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66
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CD4 of lymphocytes—T helper cells induce and control the
normal immune response.
SRB's Manual of Surgery
A B
Figs. 1.129A and B: Picture showing HIV kit and wearing of the HIV
kit as a precaution while doing surgery for HIV infected individuals.
HIV suppresses immune response completely directly by
suppressing ‘T’ cell, indirectly by suppres
it dismantles and destroys the immune system making the
individual prone to opportunistic infections.
sing ‘B’ cell. Finally
General Features in HIV
Weight loss more than 10%.
Fever more than 1 month.
Diarrhoea more than 1 month.
Neuralgia, arthralgia, headache.
Lymphadenopathy.
Cutaneous rashes, dermatitis, fungal (Candida), bacterial,
viral (herpes simplex 1 and 2) infection.
Dental infection, gingivitis, candidiasis of oral cavity and
oesophagus.
Varicella zoster infection.
Opportunistic infections.
Poor healing after surgery, trauma, infection with more
complications.
TUMOURS IN HIV INFECTION
B
x Kaposi’s sarcoma—40% common
x Lymphomas (NHL common) (3–4%)
x Cervical cancer
x CNS lymphomas
x Ano-genital squamous cell carcinoma
x Testicular tumours (Germ cell types)
x Lung cancer
x GIT lymphomas and adenocarcinomas
x Squamous cell carcinoma of anal canal and cervix
Fig. 1.130: Severe infection of ear cartilage in a HIV infected patient.
PULMONARY PROBLEMS IN HIV INFECTION
B
x Pneumonia
x Tuberculosis
x Fungal infections
x Pneumocystis carinii pneumonia
x Cytomegalovirus pneumonia
GIT PROBLEMS IN HIV INFECTION
B
x GIT infections—bacterial, protozoal, viral
x Kaposi’s sarcoma, lymphomas, adenocarcinomas
x Hepatitis (‘C’ virus), cholestasis
x Anorectal diseases
x Abdominal tuberculosis
After HIV infection, antibodies develop to virus envelope and
core proteins which persist throughout life.
Fig. 1.131: Kaposi’s sarcoma.
NEUROLOGICAL PROBLEMS IN HIV INFECTION
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B
x Encephalitis, aseptic meningitis, myelitis
x Neuropathies with demyelination
x Opportunistic infections like Toxoplasma, Crypto coccus causing
severe meningitis
x Primary CNS lymphomas
x CNS tuberculosis (Tuberculomas)
x Visual problems
Management
Investigations
Tests for HIV; Tests for specific and opportunistic infections.
Tests relevant for associated tumours.
Treatment
Antiviral therapy:
1.
¾
Nucleoside reverse transcriptase inhibitor (NRTI): Zido-
vudine, didanosine, abacavir, lamivu
¾
Non-nucleoside reverse transcriptase inhibitor (NNRTI):
Nevirapine, delavirdine.
¾
Protease inhibitors: Ritonavir, indinavir, ampre navir.
Treatment of opportunistic infections.
2.
3.
Treatment of tumours.
4.
Immunotherapy:
¾
Alpha and gamma interferons.
¾
Interleukins.
Bone marrow transplantation.
5.
6.
Anti-CD3 or IL-2 after HAART (Highly Active Anti-Retroviral
Therapy).
7. Psychotherapy.
8.
Counselling of HIV patients and their families.
Life-expectancy after initial HIV infection is 8–10 years.
9.
Prevention
Continues to be our best weapon in combating the menace of
HIV infection.
UNIVERSAL PRECAUTIONS AGAINST HIV
B
x Care in handling sharp objects like needles, blades
x All cuts and abrasions in an HIV patient should be covered with
a waterproof dressing
x Minimal parenteral injections
x Equipments and areas which are contaminated with secretions
should be wiped with sodium hypochlorite solution or 2%
glutaraldehyde
dine, stavudine.
x Contaminated gloves, cottons should be incine rated
x Equipments should be disinfected with glutaral dehyde
x Disposable equipments (drapes, scalpels, etc.) should be used
whenever possible
x Walls and floor should be cleaned properly with soap water
x Separate operation theatre and staff to do surgeries to HIV patients
is justifiable
x Avoid shaving whenever possible before surgery in HIV patients
x All people inside the theatre should wear dis posable gowns,
plastic aprons, goggles, overshoes and gloves
x Surgeons, assistants and scrub nurse should wear in addition
double gloves
x Suction bottle should be half-filled with freshly prepared gluta-
raldehyde solution
x Spilled body fluids should be diluted with glutaral dehyde
x Accidental puncture area in surgeon or scrub nurse should be
immediately washed with soap and water thoroughly
x Theatre should be fumigated after surgery to HIV patient
Safe sex. Condom usage reduces the risk of transmission.
