Fig. 1.155: Always examine abdomen for liver enlargement, ascites or Krukenberg's tumour (in premenopausal age)
Examination of pelvis, spine, long bones for any swelling/tenderness/pathological fracture/restricted movements of spine, hips, etc.
Examination of central nervous system to look for any neurological deficits following metastatic disease in the brain.
 
Diagnosis
Complete diagnosis with side and staging should be given/written in case sheet. TNM staging is used.
Example: Carcinoma left breast stage II-T1, N1, M0.
 
Discussion
Breast is examined in different positions to elicit different clinical features.
Breast self examination (BSE) has got a major role in early detection of the carcinoma breast.
Ideally done once a month, just after the menstruation, as during this time breasts are less engorged. In postmenopausal age group it is done regularly at monthly intervals (fixed day of the month).
  • Examine both breasts.
  • American cancer society recommends monthly BSE after 20 years of age.
  • Remind the patient that 90% of breast lumps are not cancer.
  • Better way is in lying down position with arm raised with a mattress support behind.
  • Palpation is done over all quadrants of the breast using the fingers.
  • If any doubtful swelling is palpable, consult the surgeon.
  • Nursing mother should perform BSE just after feeding the baby.
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Fig. 1.156: Self-examination of breast is done in lying down position.
 
Assessment of Nipple Deviation
Nipple changes are assessed by inspection, palpation and measurement. Displacement of nipple is assessed by measuring distance between mid-clavicular point to the nipple. This reveals any upward/downward displacement of nipple. Outward/inward displacement is assessed by measuring the distance of nipple from mid-line.96
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Figs 1.157A and B: Quadrants of breast. Carcinoma is more common in upper outer quadrant as more breast tissue is located in this quadrant.
Fixity of the lump to breast tissue is checked by holding the breast tissue in one hand and moving the lump in other hand. If lump is fixed to breast tissue, then breast tissue moves along the lump.
Skin tethering can be demonstrated by moving the lump one side. It is due to inward puckering of the skin following involvement of the elastic Cooper's ligament which becomes inelastic. Dimpling of skin appears which can be demonstrated by raising the arms above the shoulder level. When skin tethering occurs lump can be moved in the arc anywhere without moving the overlying the skin where as lump cannot be moved at all without moving the skin in skin fixation.
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Fig. 1.158: Peau d' orange appearance of skin in carcinoma breast. It is due to blockade of dermal lymphatics.
Fixity to pectoralis major muscle is checked in sitting position. Patient is asked to keep her hands on her waist. Lump is moved along the direction of the muscle and also perpendicular to the direction of the muscle. Patient is asked to hold the hands tight and pressed over the waist to contract the pectoralis major muscle (action of the muscle is flexion of the shoulder) which is confirmed by feeling the taut muscle. Lump is again moved along the direction and perpendicular to the direction of the muscle. Mobility will be restricted, if lump is adherent to the pectoralis major muscle. It becomes T3 stage.97
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Figs 1.159A to D: Checking for fixity to pectoralis major muscle. Muscle is made taut by keeping the patient's hands over the waist and lump mobility is checked both in relaxed and contracted status of the muscle. Taut muscle should be confirmed by palpating the muscle in anterior axillary fold.
Fixity to latissimus dorsi muscle is checked in sitting position with examiner by the side of the patient. Latissimus dorsi is an extensor of the shoulder joint. Initially mobility of the lump is checked and then arm is extended against resistance with elbow flexed 90° to contract the latissimus dorsi. If now mobility of the lump is restricted, then it confirms that lump is fixed to latissimus dorsi muscle.
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Fig 1.160: Fixity to latissimus dorsi muscle is checked by checking the mobility of the mass while extending the arm against resistance.
Fixity to serratus anterior muscle is checked by checking the mobility of the lump before and after contracting the serratus anterior. Contraction of serratus anterior is achieved by pushing the outstretched both hands against resistance over the wall and checking for restriction of mobility of the lump. It signifies involvement of chest wall—T4.
Chest wall fixity can be assessed by absence/presence of mobility of the mass; and breast with mass will not fall forward if it is fixed to underlying chest wall; and on raising the arm above shoulder breast with mass will not raise upward. Chest wall fixity means fixity to ribs and intercostals muscles.
Palpation of axillary lymph nodesis an important step in examination of carcinoma breast.98
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Figs 1.161A and B: Fixity to serratus anterior is checked by checking the mobility of the lump while pushing the outstretched both hands of the patient, over the wall against resistance.
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Fig. 1.162: Inspection of the axilla with raised arm is very important clinical method.
Anterior/pectoral group of nodes are commonly involved nodes. Patient will be in sitting position. Raise the patient's arm high and inspect the axilla. Place the patient's forearm over examiners forearm. Palpate the relaxed axilla over pectoralis major muscle for any lymph nodes. Examiner will use his left hand to examine the nodes (of right axilla) and his right hand will be over patient's left shoulder to support.
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Fig. 1.163: Examination of pectoral group of lymph nodes.
Interpectoral nodes (Rotter's) are also palpated similarly by insinuating the fingers between the two pectori. It signifies retrograde spread of the tumour. It is often difficult to palpate.
Central/medial group of nodes are palpated in similar way like pectoral nodes but hand in the axilla is directed medially over the lateral chest wall and with gentle rolling movements.
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Fig. 1.164: Examination of central group of lymph nodes.
99
Lateral/humeral group of nodes are palpated with examiner's right hand (for right axilla) with left hand placed over same side shoulder.
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Fig. 1.165: Examination of lateral group of lymph nodes.
Posterior/subscapular nodes are palpated with patient in sitting position and examiner standing behind the patient. By raising the arm and forearm of the patient from opposite side the posterior axillary fold is palpated between thumb and fingers.
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Fig. 1.166: Examination of posterior group of lymph nodes.
Apical nodes are palpated (for right axilla) with left hand of the examiner placing high in the axilla with right hand supporting over the shoulder and supraclavicular region of the same side of the axilla. It is often difficult to palpate.
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Fig. 1.167: Examination of apical group of lymph nodes.
Supraclavicular nodes are palpated using fingers over supraclavicular fossa by standing behind the patient who is asked to shrug the shoulder.
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Fig. 1.168: Examination of supraclavicular group of lymph nodes.
Axillary nodes on opposite side are also examined. Opposite axilla can be examined by examiner standing on the same side by leaning over the patient or can be examined by standing on the opposite side. Its involvement signifies stage IV disease. It is confirmed by FNAC.100
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Fig. 1.169: Surgical levels of lymph nodes in the axilla draining from breast.
Axillary tail of the Spence is the extension of the upper outer quadrant of breast across foramen Langer deep to deep fascia. Foramen Langer is an opening in deep fascia over outer aspect of the breast which allows part of breast tissue to extend under deep fascia, otherwise rest all breast tissue is in subcutaneous plane. Axillary tail is located adjacent to outer border of the pectoralis major muscle. When it is involved by carcinoma it should be differentiated by pectoral node enlargement. Axillary tail will move along with main breast tissue whereas pectoral node will not move when breast is moved but it has got independent mobility. Axillary tail often extends over the lateral edge of the pectoralis major muscle up to axilla.
Fixed enlarged axillary nodes can cause lymphoedema due to lymphatic block; venous thrombosis and venous oedema due to venous block; and severe excruciating pain along the distribution of the median and ulnar nerves (rare in radial nerve) with often significant sensory and motor deficits due to tumour infiltration of the cords of brachial plexus (medial cord often lateral cord).
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Fig. 1.170: Axillary tail of Spence.
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Differences between Paget's disease and eczema of nipple
In Paget's disease, there will be a hard nodule just underneath the areola, which later ulcerates and also causes destruction of nipple. Histologically it contains large, ovoid, clear Paget's cells with malignant features.
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Figs 1.171A and B: Paget's disease of the breast.
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Fig. 1.172A: Subareolar carcinoma with destruction of nipple-areolar complex.
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Fig. 1.172B: Carcinoma breast with rib secondaries.
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Fig. 1.173: Ulcerated carcinoma breast with Peau' d orange. Note the lymph node enlargement.
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Fig. 1.174: Carcinoma breast over the commonest site—upper outer quadrant—more visible on raising the arm.
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Fig. 1.175: Carcinoma breast with extensive skin involvement.
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Fig. 1.176: Recurrent carcinoma of breast. Note the recurrent tumour nodules.
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Staging of Carcinoma Breast (Manchester and TNM Staging)
The Columbia Classification (Haagsen, Cooley and Stout)
Stage A —
No skin oedema, ulceration, or fixation to chest wall.
Axillary nodes are not clinically involved.
Stage B —
Clinically involved axillary nodes less than 2.5 cm in diameter.
Not fixed.
Stage C —
Grave signs of comparatively advanced carcinoma.
Oedema of skin, skin ulceration, fixation to chest wall
Massive axillary involvement with nodes > 2.5 cm in diameter
Axillary fixation.
Stage D —
Advanced carcinoma including two or more signs in stage C.
In addition satellite nodules, supraclavicular nodes.
Inflammatory cancer, arm oedema or distant metastasis.
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Fig. 1.177: Carcinoma right breast with retraction of nipple and areolar changes.
 
How carcinoma breast is suspected?
Any lump in the breast can be malignant unless proved otherwise. But one has to remember that every breast lump need not be always malignant. Duration, progression, nodal status, hard consistency, often irregular surface and late features like fixity, ulceration/fungation and distant spread are the features to consider carcinoma breast.
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Fig. 1.178: Carcinoma right breast with ulceration in the primary with axillary lymph node secondaries.
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Fig. 1.179: Advanced carcinoma left breast involving entire breast with nodularity.
One has to remember that differential diagnosis for carcinoma breast is same as all conditions which are benign diseases of the breast (Refer table).
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Figs 1.180A and B: Fungating carcinoma breast. Note the extension of fungation into the chest wall.
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Fig. 1.181: Cancer-en-cuirasse with malignant nodules in chest wall and skin.
 
What are the investigations done for breast lump?
Investigations in carcinoma breast—
 
1. Mammography
It is plain X-ray of soft tissue of breast using low voltage and high amperage X-rays. Two films are taken.
Cranio caudal from above downward.
Mediolateral from side to side.
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Fig. 1.182: Mammogram.
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Fig. 1.183: Medio-lateral and cranio-caudal mammographic pictures showing microcalcification, spiculations and irregularity.
Dose of radiation is 0.1 Gy, a low dose. So it is a safe and effective procedure.
Breast imaging reporting and data system (BI-RADS) has got its own categories, assessment and recommendations.106
Digital mammography is computerised electronic image of the breast with enhanced magnified pictures.
Digital spot-view mammography allows faster and more accurate stereo tactic biopsy.
Indications
  • For screening purpose it is done after 40 years. Early screening is indicated when there is family H/o carcinoma breast or histological risk factor. Mammography before 25 yr of age is usually not done unless there is a lump or a strong family history.
  • In obese patients.
  • To find out spread or de novo tumour in the opposite breast.
  • Mastalgias.
  • Mammography guided biopsy can be done.
  • Evaluation and follow up in benign breast disease with malignant potential.
  • Follow up mammography after conservative breast surgery.
Mammography is usually not done before the age of 25 yr, unless there is a strong family history or any suspicious lump.
Xeromammography is same as above, but here a photoconductor is used to produce a final image on a Selenium paper rather than on X-ray film.
Advantages: Edge enhancement effect, therefore useful in dense breasts.
Disadvantage: Exposure to high radiation dose and selenium plate is needed.
The condition when lump is clinically not palpable but mammogram shows identifiable carcinoma is ideal for breast conservative surgery like quadrantectomy/QUART therapy.
 
2. Ultrasound of breast
  • To look for whether the lesion is solid or cystic, margin of the lesion, internal echoes, retro-tumour acoustic shadowing, compressibility, dimensions.
  • Irregular margin, irregular internal echoes, irregular posterior shadowing, non-compressibility, ratio between antero-posterior to width (lateral/horizontal) dimensions more than 1 are the features of carcinoma. Doppler will show high frequency signals with continuous flow.
  • Benign lesions are smooth, rounded with well-defined margins with weak internal echoes and compressibility.
  • Disadvantage is lesions less than 1 cm may not be identified.
  • FNAC can be done under U/S guidance.
  • It is cheaper, easily available and there is no risk of radiation.
  • It is preferred method of screening in pregnancy and early lactation.
 
3. FNAC
FNAC is very useful in diagnosing the carcinoma breast. FNAC is also done under U/S guidance. But negative results are difficult to interpret because it may be due to sampling errors and so requires further diagnostic methods. FNAC of opposite breast, lymph nodes, opposite axillary lymph nodes are also often required. It is done with 23 gauge needle using FNAC aspiration special syringe. With the lump held firmly, the needle is passed into the lump and with negative pressure continuous aspiration is done until adequate material comes through the needle.
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Figs 1.184A and B: FNAC of breast lump
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Needle with syringe is removed without negative pressure. Material is collected on a slide; a smear is made using 100% alcohol. Cytology is studied after staining it under microscopy.
Advantages:
FNAC is least painful, can be done on OP basis, reliable and cheaper. Malignant deposits will not occur along FNAC track (only contraindication for FNAC is testicular tumour).
FNNAC is Fine Needle Non-Aspirating Cytology.
Reliability of FNAC and mammography
 
4. Frozen section biopsy
If FNAC fails even after two trials or in cases of negative FNAC, then on table frozen section biopsy is done for diagnosis. It is often difficult to differentiate between severe atypia and carcinoma by frozen section and so its validity and use is under debate. In such situation excision biopsy is better. While doing excision biopsy incision is placed in such a way that it can be included in eventual mastectomy. Trucut biopsy is also used nowadays in many centers.
 
5. Chest X-ray:
To look for pleural effusion, cannon ball secondaries in lungs, mediastinal lymph nodes, secondaries in rib. CT chest is more reliable method to see lung secondaries.
 
6. Ultra sound abdomen:
To look for liver secondaries, ascites, and ‘Krukenberg’ tumour.
 
7. X-ray spine or MRI spine/pelvis
shows osteolytic secondaries in the bone like vertebra and pelvic bones.
 
8. Radioisotope bone scan
to look for secondaries in bone in advanced cases. It is not done routinely in early carcinoma of breast.
 
9. Estrogen receptor study
  • They are estrogen sensitive receptors, which are cytosolic glycoprotein present in the breast and tumour tissue. It is an important indicator of prognosis of carcinoma breast.
  • Tissue for receptor study is sent in low temperature in ice flasks. It is assessed by quantitative analysis. (Frozen −70°).
  • If value is more than 10 units (Femto mols) per ng gram tissue it is called as ER +ve status. If value is 5–9 it is borderline and if it is less than 5 femtomoles per nanogram tissue it is called as ER –ve status.
In ER +ve status
  • Prognosis is good.
  • Hormone therapy including Tamoxifen is very beneficial.
  • Response to treatment is better.
In ER –ve status
  • Prognosis is poor.
  • Hormone therapy is not very beneficial (but used) as compared to ER +ve patients.
  • Response to treatment is not good.
ER positivity is common in post-menopausal women (60%) compared to premenopausal women (30%).
Progesterone receptor (PR status) study and Her 2 neu receptor status are other studies done at present to plan the therapy and assess the prognosis.
 
10. Study of discharge from the nipple
Nipple discharge is usually unilateral in carcinoma breast.Ductal lavage may be useful 108in some patients. Micro-catheter of 1 cm length is introduced gently into the ductal opening. 10 ml saline is infused through the catheter. Fluid is withdrawn into the syringe and cytological analysis is done.
 
