General 1

'It is more blessed to give than to receive.
By: II.B.
20tB
WhiteKnightLove
Freely you have received; freely give.
Index
Thyroid gland
i. Embryology....
2- Anatomy.
3. Physiology.....
4. Congenital anomalies-.--5. Goitre..
6. Simple goitre.
7. Toxic goitre.
8. Thyroid crisis...
g. Neoplastic goitre.
10.Thyroiditis...
ll.Retrosternal goitre.
12. Management of solitary thyroid
Serotum
l.
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nodule--.
Anatomy & embryologyMaldescended testes.

Inflammatory conditions--.--Testicular tumours..-Torsion testis.
2.
3.
4.
5.
6. Varicocele.....
7. Epididymal cysts & spermatocele-.
8. Encysted hydrocele of the cord.
9. Hydrocele of the hernial sac..-
10. Congenital & infantile hydrocele

11. Vaginal hydrocele.-.
12. Haematocele, pyocele & chylocele.....
Ifernia
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1. Anatomy of the inguinal canal.

2. Oblique inguinal hernia.
3. Direct inguinal hernia.
4. Recurrent inguinal hernia-.
5. Sliding hernia.
6. Anatomy of the femoral triangle.
7- Femoral hernia'
8. Exomphalos--.
g. Infantile umbilical hernial0.Paraumbilical herniall.Epigastric hernia..-..
l2.Incisional hernia
Burst abdomen14. Rare forms of hernia & lumbar hernia.

15. Complications of hernia
16.D.D of inguinal & scrotal swellings-.-...
13-
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Anutomg
Emhryology :
A The thyroid gland appears ernbryologically by the
of gestation from :l- Fktor of the primitiue phrr;runx :
S,d useek
Alftre thyroid gland appears
as an epithelial
proliferation (bilobed diverticulum)
from the floor of the pharynx at the base of the tongue at a point latter indicated
by the foramen caecum.
Attre thyroid gland descends to its anatomical position (in the lower part of the
front of the neck) through the thyroglossal duct (thyroglossal tract) which also
appears at the foramen caecum-
Attris part forms tlp
istlmxs Athl- mqiot P*t of eanJr loba
AAfter the thyroid gland reaches its location in the lower neck, the thyroglossal
duct undergoes obliteration and disappears.
l)ot SUtI ()l'
I (ItqU(!
['uUer <:rrl urn I illpar
(Anl.
2/l)
lll.,l)(rbr ;rr('lt
faln
I :r
i rrerrc c
il,o-st _ r/')t
-l
lr\;r
()1) I
ossa
t d i -su 1r1>ca: r's

(:Otrrl) I (, I (. I !,
<-
lryr=-r-gll-glr:l
Ilv.) i (l {lorc
CJ )
lrYr-()i (l Car-I i I ?)ge (C1. )
(rl.rli(tllc Ilidge
t-irI t- i l:r!te
of
Ihyr-old
(.1'i(:r)trt r:Jr'l i l:tge

I'yr:tilr id;rl
Lol)c ( *
Lc f t I-obe
l -5Ll)rnlr-s
I l'aclr(:a L
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i nlt-s
(C(r)
)
2- 4th pltarttnqeal oottr,h :
A Gives the ultimo-branchial
body that unites with the above part during its
descent.
A This part forms the tatproL Part of tlz furcid lobeitlre supettot pomthgrrit gtands.
_l
N.B. : the inferior parathyroid glands develop from the 3'd pt rwng.rl p;"t
3- Neuro,l erest :
A Gives the pam&{linrrlat a"lls tO-erlts) that reach the gland via the
ultimo-branchial body.
N.B.
The fetus starts making its own TSH by the 8th week.
And the follictes of the thyroid begin to synthesize thyroxine by
the loth week.
Anatomy cf the thyroid Sland :

STRUCTURE
S 2 lateral lobes.
S Isthmus
$ A small pyramidal lobe (*uy
be absent) projects from the isthmus
and
is
connected to the hyoid bone by a fibrous band called the levator glandulae
thyroidae (remnant of the thyroglossal tract)
SITE & SHAPE
H It lies in the front of the lower part of the neck in the mrrsor.lar triarqls
H
lfne normal thyroid gland is about 20-25 qms-
Each lobe measures
2rlrlinoles
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Each lobe is Pear shaPedwith its apex directed upwards while the whole
gland is
btfta&
in shape.
The apex of the lobe lies at the level of the obhf.s tine of
tl.^s
tJ.{roid
oant;loqe
H ttre base of the lobe lies at the level of the 56 ot 6& tracheal
H
The isthmus lies opposite the
CAPSULE
2il,3r{- 4etracheal
rings.
rings
*True fibrous capsule : from the C.I of the gland itself

*False fascial capsule : from the pretrachealfascia.
N.B. : The
suspensory ligament of Berry
ls thickening in the pretracheal fascia that fixes the

posteromedial part of each lobe to the cricoid cartilage-
Thlroicl Cartrlage
Cncoicl Cartilage
[r.i roitl ( J !:lurl

Pyranriclal Lobe
Right Lobe
Istluuus
Left Lobe
Trachea
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RELATIONS OF TTIE THYROID GLAND:
Arttero lnteral srrrfuee :

1. Skin, superficial fascia containing the plaQsma muscle
&
deep fascia
2. Superior belly of omohyoid in its upper part.

3. Sternohyoid
& sternothyroid
muscles.
4. Sternomastoid muscle overlapping the lower part.
Nledial surfaee
* Upper psrt:
l.
Larynx ( Cricoid & thyroid cartilages & -c_ricothyroid muscle
2.
Pharynx
3.
ELN in between
,n.d'
gtfot>
Lower part:
1.
Trachea.
2.
3.
Oesophagus.
RLN in between
Posterior
str;rfo,ee :
l. Superior & inferior parathyroid glands (between the false & true capsules).
2. Carotid sheath ( CCA ; IJV & Vagus nerve )
3. Sympathetic chain outside the sheath & behind it
4. Inferior thyroid artery before it enters the gland
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l. Superior thntroid, arteru :

H Branch from the external carotid artery.
H It is related to the external laryngeal nerve.
2. Inferior Jhqroid. arteru
H Arises from the thyrocervical trunk which is a branch of the first

part of the subclavian artery.
H Its terminal branches near the gland are in close relation to the
recurrent
la
ryngeal nerve.
3. Thuroid itnrl- arteru
H Might be found from the arch of the aorta or the innominate

4. Aecessorq traaltea,l & esopltrr,qeal brannc,h,es.
In
terna
External
artery"
Carot
a.
tr1
Strpe_.r'icrr
'l'hyroid
?l
Common
Irrferior
l'hy ro
id
Sca I enus
.+--
Ant. tlusc I e
l'ralrsverse
Cerv i ca
Suprascapu Iar-
Left
subclavlan
Thyro-cervi
l-r
ca I
rrn k
Thyroi<l Ima a
I nnom i nat,e
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'/enous frainage :
Superior thqroid, aein : Drains into the internal jugular vein.
, IWiddlc thqroid aein : Drains into the internal jugular vein.
H ivtiaale thyroid vein is the shortest vein so it should be the first
7.
vein to be ligated & divided during thyroidectomy.
3. Inferior thuroid roeil$:

H Join the left innominate vein
(brachiocephalic vein)
or
the
innominate vein of the corresponding side.
Internal Jugular v.
Superlor Thyrold
V.
Mlddle Thyrold v.
subc I av I an v.
Innomi
nate v.
Inferlor Thyroid v.
Superior' venB Cava
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Lyrytfratic frainage :
Peripheral part :
l.
Upper deep cervical tymph nndes.
2. Lower deep cervical lymph nodes.

Medial psrts :
1. Prelaryngeal lymph
nodes ( Poirier).
2. Pretracheal lymph nodes (Delphic).

3. Mediastinal lymph
nodes.
Upper deep eenvical
prelaryn geal
glands.
pretracheal
glands __
glands
,,,
r,
l/\l
r,
l,/
v
lr f,t
-Nrr
ll
.t
.t
It
t
t -t ./---\
!r
tl
aI
v rr
/S,i./\
rr
Lower deep cervical

glands
I.nternal Laryngeal
R
i a,ht-
Left Vagus
External Laryngeal
vagus
Right Recurrent
Laryngeal n.
Cri co-ThyroId
Risht Subclavlan
Ar tery
Left Recurrent
Musc I e
Laryngea I fi .
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A: Zhe su".erior thuroid aessels ane related to tlte

erternal larunoeal nerae ausau froru tlte oland:
V
The ner-ve arises from the superior laryngeal nerve which is a branch of
the vagus nerve.
t2 This nerve is motor to the cricothyroid
muscle
& inferior constrictor
muscle of the pharynx
When the nerve injured
it leads to loss of high pitched voice ( hstir,ss
of toico = moaotoaorrs taotcs).
To avoid injury of the ELN during thyroidectony, the superior thyroid

vessels are ligated near or even
within the gland
Sup loryngeol
A internol
B.
n-
br.
externol
br:
Sup.
thyroid
o,
.Cricothyroid m
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inferior thuroid arteru branehes are related

to the reeurrent larunqeal nerae near the qland:
,R: Zhe
Course of the QLN :

H
1itre Rt.
RLN is a branch of the Rt. Vagus nerve & hooks around the
ld
part of RL Subolaran 0ftP4.
H The Lt. RLN is a branch of the Lt. Vagus nerve & hooks around the
l4amentr.m artetimurn
urrdp;-
tlp
aroh of tl..e oMto.
This antrl"tornieo,l urr;rio,tiort, is related to etnbrgologieal

aspeets as the ,RLN is th.e nerDe of the 6'h brunchio,l olreh.
The distal part of the Rt. 6th arch artery disappears leaving the Rt. RLN to
turn around the Rt. 4th arch artery which is the Rt. Suhclavian.
The distal part of the Lt 6th arch artery forms the ductus arteriosus.
Each nerve then ascends obliquely upwards
& forwards in the tracheo-
oesophageal groove closely related to the posteromedial surface of the
thyroid lobe between the branches of the inferior thyroid artery.
H The nerve then disappears under the lorrer boder of t],.e

infeliot ooastrinjtot rursele of
tls
Ph"rgn q passes behind
the oticot[groidjoi"t and finally enters the larynx at the
hfuio,r hotn of th{rcd eartdag e "McGregor's surgical

anatomy"
H The nerve during
its terminal course runs medial or lateral
or through theBerry's l4arnent "Last's Analomy"
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Branclres of the QLN :

H Cardiac branches to the deep cardiac plexus.
H Anterior terminal branch "motor" to all intrinsic muscles of the larynx
except the cricothyroid muscle.
Posterior terminal branch "sensory" to the mucous membrane of the larynx

below the vocal folds.
How to avoid
iniury of the pLN during thrrroidectomy
H In the past surgeons used to ligate the inferior thyroid artery away from gland.
H And it was ligated in continuity to avoid fall of the proximal stump in the
chest which necessitates thoracotomy
if slipped ligature occurs.
H lBut ligation of the inferior thyroid artery away from gland carries the risk
of damaging the blood supply to the parathyroid glands with subsequent
hypoparathyroidism.
TLe best nou)
is
to identify the RLN along its whole course to avoid its
injury & then ligate under vision the inferior thyroid artery after giving its
branch to the superior parathyroid gland (i.e. ligate its terminal branches
near the gland).
Ways of
identification of the
QLN :
H It can be palpated as a tight strand in the tracheo-oesophageal

H Forms the medial border of a triangle bounded
superiorly by the inferior thyroid artery & laterally by
the CCC "Skandalakis surgical analomy"
H If it is difficult to identify
the RLN, use the ner-e stimulator.
l0
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groove.
lYhat is the non recurr.ent pLN ?

The nerye might be non recurrent in small
percent of cases in the Rt. side. (ln this
situation it might be injured with
the middle thyroid vein).
fffect of iniur^y of the
QLN :
- --l
lniury to thc rccurrc.t larv.geal nerve leads t.
Conrplctc
Urrilaleral
Unil:rtcral
Bilateml
Dysnca <ln crccrtit)n
Stridor
Bil:"rter-:rl
rl
l+
Hrurlsencss
N.B
ol-voicc
apltonia
O
O
Fibers of the adductors are in the middle of the RLN.

Fibers of abductors are in the periphery of the nerve.
lf both RLN &
ELN nerves are iniured
The cord is in the cadaveric
position i.e airway is good but voice is poor.
Imrrortant Questions & Answers

O Because itis enclosed within the pretracheal
the thyroid cartilage
Q: What is
& hyoid bone
so
fascia which
is attached to
it moves with them during swallowing.
tlw attaehment of the pretro,eheo,l fo;seill- ?
Upward : oblique line on the thyroid cartilage
Below : the fibrous pericardium.
ll
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& hyoid bone.
On bolh sides.' the carotid sheath.
Q: Wh,at are the contents of th,e plretr.,,elr.eul fq,seig- (i.e.

struetrwes mobile with. d,eqhLtitionl ?
l. Thyroid & Parathyroid glands.
2. Thyroglossal cyst & tract if fbund.
3. Pretracheal
& Prelaryngeal L.Ns.
Q: Wh,at rm,oues hqoid bone

1. Digastric muscle
4. Subhyoid bursa.
& thuroid curtiloqe up? The suprahyoid ms:
O Anterior belly supplied by mandibular nerve (nerve of 1" arch).

@
Posterior belly supplied by facial nerve (nerve of 2"d arch).
2. Mylohyoid muscle : (mandibular
nerve).
3. Stylohoid muscle : (facial nerve).

Q: Whnt moaes the lwoid bone & thuroid. cartilacre d.ottyt,?
Infrahyoid ms
Strap ms: prelracheal ms:-
1. Sternohyoid.
2. Sternothyroid.
3. Thyrohyoid.
4. Omohyoid.
Nerve supply : Ansa cervicalis (C 1,2,3 ) except thyrohyoid by

nerve to thyrohyoid ( Cl ) which is a branch from the hypoglossal nerve.
Surqical anatomv: The
ansa cervicalis enter the muscles
from below so the
muscles must be cut as high as possible during thyroidectomy.
Ansa cervicalis : ansa = loop

O lt lies infront of the carotid sheath.
lt
is formed by the union of 2 descending nerves
a. Descendens
hypoglossi : branch of Cl
via the
hypoglossal nerve
b.Descendens cervicalis G2 & C3 : branch of the

cervical plexus
t2
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Q: Wtnt is the strrfo,ce anatomu of the CCA ?

O Lower 2/3 of line drawn upwards & backwards from the
sternoclavicular joint to a point midway the angle of the mandible

and the mastoid process.
Thyroid Cland Physiolcgy

THYROI
GLAND
CI RCULATION
I norgan i c
Organic
iodine
iodine
*
I
iodoLYros
'[yros i ne
Jttorro
rl
odolyrosi
LDi
ne
T:
To
l1
ll
I
I
I
I
BI NDI NG
TRAPP I NG
SYNTHESIS
COUPLI
NG STORAGE
RELEASE
l) Trupping
of inorganic iodide from the blood. This is an active process
dependent on ATP.
2) Orido;tion, of iodide into iodine by the peroxidase enryme.

3) Binding of iodine with tyrosine by the fyrosinase "peroxidase" enzyme
to from mono and di-iodotyrosine
\ Cou,pling of mono-iodotyrosine
(organifi,cution).
and di-iodotyrosine to from T3 and T4
"thyroxine" by the coupling "peroxidase" enzyme
5)
T3 & T4 unite with thyroglobulin and are stored in the follicles
l3
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RETEASE
Release of T3
N.B
&T4 from the colloid
is done by protease enzyme.
Thyroid hormones that are secreted from the gland are about 90"/o T4 and
about l0oh T3.
T3 is the quick acting physiologically hormone, being also produced by
peripheral conversion from T4 within cells by deiodinase enryme
T3 & T4 in the circulation are carried on plasma proteins (Thyroxine binding
globulin "TBG" & thyroxine binding prealbumin "transthyretin").
O
O
Only
0.3'
of T3 is free & 0.03% of T4 is free.
Half life of T3 is few hours while half life of T4 is 10-14 days.
t4
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thyroid gland
Diseases of the
Congenital enomalies
l- Frctopic thyroitl :
A Usually part of the gland ( rarely the whole gland ) along the
course of the tract e.g. lingual, cervical or mediastinal
[Al Lingual thgroid

C/P : b. Tongue swelling.
a. Impaired speech, dysphagia and respiratory obstruction.
INV :
TTT
:s.
Thyroid scan is a must as it may be the only thyroid tissue in the body
H If it is not the only thyroid tissue )
H If it is the only thyroid
tissue:
I. Medical ttt with L-Thyroxine

2. If medical
Surgical excision.
is started
first but usually fails.
ttt fails ) Surgical excision & replacement therapy.
[Bl Median [Eervicall Ectopic ttrgroid :
e/P
D.D :
Sotia midline neck swelling moving up and down with deglutition.
Thyroglossal cyst (cystic with Paget's test) & all midline neck swellings.
INV :
Neck U.S to differentiate between it & thyroglossal cyst.
O Thyroid scan as it may be the only thyroid tissue in the body.
TTT
@ Excision if it is partially ectopic.
e Leave it if it is totally ectopic.