Health education.
Use of disposable needles to prevent infections.
HIV, hospital and surgeon
Isolation per se of HIV patient is not required.
Proper care should be taken to prevent transmis sion of the virus.
Open wounds, disposal of excreta, fluids, dis charge, pus and
other infective materials should be taken care of properly.
Risk of HIV infection through needle prick is very less
(0.03%).
Following measures should be taken while managing HIV
patients:
Wearing double gloves.
Wearing proper spectacles (as HIV can get transmitted
through eyes directly).
Wearing proper head mask, theatre shoes, apron.
Measures to prevent spread of infection from patient to
patient in the hospital.
Disposal of needles through a sharp disposing container.
Disinfection
Autoclave is ideal.
Boiling.
Sodium hypochlorite solution.
2% glutaraldehyde solution.
67
CHAPTER 1D General Surgery: Infectious Diseases
The drops of rain make a hole in the stone not by violence, but by oft falling.
C hapter Outline
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E. Swellings
·
Lipoma
·
Cysts
·
Dermoids
·
Sebaceous Cyst
·
Neuroma
·
Fibroma
·
Neurobroma
·
Neurilemmoma
(Schwannoma)
·
Ganglion
·
Papilloma
·
Warts
·
Glomus Tumour
·
Bursae
·
Semimembranosus
Bursa
·
Morrant Baker’s Cyst
·
Lymphangioma
·
Lymph Cyst (Lymphatic
Cyst)
·
Calcinosis Cutis
·
Chordoma
·
Epignathus
‘Swelling’ is an obvious enlargement of a part of the body due
to various causes like congenital, inflammatory or neoplastic.
Mass denotes a lesion which has difficulty to define the extent,
e.g. mass abdomen; Lump denotes a defined lesion within an
organ or the one causing the alteration in the gross nature/shape
of a part or organ, e.g. breast lump.
A
Figs. 1.133A and B: (A) Swelling chest wall; (B) Multiple swellings in
the scalp with ulceration.
B
LIPOMA
It is a benign neoplasm arising from yellow fat. Often it can
be hyperplasia or combination of neoplasm and hyperplasia.
A lipoma is composed of mature adipocytes and uniform
nuclei that are identical to those seen in normal adult fat.
The fat in lipoma is considered unavailable for general
metabolism.
It is the most common benign tumour (karyotype 12
change). Prevalence is 2.1 per 100 people.
It is called as universal tumour (ubiquitous tumour) as it can
occur anywhere in the body except brain.
It can be localised (encapsulated) or diffuse (nonencapsu-
lated).
¾
Localised lipoma is encapsulated with yellowish orange
colour.
¾
Diffuse lipomas are not encapsulated and not localised. It
is common in palm, sole, head, neck. It is seen in subcutaneous and intermuscular tissues. It is difficult to remove
surgically. Recurrence is high after incomplete removal.
q
Fig. 1.132: Swelling scalp; could be sebaceous cyst.
A
Figs. 1.134A and B: Large lipoma in the nape of neck.
B
Lipoma can be superficial or deep.
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¾
Superficial lipomas are more common; common in subcutaneous plane. It is commonly seen on back, neck, proximal
extremities and abdomen. It is commonly less than 5 cm;
but can attain large size. There is no gender predisposition.
¾
Deep lipomas are commonly intramuscular, but often
may be intermuscular; often both intra- and intermuscular
(infiltrating lipoma). They are common in lower limbs
(45%), trunk (17%), shoulder and upper limb. They attain
large size compared to superficial lipomas. They are more
common in men.
Lipoma can be single or multiple.
¾
Single lipoma is common. It is usually superficial in
subcutaneous plane but can be deep also.