11. MRI of breast and MRI of spine (in case of suspected spine secondaries)
  • To differentiate scar from recurrence.
  • To image breasts of women with implants.
  • To evaluate the axilla and recurrent disease.
  • Both pre contrast and post contrast MRI are done. T1 and T2 weighed images are taken
  • Irregular mass with spiculations, changes in skin and nipple, lymphoedema are the findings in carcinoma breast.
 
12. Edge biopsy:
Done only when there is skin involvement—ulceration and fungation. Diathermy should be avoided in incision biopsy as it may distort the histology of tumour and study of hormone receptor status may not be possible.
 
13. Tumour markers
are used mainly during follow up period. CA 15/3 is commonly done when needed.
 
14. Sentinel node biopsy (SLNB):
The first axillary (SLN) node draining the breast (by direct drainage) is designated as the sentinel node. SLN is first node involved by tumour cells and presence or absence of its histological involvement, when assessed will give a predictive idea about the further spread of tumour to other nodes. Involvement of other nodes without SLN is less than 3% and so if SLNB is negative nodal dissection can be avoided but regular follow up is needed. SLNB is done in all cases of early breast cancers, T1 and T2 without clinically palpable node. It is not done in clinically palpable axillary node as there is already distortion of lymphatic flow due to tumour. It is also not done in multifocal and multicentric tumours, as there is involvement of many lymphatic trunks from different places of breast, chances of false negative is high. Sentinel node is localised by pre-operative (within 12 hours) or peroperative injection of patent blue (Isosulfan vital blue dye) or 99m Tc radioisotope labeled colloid albumin near the tumour (peritumour area). Marker will pass through the sentinel node which can be detected visually as blue staining or with a hand held gamma camera; and is biopsied with a small incision directly over it. If there is no involvement of sentinel node by tumour, then further axillary dissection is not required as skip lesions (skipping sentinel node) occur only in less than 3% cases.
Note: Facility for SLNB is not available in many centers.
SLNB is done in—
  • Carcinoma breast.
  • Carcinoma penis.
  • Malignant melanoma.
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Fig. 1.185: Sentinel lymph node biopsy (SLNB) of breast. Note: Spread by skipping the sentinel node is less than 3%.
Axillary sampling is often done with an adequate axillary incision. 10–15 nodes are removed for sampling. It is not commonly practiced now. (Minimum 10 nodes should be removed—level I nodes).
 
15. CT scan
of chest, abdomen and brain whenever needed. CT is said to be more useful to detect secondaries in these regions.
 
16. Triple assessment:
Includes—
  1. Clinical assessment.
  2. Radiological imaging.
  3. Cytological or histological analysis.
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17. Ductography
It is contrast study of ducts of breast in case of unilateral nipple discharge. Fine cannula is passed under vision carefully through the duct opening into the duct and 0.2 ml of dilute water-soluble contrast media is injected into the duct. Craniocaudal and mediolateral X-ray films are taken. Contrast irregular filling defect may be observed.
 
18. Thermography
is not very sensitive test (50%). Malignant tumours are hypervascular and so transmitted temperature is detected through different thermographic methods.
 
What is the treatment for early breast cancer?
In early breast cancer, aim of the treatment is—to achieve cure, to conserve breast form and function, to prevent recurrence and distant spread.
In early cancer, breast conservative surgery like quadrantectomy, axillary dissection (levels I and II) and postoperative radiotherapy (to the breast) is used which prevents the disfigurement and psychological trauma of mastectomy to the patient.
 
Principles of conservative breast surgery
  • Curvilinear nonradial incisions (Do not place radial incisions, as if there is a need to convert into total mastectomy, then incision plan may be difficult).
  • Separate incision for axillary dissection.
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Figs 1.186A and B: Curvilinear incision should be placed in conservative breast surgeries. Never place wrong radial incisions. If conversion to total mastectomy is needed placement of incision will be difficult if radial incision is placed. In conservative breast surgery for axillary dissection separate incision in the axilla should be placed.
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  • Try to avoid undermining of the skin flap
  • Confirm tumour clearance by frozen section. It may be often difficult and so tumour is cut and only margin which is close and doubtful is advocated for frozen section.
  • Radiotherapy is a must to breast and chest wall region (locally)
 
What is QUART therapy?
It is quadratectomy, axillary dissection of level I and II nodes with separate axillary incision and postoperative radiotherapy to breast (5000 cGy) and axilla (1000 cGy). First it is started by Umberto Veronesi from Milan.
 
What is skin sparing mastectomy (SSM)?
  • It is like a key-hole surgery of breast
  • Skin sparing/limited skin excision (5–10%) will not alter/affect the recurrence rate.
  • Indications are— central tumour/multicentral/extensive intraductal/T1/not feasible for conservation.
  • Excision of nipple—areola complex with very limited skin removal.
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Figs 1.187A to C: Skin sparing mastectomy for carcinoma breast—different approaches. Skin sparing mastectomy (SSM) does not affect the recurrence rate.
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  • Marginal skin excision over the tumour/biopsy site.
  • Total glandular mastectomy.
  • Axillary dissection using either same (extension of SSM incision) or separate incision in the axilla.
 
When total mastectomy is done in early breast cancer?
  • When tumour is more than 4 cm.
  • Multicentric tumour.
  • Poorly differentiated tumour.
  • Tumour margin is not clear of tumour after breast conservative surgery.
 
How axillary nodes are treated when clinically not palpable?
Sentinel lymph node biopsy (SLNB) is done. If node is positive for tumour, then axillary dissection is done. But facility for SLNB is not available in most of the centers and so axillary dissection is done. Usually level I and II nodes - below the axillary vein are dissected.
Axillary sampling is done by separate curved incision between the outer border of pectoralis major and latissimus dorsi 6 cm below the apex of axilla. About 10–15 nodes (level I) are sampled. Axillary sampling is now not advocated anywhere.
 
What are axillary dissection/axillary clearance?
It is removal of axillary nodes with fat, fascia of the axilla. Different levels of nodes are removed.
 
What are the problems with axillary dissection?
  • Injury/thrombosis of axillary vein
  • Seroma—50%.
  • Shoulder dysfunction 10%.
  • Pain (30%) and numbness (70%).
  • Flap necrosis/infection.
  • Lymphoedema(15%) and its problems
  • Axillary hyperesthesia (0.5–1%).
  • Winged scapula.
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Fig. 1.188: Post mastectomy lymphoedema. Note the mastectomy scar.
 
Drugs Used for Chemotherapy
Anthracycline regimes
 
Taxanes
They are newer chemotherapeutic drugs which act by G2/M phase of cell cycle. It is commonly used in metastatic carcinoma of breast. Drugs are paclitaxel and docetaxel. Taxanes have no cross resistance with anthracyclines and so can be used sequentially or concurrently with anthracyclines.
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Fig. 1.189: Alopecia after chemotherapy to carcinoma breast.
 
What are different types of surgeries for carcinoma breast?
  1. Simple (total) mastectomy: Along with the tumour, entire breast, areola, nipple, skin over the breast, including axillary tail are removed. There is no axillary dissection. Often the patient is later subjected to radiotherapy (external) to axilla.
    CMF is commonly used.
    All regimes are given in monthly cycles/3 weekly for 6 months.
    Toxic effects are: Alopecia, bone marrow suppression, cystitis, megaloblastic anaemia, GIT disturbances, and nephritis.
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  2. Simple mastectomy with axillary clearance: Commonly used procedure. Total mastectomy is done along with removal of axillary fat, fascia and lymph nodes.
  3. Modified radical mastectomy (MRM)
    1. Patey's operation: Commonly done. Here along with tumour, entire breast, overlying skin, nipple, areola, fat, fascia and level I, II and III lymph nodes of axilla are removed. Pectoralis minor is divided from its origin or removed completely, (so as to have good assess to the upper part of axilla and also to clear the interpectoral nodes of Rotter, which are commonly involved) but pectoralis major is retained so as to have better cosmetic result.
    2. Scanlon's operation: Is a modified Patey's operation wherein instead of removing pectoralis minor, it is incised to approach the affected Level III lymph nodes.
    3. Auchincloss operation: Here pectoralis minor muscle is left intact and level III lymph nodes are not removed.
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      Fig. 1.190: Stewart incision for mastectomy.
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      Fig. 1.191: Gray incision for mastectomy in carcinoma breast which extends to opposite side.
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      Fig. 1.192: Greenough's incision for mastectomy.
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      Fig. 1.193: Other incision often used for total mastectomy—horizontal incision.
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      Fig. 1.194: Kocher's incision for mastectomy.
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      Fig. 1.195: Orr incision for mastectomy.
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      Fig. 1.196: Rodman's incision for mastectomy.
  4. Halsted Radical Mastectomy.*[Complete Halsted)[R M):
    *Not commonly done at present.
    Complications are lymphoedema and eventual lymphangiosarcoma (after 3 to many years later) of the limb.
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    Fig. 1.197: Note the original Halsted and modified Halsted incision.
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    Fig. 1.198: Other incision used for radical and often modified radical mastectomy. Note the extension of the incision into the anterior axillary fold.
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    zoom view
    Fig. 1.199: Complete Halsted operation—radical mastectomy with removal of fat, lymph nodes, pectoralis major, pectoralis minor, entire breast with tumour and skin over the breast, nipple and areola.
  5. Conservative breast surgeries: Tumour is removed with a rim of 1 cm of normal tissue. It may be
    1. Wide excision.
    2. Lumpectomy.
    3. Quadrantectomy as part of Quart Therapy- Entire segment of the involved breast is removed along with axillary dissection (done through a separate incision in the axilla, level I and either level II or level III removal) and radiotherapy.
  6. Toilet mastectomy: In locally advanced tumour, tumour with breast tissue and whatever possible is removed to prevent further fungation. But its use and significance is under question.
  7. Extended Radical Mastectomies: It includes Radical mastectomy + removal of internal mammary lymph nodes of same side with or without opposite side. It is not done at present.
 
What is Patey's modified radical mastectomy?
It is total mastectomy along with clearance of all levels of axillary nodes and removal of pectoralis minor muscle. It is enblock dissection of breast and axilla. An elliptical incision is made from medial aspect of the second and third intercostals space enclosing the nipple, areola and tumour extending laterally into the axilla along the anterior axillary fold. Upper and lower skin flaps are raised. Breast with tumour is raised from the medial aspect of the pectoral major muscle. Dissection is proceeded laterally with ligating pectoral vessels. Once dissection reaches axilla, lateral border of pectoralis major muscle is cleared with level I nodes. Pectoralis minor is divided from coracoid process to clear level II nodes. Medial and lateral pectoral nerves should be preserved (otherwise atrophy of pectoralis major muscle occurs). Later from the apex of axilla level III nodes are cleared. Nerve to serratus anterior, nerve to latissimus dorsi, intercostobrachial nerve, axillary vein, cephalic vein and pectoralis major muscle are preserved. Wound is closed with a suction drain.
 
How mastectomy specimen is sent and for what all examinations?
  • Specimen is sent in formalin for histology.
  • It is sent in saline in low temperature for ER/PR/Her 2 neu status study (histochemistry).116
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    Figs 1.200A to E: Different steps of Patey's mastectomy with incision, flap raise, dissection in breast and axilla and specimen after surgery.
  • Tumour grading, tumour clearance, nodal involvement—its number and capsular breach are assessed histopathologically.
 
What is tamoxifen?
  • It is an antiestrogen. It blocks cytosolic estrogen receptors.
  • Dose is 20 mg daily for 5 years.
Adverse effects:
  • Tamoxifen flare—flushing, tachycardia, sweating.
  • Occasionally it causes bone pain associated with hypercalcaemia, particularly in patients with bone metastasis.
  • It increases the incidence of endometrial cancer.
Advantages:
  • It reduces the recurrence rate by 25%.
  • It improves the prognosis.
  • It is used presently in all age group, ER +ve and ER –ve patients; even though it is more 117effective in ER + ve patients and perimenopausal age group.
  • Cheap, easily available, less toxic effects, very effective.
  • It is equally effective in carcinoma male breast.
Note: It is also used for certain benign diseases of breast (ANDI, Cyclical mastalgia), desmoid tumour, and male infertility.
 
Selective Estrogen antagonists
  • Do not cause endometrial hyperplasia or endometrial carcinoma.
  • Drugs include Raloxifen, Tormefin.
 
Locally advanced carcinoma of breast (LACB)
  • It means locally advanced tumour with muscle/chest wall involvement, extensive skin involvement or fixed axillary nodes. It will be T3, T4a, T4b, T4c or T4d or N2 or N3.
  • It is investigated by FNAC of tumour, mammography of opposite breast, chest CT, CT abdomen or whole body bone scan.
  • Treatment of LACB is always palliative by simple mastectomy, chemotherapy and hormone therapy using tamoxifen.
  • Palliation is to control pain, to prevent fungation or bleeding.
  • In inoperable fixed tumour initial chemotherapy is given. Later, after 3–4 cycles of chemotherapy, when tumour size reduces and becomes operable, total mastectomy is done.
  • Postoperative radiotherapy is given to breast field and axilla.
  • Usually axillary dissection is not necessary in LACB.
  • Only chemotherapy and radiotherapy to breast and axilla (without palliative mastectomy) also can be used in LACB.
  • There is no role of breast conservative surgery for LACB.
  • 5 year survival is 40% and 10 year survival is less than 25%.
  • Inflammatory carcinoma is T4d LACB. It is also called as mastitis carcinomatosis or lactating carcinoma of breast. It is 2% common. It is observed in younger age group usually pregnancy or lactating period. There will be extensive skin involvement with pain. It often mimics mastitis of lactation. FNAC or incision biopsy concludes diagnosis. It is treated by initial chemotherapy or radiotherapy; later if tumour reduces in size then total mastectomy with axillary clearance can be done. But most often it is inoperable. After surgery, chemotherapy and tamoxifen is given. 5 year survival for inflammatory carcinoma of breast is 25–30%.
 
What is letrozole?
  • It is a non-steroidal competitive inhibitor of the enzyme ‘aromatase’. This enzyme converts adrenal androgens to estrogen (aromatization). So it is an aromatase inhibitor.
  • Other aromatase inhibitors are anastrozole and exemestane.
  • Letrozole is used as an adjuvant endocrine therapy in post-menopausal women with hormone sensitive breast cancer. (In pre-menopausal women this will cause rise in gonadotrophins and ovarian aromatase is not well suppressed). It can also be used in metastatic and recurrent cases. It slows down and stops the growth of estrogen sensitive breast tumours. It reduces estrogen level by 98%. Its half-life is 45 hours. It decreases the bone density.
  • Dosage of letrozole is 2.5 mg once daily.
  • It is given for 5 years or for 2 years following 3 years of tamoxifen.
  • Side effects of letrozole are vaginal dryness, night sweats, hot flushes, vaginal bleeding, cardiovascular problems and osteoporosis.
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What is transtuzumab? (Herceptin)
  • It is a monoclonal antibody that blocks HER-2/neu receptors thereby preventing growth of cancer cells. It is a new drug. It is presently marketed as herceptin. It is ErbB2 inhibitor.
  • It has very little effect on HER-2/neu negative cancers.
  • It is useful only in HER-2/neu positive cancers. It is currently approved by FDA for use only in metastatic disease. It is given as intravenous infusion.
  • Studies have shown that substantiate improvement in disease free and overall survival can occur.
  • It has got cardiac side effects.
 
What is metastatic carcinoma of breast?
It is blood spread into different places like bone, lungs and pleura, liver, soft tissues, brain and adrenals. It is evaluated by FNAC/incision biopsy, chest CT, LFT, U/S abdomen, CT abdomen, whole body bone scanning, CT brain, tissue study for ER/PR/HER-2 neu receptor status.
 
Treatment concept in metastatic carcinoma of breast
  • To improve quality of life.
  • To relieve pain of secondaries like bone, lungs.
  • To relieve neurological problems like convulsions, space occupying cranial problems.
  • Other symptomatic relief.
 
