16. Surgical procedures on bile ducts, Inflammatory disease of mammary gland & Hirschsprung´s disease

What is the definition of CHOLECYSTECTOMY?

Cholecystectomy is the surgical removal of the gallbladder.

What are the indications of CHOLECYSTECTOMY?

Indications include gallstones, cholecystitis, cholangitis, gallbladder cancer, and living donor liver transplantation.

What are the types of CHOLECYSTECTOMY?

The types are laparoscopy, which is the preferred technique, and open surgery.

What structures are removed in CHOLECYSTECTOMY?

The gallbladder is removed, and the cystic duct and cystic artery are resected.

What are the key steps in CHOLECYSTECTOMY?

Key steps involve identifying and resecting Calot's triangle, clipping or tying the cystic duct and artery, and dissecting the gallbladder from the liver bed, typically retrogradely.

What anatomical landmarks must be identified in CHOLECYSTECTOMY?

Calot's triangle, the cystic duct origin from the gallbladder neck, and the cystic artery must be identified.

What type of anesthesia is typically used in CHOLECYSTECTOMY?

General anaesthesia is typically used for this surgery.

What are the contraindications of CHOLECYSTECTOMY?

Contraindications include an inability to tolerate surgery under general anaesthesia, such as in cases of end-stage liver disease, portal hypertension, or coagulopathy.

What is the definition of CHOLEDOCHO-DUODENO (OR JEJUNO)-STOMY?

It is an anastomosis connecting the common bile duct to the second portion of the duodenum or jejunum, performed in a side-to-side fashion. It is a type of bilio-digestive anastomosis.

What are the indications of CHOLEDOCHO-DUODENO (OR JEJUNO)-STOMY?

Indications include stones impacted in the ampulla, primary common bile duct stones with a dilated common bile duct, and benign strictures of the distal bile duct. It is also performed if stones cannot be cleared or the duct is very dilated.

What is the definition of HEPATICOJEJUNOSTOMY?

It is a surgical procedure that creates a communication between the hepatic duct and the jejunum. This is another form of bilio-digestive anastomosis.

What are the indications of HEPATICOJEJUNOSTOMY?

Indications include common bile duct tumours, hepatic duct tumours, bile duct injury (e.g., iatrogenic or trauma), and infection or inflammation (e.g., pancreatic pseudocyst).

What is the definition of EXPLORATION OF THE COMMON BILE DUCT?

It involves making an incision in the common bile duct, usually in its supraduodenal part, to explore the biliary tree.

What are the key steps in EXPLORATION OF THE COMMON BILE DUCT?

Stone retrieval involves manipulation, irrigation, grasping with forceps, and using a balloon catheter. The choledochotomy is then sutured primarily or over a T-tube.

What is the definition of OPERATIVE CHOLEDOCHOSCOPY?

It is a procedure using a flexible fibre optic choledochoscope to check for and remove residual stones within the biliary tree.

What are the key steps in OPERATIVE CHOLEDOCHOSCOPY?

The procedure involves using the scope to check for and remove residual stones, then a latex T-tube is often put in to drain bile and provide access for cholangiograms.

What are the indications of DRAINAGE PROCEDURES (FOR STONES)?

They are performed if stones cannot be cleared from the common bile duct or if the duct is very dilated.

What are the types of DRAINAGE PROCEDURES (FOR STONES)?

Options include side-to-side choledochoduodenostomy or jejunostomy with a Roux-En-Y limb of jejunum. These are types of bilio-digestive anastomosis.

What is the definition of TRANSDUODENAL SPHINCTEROTOMY?

It is a procedure where the duodenum is incised transversely, and then the sphincter is incised to remove impacted stones. This is also known as papillosphincterotomy if the sphincter of Oddi is incised.

What are the key steps in TRANSDUODENAL SPHINCTEROTOMY?

The duodenum is incised transversely, the sphincter is then incised, and impacted stones are removed.

What is the definition of HEPATO-PORTO-ENTERO-STOMY?

It is a surgical procedure to create a connection between the liver and the small intestine to allow for bile drainage.

What are the key steps in HEPATO-PORTO-ENTERO-STOMY?

It involves connecting the porta hepatis to the jejunum via a Roux-en-Y limb.

What is the definition of WHIPPLE'S PANCREATICO-DUODENECTOMY?

It is a comprehensive resection procedure used for cholangiocarcinoma.

What are the indications of WHIPPLE'S PANCREATICO-DUODENECTOMY?

It is indicated for cholangiocarcinoma.

What structures are removed in WHIPPLE'S PANCREATICO-DUODENECTOMY?