¾
Multiple lipomas are 15% common; common in males
(6:1). Common in back, shoulder and upper arm; can be
symmetrical. It can be associated with many syndromes
like multiple endocrine neoplasia (MEN), Cowden’s,
Frohlich, Proteus, Bannayan-Zonana syndromes.
¾
Multiple lipomatosis represents a diffuse overgrowth
of mature adipose tissue; extensively involves subcutaneous and muscular planes; common in shoulder
and pelvic girdles. It is common in younger age group.
30% of them are familial; Adiposa dolorosa (Dercum’s
disease) is a multiple lipomatosis mainly seen in
females (30:1—female to male ratio); there is tender
fat deposition especially in the trunk and girdles; it is
common in epileptic and psychiatric patients.
Benign tumour arising from brown fat is called as hibernoma
(reddish brown), which has got serpentine vascular elements.
Lipoma with fibrous component is called as fibrolipoma (most
frequent nonlipomatous component in lipoma is fibrous
tissue). Fibrolipoma is nonseptal.
Lipoma with telangiectasis is called as naevolipoma.
Neurolipoma (with nerve tissue and is painful), angiolipoma
(with vascular element), myolipoma, chondroid lipoma,
spindle cell lipoma, pleomorphic lipoma—are different types
depending on the type of nonadipose component associated.
Lipoblastoma is a benign tumour of immature fat occurring
in infant boys in subcutaneous tissue of extremity.
Benign lipomatous lesions may occur focally in a joint or
tendon sheath or with diffuse villonodular proliferation in
the synovium—lipoma arborescens. Synovectomy may be
needed in this patient.
Malignant transformation of lipoma is non-existent. Liposar-
coma does not arise from mature fat cells but from primitive
mesenchymal cells.
Sites
Clinical Features
Localised swelling, which is lobular (surface), nontender.
Often fluctuant like feel but actually not (because fat in body
temperature remains soft). It is usually nontransilluminant.
Mobile, with edges slipping between the palpating fingers
(slip sign).
Skin is free.
Lipomas may be pedunculated at times.
It is rare in children.
Pain in lipoma may be due to neural element or compression
to nerves or adjacent structures. Angiolipomas being highly
vascular is commonly tender.
Trunk is the most common site; nape of neck and limbs are
next common.
Clinically lipoma can be single, multiple or diffuse.
A
B
Figs. 1.135A and B: Diffuse lipoma on the plantar aspect of
foot and back.
69
CHAPTER 1E General Surgery: Swelling
ANATOMICAL SITES OF LIPOMA
B
x Subcutaneous; Subfascial
x Intramuscular; Intermuscular in anterior abdominal wall
x Parosteal; Subserosal; Submucosal (GI tract)
x Extradural (not intradural); Intra-articular; Subsynovial;
Subperiosteal, interosseous
x Intraglandular—breast, pancreas, kidney
Fig. 1.136: Slip sign of lipoma.
Eyes that look are common; eyes that see are rare.—J Oswald Sanders
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• A diagnostic criterion used by some clinicians for superficial lipomas
is hardening of swelling after application of ice. This test is of less
important.
SRB's Manual of Surgery
Fig. 1.137: Large lipoma in the back over scapula.
A
A B
Figs. 1.138A and B: Pedunculated lipoma. It is common in axillary
region. Lobular surface with narrow pedicle is typical. Often ulceration
can occur in the surface due to repeated friction. It often mimics
papilloma.
Differential diagnosis:
¾
Neurofibroma—it moves horizontally but not longitudi-
nally along the line of the nerve. Neurofibroma is firmer.
¾
Cystic swellings like dermoid, sebaceous cyst.
¾
Liposarcoma—all lipomas are benign. Large lipoma
should be differentiated from liposarcoma.
¾
Other soft tissue tumours.
Investigations: Ultrasound or CT or MR imaging is done
in deep or large or intracavitary lipomas; FNAC or incision
biopsy is needed in large or deep or intracavitary lipomas to
confirm it as benign.
Complications
¾
Myxomatous changes—occurs in retroperitoneal lipoma.
¾
Saponification; Calcification—11% mineralization.
¾
Submucosal lipoma can cause intussusception and so
intestinal obstruction.