Treatment strategy in metastatic carcinoma of breast
  • Chemotherapy—CMF, CAF, Taxanes in combination.
  • High dose of chemotherapy using cyclophosphamide, cisplatin, carmustine, melphalan is tried in view to get high response rate of 55–70% along with bone marrow transplant. But toxic effects are often life threatening.
  • Haemopoietic growth factor also used along with chemotherapy to enhance the cell kill with less bone marrow toxicity. It also may allow multiple high dose chemotherapy to increase the response rate.
  • Radiotherapy is used in bone metastasis, brain secondaries, to prevent paraplegia in spine involvement, and advanced axillary nodes.
  • Hormone therapy has got important role.
  • Blockage of over expression of epidermal growth factor (EGF)/transforming growth factor alpha (TGF-alpha) which are related to ErbB1/ErbB2 receptors in relation to aggressive carcinoma factor.
  • Palliative surgeries done are total/toilet mastectomy, fixation of bones in case of pathological fractures, lung resection in case of localized secondaries, bilateral oophorectomy.
  • Trastuzumab (herceptin) is monoclonal antibody used in cancers with good results. It blocks the Her-2/neu and erbB2 receptors.
Surgical endocrine ablations
  • Bilateral oophorectomy (Beatson—1896).
  • Bilateral adrenalectomy.
  • Pituitary ablation.
 
Hormone Therapy in Carcinoma Breast
Includes:
  • Estrogen receptor antagonists - Tamoxifen.
  • Ovarian ablation by surgery (Bilateral oophorectomy) or by radiation.
  • LHRH agonists. (Medical Oophorectomy). Goserelin causes reversible ovarian ablation by suppressing gonadotrophin release. It acts at hypothalamo-pituitary axis via tachyphylaxis causing reversible chemical castration (ovarian ablation). 3.6 mg/28 days cycle for 2 years.
  • Oral aromatase inhibitors for post menopausal women. Letrozole and anatrozole are recent aromatase inhibitors available.
  • Adrenalectomy or pituitary ablation.
  • Progesterone receptor antagonist.
  • Androgens. – Inj Testosterone propionate 100mg IM three times a week.
  • Aminoglutethimide - blocks the synthesis of steroids by inhibiting conversion of cholesterol to pregnenolone - medical adrenalectomy.
  • Progestogens, e.g. medroxyprogesterone acetate.
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Radiotherapy in Carcinoma Breast
  • RT reduces the local recurrence of tumour and in the axillary region; and improves the quality of life.
  • But survival benefit?—Not proved.
 
Indications
  • Patient who undergoes conservative breast surgery—breast is irradiated after surgery using external radiotherapy.
  • After simple mastectomy—external irradiation is given to axilla.
  • Patients with higher risk of local relapse after surgery:—a) Invasive carcinoma. b) Extensive in situ carcinoma. c) Patients under 35 years. d) With multifocal disease.
  • In bone secondaries—to palliate pain and swelling. If there is pathological fracture in the bone, internal fixation has to be done along with external irradiation.
  • Inflammatory carcinoma of breast.
  • In atrophic scirrhous carcinoma of breast, as a curative radiotherapy.
  • As preoperative radiotherapy— to reduce the tumour size and to downstage the tumour, so that the operability is better.
  • In conditions where there are more than 4 positive axillary nodes, pectoral fascia involvement, positive surgical margins, extranodal spread or axillary status not known/not assessed.
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External radiotherapy is given to breast, axilla, and internal mammary and supraclavicular area. Total dosage is 5000 cGY units. 200 cGY units daily 5 days a week for 6 weeks.
 
What are the aetiologies for carcinoma breast?
 
Aetiology:
  • Carcinoma breast is more common in developed western countries. In African-American women, it is more aggressive. It is less common in Japan.
  • It is second most common carcinoma in females. Incidence is 19–34%. Median age is 47 years.
  • It is more common after middle age, but do can occur at any age group after 20.
  • It is familial in 2–5% cases.
  • Carcinoma in one breast increases the risk of developing carcinoma on opposite breast by 3–4 times. Incidence of bilateral carcinoma is 2%.
  • Diet low with phytoestrogens and high alcohol intake.
  • It is common in nulliparous woman. Early child bearing and breast feeding reduces the incidence of malignancy. Breast carcinoma is directly related to oestrogen level increase. Early menarche and late menopause has got higher risk probably due to increased oestrogen level.
  • It is more common in obese patient.
  • Breast cancer relative risk is qualified as Relative Risk (RR). RR 2.0 means risk is twice the normal population. If RR is 0.5 means risk is 50% less than normal population.
  • In males, occasionally gynaecomastia turns into carcinoma.
  • Benign breast diseases with atypia, hyperplasia and epitheliosis have got higher risk in a patient with family history of carcinoma breast.
  • Mutation of tumour suppressor genes BRCA 1 and BRCA 2 has got high risk of carcinoma breast. BRCA 1 has got more risk (35–45%). It is located in long arm of chromosome 17. It is also associated with ovarian carcinoma. BRCA2 is located in long arm of chromosome 13. It is also associated carcinoma male breast. Occasionally mutation of BRCA3 and p53 suppressor gene is also involved.
  • Cowden's syndrome and Li-Fraumen's syndromes are associated with carcinoma breast.
  • Presently carcinoma breast is considered as systemic disease. Halsted concept of spread is sequential spread. Breast—axillary lymph node—systemic spread. Fischer concept is early 121to begin with itself, only then there is distant blood spread because of micrometastasis without nodal disease. Only tumour lesser than 1 cm size can be sequential.
  • Prior diagnosis of uterine/ovarian/colonic cancers.
 
What is duct carcinoma in-situ? (DCIS)
It is intraductal carcinoma without any invasion in to the basement membrane.
It is 5–20% common.
It can be:
  • Solid.
  • Comedo with necrosis is high grade with increased chances of micro invasion.
  • Cribriform.
  • Papillary.
  • Micropapillary.
It is associated with high expression of C–erb2 gene (80%).
Nipple discharge and often-small swelling are main presentations.
U/S assisted FNAC and mammography are the needed investigations.
Risk of lymph node spread in DCIS is less than 4%. So axillary dissection is not necessary.
Sentinel Lymph Node Biopsy and proceed is the preferred method (if facility is available).
 
Which is the commonest pathological type of carcinoma breast?
Scirrhous type of carcinoma breast is the commonest pathological type of carcinoma breast. It is whitish, hard, and gritty/cartilaginous in consistency without any capsule.
 
What is medullary carcinoma of breast?
It is also called as encephaloid carcinoma because of its soft consistency. It contains malignant cells with lymphocytic infiltration. It has got better prognosis than scirrhous carcinoma of breast because of more lymphocytes.
 
Which has got worst prognosis and which has got best prognosis?
Inflammatory carcinoma has got worst prognosis. Atrophic carcinoma (in post-menopausal women) has got best prognosis.
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How is carcinoma breast classified?
 
Classifications
  1. Ductal carcinoma.
    Lobular carcinoma.
    1. In situ carcinoma
      • DCIS (Ductal carcinoma in situ).
      • LCIS (Lobular carcinoma in situ).
    2. Invasive.
      • Invasive ductal carcinoma.
      • Invasive lobular carcinoma. It is commonly multifocal and often bilateral.
  2. Unilateral.
    Bilateral. 2–5% common.
  3. Unifocal.
    Multifocal.
  1. Multifocal—tumour tissues within the same quadrant.
    Multicentric—tumour tissues within the breast but in different quadrant.
 
What are the prognostic factors for carcinoma breast?
  • Spread to axillary nodes is the most important prognostic indicator. More than 2 in number of nodes and nodal size more than 2.5 cm carries poor prognosis. More than 4 nodes/level III (apical nodes) involvement has got worst prognosis (5 year survival is 30%) and also decides for radiotherapy to axilla.
  • Age: Younger the age worse the prognosis.
  • Sex: Carcinoma male breast has got worse prognosis compared to female breast, because of early spread in carcinoma male breast.
  • Stage I and II has got better prognosis.
  • Atrophic scirrhous has got best prognosis.
  • Medullary carcinoma has got better prognosis than scirrhous carcinoma because of lymphocytic infiltration.
  • Invasive carcinoma has got worse prognosis.
  • Inflammatory carcinoma breast has worst prognosis.
  • ER +ve tumours has got better prognosis.
  • Differentiation also decides prognosis.
  • Presence of elastic fibers in histology has got better prognosis.
  • Tumour grade, growth factor and oncogene factors. ErbB2 –Her-2/neu positive has got poor prognosis. ErbB1 with over expression of epidermal growth factor (EGF) and TGF alpha has got poor prognosis.
  • DNA flow aneuploid status has got poor prognosis. Low S phase fraction has got good prognosis.
 
What are the specialities of bone secondaries in breast?
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Fig. 1.201: X-ray showing typical osteolytic bone secondaries in pelvis in carcinoma breast.
 
What are the features of pleural effusion due to secondaries?
Malignant pleural effusion as secondaries from carcinoma breast—
  • It signifies terminal event.
  • It has got poor prognosis.
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  • HRCT is ideal diagnostic tool.
  • Respiratory distress and failure is the main feature.
  • Treated by
    • Intercostal tube drainage.
    • Pleurodesis using talc/tetracycline.
    • Chemotherapy.
 
How carcinoma breast in pregnant woman is managed?
Carcinoma breast in pregnancy
  • Incidence is 3%.
  • Treatment is modified radical mastectomy (MRM).
  • Chemotherapy can be given in 2nd trimester with care.
  • Radiotherapy has no role.
  • As commonly ER negative, hormone therapy is not used.
  • When distressing secondaries are present termination of pregnancy may be required.
  • Women with breast cancer can become pregnant 2 years after the completion of therapy, as recurrence is more common in 2 years.
 
Breast Reconstruction
 
Types of Reconstruction
  • Immediate reconstruction.
  • Delayed reconstruction.
 
Types of Materials for Reconstruction
  • Silicon gel implant under pectoralis major muscle.
  • Expandable saline prosthesis with prior tissue expansion.
  • If there is less skin or after radiotherapy- Latissimus dorsi musculocutaneous flap (LD flap) or contra lateral transversus abdominis muscle flap (Tram flap).
Note:
  • Breast reconstruction is done in young patients with early stage disease.
  • Skin sparing mastectomy with removal of nipple areola complex may be better for reconstruction.
    zoom view
    Fig. 1.202: LD flap (A) Donor area (B) Recipient area.
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    Fig. 1.203: Latissimus dorsi flap (LD FLAP) placed after mastectomy. It is based on thoracodorsal artery.
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    Fig. 1.204: Transverse rectus abdominis myocutaneous flap. Note the blood supply of the flap.
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    Figs 1.205A to D: Different operative steps in TRAM flap.
  • Symmetry is the most important factor in breast reconstruction.
  • External breast prosthesis which fits within the bra is a simpler cosmetic method.
Nipple is created using—
  • Local breast flaps 3 months after breast reconstruction.
  • Nipple sharing from contralateral nipple using composite graft.
  • Skate flap: Local flap with deepithelialised donor site around the periphery over which a full thickness graft is applied to reconstruct the areola.
Areola pigmentation is created using (it is done 3 weeks after nipple creation)—
  • Full thickness skin graft from non hairy skin lateral to labia majora, as the pigmentation of this graft matches that of the areola.
  • From contralateral areola if reduction mammoplasty is done on that side.
  • Tattooing – Colour tends to fade with time and may need to be repeated.
  • SSG from retroauricular area or from thigh.
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Other flaps used for reconstruction
  • Superior gluteal flap based on superior gluteal vessels.
  • Ruben's flap using soft tissue pad overlying the iliac crest based on deep circumflex iliac vessels.
 
What are breast implants?
They are synthetic non-reactive materials placed under the breast to give breast contour.
  • Technically simple.
  • Achieves symmetry easily.
  • Implant in submuscular plane is better whenever muscle has not been removed during surgery.
  • If muscle is removed like during radical mastectomy, then subcutaneous implant is placed.
  • Silicon gel implants are used.
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Figs1.206A and B: Typical breast implant and its placement. It can be placed in subcutaneous or submuscular plane.
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Fig. 1.207: Carcinoma male breast in a pre-existing gynaecomastia. Note Gynaecomastia on opposite side.
 
What is fibroadenoma?
It is a benign encapsulated tumour occurring commonly in young females of 15–25 yrs age group.
Presently it is considered as hyperplasia of a single lobule of the breast (may be classified under ANDI).126
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Fig. 1.208: Carcinoma male breast showing mass, puckering and retraction.
 
Types
Gross
  • Soft.
  • Hard.
  • Giant (>5 cm in size).
Microscopy
  • Intracanalicular—small and hard—mainly fibrous.
  • Pericanalicular—large and soft—mainly cellular.
Clinical features
  • It presents as a painless swelling in one of the quadrants, which is smooth, firm, non tender, well localized and moves freely within the breast tissue (‘mouse in the breast’).
  • Axillary lymph nodes are not enlarged.
Investigations
  • Mammography (well localized smooth regular shadow).
  • FNAC.
  • Ultrasound (to confirm solid nature).
Treatment
Excision through a circumareolar incision (Webster's) or sub mammary incision (‘Galliard Thomas incision’) is done.
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Fig. 1.209: Circumareolar (Webster's) and submammary (Galliard Thomas) incisions.
 
Fibrocystadenosis (Fibrocystic disease of the breast/mammary dysplasia)
It is due to Aberration ofNormal Development and Involution (ANDI) of breast causing.
  • It is an estrogen dependent condition. One of the cysts may get enlarged to become a clinically palpable well localized swelling - bluedome cyst of Bloodgood.
  • Diffuse, small, multiple cysts in fibrocystadenosis is called as Schimmelbusch's disease.
  • Disease is common in upper outer quadrant.
    127
 
Clinical features
  • Presentation is during menstruating age group as a bilateral, painful, diffuse, granular, tender, swelling which is better felt with palpating fingers (poorly felt with palm).
  • Not fixed to skin, muscle or chest wall.
  • Pain and tenderness are more during menstruation (Cyclical mastalgia).
  • It subsides during pregnancy, lactation and after menopause.
  • Discharge from the nipple when present will be serous or greenish.
 
Investigations
  • FNAC (Epitheliosis, when florid is undoubtedly premalignant).
  • Ultrasound, mammography.
 
Treatment
  1. Conservative line of management is preferred.
    • Reassurance.
    • Oil of evening primrose (capsules): Contains gamolenic acid which reverses the saturated fatty acids to unsaturated fatty acids.
    • Gamolenic acid — 120mg.
    • Bromocriptine.
    • Vitamin E and B6.
    • LHRH agonist.
    • Danazol.
    • NSAID'S.
    • Tamoxifen—antiestrogen.
  2. Surgery: Subcutaneous mastectomy with prosthesis placement.
 
Phylloides Tumour (Cystosarcoma phylloides/Serocystic disease of Brodie)
  • They are not simply giant fibroadenoma.
  • They show a wide spectrum of activity, varying from almost a benign condition to a locally aggressive and sometimes metastatic tumour.
  • Depending on mitotic index and degree of pleomorphism they are graded as low grade to high grade tumours.
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Figs 1.210A and B: Cystosarcoma phylloides of right and left breasts in two different patients. Note the dilated veins. Tumor occupies the entire breast. Post-surgery specimen signifies enormous size of the tumour.
 
Gross
Large capsulated area with cystic spaces and cut surface shows soft, brownish, cystic areas.
 
Microscopy
  • It contains cystic spaces with leaf like projections, hence the name.
  • Cells show hypercellularity and pleomorphism.
  • It may be a variant of intracanalicular fibroadenoma of breast.
 