It involves en bloc removal of the distal segment of the stomach (antrum), the first and second portions of the duodenum, the head of the pancreas, the common bile duct, and the gallbladder.

What are the key steps in WHIPPLE'S PANCREATICO-DUODENECTOMY?

Key steps involve en bloc removal of specific organs followed by the creation of new anastomoses.

What is the definition of ENDOSCOPIC DILATATION?

It is a procedure used to treat Primary Sclerosing Cholangitis.

What are the indications of ENDOSCOPIC DILATATION?

It is used to treat Primary Sclerosing Cholangitis.

What is the definition of PYLORUS-SPARING PANCREATICODUODENECTOMY?

It is a resection procedure specifically used for carcinoma of the ampulla of Vater, which spares the pylorus.

What are the indications of PYLORUS-SPARING PANCREATICODUODENECTOMY?

It is indicated for carcinoma of the ampulla of Vater.

What structures are removed in PYLORUS-SPARING PANCREATICODUODENECTOMY?

It involves en bloc removal of the first and second portions of the duodenum, the head of the pancreas, the common bile duct, and the gallbladder.

What are the key steps in PYLORUS-SPARING PANCREATICODUODENECTOMY?

Key steps include en bloc removal of the specified organs and the creation of new anastomoses.

What is the definition of CHOLEDOCHOTOMY?

It is an incision of the common bile duct, typically in its supraduodenal part.

What are the key steps in CHOLEDOCHOTOMY?

It involves making an incision to explore the biliary tree, and then the choledochotomy is sutured either primarily or over a T-tube.

What is the definition of PAPILLOTOMY?

It is an incision of the fibrous part of the papilla of Vater.

What are the types of PAPILLOTOMY?

It can be performed by endoscopy during ERCP or by open surgery via duodenectomy.

What is the definition of PAPILLOSPHINCTEROTOMY?

It is an incision of the sphincter of Oddi.

What are the types of PAPILLOSPHINCTEROTOMY?

It can be performed by endoscopy during ERCP or by open surgery via duodenectomy.

What is the definition of BILIO-DIGESTIVE ANASTOMOSIS?

It is a surgical connection created between the biliary system and the digestive system.

What are the indications of BILIO-DIGESTIVE ANASTOMOSIS?

It is performed either for bile drainage (as a palliative measure) or as a reconstructive procedure after resection of the extrahepatic biliary tree.

What are the types of BILIO-DIGESTIVE ANASTOMOSIS?

The gallbladder, common bile duct, or common hepatic duct may be connected to the duodenum, stomach, or a Roux limb of jejunum.

What is the definition of MASTITIS?

Mastitis is the inflammation of the breast tissue or breast parenchyma.

What is the classification of MASTITIS?

It is classified as milk stasis, noninfectious or infectious inflammation, and abscess.

What are the types of MASTITIS?

The types include puerperal and non puerperal mastitis.

What is the etiology of MASTITIS?

It is commonly caused by S. aureus, but also S. epidermis, streptococci, and rarely E.coli.

What is the pathophysiology of MASTITIS?

Pathophysiology involves infant manipulating the nipple, bacterial colonization, and milk retention. For puerperal mastitis, it is thought to be caused by blocked milk ducts or milk excess.

What is the clinical presentation of MASTITIS?

Early stages present with local pain, redness, swelling, and warmth. Later stages show systemic symptoms like fever, flu-like symptoms, malaise, and chills.

What are the signs of MASTITIS?

Signs include tender, firm, swollen, erythematous breasts, usually unilateral. Fever above 38 degrees Celsius may also be present.

What are the symptoms of MASTITIS?

Symptoms include local pain, pain during breastfeeding, and reduced milk secretion. Flu-like symptoms, malaise, fever, and chills are also common.

What are the diagnostic methods of MASTITIS?

Diagnosis is typically clinical. Breast milk cultures and imaging are used if there is no response to treatment. CRP and blood count can also be checked.

What is the pharmacological treatment of MASTITIS?

Analgesics like ibuprofen can be used. Antibiotics (dicloxacillin, cephalexin, amoxicillin, or cephalosporins) are used if there is a bacterial infection.

What is the surgical treatment of MASTITIS?

Surgical drainage is required if an abscess develops.

What is the prophylactic measures against MASTITIS?

Frequent emptying of the breast by breastfeeding is essential, along with maintaining adequate fluids. Oxytocin and breast massage can help with emptying.

What are the complications of MASTITIS?

Complications include recurrence, milk stasis, and abscess formation.

What are 3 main differential diagnoses of MASTITIS and how do we differentiate?