B
Figs. 1.139A and B: Large lipoma in buttock region.
LIPOSARCOMA
B
x Common in retroperitoneum, thigh and back
x Rapid growth; Warm and vascular
x Dilated veins over the surface
x Infiltration into deeper plane with restriction of the mobility
x Skin fixation and fungation
x Blood spread to lungs
Treatment: Excision—small lipoma is excised under local
anaesthesia and larger one under general anaesthesia. Recurrence is 11%.
Note:
• It is now considered that all sarcomas are of de novo in origin to
begin with at mitochondrial level; so benign soft tissue tumour
turning into sarcoma is not existing (except of neural origin like
neurofibroma).
Fig. 1.14 0 : Gross feature of specimen of lipoma.
CYSTS
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Cyst is a collection of fluid in a sac lined by epithelium or endothelium. Word meaning of cyst is “bladder” (Greek) (Greek word
‘KUSTIS’ means bladder).
True Cyst
Cyst wall is lined by epithelium or endothelium.
If infection occurs, cyst wall also will be lined by granulation
tissue.
Fluid is usually serous or mucoid derived from the secretion
of the lining.
False Cyst
It does not have epithelial lining.
Fluid collection occurs as a result of exudation or degenera-
tion.
Example:
Pseudocyst of pancreas.
Wall of cystic swelling in tuberculous peritonitis.
Cystic degeneration of tumour.
After haemorrhage, in a haematoma, RBC’s are lysed, gets
absorbed and fluid remains as a false cyst.
“Apoplectic cyst” is formed in brain as a result of ischaemia,
causing collection of fluid.
CLASSIFICATION
B
a. Congenital cyst
– Dermoids: Sequestration dermoid.
– Tubulodermoids: Thyroglossal cyst, postanal dermoid,
ependymal cyst, urachal cyst.
– Cysts of embryonic remnants: Cysts from paramesonephric
duct and mesonephric duct, cysts of urachus and vitellointestinal duct.
Acquired cysts
b.
– Retention cysts: They are accumulation of secretions of a
gland due to obstruction of the duct, e.g. sebaceous cyst,
Bartholin’s cyst, cyst of parotid, breast, epididymis.
– Distention cyst: Lymph cyst, ovarian cyst, colloid goitre.
– Exudation cyst: Bursa, hydrocoele, pancreatic pseudocyst.
Cystic tumours: Dermoid cyst of ovary, cystade nomas.
c.
d. Traumatic cyst: Due to trauma, haematoma occurs usually in
thigh, loin, shin. It eventually gets lined by endothelium containing
brown coloured fluid with cholesterol crystals.
e. Degenerative cyst: Due to cystic degeneration of a solid tumour
(due to necrosis of tumour).
f. Parasitic cyst: Hydatid cyst, trichiniasis, cysticercosis.
Cyst can be single or multiple. Sebaceous cysts are often
multiple.
A
B
Figs. 1.141A and B: Traumatic cyst thigh with
false cyst wall with clot inside.
Effects of a Cyst
Compression of adjacent structures. Example: Choledochal
cyst compressing over the CBD.
Infection; Sinus formation; Haemorrhage.
Torsion, e.g. ovarian cyst.
Calcification, e.g. hydatid cyst, cysticercosis.
Cachexia: In malignant ovarian cyst patient goes for severe
cachexia.
SWELLINGS WHICH ARE BRILLIANTLY TRANSILLUMINANT
B
x Ranula x Hydrocoele
x Cystic hygroma and lymph cyst x Meningocoele
x Epididymal cyst (Chinese-lantern
pattern)
71
CHAPTER 1E General Surgery: Swelling
Clinical Features of a Cyst
Hemispherical swelling which is smooth, fluctuant, nontender,
well-localised.
Some cysts are trans illuminant.
Presentation varies depending on its anatomical location
and pathology.
There can be no substitute for detailed appraisal of the history and clinical signs.— Harold Ellis
A
Figs. 1.142A and B: Brilliantly transilluminant swellings—
possibly lymph cyst.
B
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DERMOIDS
Types
1. Sequestration Dermoids
It occurs at the line of embryonic fusion, due to inclusion of
epithelium beneath the surface which later gets sequestered
forming a cystic swelling in the deeper plane.
