Abdominal lump pelvic mass from bailey and love

It is a surgery ppt

1. D D’s AND APPROACH IN MANAGEMEN OF CASE OF ABDOMINAL LUMP- PELVIC MASS Vishnu P P ROLLNO. 98

2. 1. Parietal swelling Normally the urachus (the remnant of the allantois extending from the bladder to the umbilicus) becomes obliterated. If it remains patent, it forms a urinary fistula at the umbilicus in a new born baby. Closure of the umbilical and vesical ends and persistence of the middle segment gives rise to the urachal cyst. It is a cystic swelling,lies deep to abdominal musculature and is relatively fixed.

3. MANAGEMENT USG abdomen : Shows fluid filled enclosed lump in the location of urachus. Fistulography CT scan Urine analysis.

4. Surgical excision of embryologic remnants is the therapeutic mainstay for symptomatic urachal disease but preoperative management strategies often vary. Some advocate for a two-stage management approach focused on treating the urachal cyst infection with antibiotics and ultrasound-guided drainage before operative excision

5. 2. Distended urinary bladder Due to urinary retention Retention of urine means accumulation of urine in the urinary bladder. Patient unable to pass urine or passes small quantity of urine. Smooth, soft swelling. Dull on percussion . Normally resonant Acute retention – painful , chronic retention – painless. Per rectal examination Prostate and uterus pushed backwards and downwards.

6. ACUTE RETENTION Acute retention:sudden inability to pass urine - extremely rare and occurs only after anaesthesia, an injury to the urethra or afte a surgical operation. - In majority of cases there has been a chronic retention before the acute attack.Sudden inability to pass urine with severe pain and with an exaggerated desire to micturate is the main presenting feature of this condition.

7. CHRONIC RETENTION Gradual retention of urine because of the inability to v oi d completely Usually in elderly The symptoms may be in the form of increased frequency of micturition, difficulty of micturition or even overflow incontinence. O/e foreskin and urethral meatus ( phimosis meatal stenosis). The length of the urethra as far as the bulb should be palpated a stricture, periurethral abscess or presence of a stone or a foreign body. Urethral discharge, . The prostate must be examined

8. Bladder always palpable. It may reach the umbilicus or somewhere in between the pubic symphysis and umbilicus. It is neither tense nor tender. Pressure on the bladder does not initiate the desire to micturate (cf. acute retention). dull to percussion. – fluid thrill (if the patient is thin ) nervous system –Bladder sensation/micturition reflex arc may be inhibited by a disease of CNS Absent ankle jerk and diminished or absent cutaneous sensation in the perineum and perianal regions are usually associated with such lesion.

9. ACUTE ON CHRONIC RETENTION If an infection supervenes on a chronic retention it becomes painful

10. MANAGEMENT Investigations Clinical and sonological assessment of kidney, ureter, bladder Evaluation for obstructive uropathy and renal function Ultrasound abdomen Blood urea Serum creatinine Urine microscopy

11. Treatment Fine urethral catheter is passed and urological management is arranged Post op retention —warm bath can help CATHETERIZATION Aseptic precautions Lidocaine gel is inserted The jelly applied -posteriorly- anaesthetise - sphincter region A small Foley catheter should be passed while the penis is held taut

12. In a female patient, the labia should be parted using the middle and index fingers of the left hand Provided that a stricture is not the cause, the catheter should pass freely. Once urine begins to drain it is wise to pass a few more centimetre into the bladder . Afterwards. —volume drained ,examine abdomen

13. If catheter not passed Supra pubic puncture using commercially available catheter (cystofix or add a cath ),provided the bladder is palpable Urethral instrumentation –In a patient with a known stricture, an experienced urologist may elect to dilate the stricture or to take the patient to theatre to carry out an optical urethrotomy Intermittent catheterization in neurogenic bladder

14. 3. Urinary bladder carcinoma Initial symptom –profuse and intermittent haematuria. Later -symptoms of cystitis. Loin pain –obstructed ureter. When the growth has invaded the tissues around the bladder, pain in the suprapubic region, buttock, perineum and even down the thigh . tumour which is sessile, lobulated, deep red and bleeds to touch is a carcinoma. Unless a bladder tumour is large, it is not usually palpable. The majority of the bladder tumours (80%) are superficial i.e. not involving the muscle of the bladder wall.

15. Investigation Urine (culture and cytology) Blood (Hb, electrolytes,urea) CT,MRI IV Urograpghy (people with painless haemtauria ) Cystourethoscopy (mainstay of diagnosis) Bimanual examination before and after endoscopic surgical treatment.

16. Treatment Endoscopic surgery for non muscle invasive tumors Muscle invasive Radiotherapy Surgery Partial cystectomy –small adenocarcinoma Radicle cystectomy and pelvic lymphadenectomy

17. 4 . Carcinoma rectum Globally colorectal cancer is 2nd most common malignancy. Rectum is most frequently involved site accounting for 1/3rd of the cancers Can occur early in life, but usually above 55 years, Often, the early symptoms are so insignificant that the pt does not seek advice for 6 months or more, and the diagnosis is often delayed in younger patients as the symptoms are attributed to benign causes. Initial rectal examination and a low threshold for investigating persistent symptoms are essential.