Inflammatory breast cancer is easily confused with mastitis due to similar presentation of swollen, red breasts. Differentiation relies on biopsy for inflammatory breast cancer, as it detects cancer cells in sub dermal lymphatics.

What is the definition of PUERPERAL MASTITIS?

Puerperal mastitis is inflammation of the breast connected with pregnancy, breastfeeding, or weaning.

What are the types of PUERPERAL MASTITIS?

Light cases of puerperal mastitis are referred to as breast engorgement.

What is the etiology of PUERPERAL MASTITIS?

It is caused by blocked milk ducts or milk excess.

What is the definition of NON PUERPERAL MASTITIS?

Non puerperal mastitis is an inflammatory lesion of the breast unrelated to pregnancy and breastfeeding.

What is the definition of INFLAMMATORY BREAST CANCER?

It is a rare, very aggressive type of breast cancer where cancer cells block lymph vessels in the skin of the breast. It often resembles an inflammation and may not have detectable tumours.

What is the classification of INFLAMMATORY BREAST CANCER?

It is staged as IIIA (less than one complete breast affected), IIIV (whole breast affected, possibly spread to adjacent tissues), and IV (metastasis to bones, lungs, liver, or brain).

What is the clinical presentation of INFLAMMATORY BREAST CANCER?

It presents with a quick onset of symptoms, including a swollen, red, painful, and itchy breast, often confused with mastitis. Skin changes (orange-like skin), nipple retraction/discharge, and swelling of lymph nodes in the arm or neck are also common.

What are the signs of INFLAMMATORY BREAST CANCER?

Signs include a swollen/red breast, nipple retraction, changes in breast tissue consistency, and swelling of lymph nodes under the arm or neck. Skin may appear orange-like.

What are the symptoms of INFLAMMATORY BREAST CANCER?

Symptoms include quick onset of symptoms, pain, and itching of the breast.

What are the diagnostic methods of INFLAMMATORY BREAST CANCER?

The only reliable diagnostic method is a biopsy, showing cancer cells in sub dermal lymphatics on skin biopsy. MRI, mammography, or USG may show suspicious signs.

What is the pharmacological treatment of INFLAMMATORY BREAST CANCER?

Treatment includes chemotherapy, radiation, and hormonal therapy. Patients with estrogen and progesterone receptor positive cancer have a better prognosis.

What is the surgical treatment of INFLAMMATORY BREAST CANCER?

Surgery, such as mastectomy or lumpectomy, is performed in some cases.

What are 3 main differential diagnoses of INFLAMMATORY BREAST CANCER and how do we differentiate?

It is easily confused with mastitis. Differentiation is primarily achieved through biopsy, which identifies cancer cells in the dermal lymphatics for inflammatory breast cancer.

What is the definition of FAT NECROSIS OF BREAST?

Fat necrosis of the breast is a nonsuppurative inflammatory lesion that affects breast adipose tissue.

What is the etiology of FAT NECROSIS OF BREAST?

It is caused by trauma.

What is the clinical presentation of FAT NECROSIS OF BREAST?

It presents as an irregularly defined and dense breast mass, generally periareolar, causing skin retraction, erythema, and ecchymosis. This presentation may mimic breast cancer.

What are the signs of FAT NECROSIS OF BREAST?

Signs include an irregularly defined and dense breast mass (periareolar), skin retraction, erythema, and ecchymosis.

What are the diagnostic methods of FAT NECROSIS OF BREAST?

Diagnosis involves mammogram and/or ultrasound, which may show a fluid-filled cyst. If findings are suspicious or inconclusive, a biopsy is performed, revealing foam cells and multinucleated giant cells.

What are 3 main differential diagnoses of FAT NECROSIS OF BREAST and how do we differentiate?

It may mimic breast cancer. Differentiation is made by biopsy, which shows foam cells and multinucleated giant cells in fat necrosis, distinct from cancer cells.

What is the definition of MAMMARY DUCT ECTASIA?

It is a subareolar periductal chronic inflammation condition characterised by dilated mammary ducts that eventually become clogged.

What is the etiology of MAMMARY DUCT ECTASIA?

The etiology is inspissated luminal secretion stasis, which leads to periductal inflammation and fibrous obliteration.

What is the clinical presentation of MAMMARY DUCT ECTASIA?

It presents with unilateral greenish or bloody discharge, nipple inversion, and a firm, stable, painful mass under the nipple that may mimic breast cancer. It can progress to a breast abscess.

What are the signs of MAMMARY DUCT ECTASIA?

Signs include unilateral greenish or bloody discharge, nipple inversion, and a firm, stable mass under the nipple.

What are the symptoms of MAMMARY DUCT ECTASIA?