It is congenital type.
COMMON SITES ARE
B
a. Forehead, neck, postauricular dermoid.
SRB's Manual of Surgery
b.
External angular dermoid.
Root of nose; Sublingual dermoid.
c.
Anywhere in midline or in the line of fusion.
d.
Dermoids occurring in the skull may extend into the cranial
cavity.
When it occurs as an external angular dermoid, it extends
into the orbital cavity.
It can extend into any cavity in relation to its anatomical loca-
tion (e.g. thorax, abdomen).
TYPES OF ANGULAR DERMOID
B
a. External angular dermoid: It is a sequestration dermoid situ-
ated over the external angular process of the frontal bone. Outer
extremity of the eyebrow extends over some part of the swelling.
This typical feature differentiates it from the swelling arising
from the lacrimal gland. It may extend into the orbital cavity also
(Frontozygomatic suture).
Internal angular dermoid: It is a sequestration dermoid cyst in
b.
central position near the root of the nose. It occurs in frontonasal
suture line. It is rare. It mimics swelling from lacrimal sac or
mucocele of frontal sinus. Mucocele of frontal sinus is due to
blockage of frontonasal duct.
Nontransilluminating.
Free skin, often adherent into the deeper plane.
There will be resorption and indentation of the bone beneath.
Impulse on coughing may be present only if there is intrac-
ranial extension.
Differential diagnosis: Sebaceous cyst, lipoma, neurofi-
broma.
Investigations: X-ray skull or part; CT scan of skull or part
Treatment: Excision is done under general anaesthesia. Often
formal neurosurgical approach is required by raising cranial
osteocutaneous flaps.
Fig. 1.14 3 : Sequestration dermoid in skull—anatomical types.
Dermoid cyst contains putty like desquamated material, hair
follicle, sebaceous and sweat glands. It is lined by both dermal
and epidermal components.
Dermoid cyst in skull region has different anatomical types
as it often may extend into cranial cavity.
¾
Cyst which is located entirely outside the skull bone over
suture line but without bone indentation.
¾
Cyst located outside the skull bone but with a bone defect
underneath. Bone defect may be either on outer table of
skull or through both tables of skull with attachment to dura.
¾
Cyst lying partly outside and partly inside the skull with a
connecting stalk between the two like a dumb bell.
¾
Cyst is entirely within the skull bone between skull and
dura. It is very rare but known.
Features
Painless swelling in the line of embryonic fusion.
Presents in the second or third decade onwards.
Smooth, soft, nontender, fluctuant (Paget’s test positive, i.e.
swelling is fixed with two fingers and summit is indented to
get yielding sensation due to fluid).
A
B
Figs. 1.144A and B: Types of angular dermoid. (A) External angular
dermoid; (B) Internal angular dermoid (midline).
Fig. 1.14 5 : Postauricular dermoid in different patients.
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Fig. 1.148: Dermoid in the ear. It arises due to sequestration at the
fusion line of the one of the six developmental ear tubercles (Each ear
develops from six ear tubercles).
SUBMENTAL DERMOID
B
x It is a congenital sequestration dermoid occurs during fusion of
1st and 2nd branchial arches. It is deep to deep fascia of neck.
x It presents as soft, cystic, fluctuant, nontransilluminating, swelling
in midline in submental region which does not move with deglutition nor moves while protruding the tongue out.
x It should be differentiated from thyroglossal cyst, cold abscess
from submental lymph nodes or sebaceous cyst.
x It is excised under general anaesthesia with a curvilinear
submental incision.
73
CHAPTER 1E General Surgery: Swelling
A
Figs. 1.146A and B: Dermoid in the midline—suprasternal space of
Burns/sternum. It may extend into deeper plane and so it needs CT
chest and evaluation.
Fig. 1.147: External angular dermoid, right sided.
COMPLICATION OF SEQUESTRATION DERMOID
B
x Infection, haemorrhage, rupture
x Surface ulceration, calcification
x Pressure effects if there is intracavitary extension like into cranial
cavity or thoracic cavity, etc.
B
2. Tubulodermoids
It arises from the embryonic tubular structures; it is due to
accumulation of secretions of the lining of the unobliterated
portion of congenital ectodermal tube/duct.