[El Retrosternal ectopic thgroid :
l5
WhiteKnightLove
see
later
2- Corrr$enital aplasia or hylroplasia : )
Cretinism.
3- Physiological anornalies :
O In-born error of iodine metabolism
due to peroxidase enzyme
deficiency within the gland known as Pendered's syndrome in
which there is goiter, deafness, mental retardation
N.B :
LATERAL ABERRANT THYROID
It is L.N metastasis of an occult papillary carcinoma.

STRUMA OVARII : (STRUMA : GOIRE)
It is a part of ovarian teratoma.
4- Thyrogflossal cyst:
CAUSE i Non obliteration of part of the thyroglossal track .
STRUETURE
&
PATTIOLOGY
O Linine : (columnar
epithelium)
@ Content : (mucus)
@ Wall: (contains lymphoid tissue)
SITES I * Lingual (rare). * Suprahyoid (rare). * Infrahyoid
AGE
c/o
O
(common).
5-7 years.
Slowly growing, painless, cystic swelling in the midtine of the neck
moving up and down with deglutition
& tonque ptuttusiort.
OIE I
We have to feel the tract above the cyst (pathognomonic).
D.D :
Median cervical ectopic thyroid & all midline neck swellings.
INV
@ Thyroid scan is a must
as
it may be the only thyroid
l6
WhiteKnightLove
tissue in the body.
Neck U.S to differentiate it from cervical ectopic thyroid.
COMPLICATIONS
* lnfection & inflammation as the wall of the cyst is rich in lymphatics.

* Thyroglossal fistula.
Thyroglossal fistula
ETIOLOGY :
Always
acquired
(never congenital)
(A) Incomplete excision of thyroglossal cyst.

(B) Drainage or rupture of infected thyroglossal cyst.
c/P
e/O I
otB
Discharging opening in the neck
A Ttre opening is near the midline on the left side & is overlapped by
a transverse crescentic skin fotd (pathognomonic) that
becomes
more apparent on tongue protrusion.
A Ttre opening
moves up and down on tongue protrusion and with
deglutition.
The tract is felt above the fistula (pathognomonic)
The discharge is serous or purulent.
INV !
Same as thyroglossal cyst.
TTT OF CYST AND FISTULA : Sistrunk"s operation :

A Surgical excision of the cyst & (fistula) and its associated track up to
the base of the tongue & this requires removal the middle third of the
hyoid
bone.
A If it was the only thyroid tissue )
l1
Replacement therapy after excision
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Goitre
It is enlargement of thyroid sland
ELASSIFIEATION
I- Sirnple goitre :
1. Diffuse goitre.
a)
Physiologic
b) Colloid
2- Nodular goitre.
II- Toxic goitre

I Primary or diffuse toxic goitre "Graves' disease".
2 Toxic nodular goitre "Plummer's disease".
3 Toxic nodule
4 Rare causes.
Ir[- Neoplasdc goitre
Benign.
Malignant goitre.
fV- Inflarrunatory goitre = Thyroiditis
Auto-immune thyroiditis as Hashimoto s thyroiditis.
2
3
4
Sub-acute thyroiditis (viral).
Collagen disease as Riedle's thyroiditis.
Bacterial specific as TB, Syphilis.
or acute suppurative (very very rare).
l8
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Simple Goitre
Non inflammatory, non neoplastic, non toxic enlargement of the thyroid gtand
ETIOLOGY
Persistence decrease in the level of circulating T3
& T4
Stimulation of anterior pituitary gland

I
Increase TSH
I
Thyroid enlargement
l.lodine deliciency t Most important lactor I :
Daily requirementsfor adults is 0.1 mg/day:100 - 125 pg/day

A) Absolute deficiencV : in the soil, food or in water supply as in oasis
and mountains.
B) Relative deficiencv : during stress periods of life as puberQr,

pregnancy, lactation, etc.
ll. Delect
in synlhesis of thyroid hormores:
A) Goitroqenic substances
Dietary : cabbage and cauliflower contain thiocyanate that blocks the

active transfer of iodide into the follicles.
A Pollution of water by human or animal excreta.

A Drugs : That contain iodide preparations and used by asthmatic
patients for long periods.
S*Pri.*gh I, ir" large quartilics
is gottmguric os il, inkbils tho otgartio btndtng steP
B) Enzvmatic deficiencv with in the thvroid qland
l9
WhiteKnightLove
see before
PflTTTOPYSruLOCY OF SIMPLE GOITRD

Stress (
relative Vof iodine
) ., T3 & T4 + 4 TSH )
a,
Hyperplasia & hypertrophy of the gland

.1,
Physiological goitre
Stress
will be
alz
Over
Repeated
* Complete involution
(uncommon) or.
* Incomplete involution.
Prolonged with hyperinvolution

I
tI
Nodular goitre
Colloid goitre
Parenchymatous goitre
l- Simple Dhysiological (also lcnown as

Hyrrerrr I asti c = rDa ren ChymatoltS = D iffu se) Goitre
C/P : * Female in puberty * Pregnancy. * Lactation
SYMPTOMS
* Painless mild enlargement of gland
SIGNS
General
: NAD (i.e. : no signs of toxicity).
Local:
@ Gland is mildly enlarged.
O Diffuse, smooth, mobile, symmetric & fleshy

O No toxic, pressure or infiltrative signs.
TTT
O
Reassurance (Venus neck).
20
WhiteKnightLove
Iu
intake
O L-rhyroxine tab 0.3m g tday gradually tapered to 0.1 mg / day for

many years.
l!- Colloid Goitre

When thc stress is prolonged , tne gland becomes exhaustcd and
hyperinvolation
o GGU
ts.
And with lz therfl[y, lhe
follicles [ecome distended with thy]oglobulim
leading t0 Golloirl goitre I A rare [athological entity I

PATTIOLOGY
*
*
*
N.E : diffuse, smooth, symmetrical, soft or elastic gland.
Cut section : golden brown and glistening.

Microscopically : Large acini, fully distended with colloid &
lined with flattened epithelium.
C/P :
OFemale 20-30 years.
0 Moderate
enlargement which is diffuse, smooth, symmetrical,
soft or elastic gland.
O May reach huge size.
COMPLICATIONS
TTT
pressure on the trachea
L-Thyroxinee tab 0.3 mg I day --, decreases the size ---+ therapeutic
trial.
Subtotal thyroidectomy four huge goitre or failure of medical ttt.
2l
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lll- Simple Nodular Goitre

With repeated cycles of hyperplasia and involution & fluctuation in
TSH level, for unknown reason the process tends to become irregular
affecting different pads of the gland in different ways, also

hemorrhages uccur in the areas with hypervascularity producing
central necrosis and fibrous tissue tends to form around these areas
investing them with capsules and thus nodules are formed resulting in
nodular goitre.
The nodules ale inactiue and
FORMS
: *S.M.N.G.
PATTIOTOGY
t[e actiue follicles a]e ]resent in between.

*Solitarynodule
il.E:
V Gland is enlarged, firm & irregular.

V With multiple nodules (l-3cm) and may be cyst formation.
V Cut section Honeycomb appearance.
MiC: Multiple nodules with incomplete fibrous capsule
c/P
c/o
H Painless swelling in the neck & cosmetic disfigurement.

H Mild pressure symptoms mainly dyspnea.
H One of the complications may be the presenting symptom.
otE
Geneml: NAD (i.e. : no signs of toxicity).

locar
: Swe,in:
''J::
'r"' T:,'r',:l;;"-
Shape t
Surface
with the ro,owing criteria:
butterfly or irregular in shape.
nodular
22
WhiteKnightLove
Special character
Edge I
moves up
well defined.
Consistency
firm or fleshy.
Relation to surroundings
COMPLICATIONS
& down with deglutition.
normal.
1- Toxic changes | 25 o/o to toxic nodular goitre.
2- Malignant change: 3-5o
Follicular carcinoma or anaplastic (rare).
3- Cystic degeneration in the nodules.
4- Haemorrhage inside cyst
(A) Subclinical
(B) Acute ---+ sever
pain, Dyspnea
& suffocation.
The suffocation is [Qt only due t0 sudden Gom[]ession on the tlaonca by thCI
enlarged cyst but due t0 rellcx s[asm
im[aiment
0J
the p]etracheal muscles leading t0
0[ uenous d]ainage 0I me larynx & laryngeal edema.
TTT : Aspiration & then urgent thyroidectomy

5- Retrosterna! extension & Pressure changes : (2 tubes, 2 nerves,2 vessels).
AlTrachea: )dyspnea
V Unilateral compression ) kink.
V Bilateral compression ) scabbard trachea.
V Tracheomalacia & laryngeomalacia in long standing goitre.
Bt Esophagus
Ct lnternal
: )
Dysphagia
jugular vein :
Dl Common carotids : I
EI R.L.N.
Dilated veins on the sternum & edema of face.

Postu
ral dizziness (uncommon).
Hoarseness of voice (uncommon).
Fl SVmp. Trunk : Horner's

N.B.
syndrome (very rare).
All these pressure manifestations (except trachea & IJV) are more
common with malignant retrosternal goitre.
73
WhiteKnightLove
INV :
1. Thyroid
function tests:
V Total serum T3 & T4.

V Free serum T3 & T4 : (More accurate than total).
V Serum TSH.
Free serum T3 is 3-9 pmol/l
Free serum T4 is g-27 pmolr/l
2. Neck U.S
V Differentiates befween diffuse & nodular goitre.

V Detection of impalpable nodules.
V Differentiates between solid and cystic nodule especially if the
patient is presented by the solitary form of SNG "solitary nodule".
3. lndirect Iaryngoscopy:
V
V
To asses vocal cord mobility preoperative.

Medico legal aspects as 3-4oh of people have idiopathic vocal cord
paralysis on one side.
4. X-ray chest
5. Thyroid scan
TTT
to exclude retrosternal extension.
May
be done
but it is not a routine in sMNG.
Subtot l tlwroideetotnu follawed blt L-Thyroxirte O.l-o.2 m.g

/dW till menoprr;u,se to ansoid. reeurrettee is the elossie treatmcnt.
ln subtotal thyroidectomy for simple goitre (previously known as partial
thyroidectomy), the whole gland is removed leaving on each side a part
equivalent to a normal lobe (2x1x1 inches).
This pad left is always from the posteromedial part of the lobe
Airn of the operation
l.
To prevent complications.
2. For cosmetic purposes.

24
WhiteKnightLove
3. To relieve the pressure symptoms if present.

OtLer rr,orieties in treatrnent :
7) Medical treatment
: L-Thyroxine
0.1-0.2
^g
lday & follow up
V ft gland is mildly enlarged.

V No pressure symptoms.
V Female less than 25 years of life.
N.B.: This option is recommended by some surgeons especially if the
nodules are less than 1 cm in diameter
2)Totat thyroidectomy & post operative replacement therapy :
V No incidence of recurrence.
V No need for completion thyroidectomy if there was a histological
surprise "histologicol surprise means that after operationfor SMNG,
the hislopathological examinalion of the removed specimen revealed
malignant goitre".
V Both patients undergoing total or subtotal thyroidectomy will

postoperative L-thyrox ine
" i. e. :
ub
total thy ro idecto my
do es n'
need
h uv e
lhe advantage of no postoperative medication".
Concerning the problem of total or subtotal thyroidectomy, many

surgeons advise now to do total lobectomy of the more affected lobe
and subtotal lobectomy of the other one so as to decrease the
incidence of complications of total thyroidectomy.
25
WhiteKnightLove
TO'ITC GOITRE
ErlorocY & Curulcnl Tyrrs

(1) Diffuse Toxic Goitre : (Primary toxic
goiter: Graves' disease) :70-7Soh.
It is ant, autoilnnunte disease (Type V hgpersensitiuitg

Artti- reeeptor hgper sensitirsitA)
*
.i.
Antigen : TSH receptors on the follicular cells of the thyroid gland.
Antibodv: TSH-RAb (IgG)
Eoid,enees
that
Gro;toes' diseorse
is
ant
autoimrnune d.isease:
1. TSH-RAb is present in the serum of patients with Graves'
disease.
2. Lymphocytic infiltration of the thyroid gland.

3. Enlargement of other members of R.E.S.
e.g. spleen
& LNs..
4. Extra-thyroid tissue affection.

Glaues'disease is an autoimmune discase affecting Uimailly the thwoirl gland
leading t0 hyrcrthyroidism with 0the1 extra thyroid tissue affection as part 0f the
autoimmune diseasG in tne lorm of:
$ Thyroid exophthalmopathy : 50-70% of cases.

$ Thyroid dermopathy (acropathy) : 5%
$
Thyroid myopathy : 5%
(2) Toxic Nodular Goitre : (2ry toxic gitre
a. In some toxic nodular goiters
Plummer's disease) z 25oh
one or more nodules are overactive and
here the hyperthyroidism is due to autonomous thyroid nodules.
b. In other toxic nodular goiters, the nodules are inactive & it
is the
internodular thyroid tissue that is overactive. Here hyperthyroidism

is may be due to TSH-RAb.
(3) Solitary toxic Nodule
: l"h
H Autonomous nodule not due to TSH-RAb.

H It is thought to be a functioning adenoma.
26
WhiteKnightLove
(4) Hyperthyroidism due to other rare causes
l.
Thyrotoxicosis factitia : Induced hyperthyroidism by taking Lthyroxine e.g. those given thyroid extract as "tonic"
lod-Basedow thVrotoxicosis : Large
2.
doses of iodide given to
hyperplastic endemic goitre.
Subacute or acute forms of Hashimoto's or of de Ouervain
3.
thVroiditis: Mild hyperthyroidism may occur in the early stages

due to liberation of thyroid hormones from damaged tissue.
4.
A large mass of 2'v carcinoma: will rarely produce sufficient

hormone to induce hyperthyroidism.
5.
Neonatal thvrotoxicosis: occurs in babies born to hyperthyroid

mothers (due to TSH-RAb crossing placenta ).
It gradually
subsides
in 3-4 weeks.
CIINICnI PICTuRE oF GnnvES'

Age a SGX:
DISEASE
More in females (8 times more than males) around 20-40 years.
Symptoms
(Il
lVletabolic :
1. Rapid loss of weight in spite of increased appetite
(10% of body weight in one mouth).
2. Intolerance to hot weather.
3. Slight pyrexia.
4. Excessive sweating.
(IIl
UI Nertr,ous :
T3
&
T4 increase sensitivity
of
tissues to circuloting catecholumines
1.
Irritability, anxiety, insomnia & night mares.
2-
Tremors of the hands & tongue.
21
WhiteKnightLove
(IIf) CyS .' T3 & T4 increase sensitivity of tissues to circulating

1.
Palpitation.
catecholamines
2. Exertional dyspnea.
(Nl Gastrointestinal
1. Loss of weight in spite of increased appetite .
2. Loose stools (tendency to diarrhea).

Polyuria due to
.l Excess formation metabolic H2O.

{. Increased renal blood flow.
.l Increased fluid intake as a part of polyphagia.
{. Glucosuria.
fVII
Gono,d,ul :
1. Increased sexual libido at first and impotence in advanced stage.
2. Menstrual disturbances starting by polymenorrhea, menorrhagia &

ending by amenorrhea.
fVIII lWuseu,lo - skeletal :

1. Weakness, fatigability & wasting of the proximal limb muscles
(myopathy usually affects the quadriceps femoris & deltoid muscles)-
2. Generalized bone aches due to osteoporosis of bone.
(VIIII General :
1. Swelling in the thyroid gland.
2. Protrusion of the eye ball.

3. Diplopia : due to :
'1. Unequal eye bulge.
'l Weakness of extra-ocular muscles (ophthalmoplegia).
0Rhthalmottlegia : is an autoimmune disease duet0 TSH- BAI affecting oculal
musGles.
28
WhiteKnightLove
Signs
(A) General Examination
(Il Und,ertoeiqht
Ll
:
H Body mass index ( BMI ) is usually tess than 2O Kgtm2
isrus :
I. PULSE :
*
Rate : Tachycardia with a sleeping pulse more than 90 beats/min
"
Pulse rate is always increased to 100-120 beats/min.
fn severs cases it may reach 140-160 .
*
*
Character : Big pulse volume (water
hummer character).
Rhvthm : All types of arrhythmia except heart block
&
V.F.
V ivtuttiple extrasystoles & Paroxysmal atrial tachycardia.

V Paroxysmal atrial flutter.
V Persistent atrial fibrillation not responding to digoxin.
z. B.P.
V Systolic B.P. is high but the diastolic is usually low or normal or not much
raised (due to peripheral V.D)
7. IIEART
Increased pulse pressure.
V A.""ntuation of heart sounds.

V Functional soft systolic murmur maximum
(IIII
over pulmonary & aortic area.
Neruous siqns :
H lrritability and anxiety.

H Fine tremors in the tongue & in the fingers of the outstretched
H Reflexes are exaggerated due to hyperexcitability of nerves.
H Myopathy : Weakness of the proximal limb muscles.
(IVl Cutaneous eho;nqes :

H Moist warm extremities.
H Profuse sweating & flushed
face.
29
WhiteKnightLove
hands
H Falling of hairs & sometimes alopecia.

