1. Jonny Lenihan Surgical CT1 NWTD
Surgical Short Cases
Jonny Lenihan
Surgical CT1 NWTD

2. Overview Common pathologies Examination technique Presentation skills
Background Information
X-rays
Summary
Questions

3. Hypertrophic scar

4. Describing Site Surface Size Edge Shape Pulsatility Consistency
Colour
Tenderness
Temperature
Surface
Edge
Pulsatility
Mobility
Transillumination
Auscultation
Local lymph nodes

5. Keloid Scar

6. Hypertrophic and Keloid Scars
Types of wound prone to these:
Infection; trauma; burns; tension
Hypertrophic occur soon after insult; spontaneously regress
Keloid scars appear months after and continue to grow
Rx:
Mechanical pressure dressings with topical agents
Surgical excision
Intralesional steroid therapy

7. Hypertrophic scars
Keloid Scars
Appearance
Confined to wound margins
Extend beyond wound margins
Site
Flexor surfaces and skin creases
Earlobes, chin, neck, shoulder, chest
Age
Any age (commonly 8-20)
Puberty to 30
Gender
M=F
F>M
Race
Any
Black and Hispanic
Pathology
Normal rate of collagen synthesis, but increased rate of collagen breakdown
Increased rate of collagen synthesis and increased rate of collagen breakdown

8. Ulcer = interruptions in the continuity of an epithelial or endothelial surface
Neuropathic ulcers:
Repeated injury to a pressure area.
Underlying conditions = diabetes, alcoholic peripheral neuropathy, tabes dorsalis

9. Venous ulcer:
Increased pressure within venous system forces blood out causing lipodermatosclerosis and poor oxygenation of the tissues. Presisposes to ulcers. Commonly on medial side of leg as this is site of GSV.

10. Pyoderma gangrenosum: Associated with inflammatory bowel disease

11. Examination of an ulcer
Site
Size
Shape
Colour
Depth
Discharge
Tenderness
Temperature
Local lymph nodes
Local tissues
Edge:
Sloping = healing ulcer
Punched out = syphilis, trophic
Undermined = TB
Rolled = BCC
Everted = SCC
Base:
Red = granulation tissue
Grey = slough

12. Management Keep clean and dry Antibiotics if infected Topical agents
Dressings:
4 layered bandaged technique for venous ulcers

13. Triangles of neck

14. Lumps in the neck Anterior Triangle Posterior Triangle Pulsatile
Carotid artery aneurysm
Tortuous carotid artery
Carotid body tumour
(Chemodectoma)
Non-Pulsatile
Thyroglossal cyst
Dermoid cyst
Ectopic thyroid tissue
Branchial cyst
Lymph nodes
Cervical rib
Cystic hygroma
Pancoast’s tumour
Subclavian artery aneurysm
BC = embryological remnant of 2nd pharyngeal cleft; upper 2/3 of the anterior border of sternomastoid; soft, fluctuant and transilluminates. Classically contains cholesterol crystals.

15. Thyroglossal cyst:
Moves up on swallowingand protrusion of the tongue

16. Multinodular goitre:
Most common type of goitre in the UK

18. EXAMINATION Introduction - ?obvious swelling ?scars HANDS: EYES:
Thyroid acropachy and palmar erythema
Temperature and pulse
Fine tremor
EYES:
Exophthalmos
Eye movements ?lid lag
Proptosis (stand behind patient)
Stand in front: ask to swallow
Protrude tongue
Stand behind: palpate each lobe separately; does it move on swallowing?
Palpate for local lymph nodes
?Tracheal deviation
Percuss sternum ?Retrosternal thyroid
Listen for bruit (Grave’s disease)
Ask patient to stand – proximal myopathy
If you find a lump describe it as you would any other, using previous descriptions

19. Focused history Symptoms of hyper/hypo – thyroidism:
Weight, Appetite, Sweating, Tremor, Palpitations, Menstrual irregularities, Irritability, Diarrhoea
Have they noticed a lump
Change in size over time?
Change in voice?
Any pressure symptoms?
Dyspnoea, Dysphagia
Diet (deficient in Iodine)
Any history of radiation exposure?
Family history

20. INVESTIGATIONS Biochemistry: Radiology: Special:
Thyroid status: T3, T4 and TSH
FBC, U+Es, Ca2+, LFTs and ESR
Radiology:
CXR
Ultrasound (solid, cystic masses)
CT scan
Special:
Fine needle aspirate (not reliable for follicular adenoma/carcinoma)
Tru-cut biopsy
Radioisotope scan (Tc99)
Laryngoscopy (?paralysis of vocal chords pre-operatively)
Not reliable because need to know as requires knowing if cancer has invaded through the capsule.

21. Management of Thyrotoxicosis
MEDICAL
Pharmacological:
Carbimazole; Propylthiouracil; Propanolol
Radioiodine (nb: teratogenic)
>50yrs old, recurrent episodes or post surgery
SURGERY
Once medical therapy failed or pressure symptoms
Sub-total thyroidectomy (after antithyroid drugs)
Collar incision

22. Soft, fluctuant, transilluminates
Cholesterol crystals on fna

23. Branchial cyst

25. Dermoid cysts Inclusion dermoids: Implantation dermoids:
At site of embryological fusion: midline neck, angle of orbit
Firm, not attached to skin
Rx = excise
Implantation dermoids:
Subcutaneous swellings after penetrating injury
Epidermal tissue introduced beneath skin

27. Ileostomy:
Spouted to avoid excoriation
Digitate lumen for patency
Check contents of bag: urine vs faeces

28. End colostomy:
Check patency of anus – patent: Hartmanns
Non-patent: AP resection
What operation could they have had this for:
UC/ diverticulitis/ Malignancy

29. Complications

30. Prolapse

31. Retraction

32. Necrosis

33. HOW WOULD YOU TREAT?

34. WHAT WOULD YOU DO???

35. WHAT WOULD YOU DO????

36. WHAT WOULD YOU DO???

37. Summary Covered common presentations for Finals Examination methods
Presenting your findings
Typical XRs in shorts
Google pathology
Questions?