Clinical features
  • They occur in premenopausal women (30–50 years).
  • It is usually unilateral, grows rapidly to attain a large size.
    128
  • Swelling is smooth, non tender, soft, fluctuant with necrosis of skin over the summit due to pressure.
  • Recurrence is common.
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Fig. 1.211: Recurrent cystosarcoma phylloides.
 
Investigations
U/S, FNAC, mammography and chest CT.
Treatment
  • Excision or subcutaneous mastectomy is done.
  • If malignant (sarcoma), total mastectomy is indicated. Sarcoma may spread to lungs and so chest X-ray/chest CT has to be taken.
 
Traumatic Fat Necrosis
It may be due to either direct or indirect trauma (most often trauma may not have been noticed or forgotten).
 
Pathogenesis
Capillary ooze causes triglyceride in the fat to dissociate into fatty acids. It combines with calcium from the blood resulting in saponification which causes inflammatory reaction and later presents as a nonprogressive swelling in the breast.
 
Features
  • Painless swelling in the breast which is smooth, hard, nontender and adherent to breast tissue. (D/D-Carcinoma). It is nonprogressive.
  • FNAC shows chalky fluid with fat globules.
  • Mammography is done to rule out malignancy.
  • It often mimics carcinoma breast.
  • Treatment is excision.
 
Galactocoele
It is seen in lactating women. It is due to the blockage of lactiferous duct resulting in enormous dilatation of lactiferous sinus. It contains milk within. It is a retention cyst due to blockage of single duct which begins under the areola.
 
Features
  • Lump in the lower quadrant of the breast which is usually unilateral, large, soft, fluctuant, with smooth surface and nontender. It is a retention cyst — subareolar type.
  • It may get precipitated, inspissated, or get calcified.
  • When it is calcified it mimics carcinoma breast.
  • If it gets infected it will form an abscess.
  • U/S and FNAC are used to diagnose.
  • Treatment is excision (by submammary incision). Abscess when formed should be drained under general anaesthesia under cover of antibiotics.
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Fig. 1.212: Galactocoele. Note the block at the opening of the duct.
 
Mastitis
 
Types
  • Subareolar.
  • Intramammary.
  • Retro mammary (Submammary).
 
a. Subareolar mastitis
  • It is the infection under the areola due to cracks in the nipple or areola.
  • Red, inflamed, oedematous areola with tender swelling underneath.
    129
  • Differential diagnosis is Paget's disease of the nipple.
  • Treatment is under cover of antibiotics pus is drained of by making a sub areolar incision.
 
b. Intramammary mastitis
  1. Lactational abscess of the breast
Commonly seen in lactating women.
Mode of infection
Bacteria (Staph aureus) enter the breast during sucking through the cracked nipple. Occasionally it can be haematogenous. Gram-negative and other bacterial infection can supervene later.
Features
  • Pain in the breast and fever.
  • Diffuse redness, tenderness, and induration in the breast.
  • Purulent discharge from the nipple.
  • Full breast may get involved eventually.
  • Differential diagnosis is inflammatory carcinoma of breast.
Treatment
Antibiotics—Cephalosporins.
Drainage under general anaesthesia, a counter incision may be needed.
It is not advisable to wait till the formation of abscess.
Complications
  • Antibioma formation.
  • Sinus formation.
  • Recurrent infection.
  1. Non-lactational abscess of the breast
It commonly occurs in duct ectasia and periareolar infections. Common organisms are bacteroides, anaerobic streptococci, enterococci and gram-negative organisms. It is commonly recurrent with tender swelling under the areola.
Treatment
  • Antibiotics.
  • Repeated aspirations.
  • Drainage and later cone excision of the duct is done.
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Figs 1.213A and B: Typical look of breast abscess/mastitis.
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Fig. 1.214: Incision and counter incision for breast abscess.
130
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Fig. 1.215: Placement of drain in breast abscess.
  1. Retromammary mastitis
It is due to tuberculosis of the intercostal lymph nodes or ribs beneath or suppuration in the intercostal lymph nodes.
Breast is normal.
Investigations
  • Chest X-ray, FNAC, ESR.
  • Peripheral smear.
  • CT chest.
Treatment
  • Cause has to be treated. Antibiotics are used.
  • Drainage under general anaesthesia with sub- mammary incision reaching submuscular plane.
  • Often may need intercostal tube drainage in specific causes.
 
Antibioma
If intramammary mastitis is not drained but only treated by antibiotics, pus localizes and becomes sterile (flaques) with a thick fibrous tissue cover, it is called as antibioma.
 
Features
  • Previous history of mastitis treated with antibiotics.
  • Swelling which is painless, smooth, non tender, hard, fixed to breast tissue without involving the pectorals and chest wall.
  • Differential diagnosis is carcinoma breast. (Scirrhous carcinoma breast).
  • Investigations are FNAC, mammography and U/S breast.
  • Treatment is excision (Submammary incision). Later antibiotics are given.
 
Duct ectasia
  • It is dilatation of lactiferous ducts due to muscular relaxation of duct wall with periductal mastitis (Plasma cell mastitis). Many ducts are commonly involved.
  • Greenish discharge from the nipple.
  • Indurated mass under the areola which is often tender.
  • Retraction of nipple which occurs at later stage of the disease.
  • Eventually it forms an abscess, and fistula.
  • Often they are bilateral and multifocal.
  • Differential diagnosis is carcinoma breast.
  • Investigations are — discharge study and mammography.
  • Treatment is cone excision of involved major ducts (Hadfield operation) with antibiotics.
 
Mondor's Disease
  • Mondor's disease is thrombophlebitis of the superficial veins of the breast and anterior chest wall.
  • Presents as a thrombosed subcutaneous cord which is attached to the skin.
  • It is often a self limiting disease without any recurrence, complication or deformity.
  • It mimics the lymphatic permeation of carcinoma breast.
 
Duct Papilloma
  • It is usually single, from a single lactiferous duct.
  • It is the commonest cause of nipple discharge.
  • By blocking the duct it causes ductal dilatation.
 
Features
  • Papilliferous swelling (projection), usually near the nipple orifice (4–5 cm from orifice).
  • Blood stained discharge from the nipple is common.
    131
  • But serous or serosanguinous discharge can also occur.
  • Single papilloma is not premalignant.
  • But multiple papillomas in many ducts can be premalignant
  • Study of discharge and ductogram may be needed.
  • Treatment—Microdochectomy: Probed lactiferous duct is opened with excision of the papilloma using tennis racquet incision.
 
Galactorrhoea
  • It is secretion of milk not related to pregnancy or lactation.
  • Primary galactorrhoea is due to stress and other factors. Reassurance is the treatment.
  • Secondary galactorrhoea is due to enhanced dopamine activity.
    • By drugs (haloperidol, methyldopa, chlorpromazine, metoclorpramide),
    • Hyperprolactinaemia due to tumours.
  • Treatment—bromocriptine/cause has to be treated.
Witch milk is secretion of milk in both male and female infants due to maternal hormonal effects in foetus which lasts for 3 weeks after child birth.
 
Gynaecomastia
  • It is hypertrophy of male breast more than usual, often attaining features of female breast.
  • It can be unilateral or bilateral.
 
Presentations
  • Diffuse enlargement of breast occupying all quadrants or as a well localized, small, firm or hard nodule under the areola which is often painful and tender.
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Fig. 1.216: Gynaecomastia – right side breast. Compare to opposite side to note the difference in size.
 
Causes
  • Idiopathic.
  • Teratoma testis.
  • Ectopic hormonal production in bronchial carcinoma.
  • Anorchism, after castration.
  • Adrenal and pituitary disease.
  • Leprosy, because of bilateral testicular atrophy.
  • Drugs: Stilboestrol, Digitalis, Cimetidine, Spironolactone.
  • Liver diseases and liver failure.
  • Klinefelter's syndrome. (XXY Trisomy).
Investigations are relevant to the cause.
Example: Liver function tests, DNA study, Hormone assay. Often gynaecomastia may turn into carcinoma.
 
Treatment
  • When symptomatic or large or long standing, excision through circumareolar incision is done.
  • Often subcutaneous mastectomy is needed.
 
Mastalgia
It is pain in the breast.
 
Types
• Cyclical
• Noncyclical
132
THYROID
 
WRITING A CASE SHEET IN CASE OF THE THYROID DISORDERS
 
 
 
Name:
 
Address:
Residential place may be important in certain goitres. Iodine deficiency endemic goitre is common in interior areas, mountain areas like Vindhyas, Himalayas. Goitre is more common in south India than north India. It was also common in Middle East and European countries, North America, in Bulgaria near river Struma which eventually reaches Aegean Sea. Follicular and anaplastic carcinoma may be more in iodine deficiency areas but papillary carcinoma is not related to iodine deficiency.
 
Occupation:
 
Age:
Simple goitre is seen often in puberty in girls. Dyshormonogenesis goitre occurs in younger age group. Physiological goitre occurs when there is increased metabolic demand of the hormone like in puberty, pregnancy. Solitary nodule, colloid goitre, papillary carcinoma and primary thyrotoxicosis are seen between 20–40 years. Multinodular goitre, follicular carcinoma and Hashimoto's thyroiditis are seen in middle aged women.
 
Chief Complaints
  • Swelling in front of the neck and its duration
  • Pain in the swelling and its duration
  • Hoarseness of voice due to recurrent laryngeal nerve palsy.
  • Difficulty in swallowing or breathing
  • Tremor in the hands
  • Generalized weakness
  • Palpitation
  • Loss of significant weight
 
History
 
History of Present Illness
 
Swelling:
Its duration, onset sudden or insidious. Origin of the swelling, its progress- gradual (benign), rapidly progressive (malignancy) or in an existing swelling rapid increase recently (benign turning into malignancy) or sudden rapid increase may be seen in haemorrhage. Thyroglossal cyst may be present since childhood. Swelling may be single/multiple or occupying one lobe, or both lobes or isthmus.
Any thyroid of any size or any duration or any consistency or in any age group can be malignant unless proved otherwise.
 
Pain:
Its duration, character like dull aching/pricking, site of pain, radiation, factors which alters the pain. Usually goitres are painless. Thyroiditis may be painful. Malignancy is initially painless but later becomes painful. Infiltration into surrounding structures/necrosis/haemorrhage makes it painful and tender.
 
Pressure symptoms:
Dysphagia (oesophageal compression), dyspnoea (tracheal compression), stridor (infiltration into trachea), hoarseness of voice (recurrent nerve compression) and Horner's syndrome (infiltration of cervical sympathetic chain – ptosis, loss of sweating, in face same side, miosis and enophthalmos). Their duration, onset and progression.
 
Features of toxicity:
Increased appetite/loss of weight/diarrhoea/chest pain aggravated by exercise/palpitation/amenorrhoea/irritability/nervousness/sleeplessness (insomnia)/hand tremors/increased sweating/cold preference/heat intolerance/proximal muscle weakness in the thigh or arm like in getting down steps or lifting weight using arms (myopathy) due to difficulty in isometric contraction and increased muscle metabolism/wasting of muscles/visual disturbances with bulging of the eyes.133
 
Features of hypothyroidism/myxoedema:
Muscle weakness/lethargy/weight gain/poor appetite/facial swelling/cold intolerance/menorrhagia/constipation/superciliary madarosis in lateral half of the eye brows/loss of hairs in scalp/change in voice due to vocal cord oedema/dry skin.
 
Past history:
Irradiation history for carcinoma thyroid. Irradiation to head and neck region for benign lesions like adenoids, tonsillitis, thymus, acne vulgaris or hamangiomas or malignancy in younger age groups like of lymphomas. Chernobyl nuclear disaster in Ukraine in 1986 caused increased incidence of papillary carcinoma of thyroid in children. Previous history of having Thyroglossal cyst which might have infected causing fistula either due to spontaneous burst or after surgical drainage of an infected cyst. Previous surgery for thyroid in recurrent thyroid swelling or earlier surgery for thyroglossal cyst in case of thyroglossal fistula should be asked for.
 
Personal history:
Smoking, alcohol intake or any drugs which may cause alteration in thyroid function. Patient may be on thyroxine or on antithyroid drugs or beta blockers or other drugs like lithium, PAS or sulphanylureas which alter the thyroid function. Dietary habits should be asked. Brassica family vegetables like cabbage, kale and rape are goitrogens. Type of salt used in the family iodized/home rock salt is also important.
 
Family history:
Dyshormonogenesis, medullary carcinoma of thyroid can be familial (MEN syndrome). Endemic goitre and Grave's disease can occur in families. Altered thyroid function may be cause for infertility.
 
Menstrual History
Treatment history: History of undergoing investigations or treatment relevant to thyroid disease.
 
General Examination
 
 
Like any other long case.
  • Thyrotoxic patient is anxious/thin and undernourished. Obesity is seen in myxoedema. Patient may be cachexic in thyroid carcinoma which is advanced.
  • Exophthalmos should be looked for in toxic patient. Irritable/agitated tensed face with eye signs is seen in toxic thyroid.
  • Myxoedema face is typical. It is expression- less, mask-like puffy face. Patient will be dull with low intelligence.
  • Hasty—rapid gait is seen in hyperthyroid and slow—lethargic gait in hypothyroidism.
  • Pulse—its character, whether tachycardia, collapsing or pulsus paradoxus or ectopic or fibrillation has to be looked for.
  • Blood pressure may be high in toxic thyroid.
  • Sleeping pulse rate is checked at late night or early morning for three consecutive nights and average is taken. Sedation like diazepam or phenobarbitone to be given to check sleeping pulse rate prior to sleep is a controversial. Sleeping pulse rate is graded as Crile's grading.
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    Fig. 1.217: Palpation of radial pulse for its count, volume, variations should be done in thyroid diseases.
    134
  • In toxic thyroid, patient will be thin and underweight. In hypothyroidism, patient will be obese and overweight. In metastatic thyroid cancer patient is cachexic.
  • Agitated stressful facial expression is observed in toxic thyroid. Puffy, expressionless, dull and mask-like face is seen in myxoedema.
  • Rapid aggressive gait is seen in toxicity but lethargic and slow gait is observed in hypothyroidism.
  • Skin is wet and warm in hyperthyroidism (moist palm while shaking hands).
  • Ankle (Achilles tendon) reflex is prolonged with delayed relaxation in hypothyroidism and it is shortened and brisk in hyperthyroidism.
  • Both legs and ankle region in front should be inspected for pretibial myxoedema. It is a feature of primary thyrotoxicosis. It is due to deposition of myxomatous tissue.
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Fig. 1.218: Pretibial myxoedema is seen in primary thyrotoxicosis.
 
Tremor of the hands and tongue
Hand tremors observed by outstretching the hands and fingers forward to see tremors of the fingers. Often small object like pen may be kept to watch the tremor better. Fine tremor is observed in toxic thyroid. It is due to diffuse irritation of the gray matter. Tongue twitching can be observed by opening the mouth and carefully observing the tongue.
 