H Clubbing of fingers & toes.
H Soft and brittle nails.
H Onycholysis : The nail lifts off the nail bed.
H Prctibial myxoedema (3-5o of cases only) :
* Thickening of the subcutaneous tissues infront of the chin of tibia.
* Parl of the autoimmune
disease.
* Usually bilateral.
* None pilting.
* Self limiting.
(Vl Eue manifestations :

6. Exophlhalmos f> 50
TYPES
of cases)
a. Apparent (mild = falsel exophthalmos :

A It consists of widening of the palpebral fissure due to spasm of Muller's
muscle "deep part of levator polpebrae superioris & supplied by
fibres" without any bulging of the eyes.

b. True exophthalmos : actual protrusion of the eyeballs.
sympathetic
Ttue Exophthalmos t ptoilosis I is also an autoimmune discase due t0 antigcn-
anti[ody inflammatory Uocess in the let]o[ul[artissue leading t0 infilt]ation

with inllammatory 10und Gells & acoumulation of inllammatory fluids.
Probably due to cross- reaction of thyroid antigen & eye

(Schwartz )
Grades of true exophthatmos
l.
Moderate.
2. Severe.' Ophthalmic vein compression leading to lid edema, conjunctival

injection & ecchymosis
30
WhiteKnightLove
3. Progressive (malignant) : Papilledema, corneal ulcers & optic nerve neuropathy

DIAGNOSIS
: See
clinical notes.
B. Gerfain eye sif,ns
1. Rosenbach's sign. Tremors on closing eye lids.

2. Stellwag's sign : Staring iook with infrequent blinking
3. Dalrymple's sign : A rim of sclera
is seen between the
cornea and the upper eye lid.
4. Von Graef's sign : Lagging of the upper
eye
lid when the
patient is asked to look gradually down
without moving the head.

5. Joffroy's sigln : Lack of corrugation of the forehead when
looking up without moving the head.

6. Moebius' sigln : Lack of convergence when looking to near
object (due to ocular myopathy )
fVII Retieulo-end,othelial siqns (lWild,l
Z"i,';\
(ir%*=-"^hl
O Just palpable spleen and may be generalized

lymphadenopathy.
(B) Local
Examination (Thvriod sland)
@ Site : Swelling in the lower part of the
A Size : slight to moderate
front of the neck.
enlargement.
@ Shape : symmetrical and butterfly.

@ Surface : smooth.
@ Skin overlving
: is warm.
@ Special character : moves up
& down with deglutition.
@ Consistencv : soft.
Edge : well defined.
O Pulsations & thrills are detected usually at the upper
poles over the
superior thyroid artery due to increased vascularity & A-V shunts.
31
WhiteKnightLove
D.D. oF GnnvES, DISEASE
1) Other causes of hyperthyroidism especially toxic nodular goitre
Toxic nodular soitre

40 y. i.e.older
Gravest
I
2
20-30
Age
Onset
&
i.e youns
* Acute onset ( previously healthy

gland )
* Toxic manifestation hand by hand
with the gland manifestation.
* Remission & relapse course.
course
c/p.
* CVS
* CNS
* Dermopathy
* Exophthalmos
* Gradual onset.
*Toxic manifestation on top of simple
nodular goitre.
* Progressive course.
++{. (d.t. older age
#+
& atherosclerosis)
+
No dermopathy
False only
+++
+++
* Gland
Nodular, fi rm, irregular enlargernent.
Smooth, soft, diffuse enlargement
2) Other cause of loss of weight in spite of good appetite:
A Uncontrolled diabetes.
A Intestinal parasitic infestation.
A Malabsorption syndrome.
3) Neurosis and panic attacks.
4) Other causes of arrhythmias.
THE MOST SIGNIFICANT SYMPTOMS OF TOXIE COITRE ARE
a. Loss of weight in spite of good appetite.

b. Palpitations.
c. Intolerance to hot weather.

d. Exophthalmos.
e. Goitre.
TTIE MOST SIGNIFTCANT SIGNS ARE
a. Goitre.
b. Exophthalmos.
c. Cardiac arrhythmia.
d. Excitability.
32
WhiteKnightLove
ITvESTIGATIoNS FoR GRAVES' DISEASE

1. Thyroid function tests
a) Total serum T3 &
74.
b) Free serum T3 & 74. (More occurate than total).

c) Serum TSH.
Free serum T3 is 3-9
pmol/l
Free serum T4 is 9-27 pmol/l
d) T.R.H test :
?.,R.Il: Test: In thyrotoxicosis, T.S.H.
secretion is suppressed and I.V.
injection of T.R.H. does not result in a rise in serum T.S.H.
I It is useful in confirming diagnosis in difficult cases e.g. if there is

manifestations of toxic goitre with high normal serum T3 & T4
Fallacies in the measurement of total T3 &74 :
False hiqh results
A Oral contraceptive pills

A Pregnancy (because of an increase in TBG).
False Low resrrlts :
A llypoproteinemia e.g. nephrotic syndrome .
A Drugs which are protein bound such as salicylates &
penicillin compete with T3 & T4 for protein binding.
ll.B: I3-tOXiG0SiS: In this condition the T4 is normal and the manifestations
of hyperthyroidism are due to excessive production of T3.
This condition usually appears in elderly and its main features are cardiac $
as A.F. and heart
failure together with severe muscle weakness and diarrhea.

High T3 level is diagnostic.
e) Free thyroxine index "FTI" :
A Total serum T4 lT3 uptake%o x 100.

A A figure between 55 and 145 means euthyroid state,
A Not done now after ability of measurement of free T3 &T4.
WhiteKnightLove
JJ
2. Neck U.S : Differentiates

3. Thyroid scan
between diffuse
& nodular toxic goitre.
Hot scan.
4. lndirect laryngoscopy : done if operation

5. Miscellaneous Tests :
*
{.
*
.:.
E.C.G & Sleeping pulse.

Hypocholesterolaemia.
Hypercreatinaemia.
Glycosuria in severe cases (Lagstorage curve).
TnTaTMENT
oF GnnvES' DISEASE :
(I) Medical
INDIEATIONS
1. All
is planned.
cases
Treatment
of diffuse toxic goitre should receive a trial.
2. Postoperative recurrence.
CONTRAINDIEATIONS
1. Retrosternal or large diffuse toxic goitre as it will enlarge under

medical treatment & may result into mediastinal syndrome.
2. Pregnancy & lactation not to reach the fetus.

TINES OF MEDICAT TREATMENT
I.
Mental & physical rest.
2. Sedation & tranquilizers to ensure sound night sleep .

3. High protein diet and vitamins.
4- Beta - adrenergic blockers as propranolol (lnderal) :
V Blocks the action of catecholamines on the heart & CNS.

V Partially inhibits the peripheral conversion of T4 to T3 .
V Dose.' 10-40 mg TDS orally .
5. Antithyroid drugs.'The thiourea group is the only used now
A, Carbimazole (Neomercazole): The commonest antithyroid drug used.
34
WhiteKnightLove
Mode of action
: lt inhibits peroxidase enzyme
a. Interferes with oxidation of iodide to iodine.

b. Interferes with the binding of iodine with tyrosine.
c. lmmunosuppressive action on TSH-RAb production.

Onset :
O ft does not affect
the already formed thyroid hormonesl hence its
effect does not appear except after 10 -14 days.
Dose .'
O f 0 mgl6 hours till euthyroid
state is reached (clinically
& by thyroid
profile).
O Then maintenance
dose of 5 mg/8hours
for about 12-18 months.
The aim of this long term treatment is to maintain the euthyroid state for
a prolonged period of time hoping that a permanent remission will occur
& the production of TSH-RAb will cease from the immune system.
DISADVANTAGES OT' MEDICAL TREATMENT:
1. Prolonged treatment with failure rate 50-60%.
2. Impossible to predict which patient is likely
3.
Some goiters enlarge
& become very vasculur:
Give L- thyroxin 0.1mg/day (Block
4. Drawbacks
to go into a remission.
& replacement therapy)
& toxicity of neomercazole:
a. Aplastic anemia.
b. Agranulocytosis ( sore throat & fever are early signs ).
If
this occurs : Stop the drug + Penicillin
Fresh blood + Vitamin 86.
c. Hypersensitivity reaction :
Skin rash, haematuria, arthalgia & liver toxicity.
B. Propylthiouracil : It
also inhibits peroxidase enzyme
O Also prevents peripheral conversion of T4 to T3.

O Safer in pregnancy as it crosses placenta to a lesser extent.
35
WhiteKnightLove
(ll; Srrgical Treatment after Dreparation

AIM
Surgery cures by reducing the mass of overactive tissue (antigenie glandl
resulting in a reduction of TSH-RAb.

INDICATIONS
l) Failure of medical treatment:

A Relapse after full course of treatment.
A Failure to reach the euthyroid level after > 2 months from the
start of medical treatment.
Occurrence of adverse effects of neome rcazole.
2) Large diffuse toxic goitre.
3) Retrosternal diffuse toxic goitre.
PRE-OPERATM PREPARATION
(A)
: (A) OR (B)
Anti-thyroid drugs "classic method"
l)
Neomercazole is given
till the euthyroid state is rcached. The last dose
of neomercazole is given on the evening prior to surgery.
2) Lugol's iodine is given with neomercazole for 10-14 days immediately
prior to operation "mainly to decrease the vascularity of the gland".
Lugol's iodine (5 % iodine + I O % Kl in water) :

MOde 0f AGti0n:
Not exactly known but

hormones by
it
prevents release of thyroid
a. Reduces effect of TSH on gland, so
it becomes more firm &
b. Inhibition of protease enryme which releases T3

c.
less vascular.
& T4 from thyroglobulin"
Inhibition of organic iodine formation.
llose: 10 drops TDS .

lltaW[aC[: Action cannot be maintained for more than 2 weeks
IOXiCity: a. Skin
rash
b. Parotid
swelling.
36
WhiteKnightLove
c. Excessive salivation.
(B) F-Blockers alone :
A For few days before surgery, during surgery & for 7 days postoperatively.
Inderal : 40 mg TDS up to 80 mg TDS.
D Nadolol (longer acting) : 160 mg up to 320 mg once daily

INDICATIONS OF TTIIS WAY
O Onty line of preparation in toxic retroslermal goitre.

O Other surgical emergencies with Graves' disease.
OPERATION
: SUBTOTAL OR TOTAL
THYROIDECTOMY.
ln subtotal thyroidectomy for toxic goitre, the whole gland is removed

leaving on each side a part equivalent
lo 1/3 of a normal lobe (2x1x1
cm).
This pad left is atways from the posteromedial part of the lobe
(IlI) Qadio-flctive lodine TherarDy (tttl)

INDICATIONS
a. Poor risk surgical
case (elderly or cardiac).
b. Recurrence of toxicity after operation.

MODE OF ACTION
O The thyroid gland traps & concentrates radioactive iodine in the same
way as inorganic iodine.
O Radioactive iodine liberates
p rays, which destroy the thyroid cells without
affecting much the surrounding tissue because of their low penetrability.

ONSET : lmprovement is to be expected in 8 - 12 weeks .
DOSE
O 160 pCi tl
g- of thyroid tissue (about 8-10 millicuries) of t3'[ is given
orally once.
O If no clinical improvement after 3 months, a further does is given.

COMPLICATIONS
1. Hypothyroidism (80% after
10 years) due to higher dose.

37
WhiteKnightLove
2. Recurrence of toxicity due to smaller dose.

3. Fetal abnormalities & hypothyroidism of newborn if given in pregnancy.
4. Riskof inducing thyroid carcinoma & Ieukemia after 10 - 15 years. "No
definitive proof' (Bailey & Love).
EONTRAINDIEATIONS
1.
Young age : Avoid its use before the age of 45 y because there is risk of
inducing thyroid carcinoma & leukemia after 10 -15 years.
2. Pregnancy & lactation .' Risk to the fetus.
3. Toxic nodular goitre.' Irradiation
SUUNAARY
is ineffective due to fibrosis.
oF
Start with rnedieal
O
O
Under 45 years
Over 45 years
TREATMENT
ttt + If failcd
Subtotal thyroidectomy after preparation

Radio-active iodine therapy.
PnOELEMS FACING US DURING TREATMENT

I- Graves' in ehildren " Pediatrie Graves' " :
Pediatilc Graues'should [e sus[eotcd in:
A Children with growth spurt, behavioral problems or myopathy.

A Unexplained diarrhea. A Unexplained loss of weight.
lhanagement:
A Radioactive
12
is contraindicated as it is potentially carcinogenic
&
causes
late hypothyroidism.
A Antithyroid
drugs are tried but usually with poor response & adverse effects"
A Near total thyroidectomy after preparation is the ttt of choice.

II- Graves'with pregnaney :
A l" trimester : Antithyroid drugs ( neomer cazole or better propylthiouracil
given in the least dose as surgery carries the risk of abortion.
2"d trimester
: Subtotal thyroidectomy after preparation.
38
WhiteKnightLove
) is
3'd ffimester :
a. Neomercazole or propylthiouracil
is given
with small dose of L-
thyroxine to avoid transmitted thiouracil goitre.
b. After labour propylthiouracil
neomercazole.
is given as its excretion
in milk is 1/10 of
III- Th;rroeardiae patients

A The cardiac condition
^.
must be controlled
l't & then either
Cardiac condition improves ) Subtotal thyroidectomy
b. Cardiac condition did not improve
Radioactive12
fV- Exophthalmos
A. False exopthalmos
1. Usually disappears when hyperthyroidism is treated.
2. p-blockers
as guanethidine eye drops improves the condition
B. True exophthalmos : Usually is self limiting
But do not terminate the toxic status abruptly by surgery or
radioactive l, as this may lead to progressive malignant

exophthalmos.
lf surgery or radioactive I, are planned ) Antithyroid drugs are used until

proptosis has been stationary for 6 months after which operation is possible"
And during this period
A Sleeping semi-sitting.
A Diuretics : To decrease retobulbar edema.
A Dark glasses : To protect the eye from light and dust.
A Ointment at night.
A Prednisone locally is of great benefit but it is risky especially in presence
of venous congestion.
A In severe cases not responding to the above measures we can do :

* Lateral tarsorrhaphy. * Orbital decompression.
39
WhiteKnightLove
V- Retrosternal toxie goitre
V Surgery is the only line of treatment.

V Preoperative preparation by inderal only.
Toxic nodular goitre

ETIOLOGY
O Long
standing SMNG.
PATHOPHYSIOLOGY
a. In
some toxic nodular goiters one or more nodules are overactive and
here the hyperthyroidism is due to autonomous thyroid nodules.
b. In other toxic nodular goiters, the nodules are inactive & it
is the
internodular thyroid tissue that is overactive. Here hyperthyroidism is

may be due to TSH-RAb.
CLINICAL PICTURE 1 as Graves'with thefollowing

1. Affects patients around
40 years of age
differences:
with previous history of SMNG.
2. The disease has gradual onset and slowly progressive course.

3. Main complaint
is cardiac symptoms.
4. No autoimmune symptoms "i.e. : no true exophthalmos, no dermopathy or

myopathy".
5. Exophthalmos if present, it is only false exophthalmos.

6. The gland
is nodular, asymmetrical
& firm.
INV '. as Graves' disease.

The value of thyroid scan here is that
it differentiates between toxic nodular
goitre due to autonomous nodules or due to active internodular thyroid tissue
TTT
O Subtotal or total thyroidectomy after preparation is the only line.

O Radioactive 12 is ineffective because of the excessive fibrous tissue
within the gland.
40
WhiteKnightLove
@ Medical treatment is used only as preoperative preparation.
Solitary Toxic Nodule

ETIOLOGY
El Autonomous nodule not due to TSH-RAb.
H It is thought
to be a functioning adenoma.
CLINICAL PICTURE i
os Graves'with thefollowing differences:
1. The disease has gradual onset and slowly progressive course.
2. No autoimmune symptoms "i.e. : no true exophthalmos, no dermopathy or

myopathy".
3. Exophthalmos if present, it is only false exophthalmos.
4. Clinically the patient
presents by a solitary thyroid nodule.
INV '. as Graves' disease.

ere the thyroid scan reveals a solitary hot n
TTT
O Radio-active iodine
is the
ttt of choice as the suppressed thyroid tissue
around the autonomous nodule can not take up iodine and there is no
risk of delayed hypothyroidism.
O OR Hemithyroidectomy
(lobectomy
isthmectomy) after preparation.
Thyroid crisis = Thyroid storm

DEF : Is an acute exacerbation of hyperthyroidism.
ETIOLOGY
1. If a thyrotoxic patient is inadequately prepared for thyroidectomy.
2. May follow an unrelated operation extraction of a tooth or drainage of

an abscess.
3. May occur spontaneously following any stress.
c/P
l.
Hyperpyrexia up to 41oC.
4t
WhiteKnightLove
2. Excessive sweating.
3. Marked tachycardia & arrhythmia.
4. Hypertension.
5. Irritability, convulsions & coma.
6. Heart failure may occur.
TTT :
l.
Iep
batl"f- lgp.tpgrcxio.
}r Don't use salicylate as it competes with thyroxine
for its plasma
proteins binding sites leading to an increase in free thyroxin levels.
2.IndProLtV drip.
3. I.V fluids.
4. Good sedation morphia.
5. Neomercazole 20 mgl4hrs orally.
6. Hydrocortisone drip 100 mg/8hrs
as corticosteroids
inhibit peripheral
conversion of T4 to T3.
7. K-iodide I.V drip 250 mg/6hrs.
Dostgraduate forrics
Clrl,ssifi,eo;tiort,
of Grut)es) DAe l)iseose "NO SP,ECS":
Class 0: No signs or symptoms

Class 1: Only signs (limited to upper lid retraction and stare, with or
without lid lag).
Class 2: Soft tissue involvement (oedema of conjunctivae and lids,

conj unctival injection, etc).
Class 3: Proptosis.
Class 4: Extraocular muscle involvement (usually with diplopia).
Class 5: Corneal involvement primarily due to lagophthalmos "inability
to close the eyelids properly".
Class 6: Sight loss (due to optic nerve involvement).