Symptoms include a painful mass under the nipple.

What are the diagnostic methods of MAMMARY DUCT ECTASIA?

Mammogram and/or USG are used, as noninvasive imaging can determine duct diameter. Biopsy shows a central cavity filled with neutrophils and secretions, surrounded by inflamed and/or fibrotic breast parenchyma with duct obliteration.

What is the pharmacological treatment of MAMMARY DUCT ECTASIA?

Antibiotic therapy is given if the condition becomes infected.

What is the surgical treatment of MAMMARY DUCT ECTASIA?

Surgical excision is performed for persistent lesions. Most cases resolve spontaneously and do not require treatment.

What are 3 main differential diagnoses of MAMMARY DUCT ECTASIA and how do we differentiate?

It may mimic breast cancer. Differentiation is achieved through biopsy findings.

What is the definition of HIRSCHSPRUNG´S DISEASE?

Hirschsprung's disease, also known as congenital aganglionic megacolon, is a birth defect or inherited disorder primarily affecting newborns. It is characterised by the absence of ganglion cells in the myenteric plexus of an intestinal segment, commonly the rectosigmoid region, leading to a failure of relaxation and functional intestinal obstruction.

What is the classification of HIRSCHSPRUNG´S DISEASE?

The sources classify it by types rather than a separate classification.

What are the types of HIRSCHSPRUNG´S DISEASE?

The types include congenital, which is most common, and acquired types due to vascular causes like ischemia or non-vascular causes like vitamin B12 deficiency or TBC.

What is the epidemiology of HIRSCHSPRUNG´S DISEASE?

Hirschsprung's disease shows a male predominance. About 80% of cases are limited to the rectosigmoid region, and it is related to trisomy 21, other syndromes, and family history.

What is the etiology of HIRSCHSPRUNG´S DISEASE?

It results from the absence of ganglion cells in the myenteric plexus of the intestine due to migratory failure of neural crest cells. It is described as an inherited disorder.

What are the risk factors of HIRSCHSPRUNG´S DISEASE?

Risk factors include association with Down syndrome (Trisomy 21), other syndromes, and a family history of Hirschsprung's disease. Prematurity, gastrointestinal, urinary, and cardiovascular abnormalities are also associated.

What is the pathophysiology of HIRSCHSPRUNG´S DISEASE?

The pathophysiology involves the migratory failure of neural crest cells, leading to the absence of ganglion cells in an intestinal segment. This aganglionic segment cannot perform normal peristalsis or relax, causing contents to accumulate, leading to dilatation of the colon above it, constipation, and functional intestinal obstruction.

What is the clinical presentation of HIRSCHSPRUNG´S DISEASE?

Early presentation includes delayed passage of meconium, abdominal distension, bilious vomiting, and refusal to feed. In older children, chronic constipation with possible inability to pass gas may be the only sign.

What are the signs of HIRSCHSPRUNG´S DISEASE?

Signs include failure to pass meconium within 24 hours of birth, abdominal distension, bilious vomiting, and a tight hypertonic anal sphincter. Physical examination may reveal an empty rectum with a hard fecal mass in the abdomen.

What are the symptoms of HIRSCHSPRUNG´S DISEASE?

Symptoms include delayed passage of meconium, bilious vomiting, abdominal distension, and refusal to feed. Chronic constipation and failure to thrive are also common, especially in older children.

What are the diagnostic methods of HIRSCHSPRUNG´S DISEASE?

Diagnosis involves patient history, physical exam, and imaging like abdominal X-ray or barium enema. Rectal manometry and rectal biopsy are used for definitive diagnosis, with biopsy being the gold standard for confirming the absence of ganglion cells.

What is the pharmacological treatment of HIRSCHSPRUNG´S DISEASE?

No information in the sources.

What is the surgical treatment of HIRSCHSPRUNG´S DISEASE?

Surgical treatment usually involves a two-stage process: first, a diverting colostomy to relieve the dilated bowel, followed by resection of the aganglionic segment and anastomosis of healthy bowel. Alternatively, it can be done transanally, with preservation of internal anal sphincter function being crucial. Initial management includes decompression via rectal tube and irrigation.

What is the prophylactic measures against HIRSCHSPRUNG´S DISEASE?

No information in the sources.

What are the complications of HIRSCHSPRUNG´S DISEASE?

Complications include recurrent enterocolitis, toxic megacolon, and perforation. Chronic constipation and growth retardation can also occur.

What are the contraindications of HIRSCHSPRUNG´S DISEASE?

No information in the sources.

What are 3 main differential diagnoses of HIRSCHSPRUNG´S DISEASE and how do we differentiate?

No information in the sources.