Local Examination
 
Inspection
 
Swelling:
Its location/size (both vertical and horizontal dimensions of each lobe and isthmus or if it is one mass dimensions as a single swelling)/shape (butterfly shape if both lobes are involved)/extent (from posterior border of sternomastoid laterally to midline in one sided gland enlargement or from one side to opposite sternomastoid if both lobes are enlarged)/ upper extent is usually up to thyroid cartilage/lower margin is clearly visible or not or visible during deglutition/movement upwards with deglutition (thyroid moves upwards during deglutition due to attachment of the condensed vascular pretracheal fascia (Berry's ligament) which is attached above, medially and behind to cricoid cartilage and also pretracheal fascia is attached to larynx, trachea and inferior constrictor muscle which moves upwards)/scar or dilated veins (in toxic goitre, carcinoma thyroid, venous compression, retrosternal goitre) or pigmentation on the skin over the swelling/pulsation over the swelling (toxicity, malignancy)/surface on inspection (smooth or nodular).135
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Figs 1.219A to F: Tremor of the hands outstretched and tongue should be checked properly in toxic thyroid.
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Figs 1.220A and B: Simple goitre. Inspection of goitre is very important.
136
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Fig. 1.221: Thyroid moves upwards with deglutition. Often it is better to give a glass of water to the patient to drink.
In some occasions swelling whether moves with protruding the tongue or not should be looked for. Thyroglossal cyst moves upwards with protrusion of tongue. Patient is asked to open the mouth and then swelling/cyst is held firmly. Now patient is asked to protrude the tongue to feel an upward movement of the swelling with a typical ‘tug’ in the swelling.
Any other swelling in the neck should be seen like for lymph nodes. Lymph nodes can be involved commonly in papillary carcinoma of thyroid occasionally in follicular carcinoma of thyroid.
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Figs 1.222A and B: Large carcinoma of thyroid which is vascular. Note the dilated veins.
 
Palpation
 
Swelling:
Temperature over swelling (swelling may be warm in toxic thyroid, malignancy, thyroiditis)/tenderness (haemorrhage, thyroiditis, tumour necrosis can cause tenderness)/extent/position/shape/size (should be measured in centimetre both vertically and horizontally)/movement of the swelling upwards with deglutition/surface (smooth or nodular)/consistency (soft or firm or hard or variable and if so different locations of different consistencies should be mentioned)/margin (well defined or diffuse, lower margin which is most important)/independent mobility of the swelling/plane of the swelling (it is checked by contracting the sternomastoid muscles by placing examiner's hand under the chin of patient and patient has to flex the neck against resisting hand) (single side gland relation to sternomastoid muscle is checked by contracting the muscle by turning the chin against resistance of the examiner's hand)/skin is free or not.137
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Figs 1.223A to C: Examination of thyroid from behind with patient is sitting in a stool comfortably and neck flexed. Careful palpation for nodules should be made.
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Figs 1.224A to C: Contraction of sternomastoid one side/both sides to confirm that thyroid is deep to deep fascia
138
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Figs 1.225A and B: Lower border should be assessed in case of thyroid enlargement to rule out possible retrosternal extension.
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Fig. 1.226: Skin should be pinched to confirm swelling is not adherent to skin.
Digastric muscle depresses and retracts the chin. Infrahyoid muscles (strap muscles) contract and get tensed to prevent ascent of hyoid bone when the digastric is in action.
Thrill is checked in the upper pole of the gland as superior thyroid artery is superficial and enters the gland in front upper pole. Thrill signifies toxicity or increased vascularity.
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Fig. 1.227: Superior pole of thyroid should be palpated for thrill which signifies vascularity.
139
 
Method of palpation of thyroid gland:
Thyroid gland is palpated from behind with patient is sitting in a stool with neck partially flexed. Both thumbs of the examiner are kept over the cervical spine and fingers will be in front to feel the gland- both lateral lobes and isthmus for all features.
 
Crile's method of palpation of gland:
It is the palpation of the nodule/swelling in front using the pulp of the thumb.
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Fig. 1.228: Criles method of palpation using thumb for any nodules.
 
Pizzillo's method of palpation:
It is the method of palpation of thyroid gland in short neck and obese individuals. Patient is asked to keep her/his both hands over the occiput and gland becomes prominent which will be palpated from front or behind.
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Fig. 1.229: Pizzillo's method of examination.
 
Lahey's method of examination:
It is the method used to palpate the any nodules in posterior part of the gland. It is mainly useful in solitary nodule of thyroid. Examiner should stand in front of the patient. If right lobe is needed to palpate, left lateral lobe is pushed towards right to make posterior aspect of the right gland more prominent as gland gets pushed and rotated towards right side. Posterior becomes posterolateral or lateral which is felt for any nodules. Left lobe posterior aspect is palpated by pushing the right lobe towards left side.
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Fig. 1.230: Lahey's test.
 
Kocher's test:
It is the test for tracheal compression. Patient is asked to see straight. With fingers and thumb both lateral lobes of the thyroid gland are gently compressed directing postero-medially. If patient develops stridor-Kocher's test is positive. If no stridor means it is negative.
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Fig. 1.231: Kocher's test.
140
In a long standing goitre and large goitre, because of constant pressure tracheal rings get weakened which get narrowed/collapsed during compression. Goitre itself because of forward traction keeps trachea patent. But after thyroidectomy no support to trachea causes tracheomalacia—weakening of the tracheal rings. Such patients need tracheostomy after thyroidectomy. It is usually temporary tracheostomy for 2–3 weeks by then tracheal rings regain their strength to maintain the patency of the trachea.
 
Confirmation of retrosternal extension:
  • Lower margin of the swelling/goitre is not visible-even on deglutition.
  • Lower margin is not palpable on deglutition.
  • Dilated veins over neck or chest wall may be visible.
  • Normal resonant note becomes dull over the sternum on percussion.
  • Pemberton's sign—patient is asked to raise the both arms above the shoulder so as to touch the ears and made to keep like that for 3 minutes. Patient will develop dilated veins and cyanosis in the neck and upper chest wall, puffiness in face and respiratory distress and rarely dysphagia. It means sign is positive signifying retrosternal extension of goitre.
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    Figs 1.232A and B: Pembertones sign for retrosternal goitre.
  • Dyspnoea at night during lying down or neck extended.
  • Rarely recurrent nerve palsy can occur.
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    Fig. 1.233: Retrosternal extension of thyroid—diagram.
    Retrosternal goitre is defined as having > 50% goitre below the suprasternal notch.
  • Primary is rare—1%. Primary retrosternal goitre arises from ectopic thyroid tissue from mediastinum. It gets its blood supply from mediastinum itself, not from the neck. And also it is not related to the existing thyroid in the neck.
  • Secondary is common. It is extension from the enlarged thyroid from the neck.
Commonly retrosternal goitre arises from lower pole of a nodular goitre. It is more observed in short neck people. Due to negative intrathoracic pressure nodule gets drawn into the superior mediastinum. Sometimes it may be also ectopic thyroid tissue.
Retrosternal goitre may be substernal (part of the nodule in the neck-palpable) or plunging goitre (intrathoracic goitre forced into the neck occasionally by increased intrathoracic pressure) or intrathoracic goitre with normal neck. It can be toxic/non-toxic nodules/malignancy.141
Retrosternal goitre is confirmed by CT scan and radioiodine study. It is treated by complete surgical removal usually through neck approach, occasionally through median sternotomy. Radio active iodine therapy is not used for retrosternal goitre. Surgical removal should be complete because recurrent retrosternal goitre is very difficult to re-operate.
Stridor due to compression of tracheo-bronchial tree by retrosternal goitre is very dangerous because it is often not possible to clear the airway either by intubation or by tracheostomy.
Position of trachea is checked by palpation using three fingers from below. Middle finger is kept just above the suprasternal space and index and ring fingers are placed over sternal heads of the sternomastoid muscles on each side. Middle finger is run upwards along the trachea to feel the position-central or deviated. In solitary nodule or disease of only one lateral lobe trachea will be usually deviated towards opposite side. In both lobes enlargement trachea will be usually central. Other features are absence of hollowness on the side of the deviation (trail sign), on auscultation hearing of breath sounds on the side of the deviation.
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Fig. 1.234: Trachea in central position. It is central when both lateral lobes are enlarged. It is deviated to opposite side in solitary nodule thyroid.
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Figs 1.235A and B: Method examination of trachea to find out deviation using three fingers.
Superior border of the isthmus of the normal thyroid gland is inferior to cricoid cartilage. Isthmus is felt over the tracheal rings below. Bare tracheal rings are observed in ectopic thyroid (which means in normal location thyroid tissue is not present) and also in absence of isthmus (rare).
Carotid pulsation should be checked. It is normally felt at the level of the upper border of thyroid cartilage over medial aspect of the sternomastoid muscle on the Chaissagne tubercle (carotid tubercle) on the transverse process of C6 vertebra. It may be deviated posteriorly/laterally in a large goitre. It may be absent in advanced carcinoma thyroid due to infiltration of the carotid sheath by the tumour (Berry's sign).142
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Fig. 1.236: Palpation of carotid artery (common carotid) at the level of thyroid cartilage on the medial border of sternomastoid muscle over Chaisagne tubercle in transverse process of C 6 vertebra. In Berry's sign it is absent. It signifies advanced carcinoma of thyroid.
Sympathetic chain in the neck may get involved in locally advanced carcinoma thyroid causing Horner's syndrome—enophthalmos due to Muller's muscle weakness:
  • Drooping of upper eyelid (ptosis).
  • Anhidrosis.
  • Miosis due to paralysis of dilator pupillae.
  • Absence of ciliospinal reflex.
  • Flushing of face and nasal congestion.
Examination of neck lymph nodes for secondaries. It is common in papillary carcinoma of thyroid. It is usually in level III and IV nodes. It could be firm, hard or cystic. It is usually brownish black in colour often with papillary projections. Lymph nodes often can get enlarged in follicular carcinoma thyroid and lymphoma. Lateral aberrant thyroid is earlier thought as aberrant thyroid in lateral part of the neck but actually it is not so but it is secondary in lymph node with primary being papillary carcinoma of thyroid.
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Fig. 1.237: Lymph node drainage of thyroid. Primary and secondary nodes are drainage groups.
Percussion over the manubrium sterni is important. Dullness signifies retrosternal extension. Tenderness may signify the secondaries in sternum from follicular carcinoma of thyroid.
Auscultation over the upper pole of the gland for bruit- in toxic thyroid severe cases and very vascular tumours.
Cardiovascular system examination is important in thyrotoxicosis- commonly secondary type. Tachycardia, ectopic, pulsus paradoxus, extrasystoles, atrial fibrillation are the cardiac presentations.143
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Figs 1.238A and B: Percussion over the sternum is important to rule out retrosternal extension.
Respiratory system examination: Secondaries and pleural effusion can occur in follicular carcinoma of thyroid.
Abdomen examination: Hepatomegaly as secondaries in liver is known to occur in follicular carcinoma of thyroid. Hepatosplenomegaly can occur as part of Grave's disease or Hashimoto's disease.
Examination of skull and spine: Localized, warm, vascular, pulsatile secondaries can occur in skull commonly, rib and other bones occasionally as a spread from follicular carcinoma of thyroid.
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Figs 1.239A and B: Bruit over thyroid should be auscultated to find out increased vascularity over upper pole.
In primary thyrotoxicosis exophthalmos and all eye signs are looked for.
  • Both the eyelids cover the bulbar sclera partially in normal individual.
  • Upper sclera is visible in only lid retraction—due to spasm of involuntary levator palpebrae superioris muscle. Here lower eyelid is in normal position. It does not indicate exophthalmos.
  • In exophthalmos lower bulbar sclera is clearly visible and lower eyelid is below and will not cover the bulbar sclera. In severe exophthalmos sclera all over both above and below will be visible.144
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    Fig. 1.240: Cardiovascular system is examined and auscultated for cardiac problems in secondary thyrotoxicosis.
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    Fig. 1.241: Hepatomegaly can occur in Graves' and Hashimoto's diseases as part of the autoimmune disease.
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    Fig. 1.242: Abdomen is percussed for free fluid.
  • Exophthalmos is measured using exophthalmometre.
 
Other eye signs
Eye signs are common in primary thyrotoxicosis. Lid lag, lid spasm can occur in secondary thyrotoxicosis also.
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Figs 1.243A and B: Palpation of spleen in a thyroid enlargement patient.
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Fig. 1.244: Palpation of skull in thyroid enlargement to look for secondaries when primary is follicular carcinoma of thyroid (pulsatile, vascular, warm, and localized).
  1. Von Graefe's sign: Lid lag sign is inabitility of the upper eyelid to keep face with eyeball when looking downwards—lid lag. Place the examiner's left hand over the patient's head. Place examiner's right index finger near the level of eye and slowly bring it down and patient is asked to see the downward moving finger. If sclera upward is visible then it is positive lid lag sign.145
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    Figs 1.245: Lid lag check in primary thyrotoxicosis.
    Test is repeated few more times for confirmation. Normally upper eyelid follows the finger downwards properly but in primary thyrotoxicosis lid lag is observed.
  2. Naffziger's sign: While examiner standing behind the patient, patient's neck is extended and examiner looks from behind along the superior orbital margin of the patient. Eyeball is seen beyond the superior orbital margin in exophthalmos.
  3. Dalrymple's sign: Upper eyelid retraction, so visibility of upper sclera.
  4. Stellwag's sign: Absence of normal blinking - so starring look. First sign to appear.
  5. Joffroy's sign: Absence of wrinkling on forehead when patient looks up (frowns) with the neck flexed.
  6. Moebius sign: Lack of convergence of eye ball. Defective convergence is due to lymphocytic infiltration of inferior oblique and inferior rectus muscles in case of primary thyrotoxicosis. There will be diplopia. It may be an early sign of eventual ophthalmoplegia. Examiner's left hand is placed over the patient's head. Right index finger from distance is brought towards root of the nose between the eyes and patient is asked to follow the converging finger visually to look for convergence. If positive patient will be unable to converge and develops diplopia.
  7. Jellinek's sign: Increased pigmentation of eyelid margins.
  8. Enroth sign: Oedema of eyelids (lower eyelid specifically) and conjunctiva.
  9. Rosenbach's sign: Tremor of closed eyelids.
  10. Gifford's sign: Difficulty in everting upper eyelid. Differentiates from exophthalmos of other causes.
  11. Loewi's sign: Dilatation of pupil with weak adrenaline solution.
  12. Knie's sign: Unequal pupillary dilatation.
  13. Cowen's sign: Jerky pupillary contraction to consensual light.
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  14. Kocher's sign: When clinician places his hands on patient eyes and lifts it higher, patients upper lid springs up more quickly than eyebrows.
  15. Naffziger's sign: With patient in sitting position and neck fully extended, protruded eye ball can be visualized when observed from behind.
  16. Grove's sign. Upper lid resistance to downward traction.
  17. Rochin's sign: Reduced amplitude of blinking.
  18. Boston's sign: Uneven jerky movement of the upper eyelid in inferior movement.
  19. Mean's sign: Eye globe lags behind upper eyelid on upward gaze.
  20. Griffith's sign: Lower eyelid lags behind the eye globe on upward gaze.
  21. Sainton's sign: Frontalis contraction after cessation of levator activity.
  22. Vigourox's sign: Puffiness of lids.
  23. Ballet's sign: Ophthalmoplegia- paralysis of more extraocular muscles.
  24. Suker's sign: Difficulty in maintaining fixation in extreme lateral gaze.
  25. Wilder sign: Jerking of eyes on movement from abduction to adduction.
  26. Trousseau's/Payne's sign: Dislocation of the eye globe.
  27. Reisman's sign: Bruit over eyelid.
  28. Snellen/Donder's sign: Bruit over the eye.
  29. Goldzieher's sign: Deep injection of conjuctiva.
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Figs 1.246A and B: Movements of the eye ball should be checked in primary thyrotoxicosis with exophthalmos to rule out involving eye ball muscle infiltration by macrophages, inflammatory cells
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Fig. 1.247: Moebius sign
147
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Fig. 1.248: Naffziger's sign.
 
Exophthalmos
  • It is proptosis of the eye, caused by infiltration of the retro bulbar tissues with fluid and round cells, with visible lower bulbar sclera and with lid spasm of upper eyelid. (Lid spasm is spasm of levator palpebrae superioris muscle which is partly innervated by sympathetic fibres.)
  • Sclera can be seen clearly below and often above the limbus of the eye.
  • Proptosis can be measured by exophthalmometer.
  • Exophthalmos is often self limiting, but not always. Sleeping in propped up position and lateral tarsorrhaphy will help to protect the eye.
 