42
WhiteKnightLove
There are B tgpes of autoqntibod,ies to the fS^[I receptor
currentlg reeognized, in
Grantese d,iseo,se :
1) TSl, Thyroid stimulating immunoglobulins:
O These antibodies (mainly IgG) act as LATS (Long Acting

Thyroid Stimulants), activating the cells in a longer and slower
way than TSH, leading to an elevated production of thyroid
hormones.
2) TGl, Thyroid growth immunoglobulins:
O These antibodies bind directly to the TSH receptor and have

been implicated in the growth of thyroid follicles.
3) TBll, thyrotrophin Binding-lnhibiting lmmunoglobulins:

@ These antibodies inhibit the normal union of TSH with its
receptor.
Some
will actually act as if TSH itself is binding to its receptor,'
thus inducing thyroid function.
O Other
types may not stimulate the thyroid gland, but
will
prevent TSH from binding to and stimulating the receptor.
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THYROID NEOPTASMS
I
I
Benign
I
2ry (very rare)
I ry
rtl
Carcinoma Malignant Medullary

Lymphoma Carcinoma
90"h
60"
5"
20"
Local
Metastatic
infiltration
(Blood borne)
5"
naplastic
lo"h
BENIGN TTIMOTIRS
Follicular Adenoma
PATTIOLOGY
Usually a single, solid, well-encapsulated tumour.
CLINICAL PICTURE
COMPLIEATIONS
i Solitary thyroid nodule.
1. Cystic degeneration.
2. Haemorrhage into a cyst.
3. Hyperthyroidism (solitary toxic nodule).
4. lt
is unknown whether
follicular adenomas turn to carcinoma but the
majority of thyroid carcinomas are malignant from the start.
INVESTIGATIONS
1. Thyroid function
tests.
2. Neck U. S.
3. FNC is not reliable to differentiate it from follicular adenocarcinoma
as the
main differentiating point is the presence of histological evidence of capsular

or vascular invasion.
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TREATMENT : Hemithyroidectomy: lobectomy * isthmectomy.

lt.B.:
l. Papillary adenoma does not exist & all papillary tumours should
be considered as malignant even if encapsulated.
2. Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil
(Hurthle:Askanazy) cells predominate histologically.
Some consider all Hurthle cell tumours to be malignant with a poorer
prognosis than follicular carcinoma.
lTy MAI,IGNANCY OF TI{E THYROID GT,AND

A. Carcinoma arising from follicular epithelium : Adenocarcinoma
B. Carcinoma arising from parafollicular C cells : Medullary carcinoma
C. Malignancy arising from lymphoid elements : Malignant lymphoma.
ADENOCARCINOMA
A. Differentiated
*Papillary
*Follicular.
or
B. Undifferentiated : (anaplastic )
PREDISPOSING FACTORS
1. The most important one is external irradiation to the neck in childhood
V Was done in the past for the treatment of T.B lymphadenitis,

haemangiomas
& thymic gland enlargement.
Leads to papillary carcinoma.
2. Precancerous thyroid lesion
V Hashimoto's thyroiditis ) Papillary carcinoma & malignant

V Long standing SMNG I Follicutar thyroid carcinoma.
V Follicular thyroid adenoma) Follicular thyroid carcinoma.
3. A genetic element may be present as
V Papillary
V Mutation
lymphoma.
carcinoma patients.
of the RET proto-oncogene on chromosome 10 in familial MTC.
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PATHOLOGY
Adenocarcinoma
see
Table
DIFFERENTTATED
PAPILLARY
l.
Age
2.
N.E.
(60%)
FOLLICULAR O%)
Middle age
Young age
appearance
UNDIFFERENTIATED
Localized slowly
Ill defined irregular
growing nodule.
firm
mass OR
ANAPLASTIE
OO%)
Old age
*Large rapidly growing
Localized slowly
irregular, hard,
growing nodule.
infiltrating
mass.
Presence of papillae consisting

3.
of a well-defined fibrovascular
*The malignant cells
*sheets of
Microscopic
core surrounded by one or two
are cuboidal or
undifferentiated
layers of tumor cells
columnar arranged in
malignant cells mainly
*The malignant cells have
incomplete acini or
spheroidal, spindle, small
characteristic pale empty
pseudo follicles with
or large cell type.
nuclei " orphan Annie-eyed
capsular and vascular
nuclei".
*Laminated calcified
invasion.
bodies (Psammoma bodies)

are present in the stroma
*Intrathyroid lymphatic
micro-embolisation
4.Spread
5. TSH
Mainly lymphatic.
Mainly blood spread.
Yes
Yes
Mainly direct.
No
dependency
6.Prognosis
Very good
Favorable
poor
N.B.
A Multiplicity -'Multiple
foci are common in the papillary type due to either
multicentricity or intraglandular lymphatic spread.
A If tumour contains both popillary & follicular elements it is considered papitlary.

8 Hormone dependency means that the tumour is initiated by a prolonged T.S.H.
stimulation & responds to L-thyroxine administration.
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SPREAD
t. Direcf .' in ana[lastic ca]Ginoma:

V To trachea, oesophagus,
muscles
2. Lvmphatic
RLN, cervical sympathetic chain, CCA & IJV,
& skin.
in [a0illary
ca]Ginoma:
To prelaryngeal, pretracheal (Delphic) lymph node then to the deep

cervical & mediastinal lymph nodes.
V Ttre so-called "Lateral
sberrant thyroidt'(misnomer) are metastases to
Iymph nodes in the neck from occult 1ry papillary carcinoma.
3.
Blood; in lolliculr Galcinoma:
V The most common site for distant metastases is bone especially skull.
V Ttrey are solitary, pulsating, osteolytic& painful and may be functioning.
CtINICAL PICTURE : The sex ratio is 3 females to I male.
C/O:
l.
Presentation is usull,llg uoriuble
Lone standing SMNG with recent rapid rate of erowth, hardness, pain, change
of voice, dyspnea or dysphasia.
2. A goitre of recent onset with rapid rate of growth, hardness, pain, change of
voice, dyspnea or dysphasia (pain is referred to the ear along the Arnold's nerve
alderman's nerve which is the auricular branch of the vagus).
This nerve supplies the posterior half of the skin lining the acoustic
meatus & tympanic membrane.
The auricular branch of the vagus was once known as the alderman's nerve.
AIderman, those lovers of good cheer, were said, when replete at banquets, to
stimulate their iaded appetites by drooping cold water behind the ear. This
acts by reflexly encouraging gastric peristalsis because of the vagal supply to
the stomach; (McGregor's surgical anatomy textbook).
3. A solitarv thvroid nodule.

4. Hislolosical surprise after subtotal thyroidectomy for SMNG.
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5. Local metastasis.' lateral aberrant thyroid (common in PTC ).

6. Distant metastasis : (common in FTC ).
SIGNS
General .'For evidence of secondaries as skull metastasis.

Local :
1. Thyroid gland
V Either solitary thyroid nodule or

V It shows signs of malignancy
a. Tender, hard, irregular & fixed gland.
b. Sternomastoid
tugging
&
loss of
rocking movements are the earliest
signs of malignancy.
c. Berry's sign: Absent carotid pulsations.

2. The lymph nodes
a. Enlarged
& hard, at first mobile then lixed.
b. They should be tested bilaterally.
INVESTIGATIONS
[. ]0r lry lesion
1. Thyroid function tests usually reveals euthyroid state & are of limited
diagnostic significance in thyroid neoplasms.
2. Neck U.S: Differentiates cystic from solid nodules.

3. 1231 scan :
O Malignant
lesions appear as cold nodules whoever
it
is of limited diagnostic
significance as many benign lesions as cysts or hemorrhage in a cyst also

appear as cold areas.
4. Biopsy
a. FNC
* Accurate
in cases of PTC & anaplastic carcinomo.
* Has got excellent patient compliance
48
WhiteKnightLove
* Simple
& quick to perform in out patient clinic ,OPC,
* It can not
dffirentiatefollicular adenomafromfolliculor carcinomu.
b. Frozen section biopsy (less accurate).
c. Excision biopsy - (hemithyroidectomy): lobectomy + isthmectomy :

(Most diagnostic).
B.
tor seoondaries:
l.
X-Ray
: Neck, chest, skull, spine & pelvis.
2. C.T scan neck : To detect L.N metastases & invasion of surroundings.

3. Laryngoscopy I To detect invasion of the recurrent laryngeal nerve.
4. Bronchoscopy : May be needed to detect tracheal invasion.
G.
IUI||OUI ffiAIIC]
serum thyroglobulin for differentiated carcinoma
I. TREATMENT OF PTC
1. Total Thyroidectomy as PTC is multicentric.

Some surgeons recommend hemithyroideetomy
for tumours up to I
cm
in diameter as these tumours usually are not multicentric.
2. Management of lymph node metastases

a. If there are no lymph
nodes metastases
no need for prophvlactic
dissection and follow up.
b. If metastatic deposits are lymph
nodes metastases
selective removal is
performed "cherry picking maneuver".
c. If metastatic lymph
nodes deposits are extensive
modified block \eek
dissection is performed in which the accessory nerve, internal jugular
vein and sternomastoid muscle are preserved.
3. Postoperative L-thyroxine 0.2-0.3 mg / day is given

* To suppress TSH production as PTC is TSH dependent.
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III. TREATMENT OF FTC
1. Total Thyroidectomy.
O Total thyroidectomy
ablates all thyroid tissue and makes it possible to
detect distant metastasis by scanning and to treat them by radioactive
12
which is not possible in the presence of normal thyroid tissue.

Some surgeons recommend hemithyroidectomyfor tumours up to
I cm
in diameter as these tumours usually haven't sent blood borne melaslases,
2. Postoperative L-thyroxine 0.2-0.3 mg / day is given

* To suppress TSH production as FTC is TSH dependent.
3. Management of blood born metastases
V Thyroxine is stopped for a few weeks to raise TSH rendering metastases avid
to
12
and then radioactive iodine scan is performed.
a. If there is evidence of local recurren ce or functioning
metastases, a
therapeutic dose of radioactive iodine is prescribed.
b- External irradiation if metastases are none functioning.
III-
TREATMENT OF ANAPLASTIC CARCINOIT1A
(a) lf operable ( rare ) : Total Thyroidectomy.
(b) Usually inoperable
1. Palliative isthmectomy to palliate the patient
from tracheal compression.
2. External irradiation.
THE PROBTEM OF TTIE TIISTOTOGICAL SURPRISE

T
Re-operation is necessary with total thyroidectomy "completion
thyroidectomyt' because the tumour is multicentric.
(21 Follieular :
V Re-operation is necessary to remove the remaining thyroid

facilitate iodine scanning and radioactive iodine therapy.
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tissue in order to
MEDULT AQY CAPCINOATA

O This tumour arises from the parafollicular
O Not TSH dependent & does not take r23 I.
TYPES
(C-cells) secreting calcitonin.
1. Sporadic : Occurs in old age and

2. Familial : Occurs in young
is an aggressive tumour.
age either with
MEN type II syndrome or not
associated with MEN Syndrome ( non MEN ). Both are autosomal dominant.
MEN type I (Wermer's syndrome) rr3Prt
1. Anterior
pituitary adenoma.
2. Pancreatic adenoma " insulinoma or gastrinoma".

3. Parathyroid hyperplasia.
MEN type ll (Sipple's syndrome)
MEN Ila : Medullary carcinoma + Pheochromocytoma + Parathyroid hyperplasia.

MEN llb : Medullary carcinoma + Pheochromocytoma + prominent mucosal
neuromas involving the lips, tongue & eyelids + marfanoid features
PT4ITHOLOGY
MAE
O Ill
defined irregular firm mass OR Localized slowly growing nodule.
MIC
O Malignant polygonal to spindle
shaped cells which may form nests
or trabeculae.
O Amyloid
deposits "derivedfrom altered calcilonin molecules" are
present in the adjacent stoma.
SPREAD
* Lymphatic spread (50-60%) )

* Blood spread is common.
Mediastinal & cervical L.Ns.
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c/o
1. Thyroid swelling.
2. Diarrhea (307o) due to 5-HT'(serotonin" produced by the tumour cells.

3. Hypocalcaemia & tetany.
4. Colics, hypertcnsion and flushing may be present.
INV : As thyroid carcinoma *

1. FNC : Diagnostic.
2. Calcitonin
TREATMENT
is a
tumour marker.
* Total thyroidectomy
Selective neck node dissection or modified neck block
dissection.
ln case of MEN syndrome, pheochromocytoma must be excluded l*t before

thyroidectomy by measurement of urinary levels of VMA to prevent bouts of
hypedension that may cause fatal hemorrhages.
N.,B ; Prophylactic thyroidectomy at the age of 5-7 years is indicated in
carriers of the germ line RET mutation even without a clinically apparent
disease (Cushieri).
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THYROIDITTS
(I ) Auto-immune
fhyroiditis
(Haslrimoto's rlisease = LvmphadenoiO goitre)

CAUSE : Auto-immune
disease affecting females at menopause.
It is an autoimmune disease (type lV hypersensitivity-cell mediated

hypersensitivity) leading to destruction of the thyroid acini and infiltratiort of
the gland with lymphocytes and plasma cells.
PATHOLOGY
O The thyroid follicles are atrophic
and are lined in many areas by
epithelial cells distinguished by the presence of abundant

eosinophilic, granular cytoplasm termed "Hurthle cells
Askanazy
cells: oxyphil cells".

@ The cells are a metaplastic response to ongoing injury.
O The cells are also characterized by numerous prominent mitochondria.

@ Also there is dense Iymphocytic & plasma cell infiltration of the gland.
CLINICfIL PICTURE
C/O :
$
$
as SMNG "painless swelling
in the neck" with the following differences
Affects females at menopause.

Pressure symptoms are marked.
S Mild hyperthyroidism
in early cases, followed inevitably by (myxoedema)
OIE I Goitre with the following criteria

Size
Moderately enlarged
Shape: Irregular
Surface
lobulated or nodular.
Consistencv: firm.
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COMPLIEATIONS
1. Hypofunction (myxoedema).
2. Papillary carcinoma.
3. NHL "Non Hodgkin's lymphoma".

INVESTIGATIONS
as SMNG
1. High titre of antithyroglobulin & antimicrosomal antibodies.
2. FNC to differentiate it from carcinoma & SNG :
$
s
Dense lymphocytic & plasma cett infittration.
Thefollicular cells show oryphitic changes "Askanazy cells',
TREATMENT
1. Full replacement therapy with thyroxine for hypothyroidism & follow up.
2. Minimum
dose corticosteroids may be of help.
3. Thyroidectomy if
lLarge goitre. I
(2) aiedel's
Pressure
symptoms.
a FNC
is suspicious.
Thyrciditis (Strumfl - Woorty Thyroid)
ETIOLOGY:
O Some consider Riedel's thyroiditis as a l'v disease of unknown etiology.

O Other considers it as a manifestation of the systemic disorder "multifocal
fibrosclerosis" associaled with mediastinal fibrosis, retroperitoneal fibrosis,
sclerosing cholangitis
& ulcerative colitis (1/3 of patients).
PATTIOLOGY:
O Collagen disease in which the thyroid gland is replaced by extensive

fibrosis infiltrating the thyroid capsule & adjacent structures leading to
severe pressure symptoms.
O Extension of the fibrotic
process beyond the thyroid capsule to invade
adjacent structures differentiates Riedel's thyroiditis from other
inflammatory or fibrotic disorders of the thyroid.
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CLINIEAL PICTURE
s V".y hard goitre.

s Fixed.
S Severe pressure symptoms
(hoarseness, dyspnea, dysphagia
& stridor)
HYPofunction.
D.D. :
INV:
Anaplastic carcinoma : Do wedge biopsy (isthmectomy) or FNC.
1. Thyroid function tests
:)
hypothyroidism.
2. Thyroid ultrasonography has been reported to be homogeneously

hypoechoic, with loss of clear demarcation of the gland when fibrotic
invasion of adjacent anatomic structures exists.
3. CT Scan reveals enlargement of the affected thyroid gland and

compression or invasion of adjacent structures, such as the strap muscles,
trachea, esophagus, or carotids. Ilowever, these studies cannot reliably
distinguish between Riedel's thyroiditis & invasive thyroid malignancy.
4. FNC or isthmectomy as biopsy.