Thyroglossal cyst: It is due to persistent thyroglossal duct during
development of the thyroid gland.
Ependymal cyst:They originate from the sequestration of the
neuroectodermal cells. They are benign neuroepithelial cysts
lined by ependymal cells. They are most commonly located
deep in the parenchyma. Ependymal cysts have been postulated to be the entity responsible for the interhemispheric
cysts with the Dandy walker cyst and agenesis of the corpus
callosum. Large cyst can cause obstructive hydrocephalous.
Post-anal dermoid: It develops from post-anal gut, i.e remnant
of neuroenteric canal probably as a teratoma; located in front of
the sacrum and coccyx. It is symptomless unless attains a large
size or infected or causes pressure symptoms. Rectal examination reveals the cyst. It is treated by complete excision. Coccyx
may need to be removed to have an easy access.
Urachal cyst: It arises from the remnant of the urachus; presents
as swelling in the midline at lower abdomen as extraperitoneal
mass. It can get infected, or rupture into umbilicus or peritoneal
cavity or calculi can form or adenocarcinoma can develop in
the cyst.
3. Implantation Dermoid
Due to minor pricks or trauma, epidermis gets buried into the
deeper subcutaneous tissue which causes reaction and cyst
formation (trauma is forgotten often). It is an acquired cyst.
Count your blessing not your problems.
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It is common in fingers (common in tailors, gardeners), toes
and feet.
Swelling is painless, observed after minor trauma, slowly
progressing in fingers or toes.
It is smooth, soft, mobile, tensely cystic, nontrans illuminating
and is often adherent to skin.
It contains only squamous epithelium, without hair follicle/
4. Teratomatous Dermoid
It arises from all germinal layers ecto-, meso- and endo-
derms.
It occurs in ovary, testis, retroperitoneum, media stinum.
It contains hair, teeth, cartilage, sebum and muscle.
It can be benign or malignant.
sweat or sebaceous glands.
Complications are infection, rupture and pressure effect over
digital nerves.
Differential diagnosis: Lipoma, bursa.
Treatment: Excision—under local anaesthesia.
SRB's Manual of Surgery
Fig. 1.151: Dermoid cyst ovary right sided.
A
B
Figs. 1.149A and B: Implantation dermoid finger
and thumb—classical site.
A
Fig. 1.152: Cut section of dermoid cyst ovary showing sebum.
B
Figs. 1.150A and B: Implantation dermoids in the
hand and foot.
Fig. 1.15 3: Twisted gangrenous cyst ovary.
SEBACEOUS CYST (Wen)
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It is a retention cyst. It is due to blockage of the duct of
sebaceous gland, causing a cystic swelling. Sebaceous
glands are situated in dermis which secretes sebum through
sebaceous duct which opens either directly to skin surface
or in to a hair follicle.
It is common in face, scalp, scrotum.
It is not seen in palms and soles as there are no sebaceous
glands.
Sebaceous cyst contains yellowish white cheesy material with
fat and epithelium. It has putty like consistency, with a parasite
in the wall of the sebaceous cyst—Demodex folliculorum. It is
lined by only epidermal layer of squamous epithelium.
Clinical Features
Painless swelling which is smooth, soft, nontender, freely
mobile, adherent to skin especially over the summit, fluctuant
(positive Paget’s test), non transilluminating with punctum
over the summit.
It moulds on finger indentation.
75
CHAPTER 1E General Surgery: Swelling
A B
Figs. 1.155A and B: Large sebaceous cyst in the face and
scalp. Note the hair loss on the surface.
A
B
Figs. 1.154A and B: Small sebaceous cysts in face and back with
typical punctum over the summit.
Fig. 1.156: Infected sebaceous cyst face.
Fig. 1.157: Sebaceous cyst showing moulding sign.
Punctum is present over the summit in 70% of cases because
here sebaceous duct opens directly into the skin which gets
blocked. Punctum is depressed black coloured spot over
the summit of the sebaceous cyst. Because of the denuded
squamous epithelium (keratin), it is black in colour. In 30%
cases, sebaceous duct opens into the hair follicle and so
punctum is not seen.
Do not go the way life takes you; take the life the way you go.
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