 
Severe Exophthalmos
  • Eyelid oedema, chemosis, conjuctival injection.
  • Diplopia, ophthalmoplegia (Complete weakness of all extraocular muscles and so no movements possible).
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  • Corneal ulceraion.
  • Papilloedema soon develops.
  • Finally it may also cause loss of vision.
It is called as malignant exophthalmos. (Even though it is neither malignant nor related to any malignancy).
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Fig. 1.249: Malignant exophthalmos.
Treatment is emergency one, i.e. Large doses of systemic steroids (Prednisolone) are given along with orbital decompression, systemic antibiotics, steroid drops, antibiotic drops.
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Fig. 1.250: Look of eyes in different conditions including thyrotoxicosis.
Remember—Antithyroid drugs may worsen exophthalmos and so observe the patient once antithyroid drugs are started as steroids may require to be supplemented.
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Investigations for Thyroid Diseases
  • T3, T4, TSH, Free T3, Free T4.
  • U/S neck for thyroid and neck nodes.
  • FNAC thyroid and lymph node.
  • Radioisotope study.
  • CT neck in malignancies or large goitre.
  • Trucut biopsy if two trials of FNAC are inconclusive. It can injure deeper structures like recurrent laryngeal nerve and also can cause haemorrhage.
  • Frozen section biopsy on table and proceed may be needed.
  • Serum calcitonin, serum thyroglobulin estimation in neoplasms of thyroid.
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Fig. 1.251: U/S neck showing thyroid nodule.
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Fig. 1.252: FNAC thyroid is an important investigation in thyroid diseases.
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Note:
  • On table frozen section biopsy is useful in negative FNAC but doubtful cases. Definitive procedure is undertaken once frozen section report comes on table. But in frozen section biopsy itself, 15% of follicular carcinoma report may be inconclusive or negative which causes difficulty in taking decision. In such occasion hemithyroidectomy is done and once histology report of follicular carcinoma is obtained completion thyroidectomy is done usually immediately within a week. If biopsy report is delayed then completion thyroidectomy is done after 6 weeks.
  • Trucut biopsy gives tissue diagnosis but danger of haemorrhage and injury to vital structures like trachea, recurrent laryngeal nerve, vessels are likely.
 
Solitary Thyroid Nodule
 
What is solitary nodule of thyroid?
It is a single palpable nodule in thyroid on clinical examination, in an otherwise normal gland.
 
Causes
  • Thyroid adenomas—
    Colloid—commonest.
    Hurthle cell.
    Follicular.
  • Papillary carcinoma of thyroid.
  • Only one nodule may be palpable in an underlying multinodular goitre.
  • Thyroid cyst.
 
Types:
  1. Toxic solitary nodule.
  2. Nontoxic solitary nodule.
 
Based on radioisotope study:
  1. Hot—Means autonomous toxic nodule.
  2. Warm—Normally functioning nodule.
  3. Cold—Non-functioning nodule; may be malignant-20% (need not be always). Cold nodule may be due to malignancy, thyroiditis, thyroid cyst or haemorrhage.
  4. Hot or warm in 99m technetium scan but cold in I123 scan—commonly they are malignant.
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Figs 1.253A to C: Solitary nodule involving isthmus
Note:
  • Thyroid nodule in children and elderly can be malignant.
  • Rapid enlargement of thyroid nodule can be malignant.
  • Medullary carcinoma of thyroid commonly and 6% of papillary carcinoma of thyroid can be familial.
  • Recurrent laryngeal nerve palsy, fixity, stridor, presence of palpable neck nodes are usually features of carcinoma thyroid.
  • Follicular carcinoma causes pulsatile, localized, warm, vascular secondaries in skull bone.
  • 30% of solitary nodules are cystic.
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Features
  1. Single nodule palpable in one or other lobes of the thyroid which is usually smooth, globular, well-defined margin and firm. Skin overlying is normal.
  2. Lahey's test does not show any other nodules in posterior part of the gland.
  3. Tracheal deviation towards opposite side is common – confirmed by trail sign, three finger test and auscultation.
  4. U/S neck is very useful. FNAC is essential. When FNAC is inconclusive Trucut needle biopsy may be done but it can cause pain/bleeding/recurrent laryngeal nerve injury.
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    Figs 1.254A and B: Solitary nodule right lateral lobe. It is a clinical entity.
  5. T3, T4, TSH are done to find out the function
  6. Radioisotope study. (I123/I131/99mTc).
  7. CT scan or MRI neck is done only in selected cases but not routinely. Large swelling/to see vascularity/retrosternal extension are the indications.
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Fig. 1.255: Solitary nodule thyroid causes deviation of trachea to opposite side.
 
Treatment
  • If it is a nontoxic nodule due to any cause, hemithyroidectomy with complete removal of lateral lobe and whole of the isthmus is done.
  • If it is papillary carcinoma thyroid, then near total thyroidectomy is done along with suppressive dose of L-Thyroxine given 0.3 mg OD daily.
  • If it is a toxic nodule, radioiodine therapy, I 131 —5 milli curie is given orally, if the age of the patient is more than 45 years.
  • If age is less than 45 years, then initially toxicity has to be controlled by antithyroid drugs, always followed by surgery - Hemithyroidectomy.
  • If FNAC is follicular adenoma, then hemithyroidectomy is done. If histology becomes follicular carcinoma (capsular and vascular invasion) then completion total thyroidectomy is done. Completion thyroidectomy is done usually within 7 days or after 3 weeks. If frozen section biopsy proves carcinoma then total thyroidectomy is done.
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  • If there is a nodule in the isthmus, isthmectomy with excision of part of adjacent lateral lobes is done.
  • If FNAC is medullary carcinoma of thyroid, then total thyroidectomy with bilateral neck nodal dissection including central compartment is done.
  • Colloid nodule may response for conservative drug treatment using thyroxine orally in 50% cases. If nodule reappears/enlarges progressively significantly/causing cosmetic problem then hemithyroidectomy is indicated in colloid nodule.
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Figs 1.256A and B: Hemithyroidectomy specimen done for solitary nodule thyroid
 
Diffuse Hyperplastic Goitre
Initial persistent increase in TSH level causes diffuse active lobules. In late stages of diffuse hyperplasia, TSH stimulation decreases and many follicles become inactive get filled with colloid and it is called as colloid goitre. As diffuse hyperplastic goitre is a reversible stage, l- thyroxine is beneficial.
 
Nodular Goitre
 
Pathogenesis
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Fig. 1.257: Diagrammatic representation of multinodular goitre.
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Fig. 1.258: Large multi-nodular goitre.
Other factors involved are growth stimulating immunoglobulins and growth prone cell clones.
 
Features
  • It is a slowly progressive disease with many years of history.
  • Multiple nodules of different sizes are formed in both lobes, also in isthmus, which is firm, nodular, non tender, moves with deglutition.
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    Fig. 1.259: Nodular thyroid involving both lobes in a female.
  • Recent increase in size signifies malignant transformation or haemorrhage.
  • Investigations are T3, T4, TSH, U/S neck, FNAC, X-ray neck will show ring or rim calcification.
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Fig. 1.260: X-ray neck showing calcification in thyroid with retrosternal extension.
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Treatment
Nodular goitre is an irreversible stage and so surgery is the treatment.
  • Total thyroidectomy is universally accepted method presently. Only problems are chances of recurrent nerve palsy and postoperative risk of patient developing hypocalcaemia often severe.
  • Subtotal thyroidectomy is done depending on the amount of gland involved, amount of normal gland existing and location of nodules.
  • Hartley-Dunhill procedure is removal of one entire lobe which is more affected with subtotal removal of other gland.
  • Partial thyroidectomy wherein gland behind the tracheo oesophageal groove is retained with removal of diseased glands in front. Earlier it used to be a popular method. Currently it is not well practiced.
  • Postoperatively L-thyroxine is often given to prevent further fluctuation in TSH level.
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Figs 1.261A and B: Multi-nodular goitre specimen and also cut section.
 
Thyrotoxicosis and Hyperthyroidism
Symptoms due to raised levels of thyroid hormones.
 
Types
  1. Diffuse toxic goitre—(Grave's disease, Basedow's disease. Primary thyrotoxicosis).
  2. Toxic multi-nodular goitre (Secondary thyrotoxicosis.). (Plummer disease).
  3. Toxic nodule.
  4. Hyperthyroidism of rarer causes:
    1. Thyrotoxicosis factitia- drug induced. Due to intake of L-thyroxine more than normal.
    2. Jod Basedow thyrotoxicosis - because of large doses of iodides given to a hyperplastic endemic goitre.
      156
    3. Autoimmune thyroiditis or de' Quervain's thyroiditis.
    4. Occasionally carcinoma thyroid.
    5. Neonatal thyrotoxicosis. It subsides in 3–4 weeks as TsAb titres fall in the baby's serum.
(Wolf-Chaikoff effect—iodides inhibit the further release of hormone causing hypothyroidism).
 
Clinical Features
  1. It is eight times more common in females.
  2. Occurs in any age group.
  3. Primary type is seen commonly in younger age group.
  4. Secondary is common in older age group.
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Fig. 1.262: Thyrotoxicosis (primary). Note the exophthalmos and also toxic thyroid enlargement.
 
Symptoms of Hyperthyroidism
 
Gastrointestinal system
  • Weight loss in spite of increased appetite
  • Diarrhoea (due to increased activity at ganglionic level).
 
Cardiovascular system
  • Palpitations, chest pain.
  • Shortness of breath at rest or on minimal exertion.
  • Angina.
  • Cardiac irregularity.
  • Cardiac failure in the elderly (CCF).
 
Neuromuscular system
  • Undue fatigue and muscle weakness, exaggerated tendon reflexes, myasthenia like syndrome.
  • Tremor, hyperkinesias, increased sweating.
 
Skeletal system
Increase in linear growth in children.
 
Genitourinary system
  • Oligo- or amenorrhoea.
  • Occasional urinary frequency.
 
Integument
  • Hair loss.
  • Pruritus.
  • Palmar erythema.
 
Psychiatry
  • Irritability.
  • Nervousness.
  • Insomnia.
Sympathetic overactivity causes dyspnoea, palpitation, tiredness, heat intolerance, sweating, nervousness, increased appetite and decrease in weight. Because of the increased catabolism they are having increased appetite, decreased weight and so also increased creatinine level which signifies myopathy (due to more muscle catabolism).
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Fig. 1.263: Diffuse toxic goitre. Note the involvement of both lobes bilaterally.
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Fine tremor is due to diffuse irritability of grey matter.
Thrill is felt in the upper pole of the thyroid and also bruit on auscultation. It is because in upper pole, superior thyroid artery enters the gland superficially, and so thrill and bruit can easily be assessed. In lower pole inferior thyroid artery enters the gland from deeper plane and so thrill cannot be felt.
 
Signs of Hyperthyroidism
  1. Eye signs in toxic goitre (Refer above)
  2. Cardiac Manifestations:
    1. Tachycardia is common.
      Sleeping pulse rate is usually checked for three consecutive nights and average is taken as the value.
    2. Ectopic.
    3. Pulsus paradoxus.
    4. Wide pulse pressure.
    5. Multiple extrasystoles.
    6. Paroxysmal atrial tachycardia.
    7. Paroxysmal atrial fibrillation.
    8. Persistent atrial fibrillation (not responsive to digoxin).
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  3. Myopathy:
    1. Weakness of proximal muscles occurs, i.e. the front thigh muscles, or arm muscles.
    2. Weakness is more when muscle contracts isometrically either while getting down steps, or lifting a full bucket, etc.
    3. Often when it is severe it resembles myasthenia gravis. Once hyperthyroidism is controlled recovery occurs.
  4. Pretibial myxoedema is often a feature of primary thyrotoxicosis (It is a misnomer)
    • It is usually symmetrical, shiny, red thickened skin, with coarse hair.
    • In severe cases skin of whole leg below the knee with foot and ankle is involved.
    • It is due to deposition of myxomatous tissues (mucin like deposits) in skin and subcutaneous plane.
    • It might or might not regress completely after treatment for toxicity
    • It is associated with exophthalmos with high levels of thyroid stimulating antibodies.
  5. Thyroid acropachy is clubbing of fingers and toes in primary thyrotoxicosis. Hypertrophic pulmonary osteoarthropathy may develop.
 
Toxic Nodule
  • Is a solitary overactive nodule.
  • There is an autonomous hypertrophy and hyperplasia of the part of the gland where there is a nodule. (It is not due to Thyroid stimulating antibody (Ts Ab)).
  • Here high levels of circulating thyroid hormones suppress TSH secretion, and so normal thyroid tissue surrounding the nodule is itself suppressed and inactive.
  • Once patient becomes euthyroid by drugs, surgery (hemithyroidectomy) is done or radioactive iodine therapy I131 in a therapeutic dose of 5mcurie is given orally.
  • Because normal gland is inactive, radioactive iodine affects only the autonomous nodule, allowing the normal gland to remain intact which later gets activated and functions normally.
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  • Drugs are used initially, only for a temporary period to make the patient euthyroid.
 
Investigations
 
Thyroid function tests
  • Serum T3 and T4 levels are very high. TSH is very low or undetectable. Some times, only T3 level is increased and is called as T3 toxicosis. Here in T3 toxicosis, free T3 estimation is important.
  • Radioisotope study by I131 (Diagnostic dose 5 micro curie is used) will show more up take, i.e. hot nodules or hot areas. This is very useful in autonomous solitary toxic nodule.
  • TRH estimation.
  • ECG—To look for cardiac involvement and if required opinion from cardiologists' is taken and cardiac problems are managed.
  • Total count and neutrophil count are very essential base line investigations before starting antithyroid drugs (as it may cause agranulocytosis).
 
Treatment
  1. Antithyroid drugs.
  2. Surgery.
  3. Radio-iodine therapy.
 
1. Antithyroid drugs
  1. Carbimazole:
    • It is the commonest drug used.
    • Dose is 5–10 mg, exactly 8th hourly, (as T1/2 of carbimazole is 8 hours).
    • Usually given for 12–18 months.
    • Peak plasma level should be maintained in optimum concentration to have a proper benefit.
    • Often tri-iodo thyronine 20 micro gram 4 times daily or Thyroxine 0.1 mg daily is given in combination with antithyroid drugs, to prevent iatrogenic thyroid insufficiency or to prevent the increase in size of goitre.
    • It acts by blocking thyroid hormone synthesis.
    • Carbimazole also suppresses the autoimmune process in thyroid in Graves' disease. So thyroid stimulating antibody (TsAb) production diminishes.
  2. Methimazole: Similar like carbimazole. Dose is 5–20 mg daily.
  3. Propylthiouracil:
    1. It acts by blocking thyroid hormone synthesis as well as by blocking peripheral conversion of T4 to T3.
    2. It also decreases the thyroid autoantibody levels.
    3. It can be given in hyperthyroidism in children and pregnancy.
    4. Dose is 200 mg 8th hourly.
Antithyroid drugs are continued during and after surgery, for 7–10 days and after radioactive iodine therapy for 6 weeks to 12 weeks.
Response to treatment and possibility of relapse in primary thyrotoxicosis can be assessed by studying HLA status and TsAb level.
 
Propranolol:
Dose is 40 mg tid.
It reduces the cardiac problems and also blocks the peripheral conversion of T4 to T3, as it is the T3 which is the principle active agent in periphery.
Contraindications are bronchial asthma, heart block, cardiac failure.160
Lugol's iodine (5% iodine + 10% potassium iodide):
  • It decreases the vascularity of the gland and makes it more firm and easier to handle during surgery. Dose is 10–30 drops/day (minims) for 10 days prior to surgery. Potassium iodide tablets 60 mg tid also can be given instead of Lugol's iodine. But its use at present is disqualified.
    (One minim = one drop. One ml = 16 drops).
 