Post grad,uute notes :
* Fine-needle cytology in patients with Riedel's thyroiditis demonstrates
fibrotic changes in the thyroid gland; however, these cannot be reliably

distinguished from the fibrotic changes that are often associated with
anaplastic thyroid carcinoma so isthmectomy as a biopsy is indicated
* Beahrs and colleagues established the microscopic criteria for the
diagnosis of RT. These criteria, since modified, include the following
l. A fibro-inflammatory
process that involves all or a portion of the thyroid
gland.
2. The presence of gross or microscopic
extension of the fibrosis beyond the
thyroid capsule into adjacent anatomic structures.
55
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3. Infiltrates of inflammatory cells "lymphocytes, plasma cells, and eosinophils"

without giant cells, lymphoid follicles, oncocytes, or granulomas.
4.
Evidence of occlusive vasculitis-
5. Absence of neoplasm
TREATMENT
1. L-thyroxine to relieve hypofunction.

2. High dose steroid.
3, Isthmeetomy to relieve pressure
syllrptotns:
(3) Sulracute
fhvroiditis
(Yiral = De Quervain's = Granulomatous Thvroioitis)

CAUSE : Viral (Mumps).
PATHOPTIYSIOLOGY
*
: Post grad,uate
notes :
A strong association exists with human leukocyte antigen (HLA)-835.
* A proposed mechanism is that the disease results from a viral infection that
provides an antigen, either viral or resulting frorn virus-induced host tissue

damage, which uniquely binds to HLA-B35 molecules on macrophages.
* The
antigen-HlA-B3s complex activates cytotoxic T lymphocytes
that damage
thyroid follicular cells because they have some structural similarity with the
infection-re lated anti gen.
* The transient presence of autoantibodies (eg, inhibitory immunoglobulins that bind
to thyrotropin [TSHI, antibodies that block thyroid stimulation, thyroid
antimicrosomal antibodies, thyroglobulin [TGB] antibodies) has been noted in the

acute phase of the disease, but their presence is attributed to a virally induced
autoimmune response and is not implicated in the pathological process.

* In contrast with autoimmune thyroid disease, the immune response is not self-
perpetuating; therefore, the process is limited-
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CIINICAL PICTURE
I The
condition usuatty fottows an URTI.
1. Pain in the neck.

*
Puin is the main presenting symptom.
* Usually involves both lobes (in
j0% of cases, it starts on one side and then
migrates contralaterally within afew doy).

*
Radiates to lhe ear, throat, or occiput; and is aggrovated by swallowing und

head movement.
2.
Some pressure symptoms as dyspnea dysphagia or hoarseness (mitd)
3. Fever & malaise.

4. Firm, tender, irregular goitre.
CLINICAL STAGES
I : Toxic stage in the I't month.

Stage II : Euthyroid stage in the 2nd month.
Stage III : Hypothyroid phase in the 3'd & 4th months.
Stage
Stage
IV : Recovery
INV :
S Thyroid
S Thyroid
phase in the 5th
& 6th months.
function tests.
scan
uptake of the gland is depressed.
Diognoctic tl.emferrtis trst
ESR is increased.
TREATMENT
mpltsgmptomatio rcspoase to prcdrusoaa
! No place for surgery
Prednisone 10-20 mg / day for 7 days gradually reduced over the next months.
The disease is self limiting leaving a normal thyroid after
remissions & relapses over months.
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it subsides with
Retrosternal Goiter
A
retrostemal goi[e is an anatomical entity and not a [athologicalone
retrostemal goitre may [e simRle, toxic or neoplastic.
There are 3 anatornical uarieties
tll Su[stefnal goitfe: Its lower border can be felt during deglutition.
t2l PlUnging
g0itle:
The goiter is totally intrathoracic but it can be forced to the

neck by increase intrathoracic pressure
l3l lntmth0laGic: Very rare due to enlarged ectopic thyroid tissue in

the thorax and
it gets its blood supply from the
mediastinal vessels.
N.B : Factors helping downwards extension of an enlarged normally
placed thyroid gland

1.
Pretracheal muscles Ueuenting fonrard extcnsion 0I lhe gland
lcommon in males due to snon neofi and st]ong [lettacheal musclesl
2.llegatiueintlathoracic[]Gssure. 3.Grauity.
ELINICAL PICTURE:
1. Mediastinal syndrome : commonest presentation
Dvsonea
which is worse at night aggravated by lying
down so the patient prefers to spend the night on a chair.
Dvsphaeia : less common than dyspnea.
2. Toxic
& malignant goiters present with their appropriate symptoms
in addition to the mediastinal syndrome.
Siqros :
ll I lnspection:
a. The lower border of the cervical goitre is not seen.
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b. Dilated veins infront of the manubrium sterni due compression on
the innominate vein.

c. Edema of the face best noticed in the eve lids
d. Special tests
Tilting the head to one side causes face flushing
& dyspnea.
Raising the arms up until they touch the ears
&
keep them
for
a while causes face flushing
& dyspnea (Pemberton's sign).

CIl Palnati0n : During deglutition the lower border of the cervical goitre can
be
felt in substernal fype.
[3] PgfgUSSi0n : Dullness over the manubrium sterni or sterno-clavicular joint"
Inntestiqations :
1. X-Ray
chest : Soft tissue swelling occupies the mediastinum &

deviates the column of
air in the trachea.
2. Thyroid scan I reveals the nature of the space occupying lesion.

3. C.T scan chest : reveals the exact level of extension.
TRETTITMENT : Always o[c]atiue t lhyroidectomy aocolding to its pathologt,l

The retrostelnal
[ortion can [e deliuerql [y
Iinger moDilization a sternotomy is ralely needed.
N.B.:
How to prepare a case of Toxic retrosternal Goitre
Antithyroid drugs are contraindicated; so : B-blocker (lnderal).
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Managerrrent of Solitarg Thgroid Nodule

DEFINITION : It is a single palpable nodule in another
TIISTORY TAKING
wise a normal gland.
Solita]U toxlc nodule.

[atient giues histoly 0f tortio symnoms
(1) Metabolic : * Rapid loss of weight in spite of increased appetite
l. !I the
* Intolerance to hot weather. * Slight pyrexia & Excessive sweating.
(2) Nervous : Irritability, anxiety, insomnia & tremors of the hands & tongue.
(3) Cardiovascular : 1. Exertional dyspnea. 2. Palpitation.
(4) Gastrointestinal : * Loose stools (tendency
to diarrhea)
*Polyuria.
(5)Urinary:
(6) Gonadal :
Increased sexual libido at first later impotence.
polymenorrhea, menorrhagia & ending by amenorrhoea.

lL
me [atient giues n0 history of toxic symmoms & Gom[lains only 0t swelliru
llco[lastic noilule or a solitary lorm 0I S]lG.
lll. Hoarseness 0[uoice 01[ain lefe]led t0 me eat
EXAMINATION
GENERAT
Sus[icious malignant nodrle.
O Irritability, anxiety & fine tremors in tongue & hands) Solitary toxic nodule.
O Tachycardia & water - hummer character ) Solitary toxic nodule.
O Osteolytic pulsating swelling in the skull t FTC.
LOCAL
O Palpable another nodules ) SMNG.

O Cystic I Cystic degeneration in a nodule of SNG.
@ Solid
There is risk of malignancy.
O Cervical lymphadenopathy )
PTC
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INVESTIGATIONS :
1. Thyroid
@
function tests
6 serum T3, T4 & I
Serum TSH
O Normal T3, T4 & TSH

2. Neck lJ.S.
Solitary toxic nodule.
Neoptastic nodule or a solitary form of SNG.
* Detection of impalpable nodules ) SMNG.

* Cystic ) Cystic degeneration in a nodule of SNG.
* Solid
There is risk of malignancy.
3. Thyroid scan
@ Hot nodule
@ lltarm nodule
Solitary toxic nodule.
A functioning adenoma.
@ Cold nodule :
* Malignant nodule ( Only
of cold nodules are malignant ).
* Hemorrhagic area-
* Cyst.
4. FNG : [t
l0'h
can diagnose PTC
* Calcified area.
& MTC but it can't differentiate between FTC &
follicular adenoma.
5. Indirect laryngoscopy : To asses vocal cord mobility preoperative

Medicolegal as 3-4% of people have idiopathic vocal cord poralysis on
TREATMENT
!-
tor
side.
solitary mxic nodulc t Hot nodule I :
H Radio-active Iz therapy OR
H Hemithyroidectomy after preparation by neomercazole for 2 months until the
patient is euthyroid together with lugol's Iz in the last 2 weeks.
lF tor a functioning adenoma t Walm nodule I
H Hemithyroidectomy & histopathology.

lll- tor
a.
a Gold nodule :
If proved by FNC to be a PTC :

61
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H Total Thyroidectomy.
H Postoperative : L-thyroxine 0.2 mg / day is given to suppress TSII.
H Management of lymph node metastases.
If there are no metastatic deposits ) follow up.
2. If metastatic deposits are few ) selective removal is pe.formed.
3. If metastatic L.N deposits are extensive ) modified block neck diWge:JlloA,
b. If proved by FNC to be a follieular tumour :
H Hemithyroidectomy & histopathology.
1.
* Follicular adenoma ) Nothing more.

* FTC i Completion thyroidectomy
+ Postoperative : L-thyroxine 0.2 mg / day is given to suppress TSH.
H Management of blood born metastases in FTC :

* Thyroxin is stopped for few weeks and then radioactive iodine sean is
performed.
If
there
functioning metastases : radiooctive iodine therapy.

b) External irradiation if metastases are nonfunctioning .
a)
e.
is
If a eold nodule is cystie try U.S ) Aspiration
* No collapse.
* Rapid refilling.
* Collapse.
* Hgic aspirate
* Cytology suspicious
Hemithyroidectomy &
* No refilling.
* Clear aspirate.
* No malignancy in cytology.
histopathology.
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Follow up
Embryology of the teslis

A ft arises in the lumbar region from the Genital fiidge at the level of lil below
the developing kidney.
A The germ cells are derived
from tne YOlkSaC.
It migrates downwards, forwards & medially,
it a told of periGoneum
passing through the inguinal cunal carrying
with
(Processus Vaginalisf.
Normally the processus vaginalis becomes obliterated soon after bidh
from the level of the internal ring to just above the testis forming the
vestige of processus vaginalis.
l*tnal
ring atthe B* mor.th of intrauterine life.
A The testis reaches tlrc extqnat
ting at the 86 moathof intrauterine life.
The testis reaches tlre
A Ttre testis reaches tl',^e scntt ttat the *

Perl t oneu.E
^-rtlof
intrauterine life.
Proce!l3u3
vaolnalls
vestlge of
Procesaus
vagl nal ls
Test I s
Gubernacul u'l
St(tn of
scrotuD
Factors Responsible for Norrnal Descent of the Testicles
l)
Elongation of upper half of the body leading to relative caudal shift in position
of the testes.
2) Intra-abdominal pressure squeezing the testes through the ring.
3) Chorionic gonadotrophin from the maternal circulation stimulates the growth

of the testes & may play some part in the migration of the organ.
4) gubernaculum: Fibromuscular band connecting the lower pole of the testis to

the bottom of the scrotum guiding the testes into the scrotum.
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enalomy of lhe testis

Macroscopic structure of the testis
V ft is a flattened ovoid body measurin g 4 x2
x2.5 cm. It has two surfaces
(medial and lateral),2 borders (anterior and posterior) with two ends (upper
and lower).
V ft is placed obliquely
so that posterior borders are nearer to each other than
the anterior borders.
Minute structure of the testis

l-
Tunica albugineo : a tough fibrous coat which is thickened posteriorly to form

the mediastinu m testes.
2- Fibrous septa : divide the testicle into 200-300 compartments.

3- Seminiferous tubules : About 400-600 in number each is 60 cm. long, there are
about 2-3 tubules in each compartment. As the tubules reach the mediastinum
testis, they join one another and open in the rete testis which is a network of
seminal channels.
4- Inlerstitial cells of Levdig : Found inbetween the tubules. They secrete

testosterone.
5-
Vssa efferentis
: arise from the top part of the testicle from the rete testis. They
are 15-20 in number and they join the head of the epididymis.
lntornal sprmatic
anery and vein
Vas deferens
Pampinilorm ptexus
Ouctuli erl.entes
Epididymis
Appendix epididymis
Appndix testis
Tunica albuginea
Seminilerous tubules
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Coverings of the testis
(9 coverings from inside outwards )
1. Tunica albuginea "fibrous capsute".

2- Visceral layer of tunica vaginalis.
3. Parietal layer of tunica vaginalis.

4. lnternal spermatic fascta : derived fromfascia tronsversalis.
5. Cremasteric muscle and fascia: derivedfrom internal oblique muscle.
This muscle is supplied by the genital branch of genito-femoral nerve

ttcremasteric verye".
lts function is to raise and lower the scrotum in order to regulate the
temperature of the testis and promote spermatogenesis.
A In a cool environment
the cremaster draws the testis closer to the body
preventing heat loss, while in a warm environment the cremaster relaxes

allowing the testis to cool.
The cremasteric reflex is elicited by lightly stroking the superior and medial
(inner) part of the thigh. The normal response is a contraction of the

cremasteric muscle that pulls up the scrotum and testis on the side stroked.
A In infants, this reflex may be exaggerated
leading to retractile testis which is
a mistaken diagnosis of undescended testes.
6. External spermatic fascia : derivedfrom external oblique oponeurosis.

7. Colles'fascia : is the extension of the deep membranous layer of the
superficial fascia of the abdomen "Scarpa's
fascia" to lhe scrotum-
8. Dartos muscle 1 replaces the superficialfatty layer of the superficialfascia of

the abdomen "Camper's fascia".
The dartos muscle is supplied by sympathetic fibres
& is responsible for
corrugation of the skin of the scrotum
9. Skin of the scrotum.

Nerue supply of the skin of the scrotum
Anterior 1/3 (11) : through the ilioinguinal nerve & the genital branch of genitofemoral nerve "cremasterac verve".
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Posterior 2/3 (S3) : through the posterior scrotal nerues arising from the perineal
nerve arising from the pudendal nerve.
And also through the perineal branch of posterior cutaneous nerve of thigh.
Blood supplu of the testis=

1. Testicular artery "also called internal spermatic aftery" i
O Arises from the abdominal aorta at level of L2 below the renal artey.
2. Cremasteric aftery "also called external spermatic altery":
O Branch of the inferior epigastric artery, which
is branch of the external
iliac artery.
@ Usually anastomosing with the testicular artery but far from the testis.
3. Aftery of the vas
O Branch of the inferior vesical artery, which
is a branch of the anterior
division of the internal iliac artery.
Venorrs Drainage
1. Pampiniform plexus of veins
A About 15-25 veins in the scrotum & about 4-6 veins in the inguinal canal.
A Above the internal ring, the are 2 veins lying on psoas muscle on either side
of the testicular artery.
Finally the right testicular vein "internal spermatic vein" goes to the inferior
vena cava, the left testicular vein goes to the left renal vein.
2. Cremasteric vein(s) "also called external spermatic vein":
A It anastomosis with the pampiniform plexus of veins in the inguinal

A Drains into the inferior epigastric vein.
3. Vein of the vas
canal.
A Drains into the inferior
vesical vein.
Lgrnphatic drainage
1. To the para-aortic lvmph nodes.
2.
Some lymphatics from the medial side of the testis may run
of the vas and drain to the iliac lvmph nodes.
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with the artery
3. The skin of the scrotum is drained by the insuinal lvmph
Nerrre supplu
nodes.
[Al sgrnpathetic supplg :
Fibres arise from T10; pass in the greater or lesser splanchnic nerves to
relay in the coeliac ganglion.
A Past ganglionic sympathetic fibres reach the testis along the testicular artery.
lBl Sensrrrll supplg :
A Sensory fibres share the same sympathetic pathway.
Ernbrgologg of the epididgrnis l[. vas deferens

O They arise from the
/lfesonephric ( Wolffian ) d.rtct .
N.B : The mesonephric tubules give :

* fhe uasa
'Ihe a[[endix ol the epididymis.
* Ihe mradidymis [ 0r0an oI Gimldes l.
efferentia.
N.8 ; The appendix of the testrs ( Hydatid of Morgagni ) arises from

the remnant of the paramesonephric duct ( Mullerian duct ).
Abnormalities in festicular Descent

"Maldescended Testis"
I-
Und,eseend,ed, testis ( Arrested, testes
INCIDENCE
A It occurs in 3o/o of full term babies but more common in premature babies.
A Right testis ; 50o/o ( due to the later descent of the right testes ).
A Left testis : 30%o .
A Bilateral t 20o/o .
ETIOTOGY
1- Bilateral cases Usually due to a hormonal defect in muternol \-HCG.

=
i Usually associated with hypogonadism & slipped upper femoral epiphysis.
2- Unilateral cases z Due to anatomical baruier to normal descent:
Short testicular artery "spermatic vessels": most important factor.

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i
-
Associated hernial sac.
Inadequate inguinal canal.
Retroperitoneal adhesions fixing the testis in higher places.