18. Clinical f eatures Bleeding : earliest, most common symptom, bright red in colour and painless. It can be mixed with the motions or separate in the toilet bowel. indistinguishable from haemorrhoidal bleeding. Tenesmus: imp early symptom and is almost invariably present in patients with tumours of the lower half of the rectum

19. A lterations in bowel in habit : A patient who has to get up early in order to defaecate, or one who passes blood and mucus in addition to faeces (‘ early-morning bloody diarrhoea ’), is usually found to be suffering from ca rectum Pain : late symptom,colicky character Weight loss: late symptom

20. M ANAGEMENT Investigation Abdominal examination normal in early cases. Occasionally, signs of subacute large bowel obstruction may be present, with abdominal distension. an enlarged liver may be palpable along with other signs, such as cachexia. Rectal examination: neoplasm is situated within 7–8cm of the anal verge it can be felt on digital rectal examination as an elevated, irregular and hard endoluminal mass affords the opportunity to evaluate the anal sphincter complex,

21. Rigid sigmoidoscopy can be performed in the OPD and is useful to identify the neoplasm and possibly obtain biopsies colonoscopy is required in most patients to exclude a synchronous tumour, be it an adenoma or carcinoma.full colonoscopy is not possible, (stenosing cancer), a CT colonography or barium enema can be performed.

22. Spread Local circumferential spread Lymphatic spread Venous spread ;principle sites liver (38%) ,lungs (22%) adrenals (11%).

23. STAGES OF PROGRESSION-DUKES’ CRITERIA

24. TNM staging

25. TREATMENT ● Surgery is the mainstay of curative therapy ● The primary resection consists of rectal resection performed by total mesorectal excision ● Most cases can be treated by anterior resection , with the colorectal anastomosis being achieved with a circular stapling gun ● A smaller group of low, extensive tumours require an abdominoperineal excision with a permanent colostomy ● Preoperative radiotherapy with or without chemotherapy Can be used to down-stage the cancer and reduce local reccurance

26. Adjuvant chemotherapy can improve survival in node-positive disease ● Liver resection in carefully selected patients offers the best chance of cure for single or well-localised liver metastases Pre operative prep Counselling and siting of stomas,Correction of anaemia and electrolyte disturbance,Group and save of blood,Bowel preparation, Deep vein thrombosis prophylaxis,Prophylactic antibiotics

27. Results of surgery 5-year survival rate is about 50% and has not changed appreciably over the last decade. Survival rates are influenced by TNM/Dukes’ stage Local recurrence after rectal excision is a major problem. The patient may be asymptomatic with recurrence diagnosed as part of a surveillance programme, including regular measurements of blood carcinoembryonic antigen (CEA) and cross-sectional radiological imaging

28. 5. PELVIC ABSCESS U sually follows. Acute appendicitis Salpingo oopheritis Perforated peptic ulcer Puerperal sepsis common after anastomotic leakage following colorectal surgery.

29. CLINICAL FEATURES- T he most characteristic symptoms are pelvic pain Diarrhoea and the passage of mucus in the stools. Fever chills and rigor PR : bulging of the anterior rectal wall, which, when the abscess is ripe, becomes softly cystic.

30. INVESTIGATIONS Total count : raised Ultrasound is diagnostic — shows pus in rectovesical or pouch of Douglas. CT pelvis : size and extent.

31. Treatment S tart antibiotics Left to nature, a proportion of these abscesses burst into the rectum, after which the patient almost always recovers rapidly. Otherwise the absecess should be drained Posterior fornix (women)when the abscess is definitely pointing into the rectum, rectal drainage.

32. Laparotomy through lower abdomen incision is done to drain the pus and correct the cause when abscess is very large. CT or US guided drainage tube into the abscess cavity P/R, P/V or percutaneously.

33. 6. PELVIC BONE SWELLIN G Rare Bony hard consistency Fixity to any of the pelvic walls Physical examination, imaging tests like X-rays, CT scans, or MRIs may be used to diagnose osteitis pubis - Tr eatment: Rest, activity modification, ice or heat application, pain relief medication, and physical therapy are common treatment approaches. In some cases, surgery may be necessary.

34. 7. UTERUS Urinary bladder should emptied before palpation of uterus. Common swellings – pregnancy and fibroid uterus. Amenorrhea in young women with smooth uterine enlargement suggest pregnancy which is confirmed by classical signs and symptoms of pregnancy. Fibroid uterus Women above 30 before menopause , Irregular enlargement of uterus (expect submucous type)

35. Midline mass Smooth , hard. Lower border is not palpable which extends into pelvis Felt on per vaginal examination.

36. MANAGEMENT OF FIBROID INVESTIGATIONS pelvic ultrasound MRI Laproscopy TREATMENT Conservative treatment : bleeding control, shrinkage – GnRH agonist , Uterine artery embolism Surgeries: 1. myomectomy ( laparotomy, or laparoscopy) involves the removal of pedunculated, subserosal and/or (rarely) intramural fibroids, with closure of the defects left in the uterine wall. Transcervical resection of fibroid in fibroid within uterine cavity.

37. 8.F ALLOPIAN TUBE AND OVARY T UBO-OVARIAN MASS Results from c hronic salpingitis and oopheritis Young women Midline swelling or on one or the other side of midline Preceded by pelvic peritonitis in the form of pain, rise in temperature, bladder disturbance. Vaginal examination is confirmatory.

38. RUPTURED TUBAL GESTATION No lump in early stage Mass felt after few days on one side of the uterus or behind it. History of missed periods is a hint to diagnosis OVARIAN TUMOR AND CYSTS Central position Vaginal examination reveals attachment to the uterine cornua. Menstruation will be scanty or normal. Differentiating sign from ascitis : dullness on the front of the abdomen and resonant areas in the flank. BROAD LIGAMENT CYST Not as big as ovarian cyst. Diagnosis by vaginal examination

39. Management of ovarian cyst and tumors Investigation: TVS ,MRI or CT,tumors markers , pregnancy test Bilateral salpingo ophorectomy An oophorectomy may become necessary if the cyst cannot be surgically removed from the ovary. In carcinomas staging laprotomy is done treated with combination of chemotherapy and cytoreductive surgery

40. References Bailey and Love ’s short practice of surgery(28th edition) S das clinical surgery

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