Advantages of antithyroid drugs
  1. Avoids surgery and its complications
  2. Avoids radiotherapy.
Clinical improvement occurs in 2 weeks. Biochemical improvement occurs in 6 weeks.
 
Disadvantages
  1. Prolonged course of treatment for 18 months and inspite of this can not predict the remission or relapse. Relapse rate is 40%.
  2. Size of swelling may not regress.
  3. It may lead to agranulocytosis and thrombocytopenia, liver damage, hair loss.
Sore throat is the earliest presentation of agranulocytosis. If it is so, drug has to be stopped; total count has to be done. If it is less, agranulocytosis is confirmed. High doses of injection benzyl penicillin 10–20 lakh, 6th hourly, IV has to be started to prevent infection. If required, blood transfusion has to be done. Patient usually recovers by this. To control toxicity, Tab. Propranalol 40 mg tid has to be started. Rarely they need bone marrow transplantation.
 
2. Surgery:
Surgery done is subtotal thyroidectomy—Both lobes with isthmus are removed and a tissue equivalent to pulp of finger is retained in lower pole of the gland on both sides.
In autonomous nodule, hemithyroidectomy is done – Entire lateral lobe with whole of isthmus is removed.
Advantages: Rapid cure and high cure rate.
Patient should be made euthyroid before doing surgery. (It should be confirmed by repeated estimation of TSH, T3 and T4 levels).
Disadvantages:
  1. Recurrent thyrotoxicosis (5%). It is treated by radioiodine therapy or antithyroid drugs. Resurgery is technically difficult.
  2. Thyroid insufficiency (20–45%). It is revealed in 6 months to 2 years and confirmed by doing T3 and T4 and TSH estimation. Hypothyroidism is better than recurrent thyrotoxicosis. It is treated by tab. L-thyroxine 0.1 mg daily (OD) for life long.
  3. Complications of thyroid surgery itself.
 
3. Radioiodine therapy:
  • Radioiodine destroys the cells and causes the complete ablation of thyroid gland. It is given only after the age of 45yrs, as the chances of genetic mutation (damage), leukaemia; carcinomas are high in younger individual.
  • Usual dose is 50–60 milli curie, or 160 micro curie/gm of thyroid. (300–600 MBq).
  • It takes 3 months, to get full response, and so until then, the patient has to take antithyroid drugs. Often additional one or two doses of radioiodine are required to have complete ablation. Eventually they go for hypothyroidism (80%) and so require maintenance dose of l-thyroxine 0.1mg daily.
  • To give therapeutic dose, patient should be admitted and isolated for 7 days (Half life) to prevent irradiation. It is given orally soon after getting from the manufacturer without much delay to have optimal efficacy.
    161
 
Choice therapies
Advantages:
  1. No surgery.
  2. No prolonged drug therapy.
Disadvantages:
  1. Availability of facilities.
  2. Proper follow-up is essential.
 
Toxic Thyroid in Pregnancy
  • Radioiodine therapy is an absolutely contraindicated in pregnancy (High risk to foetus).
  • Antithyroid drugs can be administered carefully.
  • But, the problem here is that both TSH and antithyroid drugs crosses the placental barrier and baby born may be hypothyroid and. goitrous.
  • Propylthiouracil is preferred in pregnancy.
  • Subtotal thyroidectomy can be done in second trimester.
 
Toxic Thyroid in Children
Radioiodine therapy is absolutely contraindicated in children because of high risk of developing thyroid carcinoma. Recurrence rate is also very high after surgery. So proposed treatment is, initially antithyroid drugs are given until adolescent period and then subtotal thyroidectomy is done.
 
Thyrocardiac
Severe cardiac damage resulting from hyperthyroidism (may be partly or wholly due to same), usually secondary type, requires proper opinion from cardiologists and treatment with propranolol. Subtotal thyroidectomy is the treatment.
In a patient with thyrotoxicosis, with recent onset of proptosis, early thyroidectomy has to be avoided. Because early surgery may precipitate malignant exophthalmos. Here the patient has to be treated initially with antithyroid drugs and if required with steroids, until the proptosis has remained static for six months. Then subtotal thyroidectomy is done.
Since half life of l-thyroxine is 7 days, propranolol and antithyroid drugs has to be continued for 7 days after thyroidectomy.
T3 thyrotoxicosis should be suspected if the clinical picture is suggestive of toxicosis, but routine tests for thyroid function are within normal range.162
 
What are the different presentations of carcinoma thyroid?
  • Any thyroid swelling can be malignant. It can be of short or long duration. It can be solitary/multinodular goitre. It can be solid/cystic/complex in nature.
  • Preexisting thyroid swelling with recent history of rapid increase in size.
  • Palpable neck lymph nodes.
  • Recurrent laryngeal nerve palsy, dyspnoea, stridor are other presentations.
  • Medullary carcinoma thyroid and papillary carcinoma thyroid (6%) can be familial.
 
Classification of thyroid neoplasm
  1. Benign.
    1. Follicular adenoma.
    2. Hurthle cell adenoma.
    3. Colloid adenoma—commonest.
      zoom view
      Fig. 1.264: Carcinoma thyroid. Note the superficial tissue infiltration.
    4. Papillary adenoma—its existence is doubtful. It is invariably low grade papillary carcinoma.
Malignant (Dunhill classification).
  1. Differentiated.
    1. Papillary carcinoma (60%).
    2. Follicular carcinoma (17%).
    3. Papillofollicular carcinoma behaves like papillary carcinoma of thyroid.
    4. Hurthle cell carcinoma behaves like follicular carcinoma.
  2. Undifferentiated.
    Anaplastic carcinoma (13%).
  3. Medullary carcinoma (6%).
  4. Malignant lymphoma (4%).
  5. Secondaries in thyroid (rare) - from colon, kidney, melanoma.
 
Etiology of Thyroid Malignancy
  1. Radiation either external or radioiodine can cause papillary carcinoma thyroid. There is increased incidence of thyroid carcinoma among children following exposure to ionising radiation after the Chernobyl nuclear disaster in Ukraine in 1986. Irradiation to head and neck region used to be the therapy for benign conditions like adenoids, acne vulgaris, thymus enlargement, haemangiomas which predisposed papillary carcinoma of thyroid.
    zoom view
    Fig. 1.265: Carcinoma thyroid showing vascularity.
    163
    Radiotherapy for Hodgkin's lymphoma in younger age group may cause papillary carcinoma of thyroid.
  2. Preexisting multinodular goitre. It turns into follicular carcinoma of thyroid.
  3. Medullary carcinoma thyroid is often familial.
  4. Hashimoto's thyroiditis may predispose to papillary carcinoma of thyroid and also NHL.
 
Papillary Carcinoma
  • It is 60% common.
  • Common in females (3:1) and young age group.
 
Aetiology
  • Radiation either external or radioactive iodine therapy.
    • TSH levels in the blood of these patients are high. and so it is called as hormone dependent tumour.
    • It is a slowly progressive and less aggressive tumour.
    • It is commonly multicentric.
    • It spreads within the gland throgh intra- thyroidal lymphatics to other lobe, comes out of the capsule and spreads to lymph nodes.
    • Usually there is no blood spread.
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Fig. 1.266: Papillary carcinoma of thyroid with lymph nodal spread.
 
Types
  1. Occult (< 1.5 cm)
  2. Intrathyroidal
  3. Extrathyroidal
  4. Micropapillary carcinoma is less than 1 cm in size or clinically not detectable.
 
Gross:
It can be soft, firm, hard, and cystic. It can be solitary or multinodular. It contains brownish black fluid.
 
Microscopy:
It shows cystic spaces, papillary projections with psammoma bodies, malignant cells with ‘Orphan Annie eye’ nuclei (intranuclear cytoplasmic inclusions). (Nuclear grooving).
 
Clinical Features
  1. Soft or hard or firm, solid or cystic, solitary or multinodular thyroid swelling.
  2. Compression features are uncommon in papillary carcinoma thyroid.
  3. Often discrete lymph nodes in the neck are palpable.
 
Diagnosis
FNAC of thyroid nodule and lymph node. To see psammoma bodies, nuclear changes
Radioisotope scan shows cold nodule.
TSH level in the blood is higher.
 
Treatment
  • Near total thyroidectomy or total thyroidectomy
  • Suppressive dose of L-Thyroxine 0.3 mg O.D life long.
  • Block dissection (modified radical neck dissection) is required if lymph nodes are involved.
  • Occasionally if small lymph nodes are present, ‘Berry picking’ may be done. (Not accepted now).
  • Extrathyroidal type needs radioactive iodine therapy also (I131).
Near total thyroidectomy (by Thomas) is removal of both lobes of the thyroid and isthmus with retaining a small tissue close to recurrent laryngeal nerve and parathyroids.164
Note: If tumour is unifocal, intrathyroidal, less than 1 cm and well differentiated tumour in a patient with age less than 40 years, then hemithyroidectomy is sufficient with regular, proper follow-up.
Prognosis is good and it is one of the curable malignancies.
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Fig. 1.267: Papillary carcinoma of thyroid specimen.
Lateral aberrant thyroid is a misnomer. It is actually secondaries in neck lymph nodes which are palpable from an occult primary from papillary carcinoma of thyroid (which is clinically not palpable).
Thyroid paradox—Cellular tumours are soft, and cystic tumours are firm or hard (tensely cystic). It is observed in papillary carcinoma of thyroid.
 
Follicular Carcinoma
  • It is 17% common.
  • It is common in females.
  • It can occur either denovo or in a preexisting multinodular goitre.
  • It is a more aggressive tumour.
  • It spreads mainly through blood into the lung, bones, liver.
  • Bone secondaries are typically vascular, warm, pulsatile, localized, commonly in skull, long bones, ribs.
  • It can also spread to lymph nodes in the neck occasionally.
 
Types
  • Non-invasive-blood spread is not common.
  • Invasive- blood spread is common.
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Fig. 1.268: Follicular carcinoma of thyroid in a male patient. It involved mainly left lobe but it is extensive and spreading to soft tissues adjacent to it.
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Figs 1.269A and B: Follicular carcinoma of thyroid causing secondaries in skull. It is localized, vascular, smooth, pulsatile, warm secondaries (in skull).
 
Typical Feature
Angioinvasion and capsular invasion.166
 
Clinical Features
  1. Swelling in the neck, firm or hard and nodular.
  2. Tracheal compression and stridor.
  3. Dyspnoea, haemoptysis, chest pain when there are lung secondaries.
  4. Recurrent laryngeal nerve involvement causing hoarseness of voice, positive ‘Berry's sign’ signifies advanced malignancy. (Infiltration into the carotid and so absence of carotid pulsation).
  5. Pulsatile, warm, well localized, vascular secondaries in the skull (frontal/parietal bones), long bones.
 
Investigations
  • Most often FNAC is inconclusive, because capsular and angioinvasion which is the main feature in follicular carcinoma cannot be detected by FNAC.
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    Figs 1.270A and B: X-ray skull showing secondaries from follicular carcinoma thyroid.
  • Frozen section biopsy is very useful. But in 15% cases it shows negative results.
  • U/S abdomen, Chest X-ray, X-ray bones are the other investigations required.
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Fig. 1.271: CT scan of neck showing thyroid enlargement in follicular carcinoma of thyroid with infiltration.
 
Treatment
  • Total thyroidectomy is done, along with block dissection whenever lymph nodes are enlarged.
  • Maintenance dose of L-Thyroxine 0.1mg.O.D is given lifelong.
  • FNAC in 50% of follicular carcinomas are inconclusive as it is difficult to differentiate between follicular adenoma and carcinoma. In such occasions frozen section biopsy on table may be useful. If on-table frozen section biopsy is positive for malignancy then total thyroidectomy is done.
  • In 15% cases frozen section biopsy also may be inconclusive or frozen section biopsy facility may not be available in many places then initial hemithyroidectomy is done. If later report comes as follicular carcinoma of thyroid then completion thyroidectomy is done. It is done usually in 7 days of initial surgery otherwise 3 weeks after the first surgery.
  • When neck nodes are present in 10 % cases, modified radical dissection is done one or both sides.
    167
 
Follow-up
It is by radioisotope I123 scan done at regular intervals (6 months) to look for secondaries.
Thyroglobulin estimation is a good follow- up method to decide for Radioisotope study. Normal value is 3–5 ng/ml. High value signifies persistent/recurrent/metastatic disease. It should be estimated once in 3 months. If thyroglobulin level is normal radioiodine study is not necessary.
If it is high, radioiodine study is indicated.
 
Further Treatment
  • If secondaries are detected therapeutic dose Ra I131 is given. L-thyroxin has to be stopped for 6 weeks prior to RT, and then required dose of Ra I131 is given.
  • Secondaries in bone are treated by external radiotherapy. Internal fixation should be done whenever there is pathological fracture.
  • There is no role of chemotherapy for follicular carcinoma thyroid.
Note:
  • High dose of retinoic acid will make I131 to concentrate in tumor cells (70mg/daily for 2 weeks).
  • Fertility should be avoided for 1 year after I131 therapy.
  • Avoid contrast CT in thyroid diseases as much as possible because I131 study in later period will be difficult.
  • MRI is ideal when radioiodine therapy is needed.
Hurthle cell carcinoma is a variant of follicular carcinoma of thyroid which contains abundant oxyphill cells. It spreads more commonly to regional lymph nodes than follicular carcinoma of thyroid. 99mTc sestamibi scan is very useful for Hurthle cell carcinoma.
Note:
  • Toothpaste colloid- follicular carcinoma.
  • Chewing gum colloid papillary carcinoma.
  • Nuclear grooving papillary carcinoma.
  • Psammoma bodies papillary carcinoma.
  • Amyloid—medullary carcinoma.
  • Follicular adenoma aneuploid and in fcdiploid—DNA ploid study.
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Fig. 1.272: Carcinoma thyroid with dilated veins on the surface.
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Fig. 1.273: Total thyroidectomy specimen done for follicular carcinoma of thyroid.
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Fig. 1.274: Carcimnoma thyroid with neck secondaries.
 
Anaplastic Carcinoma
  • It is a very aggressive tumour of short duration, presents with a swelling in thyroid region which is rapidly progressive causing-
    1. Stridor and hoarseness of voice.
    2. Dysphagia.
    3. Fixity to the skin.
    4. Infiltration into the carotid sheath-Berry's sign.
  • Swelling is hard, with involvement of isthmus and bilateral lateral lobes.
  • FNAC is diagnostic.
  • Tracheostomy and isthmectomy has got a role to relieve respiratory obstruction temporarily.
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    Fig. 1.275: Anaplastic carcinoma of thyroid with infiltration through the capsule. It commonly encases the carotid artery causing Berry's sign positive.
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    Fig. 1.276: Anaplastic carcinoma of thyroid.
    169
  • Treatment is external radiotherapy as usually thyroidectomy is not possible.
  • However prognosis is poor.
Follow-up in differentiated thyroid carcinoma
  • Proper clinical examination in the neck for residual/nodal disease and for distant spread.
  • Whole body radioisotope scan after one week of surgery to see residual tumour in the neck or metastases.
  • Estimation of thyroglobulin at regular intervals is very important.
  • Follow-up whole body radioisotope scan at 3–6 months intervals. Thyroxine should be stopped for 6 weeks. It is commonly done if thyroglobulin level in the blood is significantly high.
 