Rupture gubernaculums.
PATIIOTOGY
l-
ln order of frequency the site of undescended testes is :
External ring.
2- Neck of the scrotum.

3- Inguinal canal.
4- Lumbar region (intra-abdominal).
i If bilateral the condition is known as cryptorchidism.

@
The size ond function of the testis remoin normol till the oge of 6 months.
* The destruction of the testis starts
* At2 years,
from 6 months onwards.
40o/o of germ cells are destructed.
* At 6 years, there is complete atrophy of germ cells.

@
lf left in the obdomen:

1. Testes do not grow and becomes atrophic & soft.
2. The seminiferous tubules
become atrophied because of the higher
temperature of the abdomen causing failure of spermatogenesis.
3. The interstitial cells are NOT affected and hence the 2'rsexual
characters and erection are normal.
c/o :
i
otE
The mother observes that one side or both side of the scrotum are empty.
:
1. The affected side of the scrotum is empty & not well developed.
2. The testis is palpated if arrested in external ring or neck of the scrotum.

3. The testis
is difficult to be palpated
if arrested in insuinal canal.
testis can be identified as it gives a sickeninq sensation when
4. The testis is not pglpgllBd if intra-abdominal

5. Associated congenital hernia
is commonly found in 80-90% of cases.

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--
DID
1.
2.
3.
4.
Ectopic testis : see later.
Testicularagenesis.
Surgically removed testis.
Retractile testis
It is a common condition during childhood due to active cremastric

reflex on a small mobile testis.
By careful & gentle examination in warm surroundings, the testis is

usually brought by the examiner downwards and medially to scrotum.
ln difficult cases the "chair test" should be tried. The young patient is asked
to sit on a chair and hug his knees to his chest. Pressure thus directed on to
the inguina! canal causes a retractile testis to descend into the scrotum.
The "squatting position test" is an alternative one.
- Retractile testes require no treatment.

IUITRTfCTILD
AITITIISTI]I)
a. Scrotum
Fully developed
Not well developed
b.Pulling down the
Easily pulled down
Cannot
testis to the scrotum
COMPLICATIONS
1. Liable for trauma and torsion.
2. Malignant change "All
I
(
3.
types of malignancy may occur especially seminoma"i
Increase incidence for malignancy 35 times.

Due to testicular dysgenesis (histologically abnormal).
Spermatogenesis
will be lost if surgery is delayed and if the condition is
bilateral, sterility will follow.
4. Epididymo-orchitis : Extremely rare.

INVESTIGATIONS i (for impatpable
testis onty) t
1. Diagnostic laparoscopy : lnvestigation of choice.

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Ain shams classification of abdominul undescended testis.
O Type f:
no testis visualized "vanishing testis"
& is thought to be due to
intrauterine testicu lar torsion.
O Type II:
a testis seen at the internal ring with the vas and vessels looping
to the internal ring.
Type
[[I:
testis at the internal ring, with vas and vessels going to the testis
directly.
O Type IV: intra-abdominal testis not related to the internal ring.

2. Abdominal U.S or C.T scan.
3. MRI is done if abdominal U.S and C.T scan fail to localize the testis.
TREATMENT
(l) TnenrMENT oF INGUINAL

7.
UNDESCENDED TESTts
Bilateral testes : IICG a single
eoulrse i,n, the form of :
O 500 IU/dose given twice a week for 5 weeks.

O A higher dose can cause precocious puberty,
induce epiphyseal plate fusion
and retard future somatic growth.
2.
If unilaterul or fq,iled rned,ico,l treatntent ) Orehiopexy

(best at I.5 gears).
The aim of surgery is to :
1. Mobilize the testis to the scrotum.
2. Retain the testis in the scrotum.
O The cord and testis are mobilized and freed from the surrounding structures.
O The associated hernial sac should be excised.
O The inferior epigastric artery
is sometimes divided to abolish the angulation
of the vas around it.
If omJ.bferg k $oibfto be dotrl in ons stage:

A. Two stage operation
After maximal mobilization, the testis
is anchored
and 2'd stage is done after 6 months.
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with prolene suture
B. Fowler-Stephens technique
High division of testicular artery pro
the testicular artery & the artery of

This is known by putting a small vas
testicular adery as high as possible

does not become ischaemic (bluish), the artery is
C. Microvascular technique
divided
O Division & re-anastomosis of the testicular
vessels at a lower level to the
inferior epigastric vessels.

Retaining the testis in the scrotum
l. Bevaris tec^l,niqup [Serotal, stitnh) :

-
Fixing the testes to the bottom of the scrotum by a prolene suture, to be

removed after 2 weeks.
2.B,ans,oas teclniq
u.,(2*adarto,s
Pouch)
Placing the testes in a dartos pouch beneath the skin.
(ll) TRERTMENT oF
ABDoMTNAL UNDESCENDED TESTTS
Ths ba*
1"t
stage is laparoscopic clipping of the testicular artery allowing the
testis to depend on the blood supply from the artery of vas.

2nd
stage is laparoscopic assisted orchiopexy (LAO) 6 months later.
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(lll) TnearuENT oF
eATIENTS eRESENTED LATE
a. If the pt is presented late but still before puberty
@ Orchiopexy and not orchiectomy for preserving hormonal function.

@ Orchiopexy does not diminish the liability for malignancy but improves
early diagnosis.
b.
If the pt is presented late after puberty:
@ Orchiectomy for a hopeless atrophic testis as long
II-
Detopie testis (Ileaiated testis)

a. Superficial inguinal pouch (most common).
C
Perineum.
b.
c. Root of the penis.

d. Femoral triangle.
The super-ficial inguinal pouch is a pocket formed between the
Scarpa's fascia and the external oblique aponeurosis just lateral to
external inguinal ring.
ETIOLOGY
Traction by sideway gubernaculums thfuoodTh2org).

[ctonic lnguinal
.lnguinal Arested
1. On straining, the testis becomes more
1. On straining,
apparent.
apparent.
2. Testes can be pushed medially but NOT
2. The reverse.
it becomes
laterally.
TTT
Orchiopexy is much easier because the testicular vessels and the vas
are of optimal length.
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less
Inflammafory conditions of lhe testes, epididymis

and spermatic cord
V Inflammation of the testes alone (orchitis) is rare.
V ft is usually associated with inflammation of the epididymis
(epididymo-
orchitis) or with the spermatic cord and the epididymis (funiculoepididymo-orchitis).
V ft may be acute or chronic.
Acute lnflammatory conditions :
I- Aeute non-speeifi,c epid,id,gmo-orchitis

V fnis is afairly
common disease.
MODE OF INFECTION
1. Ascending infection (common route) through the lumen of the vas seeondary
to urethritis, prostatitis and seminal vesiculitis-
lt
may occur spontaneously,
or after instrumentation (urethal catheterization or cystoscopy).
Tne commonest organisms are.' Chlamydia, E.coli, proteusr r gonococci,
streptococci & staphylococci.
2.
e/o
Blood borne infection (rare) secondary to specific fever as mumps.

:
1. There may be history of prostatitis or mumps.

2. Acute
severe scrotal and groin pain.
3. Constitutional symptoms ( FAHMR ).
otB
V the epididymis
and the testis are swollen, red, hot & tender with edema of
the overlying skin.
A small secondary hydrocele may be present.
V pm : May reveal swelling & tenderness

D.D :
Torsion testis.
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in the prostate.
COMPLICATIONS
l.
Testicular atrophy in neglected cases.
2. Testicular
abscess.
3. Chronicify leading to fibrosis of the epididymis which blocks the

conductive system on this side.
INV
1. Urine analysis and C &
S.
2. CBC: Leucocytosis.
3. Scrotal duplex to exclude torsion
TTT
testis.
1. Antibiotics for 2-3 weeks., usually a member of the quinolones group

(ciprofloxacine ) or doxycycline for Chlamydia.
2. Lead subacetate locally.

3. Advise the patient to wear a scrotal support.
4. Rest for the first few days.
5. Testicular abscess ! Drainage under G.A.
II- Aeute fi,lo;rio,l funieu,lo- epid,id,gmo -otchitis (aeute

end,emic funiculitis ) :
ETIOLOGY
V ttris
is de to lymphatic obstruction by
microfilaria and adult worms
(Wuchereria bancrofti) with secondary streptococcal infection.
PATTIOLOGY
1. Acute catarrhal funiculitis.
2. Acute suppurative funiculitis.

3. Acute gangrenous funiculitis.
4. Acute fulminating funiculitis.
C/P I
As acute non-specific epididymo-orchitis
Ttre patient lives in an endemic area, e.g., Guiza or Sharkia.

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WhiteKnightLove
V Tender inguinoscrotal
swelling, the cord is thickened, and its structures are
matted together.
INV :
V tvtidnight blood film : For microfilaria.
V CBC : Esinophilia.
TTT
V Diettryl
carbam azine (Banocide) for the parasite and antibiotics for the
secondary bacterial infection.
V Orchiectomy
may be needed in gangrenous & fulminating types.
Chronic lnfl ammatorr'' conditicns :

I - Chronie n ofl,- sp,eeifi,e epid,id,!fito -orehitis
O Ttre disease may follow an acute attack or may be chronic frorn the start.
O ft is now rare because of the availability of effective antibiotics.
II- Chronie specifi,c epidid,ymo-orchitis :

I- Tuberculous
epididgrnitis
ROUTE OF INFECTION
A) Retrograde from a tuberculous focus in the seminal vesicle or prostate
"Lymphatic born".
O The lesion occurs in the tail of the epididymis (globus minor).

B) Blood born: rare
@ The lesion occurs in the head of the epididymis (globus major).
c/o
O T.B toxemia.
O Stigtrt ache in the testis or swelling in the related testis and epididymis.
otE
l. Eniilidynis:
O Early case : Slightly tender hard nodule in the tail.

O Later : The whole epididymis
is enlarged, tender, hard and has a craggy surface.

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beadinE of the uas)-
2.Uas: (
@ Ttre vas deferens is thickened and is studded with
multiple submucosal tubercles.

S.Testes
The testes usually remains free for a long time,
but in neglected cases it may be affected,

ln ailuanced Gase: Gold a[soess ale lo]med in the lower anil
[ostefio] [art CIfffie
sctotum which may [u1sl Gausing a I.B . sinus

4. Seconilary
small lax hytlloccle.
5. P/ B:
O Hard
nodules in the prostate or the seminal vesicles.
INV :
1.
Urine and semen analysis:
* For T.B bacilli by Zeil-Neelsen stain or culture on Lowenstein medium.
2. I.V.P: For
3.
TTT
PCR:
associated urinary T.B.
For T.B.
1. Anti-tuberculous drugs.
2. If there is no response to conservative treatment after 2 months )

Excision of the vas deferens and epididymis is indicated.
ll- Bilharziasis
EA Bilharzial affection of the cord or testes can occur as a complication of

urinary or intestinal
disease.
m It is a chronic disease from the start.

ROUTE OF INFECTION:
Anastomotic channels between the superior & inferior mesenteric veins

(Portal system) and the right & left testicular veins
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PATTIOIOGY
form I : ( most common ).

O Granulomatous fusiform, firm & non tender mass in the lower
1. Nodular tVpe ( Soliturv
7-8 cm of the cord
O The mass may involve the epididymis (commonly the globus major).
O The spermatic cord is not matted.
O The v^s can be differentiated from the other constituents of the cord.
O There may be secondary hydrocele.

O P/R : Bilharzial affection of the prostate & seminal vesicle.
ll.B: ln some
[atents, mtl!fi[le masses a]e scafteled along the s[ermatio
Go]d W t0 tne
enctnalling t Bilhanial l0sary I

2. Granular form : ( less common ).
: ( rare ).
III- Fitariasis :
O Chronic funiculo-epididymo-orchitis may follow acute
3. Massive form
funiculo-epididymitis or is chronic from the start.
PATTIOLOGY
1.
Diffuse tvpe :
O
O
O
The spermatic cord is matted.

The vas cannot be differentiated from the other constituents of the cord.
There may be secondary hydrocele.
2. Nodular tvpe
( less common
D.D
Bilharzial nodule.
TTT OT BILHARZIASIS & FILTTRIASIS :

O Anti filarial drugs or anti bilharzial drugs.
O Rarelv surgical excision of a mass is needed to :
?
Settle the diagnosis.
Relieve the dragging pain.
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Neorrlasms of the testis

O Practically 99o of testicular
neoplasms are malignant.
O They constitute l-2oh of malignant tumours in males and occur at a

relatively young age.
O Bilateral in 3-5o of cases.

ETIOLOGY
@ Incompletety descended testes, especially the intra-abdominal variety.

@ Klinefelter's syndrome.
@ An isochromosome 12p (the short arm of chromosome 12 on both sides of
the centromere) is present in about 80 "A of the testicular cancers.
An isochromosome is a chromosome that has lost one of its arms and
replaced it with an exact copy of the other arm.
CLASSIFICATION
1.
tumouls..
O Seminoma
.....86"
@ Teratoma _ Non seminomatous Germ Cell Tumors
"NSGCTs"
Germ cell
O Combined
40o/"
seminoma and
2. lnterstitial tumours
teratoma
(rare).
32o/o
l4o
-...-1.5"/o
O Leydig cell tumour

@ Sertoli cell tumour
3. Lymphoma.
4. Other tumours.
PAT}IOLOGY
......7o/o
.5.5'h
(I) Gwm cell turnours
Seminoma
Teratoma
ABe
35-45 years of age.
20-35 years of age.
CeII of origin
Seminiferous tubules.
Embryonic totipotent
cells in the rete testes.
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IVIae
Moderate to large, firm

and smooth, sometimes
Variable size. Usually
it
molded by the tunica
is lobulated due to the
albuginea so always
presence of fibrous septa.
having a smooth surface.
On cut section it is
Cut section is yellowish in
homogenous and pink
colour and heterogenous
creamy in colour.
showing cysts that
contain gelatinous
material & cartilage

nodules.
IWie
Cells resemble
spermatocytes (rounded
See below
or oval with clear

cytoplasm & large
rounded nuclei).
Lymphocytic infi ltration

of the tumour.
Spread
Lymphatics to the para-
Blood spread mainly to
aortic & iliac L.Ns.
the lungs
& liver.
Teratomas are subdivided into 5 subtypes based on histopathologic characteristics:
1. Differentiated teratoma.
2. Malignant teratoma intermediate "MTl" = Teratocarcinoma.
3. Malignant teratoma anaplastica "MTA" = Embryonal carcinoma
O It a highly malignant tumour with very bad prognosis.
4. Malignant teratoma trophoplastica 'MTT" = choriocarcinoma

O Rare tumour.
O It is the most aggressive malignant tumour known.

@ Cytotrophoblast and syncytiotrophoblast without villus formation.
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5. Endodermal sinus tumour "EST" = Yolk sac tumour "YST"

lnfantile embryonal carcinoma
O It is the most common testicular tumor in infants under 3 and young boys.
@ Excetlent prognosis.
GI) Intustitial eell tumaurs :

1. Leydig cell tumour:
El Usually occurs before puberty.
H It produces excessive amounts
of androgens leading to infant Hercules
(sexual precocity and extreme muscular development).

2. Sertoli cell tumour:
H Occurs after puberty.

H It produces estrogens leading
H The tumour
to gynaecomastia, loss of libido & aspermia.
is benign and orchiectomy cures.
CLINIEAL PIETURE OF TESTIEULAR TUMOURS
c/o
0) Tg pioal presentatioa
1. Painless enlargement of the testis.
2.
Sense of heaviness occur when the testes reaches 2-3 times
its normal size.
3. In l0'/o of cases the patient gives history of trauma that merely attracts his
attention to the presence of a swelling.
otE
1.
The
testis
H Enlarged, hard, smooth and healy, later, soft protuberances appear.

H Testicular sensation is lost early in the course of the disease.
2. Ihe epididymis:
H at first it is normal.
H Later on there is obliteration of the epididymal sinus.
H Then it becomes infiltrated with the tumour.
3.
Lax secondary
hydlocele is [resenl in 10% 0[ Gases.
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The nara-aortiC lymph
5. The ingUlnal
B)
nodes: May be patpabte just above the umbilicus.
lymRh n0des :
Are not affected unless the scrotal skin is infiltrated.
Atgpaaaf prcsentatioa :
1. Occult presentation
H Cough, dyspnea and haemoptysis.

EJ Enlarged
supraclavicular L.N, particularly on the left side
2. An abdominal mass with an empty scrotal compaltment
H Should raise the suspicion of malignant transformation in an abdominal

undescended testis.
3. Hormonal effects
El Infant Hercules.
H Gynaecomastia.
4. Hurricane type
H Fatal termination occurs due to metastases from highly malignant tumours.

5. Some cases may simulate acute epididymo-orchitis :
H Acute pain and swelling are due to haemorrhage in the tumour.
6. Acute hydrocele.
D.D : l. Old clotted haematocele.

STAGING
Stage
2. Calcified hydrocele.
Tumour in the testis only.
Stage ll
lnvolvement of lymph nodes below the diaphragm.
Stage lll
Involvement of lymph nodes above the diaphragm.
Stage lV
Systemic metastases mainly pulmonary
INVESTIGA TIONS
(A) Iliagnastie
& for lrv lesiot.
1. Scrotal ultrasound
H Confirms the presence of the testicular tumour.