Medullary Carcinoma of Thyroid (MCT)
  • It is uncommon (5%) type of thyroid malignancy.
  • It is arises from the para follicular ‘C’ cells which is derived from the ultimo bronchial body (neural crest). They are part of APUD (Amine Precursor Uptake Decarboxylation) cells. C cells are more in upper pole of the thyroid.
  • It contains characteristic ‘amyloid stroma’ wherein malignant cells are dispersed.
  • In these patients blood levels of calcitonin both basal as well as that following calcium or pentagastrin stimulation is high, a very useful tumour marker.
  • Tumour also secretes 5-H.T (serotonin), prostaglandin and vasoactive intestinal polypeptide (VIP).
  • It spreads mainly to lymph nodes (60% common).
  • It may be associated with MEN II syndrome and phaeochromocytoma with hypertension.
  • There may be mucosal neuromas in lips, oral cavity.
 
Clinical Features
  1. Thyroid swelling often with enlargement of neck lymph node.
  2. Diarrhoea, flushing.
  3. Hypertension, phaeochromocytoma and mucosal neuromas when associated with MEN II syndrome.
  4. Sporadic and familial types occur in adulthood whereas cases associated with MEN syndrome II occur in younger age groups.
 
Types
  1. Sporadic: Usually solitary—70%.
  2. MCT with MEN II syndrome: MCT with MEN II B with phaeochromocytoma is most aggressive
  3. Familial MCT: It is autosomal dominant with proto-oncogene in chromosome number 10. It is commonly multicentric.
 
Investigations
  • FNAC: Shows amyloid deposition with dispersed malignant cells and ‘C’ cell hyperplasia.
  • Tumour marker: Calcitonin level will be higher. Normally, it is less than 0.08 ng/L.
  • U/S neck-thyroid region.
  • Urinary VMA, urinary catecholamines, urinary metanephrine, serum calcium, serum parathormone estimation.
  • CT neck and chest to evaluate nodal status is a must.
  • 111 Indium octreotide scanning is useful in detecting medullary carcinoma thyroid (70% sensitivity). It is also useful in postoperative follow-up to find out residual/metastatic disease.
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Fig. 1.277: Medullary carcinoma of thyroid specimen.
170
 
Treatment
Surgery is the main therapeutic modality.
  • Total thyroidectomy with Central node dissection (level 6) in all patients even if there are no nodes in the neck. + Maintenance dose of L-thyroxin.
  • Neck lymph nodes block dissection if lymph nodes are involved (bilateral modified radical dissection of neck nodes). Later regular U/S neck to detect early neck nodes.
  • Adriamycin is the drug used as chemotherapy with limited results.
  • No role of suppressive hormone therapy or radioactive iodine therapy.
  • External beam radiotherapy for residual tumour disease.
  • Somatostatin/octreotide for diarrhoea.
  • If there is associated phaeochromocytoma it should be treated surgically by adrenalectomy first and later only total thyroidectomy is done.
  • All family members of the patient should be evaluated for serum calcitonin and if it is high they should undergo prophylactic total thyroidectomy (Can also be assessed by genetic evaluation). If there is positive RET proto-oncogene in MCT with MEN II A and familial MCT types, prophylactic total thyroidectomy is done at the age of 5 years. In positive RET proto-oncogene in MCT with MEN II B prophylactic total thyroidectomy is done at the age of one year.
  • MCT with associated parathyroid hyperplasia (30%) in MEN IIA, total thyroidectomy with central nodal dissection with total parathyroidectomy and autotransplantation of half of gland in sternomastoid or non-dominant forearm brachioradialis muscle.
 
Prognosis
  • Sporadic MCT and MCT with MEN II are aggressive.
  • Familial MCT not associated with MEN II has got better prognosis.
 
Malignant Lymphoma
  • It is NHL type. Occurs in a pre-existing Hashimoto's thyroiditis (Not proved well).
  • FNAC is useful to diagnose the condition.
  • Chemotherapy is the main treatment.
  • Often total thyroidectomy is done to enhance the results.
 
Hashimoto's Thyroiditis (Struma Lymphomatosa)
  • Also called as diffuse nongoitrous thyroiditis
  • It is an autoimmune thyroiditis is common in women.
There is hyperplasia initially, then fibrosis, eventually infiltration with plasma cells and lymphocytic cells. Askanazy cells are typical (like Hurthle cells).
The river struma arises in Bulgaria and flows into Aegean Sea. Struma means goitre. Banks of this river are endemic goitre area.
 
Clinical Features
  1. Painful, diffuse, enlargement of usually both lobes of thyroid which is firm, tender and smooth (occasionally one lobe is involved).
  2. Initially, they present with toxic features but later, they manifest with features of hypothyroidism.
    Hyperplasia
    → Hyperthyroid.
    → Euthyroid.
    Fibrosis
    → Hypothyroid.
  3. There may be hepatosplenomegaly.
  4. It is often associated with other autoimmune diseases.
  5. In 85% cases significant rise in the thyroid antibodies (microsomal, thyroglobulin, or colloid antibodies) is observed.
  6. Papillary carcinoma may develop in Hashimoto's thyroiditis.
  7. Often condition may be associated with or may predispose to malignant lymphoma. It is at present not well proved.
 
Investigations
FNAC, T3, T4, TSH. Thyroid antibodies assay. Usually ESR is very high (over 90 mm/hour).171
 
Treatment
  1. L-thyroxine therapy.
  2. Steroid therapy often is helpful.
  3. If goitre is large and causing discomfort, then subtotal thyroidectomy is done.
 
De-Quervain's Subacute Granulomatous Thyroiditis
It is due to viral aetiology either mumps or Coxsackie's viruses causing inflammatory response with infiltration of lymphocytes, neutrophils, multinucleated giant cells.
 
Clinical Features
  • Pain is diffuse, swelling in thyroid which is tender.
  • Commonly seen in females.
  • Initially, there will be transient hyperthyroidism with high T3 and T4 but poor radioiodine uptake.
  • It is usually a self limiting disease.
 
Riedel's Thyroidis (0.5% common)
  • A very rare benign entity wherein thyroid tissue is replaced by fibrous tissue which interestingly infiltrates the capsule into muscles, paratracheal tissues, carotid sheath.
  • It is often associated with retroperitoneal and mediastinal fibrosis (Woody Thyroiditis, Ligneous Thyroiditis).
 
Clinical Features
Hard, fixed, swelling with stridor, often Berry's sign may be positive, i.e. absence of carotid pulsation.
 
Differential Diagnosis
Anaplastic carcinoma of thyroid.
 
Investigations
  • T3, T4 may be low due to hypothyroidism.
  • Radioisotope scan will not show any uptake.
  • FNAC to rule out carcinoma.
 
Treatment
Isthmectomy is done to relieve compression on the airway. They require l- thyroxine replacement later, as hypothyroidism is common.
 
THYROIDECTOMY
 
 
Types
  1. Hemithyroidectomy: Along with removal of one lobe, entire isthmus is removed. It is done in benign diseases of only one lobe.
  2. Subtotal thyroidectomy commonly done in toxic thyroid either primary or secondary and also often for nontoxic multinodular goitre. Here about 8 grams, or a tissue, size of pulp of finger is retained on lower pole, on both sides and rest of the thyroid gland is removed.
  3. Partial thyroidectomy is removal of the gland in front of trachea after mobilization. It is commonly done in nontoxic multinodular goitre.
  4. Near total thyroidectomy: Here both lobes except the lower pole which is very close to recurrent laryngeal nerve and parathyroid is removed. It is done in case of papillary carcinoma of thyroid.
  5. Total thyroidectomy: Entire gland is removed. It is done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid.
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Fig. 1.278: Hemithyroidectomy—entire one lateral lobe and entire isthmus are removed retaining entire opposite lateral lobe. It is done in solitary nodule/toxic or nontoxic adenoma in one lobe.
172
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Fig. 1.279: Subtotal thyroidectomy—it is done in toxic/ nontoxic multinodular goitre. Most of the gland except lower pole (4–8 gram) on both sides removed.
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Fig. 1.280: Partial thyroidectomy—it is done in nontoxic nodular goitre if there is adequate normal gland posteriorly. Tissue in the tracheo-oesophageal groove is retained. Isthmus and gland with nodules in front is removed. It is not commonly done now.
 
Preoperative Preparation
  • Blood grouping and cross matching. Keep the required blood ready.
  • Indirect laryngoscopy. Patient is asked to tell' E' to check the abduction of vocal cord.
  • Serum calcium estimation—ionic calcium
  • T3, T4, TSH.
  • Thyroid antibodies.
  • ECG and cardiac fitness especially in toxic goitre.
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Fig. 1.281: Near total thyroidectomy is done in papillary carcinoma of thyroid. Here most of the gland except lower small tissue of 1 gram is retained to safeguard recurrent laryngeal nerve and parathyroid gland. Tissue is retained either in or both sides.
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Fig. 1.282: Total thyroidectomy is done for follicular carcinoma and medullary carcinoma of thyroid.
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Fig. 1.283: Hartley Dunhill procedure. Here one entire lateral lobe, isthmus, and most part of the opposite lateral lobe except small quantity of tissue in the lower pole/ tracheo-oesophageal groove - subtotal/partial/one gram is retained.
173
 
Procedure
Position: Under general anaesthesia patient is put in supine position with neck extended by placing a sand bag under shoulder—with table tilt of 15 degree head up to reduce venous congestion.
Incision: Horizontal crease incision is done, two finger breadth above the sternal notch, from one sternomastoid to the other.
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Fig. 1.284: Note the incision for thyroid surgery.
Skin and platysma are incised – upper flap raised up to thyroid cartilage, lower flap up to sternoclavicular joint. Deep fascia is opened vertically in the midline. Strap muscles are retracted or cut in between two Kocher's forceps (in the upper part as in lower part ansa cervicalis nerve is present which supplies the muscles). Pretracheal fascia is opened to mobilize the thyroid. First, short stout middle thyroid vein is ligated, and then superior thyroid pedicle is ligated close to the gland so as to avoid injury to external laryngeal nerve. Inferior thyroid artery is ligated away from the gland so as to avoid injury to recurrent laryngeal nerve. Mobilized gland is removed. Bed is sutured with catgut so as to prevent bleeding. Drain is placed. The wound is close in layers.
Thyroid steal: Patient is taken to operation theatre for few days before doing surgery so as to reduce the anxiety of the patient.
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Fig. 1.285: Reverse Trendelenburg position used for thyroid surgery.
174
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Figs 1.286A and B: Anatomical relations of thyroid should be clear for safe thyroid surgery
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Fig. 1.287: Anatomical positions of vocal cord at different situations.
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Fig. 1.288: Suction drain is kept after thyroidectomy.
 
Complications of Thyroidectomy
  1. Haemorrhage: May be due to slipping of ligatures either superior thyroid artery or other pedicles. It will cause tachycardia, hypotension, breathlessness, and compression over the trachea may cause severe stridor, respiratory obstruction. As a first aid, immediate release of sutures including that of deep fascia has to be done and pressure over the trachea is released. Then patient is shifted to operation theatre, and under general anaesthesia exploration is done and bleeders are ligated. Blood transfusion may be required.
  2. Respiratory obstruction. It may be due to haematoma (if it is so, the haematoma has to be evacuated), or due to laryngeal oedema. For laryngeal oedema, immediate emergency endotracheal intubation is done along with steroid injections. Often emergency tracheostomy may be required as a life saving procedure.
  3. Recurrent laryngeal nerve palsy: It can be transient or permanent. Transient is 3% common. They usually recover in 3 weeks to 3 months. Often they require steroid supplement and speech therapy. Permanent paralysis is rare.
  4. Hypoparathyroidism is rare 0.5% common. Mostly it is temporary due to vascular spasm of parathyroid glands, occurs in 2–5th postoperative day. Present with weakness, +ve Chvostek's sign, carpopedal spasm, convulsions. Serum calcium estimation has to done and then 10 ml of 10% calcium gluconate— is given IV eighth hourly, and later supplemented by oral calcium 500 mg 8th hourly.175
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    Figs 1.289A and B: Anatomical location of recurrent laryngeal nerve. Note the different variations of recurrent laryngeal nerve.
    After 3–6 weeks, patient is admitted, drug is stopped and serum calcium level is repeated.
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    Fig. 1.290: Note the location of parathyroid glands.
  5. Thyrotoxic crisis (Thyroid storm): Occurs in a thyrotoxic patient inadequately prepared for thyroidectomy and rarely a thyrotoxic patient presents in a crisis following an unrelated operation or stress. They present in 12–24 hours with severe dehydration due to circulatory collapse, hypotension, hyperpyrexia, and often cardiac failure.
    Treatment is injection hydrocortisone, oral antithyroid drugs, tepid sponging of whole body, beta blocker injection, oral iodides, large amount of IV fluids for rehydration, digitoxin, cardiac monitor, often ventilator support, and observation. It has got high mortality rate with critical period of 72 hours. Fluid and electrolyte management, cardiac management are important aspects to be monitored and treated.
    176
  6. Injury to external laryngeal nerve causes weakness of cricothyroid muscle leading to alteration in pitch of voice.
  7. Hypothyroidism. Revealed clinically after 6 months.
  8. Wound infection, stitch granuloma formation.
  9. Keloid formation.
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Fig. 1.291: Postoperative sinus formation after thyroidectomy.
 
THYROGLOSSAL CYST
Thyroglossal cyst is a swelling occurring in the neck in any part along the line of thyroglossal tract. It is a tubulodermoid. It is accumulation of the cystic fluid secreted by the portion of the unobliterated part of the thyroglossal duct/tract.
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Fig. 1.292: Postoperative tetany after thyroidectomy.
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Figs 1.293A and B: Recurrent nodule thyroid. Patient has undergone thyroidectomy once earlier. Note the scar in the neck.
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Figs 1.294A to C: Operated specimen of thyroid showing nodules, cut section showling cavities, haemorrhagic areas.
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Fig. 1.295: Thyroglossal cyst.
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Fig. 1.296: Thyroglossal duct anatomy.
178
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Figs 1.297A to C: Thyroglossal cyst examination to feel the ‘tug’
It is usually congenital wherein there will be degeneration of a part of the tract causing cystic swelling. Normal thyroid may be present in the normal location (fossa). Sometimes, thyroid may not be present in the normal site but may be present in the wall of the thyroglossal cyst. It contains gel like fluid. It is lined by columnar epithelium surrounded by lymphoid tissues.
 
 
Clinical Features
  1. Swelling in the midline, towards the left.
  2. Moves with deglutition as well as with the protrusion of tongue. Patient is asked to open the mouth and keep the lower jaw still. Examiner holds the cyst between the thumb and forefinger. When the patient is asked to protrude the tongue, a ‘tugging sensation’ can be felt.
  3. Swelling is smooth, soft, fluctuant, (cystic), nontender, mobile, often transilluminant.
  4. Thyroid fossa is empty, if there is no thyroid in normal location.
  5. Thyroglossal cyst can get infected and may form an abscess.
  6. Malignancy can develop in thyroglossal cyst (Papillary carcinoma).
 
Investigations
  1. Radioisotope study I131.
  2. U/S neck.
  3. FNAC from the cyst.
  4. T3, T4 and TSH estimation.
 
Treatment
  1. Sistrunk operation: Excision of cyst along with full tract up to the foramen caecum is done along with removal of part of the body of the hyoid bone as the tract passes through it. Anaesthetist should wear a glove and support and guide over the posterior third of the tongue while reaching the tract to foramen caecum.
  2. If there is no normal thyroid gland after the surgery, maintenance dose of l-thyroxine 0.1 mg od is given life long.
If tract is not completely excised, it will result in thyroglossal fistula.179
 
Thyroglossal Fistula
  • It is not a congenital condition.
  • It either follows infection of thyroglossal cyst which bursts open or after inadequate removal of the cyst.
  • <