H Differentiates it from other lesions.
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& hepatic
metastases.
2. Frozen section biopsy via inguinal approach (Chevassu technique).

Biopsy should never be taken through the scrotum neither by
incision nor by needle aspiration as this will lead to local

implantation with subsequent involvement of the inguinal L.N.
a. Through an inguinal incision the spermatic cord is identified and
isolated at the internal inguinal ring.

b. A vascular clamp is applied as high as possible on the spermatic cord
to avoid the risk of blood dissemination while manipulating the tumour.

c. The testis split opened & any doughtful lesion is subjected to frozen
biopsy
3. Tumour markers
a. Betafraction of human chorionic gonadotrophin (B-HCG )
H
H
Raised in 1007. of patients with MTT.

Raised in l0o/o of patients with seminoma.
b. Alpha
fetoprotein (a- FP) :
El Elevated in 750' of teratocarcinomas.

c. Lactate dehydrogenase (
LDH ).
(B) For 2d'" :

1. Chest X-ray & C.T scan chest.
2. CT scan abdomen : For para-aortic lymph nodes and liver deposits"
3. t.v.P :
Detects the position of the kidneys to be shielded during radiotherapy.
Detects the presence
TREATMENT
& extent of retroperitoneal
metastases.
I. lnitial treatment is by high retrograde orchiectomy.

2. Further management depends on the pathology and stage of
the tumour.
82
WhiteKnightLove
I- Serninorna
Stage
: Radiotherapy to para-aortic lymph nodes and iliac lymph nodes in the
form of inverted Y technique
Stage ll
Radiotherapy is extended to the mediastinum and left supraclavicular
L.N.
: Radiotherapy & chemotherapy using cisplatinum

Stage lV : Mainly chemotherapy using cisplatinum with or without radiotherapy
Stage lll
II- Teratorna = The tumour
is radio-resistanl
Stage I : Follow up by tumour markers & repeated C.T scanning.

Stage ll-lV : Chemotherapy using combination of : Cispladnurn,
methotrexate, bleomycin and vincristine.
JI.B:
[etroReilIoneal lymuhadenectomy is sometimes needed in te]atoma for residual L]l
attcl Ghemothera[y.
Retrograde ejaculation occurs after this operation due to
interruption of the sympathetic nerve supply to the bladder neck.

PROGNOSIS
Serninorrra
t
@ Stage III & IV t
Teratorna :
O Stage I & tI t
O Stage III & IV )
@ Stage I &
I[
5 years
surviyal rate is 95o/o.
5 years survival rate is 75oh.
5 years survival rate is 85o
5 years survival rate is 600/".
83
WhiteKnightLove
ostgrad,u.ute ad.d.itiorn,o,l n otes :
Non seminomatous germ cell tumours "NSGCTs" are subdivided into 5 subtypes
based on histopathological characteristics.
(l) TERa.roua
H The term "teratoma" refers to a germ cell tumor that contains elements of all three
genn layers (endoderrn, mesoderm, and ectoderm), present with varying degrees
of
differentiation.
EJ Although technically no malignant tissue exists in these
terminally differentiated
tumors, metastases can occur, and death can result from slowly progressive,
unresectable disease.
Therefore, the label "benign" is misleading and should be avoided when referring to
these tumors.
El Teratoma
does not secrete either p-hCG or AFP and is not responsive to
chemotherapy.
Macroscopically, primary lesions in the testicle tend to be large, replacing normal

epithelium. Cut surfaces show large multi-loculated cystic areas, with cysts
containing serosanguinous fluid.
If solid areas are noted grossly, they should
be
analyzed histologically, as other malignant germinal elements may be present.
Subcategories include mature teratoma, immature teratoma, and teratoma with
malignant transformation. Surgical extirpation represents the only known

therapeutic option.
(A) Mature teratoma
Microscopically, mature (adult) teratoma is easily distinguished, with obvious

epithelial-lined structures, as well as mature cartilage, and striated or smooth muscle"
Although each component is histologically mature, the distribution of the elements

appears haphazard.
(B) lmmature teratoma
Several histologic features may result in a teratoma being labeled as immature. The
presence of a highly cellular stroma exhibiting mitotic figures is sufficient to make this
diagnosis
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WhiteKnightLove
More commonly, immature teratoma has areas of primitive mesoderm, endoderm, or

ectoderm mixed with the more mature elements.
(C) Teratoma with malignant transformation
O A relatively recent observation has been of a variant of teratoma that contains

malignant non-germ cell elements, presumably derived from somatic tissues within
the teratoma-
O tt is unclear whether
these elements represent partial differentiation along somatic
lines of the malignant totipotent germ cell, or malignant degeneration of a mature

somatic element of the teratoma-
O ttris histopathologic entity may include areas of adenosquamous
carcinoma, multiple
varieties of soft tissue sarcomas, neuroblastoma, or nephroblastoma.
O ttre presence of these malignant somatic tissues, either at the time of diagnosis or
following induction chemotherapy, is a poor prognostic sign in terms of relapse and
overall survival-
(ll) TenerocARCrNoMA :
H The term "teratocarcinoma" refers to a gerrn cell tumor containing elements of
mature teratoma mixed with other germ cell elements.
Macroscopically, there is a variegated appearance, with cystic areas of the mature

teratoma mixed with areas of solid tumor representing the malignant elements.
H Microscopically,
separate areas of obviously malignant germinal elements (i.e.,
embryonal carcinoma) are in proximity to mature, adult-like structures.
Clinically, the aggressiveness of this tumor lies somewhere in between that of

mature teratoma and pure embryonal carcinoma.
(lll) EveRvoNAL cARCTNoMA :

H 20% of all testicular tumours
H It a highly malignant tumour with very bad prognosis.
H Poorly differentiated large polygonal cells in cords, sheets, or papillary
formation
with indistinct cytoplasmic borders (unlike seminoma) are the rule, with pale
granular cytoplasm, large nuclei, and one or more centrally placed nucleoli. Mitotic
figures and multi-nucleated cells are common.
85
WhiteKnightLove
H In a subset of embryonal
carcinomas, spherical structures resembling embryos
of
to 2 weeks of gestation appear and are referred to as "embryoid bodies".
(lV) CHontocARcrNoMA :
H Rare tumour
H It is the most aggressive malignant tumour known.
Cytotrophoblast and syncytiotrophoblast without villus formation.
H Cyotrophoblasts
are polyhedral cells
with well-defined borders, having a
clear/eosinophilic cytoplasm with hyperchromatic nuclei or vacuolated nuclei.
Syncytiotrophoblasts are larger, multi-nucleated cells with indistinct borders having

bizarre nuclei and large amount of eosinophilic cytoplasm.
H they often surround the cytotrophoblasts.

H Stroma is sparse, but tends to be highly vascular.
(v) ENOOOERMAL STNUS TUMOUR "EST" = YOLK SAC TUMOUR
"YST" = INFANTILE EMBRYONAL CARCINOMA
H It is the most common testicular tumor in infants under 3 and young boys
H Excellent prognosis
H Microscopically, patterns show great variety, but commonly, lesions contain cystic
:
areas lined by ovoid or flattened cells that protrude into the lumen of the cyst
H The appearance
of the endodermal sinus is pathognomonic; its structure in many
ways resembles the mature glomerulus.
H Clustering of these cells around a small central blood vessel results in a structure
referred to as a "Schiller-Duval body".
Pure seminomas are subdivided into 3 subtypes based on histopathologic
characteristics.
(l) clRsstc
H
SEMINoMAS
(85%)
Demonstrate a monotonous sheet of large rounded cells with abundant cytoplasm
that frequently stain positively for glycogen and rounded hyperchromatic nuclei
with prominent nucleoli.
H A lymphocytic
infiltrate or granulomatous reaction with giant cells or both is
frequently present.
86
WhiteKnightLove
H Trophoblastic
giant cells capable of producing B-hCG are present in l0-15
o/o
of
tumors-
H Mitoses are infrequent.

(ll) ANnpuesrrc SEMTNoMA (1O%)
Is an older term used to describe seminomas with 3 or more mitotic figures per
high-power field.
H This finding has no clinical or prognostic
significance because the response of
anaplastic seminomas to standard therapy is equivalent to that of classic

seminomas.
(lll) SprRunrocylc SEMTNoMA (5%) :

H Is arare histologic variant that is not associated with carcinoma in situ.
H On gross examination, this variant has a grayish appearance and tends to be softer
than the classic variety, containing cystic areas without necrosis or hernorrhage.
Microscopically, these tumors tend to form tubular clusters and are ccmposed of
round cells of highly variable size that are closely related morphologically to the
three types of cells in the normal spermatocytic series
H No lymphocytic infiltration.
H Spermatocytic seminomas rarely metastasize,
and they occur almost exclusively in
elderly men above 60 years.
H The only recommended

H Prognosis is excellent
treatment is orchiectomy.
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Torsion Testis
'Torsion of the spermatic cord"
PREDISPOSING FACTORS
1. Arrested and ectopic testis : The testis is improperly fixed.
2. Inversion of the testis
@ Superior inversion : The longitudinal axis of the testis is directed forwands

so that the epididymis lies horizontally.
@ Anterior inversion .' Epididymis lies anteriorly, the body of the testis
tunica vaginalis posteriorly.

@ Lateral inversion
.' Epididymis lies laterally.
@ Loop inversion.' Epididymis encircles the testis like a sling.
3. Long mesorchium
O Torsion of the testis can occur in cases where the body of the testis
is separated from the epididymis by a long mesorchium.
a. High investment of the tunica vaginalis

O
Causes the testis to hang
O In most males, the testis
within the tunica like a clapper in a bell.

is attached posteriorly
to the inner lining of the scrotum.
O In this anomaly, the testis is free floating in

the tunica vaginalis, only attached to the
spermatic cord, like a bell clapper.
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WhiteKnightLove
& the
PRECIPITATING FACTORS
O Sudden straining.
O lifting a heavy object.
@ Trauma.
Sudden exposure to cold weather
Torsion is sometimes called "winter syndrome". This is because it often happens in

winter, when it is cold outside. The scrotum of a man who has been lying in a warm
bed is relaxed. The sudden contraction that results from the abrupt temperature
change can trap the testicle in that position. The result is a testicular torsion.
PATHOTOGY
(l)
Testis : Usually the testis twists in a direction away
from the septum dartos i.e. clockwise on the right &

anti-clockwise on the left, owing to the direction of
the spirally attached cremasteric muscle.
It
becomes oedeamtous, congested and
(2) Spermatic cord
Thrombosis of the vessels will occur if torsion is not reduced.
(3) Skin of the scrotum : Becomes red
CTINICAL PICTURE
c/o
finally gangreno
& edematous.
1. Sudden severe agonizing pain in the groin and lower abdomen.

Pain might be felt as dull ache in the related loin or hypogastrium according to
in organ which has migrated is invqriably

localized in the primary relative position of that organ.
Brawn's taw : "Pain an
2. Vomiting (once or twice, not persistent).

3. Abdominal distension (from reflex ileus).
otB
A. Torsion of a completely descended testis
The testis is swollen, tender & l,igho uP irt Poiliotr-
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WhiteKnightLove
i The scrotum is red, edematous & dimgled.

i There is tachycardia & sometimes shock.
6 It simulates acute epididymo-orchitis except for :
In testicular torsion
a) Elevation of the scrotum exaggerates
the
pain "*Prehn's sign".
b) Temperature is normal or slightly elevated.

c) Cremasteric reflex is usually absent.
The presence of the cremasteric reflex does not eliminate testicular torsion from
a differential diagnosis, but
it
does broaden the possibilities
to inctuded
epidydimitis, or other causes of scrotal and testicular pain.
B. Torsion of an incompletely descended testis:
Inguinal swelling which is irreducible, no impulse on cough, tender and

tense.
i It is very similar
to strangulated hernia but the corresponding side of the
scrotum is empty.
D.D l
1. Acute epididymo-orchitis.
2. Strangulated inguinal hernia ) C/P of I.O.
3. Torsion of hydatid of Morgagni "appendix testis".

4. Idiopathic scrotal edema.
INVESTICATIONS
1. Urgent scrotal duplex &
U.S is diagnostic.
2. Urgent urine analysis.
A \turia in cases of acute epididymo-orchitis.
TTT
O The condition is highlv emergencv and infraction of the testes occurs in 6 hrs.
O Through an inguino-scrotal incision the torsiott.
examined
if
ruilr,ble
or twt
90
WhiteKnightLove
is ttrtd,one and the testis is
(A) Viable
The tunica vaginalis is everted and the testis is fixed to the bottorm of the
scrotum to prevent recurrence.
Orchiopexy of the opposite testis at the same time, as the anatomical
variation responsible for torsion is likely to be bilateral.

(B) Non-viable:
A
A
Orchiectomy above the twist.

Orchiopexy of the opposite testis "ntost im"gtorturtt".
ll.B: lleglected intlacted tcstis Gauses infenility. With inlarction, the
srctm
lariel
is
[reac[ed
&
il00d
the immune systcm Gan uet access t0 thc
srcms
&
tecognizcs them as foleign material t0walds which antihodies ate formeil.
slems
in the healthy testis ale affected by this immune leaGtion.
The intractcil testis should, therelolc, be lemoucd eally t0 minimize immume
stimulati0n.
N.B : Torsion of the appendix of the testis "hydatid of Morgagni"
A Clinically mimics torsion testis.

A 1/3 of patients present with a palpable "blue dot" discoloration.
A Immediate operation with ligation and excision of the twisted appendix of
the testis cures the condition.
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WhiteKnightLove
Varicocele
A
Elongation, dilatation and tortuosity of the pampiniform plexus of veins or

the cremasteric veins.
N.B
The testicular vein has no valves & the pampiniform plexus has few
inefficient valves.
Prhnarg Varieocele :
ETIOLOGY
A Primary varicocele usually affects young adults (15-30 years).
A Its percent in males is about 20V,

A Its exact cause is not known but may be due to congenital weakness of venous
walls, which may be due to familial weakness of mesenchymal tissue
(associated
with hernia, varicose veins, and flat feet).
A Primary varicocele almosl always affects the left side due to :
1. The right angled termination of the left spermatic vein into the left renal,
vein impedes the venous return, in contrast to the oblique termination of the
right vein into the IVC.
2. The lower position of the left testes & the higher position of the left kidney.
3. Compression of the left testicular vein by the heavily loaded pelvic
colon.
4. The left renal vein passes anterior to the aorta & posterior to the superior
mesenteric artery (nutcracker action).
5. the lack of effective antireflux valves at the junction of the

testicular vein and renal vein
CtINICT1L PICTURE
c/o
1. Usually, the condition is asymptomatic.

2. Dragging pain especially on prolonged standing or in hot
weather
& relieved by lying down and during
WhiteKnightLove
sleep.
3. The patient may complain of infertility.

4. Complications may
otB
be the
l't presentation.
INSPECTION
1. Large varicoceles are also visible.
2. The affected side of the scrotum hangs lower than normal.
3. Scrotal neck test : inguinoscrotal swelling giving a thritl on cough.

PATPATION
1. On standing there are dilated, elongated & tortuous veins felt above the
testis like a "bug of worms".
2.'Tlrr-vot'tmo*)e
e,rnpti.,es
wklp
tle
patient is bing dounS tlro soroturn is
dwotd.ot bg bory tcsL
3. There is often a small 2'v hydrocele.
N.B : * Examine
the abdomen to exclude 2'v varicocele.
GRADING OF VARICOCELE
* Grade 0 Varicocele detected by duplex only.

* Grade I Varicocele detected by straining.
* Grade 2 Varicocele detected by palpation.
* Grade
Varicocele detected by inspection.
COMPLICATIONS
1. subfertility 15% ( asthenospermia mainly, then oligospermia ): Due to
I
A
Thermsl theorv : Warmth from venous congestion affects spermatogenesis.

Toxic theorv
Metabolic substances of steroids & catecholamines are toxic and

potentially spermatogenic inhibitors reach the left testicular
vein at a higher levels.
Hypoxic theorv : Venous stasis causes hypoxia & lactic acidosis affecting
spermatogenesis.
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WhiteKnightLove
N.B : Subfedility occurs even if the condition is unilateral due to

presence of intercommunicating veins between both testicular veins in
the abdomen.
2. Recurrent attacks of thrombophlebitis.
3.
2,Y
vaginal hydrocele.
Postgraduate notes: the communication between the 2 testicular veins
The testicular vein midway between the internal inguinal ring and the lower pole of the
kidney divides into the medial and lateral branch to form a delta.
The medial branch communicates with the ureteral and contralateral veins; there, it
terminates in the left renal vein or inferior vena cava on the right side.
The lateral branch communicates with colonic and renal capsular veins and terminates in
the perinephric space.
There is no cross-communication between the left and right testicular venous systems in
the scrotal, retropubic or pelvic areas.
The only cross-communication is in the abdomen, and is seen in only
50olo
of men.
The testicular vein has no valves.
INVESTIGATIONS
I.
Sernen o;no,lgsis :
A Varicocele affects count, motility and increases the abnormal forms

(stress triad).
A This is the normal grading of motility as mentioned by the World

Health Organization (WHO).
* Grade a (fast progressive) sperm are those which swim forward fast in a
straight line-like guided missiles.

* Grade b (slowly progressive) sperm swim forward, but either in a curved
or crooked line.
* Grade c (nonprogressive or local motility only) sperm move their tails
only, but do not move forward.

* Gnade d (immotile) sperm do not move at all.
94
WhiteKnightLove
ln order to give birth, grade (a + b) shoutd be at least 50% as

sperms of grade (c & d) are considered poor.
2. Saroto,l fuqiles seclrlt, detects reoersed, blood, flow in the

spflrzno,tie oeins, it also provides full assessment of the testis and detects
2ry vaginal hydrocele if present
Postgraduate notes:
With Doppler ultrasonography, 2 types of retrograde flow in varicoceles have been
described.
These include the shunt-type varicocele and the stop-type varicocele.

The shunt-type varicocele occurs in86Yo of patients and is associated with
diminished sperm quality as well as with a medium to large varicocele.

Shunt-type Doppler flow occurs because insufficient distal valves allow spontaneous
and continuous reflux from the internal spermatic vein into the cremasteric vein and
the vein of the vas deferens via collateral vessels.

The stop-type varicocele involves reflux, which is only brief, and the sperrn quality is
normal and associated with a subclinical varicocele.

The stop type of flow, also known as the pressure type, occurs in patients with intact
intrascrotal valves.
This type allows only a brief period of reflux from the spermatic vein into the
pampiniform plexus when a Valsalva maneuver is performed.
3. Abd,ominal U.S. to exclrud,e coses of secolrtdolry ourieocele

e.g. hAperneplwotna.
TREATMENT
l- Conservative treatment
O In early cases, the patient is reassured.

O For pain, a scrotal support can be used especially in hot weather.
O Advice the patient to take frequent cold bathes.
O Advice the patient to avoid sexual congestion & prolonged standing.
O Venotic drugs are somewhat helpful.
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WhiteKnightLove
ll- Surgical treatment
Indieations
1. Subfertility: After complete exclusion of all other
causes of
infertility.
2. A large painful varicocele.

3. Before admission to a military
,dlim of
college.
surgery :
Prevention of venous refluxfrom lhe lefl renal vein to the testicular vein is
achieved by attocking the venous return of the testis at one of these levels :
Operations & Approo,ehes :
Xc!.9..ta 0
,3ur..
a
rt':cr-1.,,1
1. Retroperitoneal approach (Palomo's operation)
O Ligation
as
and division of the testicular vein (1 or 2) in the retroperitoneal space
it emerges from the internal ring.
O AUv :
No postoperative hydrocele.
O Disadv : Recurrence is common as the cremasteric vein is not ligated.

2. Inguinal approach :
O Ligation and division of the pampiniform plexus of veins together with the
cremasteric vein in the inguinal canal with excision of a segment of the vein to a
avoid recanalization.
O nOv :
Less incidence of recurrence as the cremasteric vein is ligated.
O Disadv :
?Postoperative hydrocele is common due to interruption of the
lymphatic vessels so eversion of the tunica vaginalis is better done routinely.
WhiteKnightLove
3. Scrotal approach : (Not recommended by alt surgeons )

O Ligation and division of the pampiniform plexus in the scrotum.
Removal of the swelling & elevation of the testis (suitable for neurotic
illiterate patients).
No recurrence as the cremasteric vein is ligated.
Disadv:
A Here the testicular artery is an end artery with higher possibility of injury.
A Postoperative hydrocele is common due to interruption of the lymphatic
vessels so eversion of the tunica vaginalis is recommended routinely by
some surgeons.
Recent trends:
1. Laparoscopic varicocelectomy
2. Testicular vein embolisation under radiological imaging.

3. Subinguinal microsurgical varicocelectomy "Marc Goldstein
4. "Marc Goldstein" sub-inguinal microsurgical varicocelectomy
The varicocele is ligated at the neck of the scrotum just below the external
ring.
A This procedure employs a powerful operating microscope that provides 10.25

power magnification to the tiny 1 millimeter testicular artery.
A Reliable identification
and preservation of the testicular artery and
lymphatic channels.
Reliable identification & Iigation of pampiniform plexus of veins & and

cremasteric veins.
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WhiteKnightLove
A Postoperatively,
venous return is via the vasal veins, which drain into the
internal pudendal system and usually have competent valves.
Seeond,arq aafreoeeue
@ Ttris rare condition is due to obstruction of the venous flow in the
spermatic vein.
CAUSES
O Hypernephroma
as the malignant cells
form a malignant thrombus
inside the renal vein (i.e. permeation of the renal vein)
O Abdominal or pelvic tumour.

O Retroperitoneal fi brosis.
CTINICAL FEATURES
Secondary varicocele differs from the primary type:
l.
It occurs after the age of40 years.
2. [t affects both sides equally.
3. It develops rapidly and enlarges in a few weeks.

4.ltdocs not di.ofp*,
TREATMENT
o{.
bing dotrn ot tf t},e sorcturn ls dantpL
ts that of the cause.
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WhiteKnightLove
Epididymal cysts and spermatocele
I- Dpid,id,ymal cysts
ETIOTOGY
A
A
Epididymal cysts are of obscure etiology.

They are degenerative cysts of the vestigial embroyonal remnants
(Remnant
*
*
of
mesonephric tubules).
Paradidymis.
Appendix of the epididymis.
PATHOLOGY
A Ttrey are multi-locular & fitled with crystal clear fluid.

CTINICAL PICTURE
c/o
otE
Painless swelling of the scrotum.
* Site : Purely scrotal lying just above and behind the testis.
* Size.' variable.
: Multi-locular & feel like a tiny bunch of grapes.

* Special character : Brilliantly translucent with numerous septae &
* Shape & Surface
tessellated giving the Chinese lantern appearance.
* Edge : Well defined .
Consistencv
Tense cystic.
D.D
1. Spermatocele.
2. Encysted hydrocele of the cord.
The main difference from encysted hydrocele of the cord is that there
is NO gap between
it & the testis.
3. Vaginal hydrocele
A The main difference from a vaginal hydrocele is that the testis is palpable.
WhiteKnightLove
TREATMENT
A Most epididymal cysts deserve no treatmentA Excision if causing discomfort but the patient must be warned
that excision
may interfere with the export of sperms from the testes on the affected side.
II-
Sp
ertnatoeele
ETIOLOGY
V ft is a retention cyst derived from the tubules of the vasa efferentiaPATHOLOGY
V ft is unilocular and contains spermatozoa which make the fluid resembles

barley water in aPPearance.
CtINICAI PICTURE :
c/o:
V fne patient complains of a painless small scrotal swelling, but .
V ft is sometimes very large & the patient thinks that he has a third
OIE
As epididymal cyst but
It is dimlY translucent2. It is unilocular.

1.
TTT
V Small spermatocele : Can be ignored.

V Large spermatocele :
* Excision
if causing discomfort but the
patient must be warned that excision

may interfere with the export of sperms
from the testes on the affected side.
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WhiteKnightLove
testis.
Hydrocele
H
Hydrocele is colleclion of clear serousJluid inside a port of the processus voginalis.
CLASSIFICATION
1. Hydrocele of the spermatic cord.

a. Encysted hydrocele of the cord.
b. Hydrocele of fhe hernial
sac.
2. Hydrocele of the tunica vaginalis.

a. Congenital.
b. Infantile.
c. Vaginal "primary or secondarytt.
I-
Hgd,roeele of the spertno;tic eord,
A) Encysted hydrocele of the cord
ETIOLOGY
H Due to persistence
of the intermediote part of the processus vaginalis.
H Although congenital, it usually appears in childhood because fluid takes

time to accumulate.
CTINICAL PICTURE
C/O I
otE
* Site
Painless swelling in the scrotal part of the spermatic cord.
Scrotal part of the spermatic cord.
* Size.' Small.
* Shaoe: Oval in shape with its long axis is along the axis of the cord.
* Surface
Smooth.
* Special character :
H It can be moved from side to side but not from above downwards.
H With gentle traction on the testis, it is pulled downwards and becomes fixed.
* Edge
Well defined
x Consistencv
Tense cystic.
Translucent.
l0l
WhiteKnightLove
D.D : Epididymal
cysts
& spermatocele.
H The main difference from epididymal
cysts
& spermatocele is that there is
GAP between it & the testis.
TREATMENT : Excision through an inguinal incision.

N.B
Hydrocele of the canal of Nuck is similar to encysted hydrocele of
the cord that occurs in females and the cyst lies in relation to the
round ligament of the uterus.
B) Hydrocele of the hernial sac.
ETIOTOGY
H Due to fluid accumulation in an empty hernial
sac
which has been shut off
from the peritoneal cavity by omentum or by adhesions.
CLINICAT PICTURE
c/o
H There is history of a hernia.

H Later, there is an irreducible pyriform swelling in the upper
part ofthe cord.
otB
H The swelling is cystic & translucent.

H The swelling is mobile from side to side but not from above downwards.
H Gentle traction on the testis does not alter the mobility of the swelling.
TREATMENT
H Is that of the hernia.
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II- Ilgdroeele of the tuniea r:ogino,lis

A) Congenital hydrocele
ETIOLOGY
H Due to persistence of the whole processus vaginalis.

H The communication with the peritotreal cavity is too small
to permit the development of a hernia.
c/o
H
The mother complains that her infant has a scrotal swelling which is
minimal in the morning & reaches maximum size by the end of the day.
otE
1. Inguinoscrotal cystic translucent swelling.
2. The hydrocele fills gradually on standing and empties very slowly if the
patient lies down and the scrotum is elevated.
3. Abdominal examination : [s essential
because in some cases
it may be Id
man&statioa of T.B. pedonilis.
D.D :
Congenital hernia:
H The congenital hernia is easily reducible and gives expansile impulse on

crying.
TREATMENT
H Surgery through an inguinal incision.

H The sac is divided into two parts.
H Transfixion & excision of the upper part at the level of the internal ring as
a hernia
H Bversion of the lower part as in hydrocele.
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WhiteKnightLove
B) lnfantile hydrocele
H Due to obliteration
of the processus vaginalis only at the level of
the internal ring, so the tunica does not communicate with the
peritoneal cavity.
c/P
H
As congenital hydrocele but
with no diurnal variation in size
El Sometimes the differentiation is known only at operation.
TTT I
Excision of the upper part & eversion of the lower part.
C) Vaginal hydrocele
H This is a fluid collection in the tunica vaginalis.

H May be idiopathic (primary hydrocele) or may be due to an
underlying Iesion (secondary hydrocele).
I - Prirnarg vaginal hgdrrrcele

ETIOTOGY
H Primary vaginal hydrocele
occurs in middle aged and elderly males.
The cause of this condition is not known.
Theories :
l.
Obstruction of the lymphatics draining the testis due to repeated attacks

of subclinical epididymo-orchitis (most accepted theory).
2. Chronic congestion and irritation by repeated trauma.
PATHOLOGY
H It may be unilateral or bilateral.

H There is accumulation of fluid in the tunica vaginalis, which may
reach an enormous size.
H The hydrocele fluid is amber
yellow, thin and contains water, inorganic
salts, fibrinogen and albumin "igm%" in a concentration that resembles an
exudate. [n old standing cases, it contains cholesterol crystals.
Its specific gravity is 1020-1024.
The tunica becomes thickened, fibrosed in old standing cases.

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CLINICAL PICTURE
C/O :
otE
Painless swelling of the scrotum.
:
* Size :
Scrotal neck test : Purely scrotal swelling.
* Shape
* Site
Moderate to huge
* Surface
Pyriform.
Smooth.
* Special character
* Edse
There is no impulse on cough & translucent on transillutuiuqtion.
Well defined.
* Consistencv
ll.B:
Cystic with bioolar flucluation test and dull on percussion.
The hydlocele fluid
COMPLICATIONS
srilounds tne testis, which is often impalnaDle.
1. Infection leading to pyocele, usually after aspiration.
2. Hemorrhage leading to haematocele either after trauma, or spontaneously.

3. Rupture, usually follows trauma.
4. Calcification.
5. Herniation of the hydrocele
sac through the dartos muscle "hg&o,eele en
bisao".
6. Huge expansion of the scrotum leading to indrawing of the penis which may
interfere with micturition and intercourse.
INV
H
Scrotal U.S. is diagnostic and evaluates the testis that is difficutt to palpate.
TREATMENT
Qsptatlon
H Recurrence
: Treatment is essenfia tly surgical.

k hfier aordpt bwt sa
is inevitable.
Hl Furthermore it may be complicated by infection or hemorrhage.
H There may be an underlying testicular tumour.

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Surgical options
1. Eversion of the tunica vaginalis : (Jaboulay's operation).
H A small transverse incision is done in the skin of the scrotum.

H The hydrocele sac is delivered, opened & the hydrocele fluid is evacuated.
H Ttre tunica is everted & stitched behind the epididymis.
H Thus any fluid formed wilt be drained by the lymphatics of the scrotum.
H
Disadvantage
: Sometimes recurrence occurs'tgre
fudro+rllc. .
H Therefore under-running sutures are taken in the free edge of the tunica.
AtL viev
2. Subtotal excision of the tunica
vaginalis
lndicated for a large hydrocele, thick walled or calcified tunica vaginalis.
3. Plication of tunica vaginalis (Lord's operation)
a. A series of 10-12 absorbable sutures "chromic catgut" are woven

radially from the free edge of the tunica to the reflection of the tunica
from the testis & epididymis.
b. Suitable only for
cases where the
tunica is not thickened "thin tunica"
c. ADV :
* Less incidence of bleeding & scrotal haematoma.
* No Recurrence.
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2- Secondarg vaginal hgdrocele

(a) Acute
rr 2'v to acute epididymo-orchitis

(b) Chronic
or testicular tumour.
O Testis : Malignant tumours.

O Epididymis : T.B, bilharziasis & filariaisis.
O Spermatic cord : Varicocele.
@ Post-operative
:k After herniorrhaphy if external ring
is made tight.
)k After inguinol varicocelectomy.
OIE :
TTT:
2'v hydrocele is small and lax (defprfpf,bg pir.cl.ihg
test).
Of the cause.
Beware 0f aGUIe hydrocele in a young man, mele may
tcsticular ne0[lasm.
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[e
an unde]lying
Haematocel, pyocele and chylocele

Haematoeel,e
O Means accumulation of blood or blood-stained fluid in the tunica vaginalis.
l- Acute haematocele (recent haematocele)
CAUSES
1. Trauma to the testes,
injuring the tunica albuginea.
2. Postoperative.
3. Aspiration of hydrocele. 4. Torsion of the testis.
CLINICAL PICTURE
c/o
@ Acute onset of a painful scrotal swelling after history of trauma or any

surgical procedure.
OID z Like hydrocele but opaque with transillumination.
TREATMENT:
O Surgical evacuation of the blood with eversion of the tunica vaginalis.

O f there is a tear in the tunica albuginea, it should be repaired.
ll- Chronic haernatocele (old clotted haematocele)
EAUSES
1. Neglected acute haematocele.
2. Repeated haemorrhage in blood
diseases.
3. Underlying testicular tumour.
D.D I
Testicular neoplasm.
TREATMENT
l.
In early cases, dissection of the clot from the testis and excision of the tunica can
be done.
2. [n late cases, orchidectomy is performed to exclude malignancy. It is difficult to

differentiate between both cases unless the testis is bisected and biopsied.
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Pgocel,e
O A pyocele is a collection of pus in the tunica vaginalis.
CAUSES
1. Infected haematocele.
2. Infected hydrocele especially after tapping.
3. Secondu.y to suppurative funiculo-epididymo-orchitis.

4. Post-operative.
CLINICAL PICTORE
c/o
1. General constitutional manifestations ( FAHMR ).
2. Like hydrocele but pair.fuL&
otE
oPo{rrp wU}"tmnsillmirratioru
O Tender, red, hot scrotal swelling.

TREATMENT
1. lncision, drainage of pus & eversion of the tunica vaginalis.
2. Postoperative rest, elevation of the scrotum, antibiotics and antipyretics.
Chgloeele
O Ctryle (lymph)
accumulates in the tunica due to rupture of distal lymphatic
vessels in case of filariasis.
c/o
O A swelling which is similar to hydrocele but o?qt;u-o,ntransi.llrrminatioru

TREATMENT
O As vaginal hydrocele * antifiliral
drugs.
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Anatomy cf the lnguinal Canal

DEFINITION
@ ft is an oblique passage in the lower part of the anterior abdominal wall,

through which the testis passes in order to leave the abdomen and reach the
scrotum.
TENGTH : 1.5 irul2s

DIRECTION
O ft
taa.rr0.
passes downward,
forward and medially from deep to superficial ring.
SITE : It lies parallel to the medial half of the inguinal ligament.

BEGINNING : DEEP INGUTNAL RING
@ Wtrictr is an oval opening "vertical longitudinal axis" in the fascia

transvers alis
Yz
inch above tho mid point of irrguir.al- Qarnent just latemlto the
inferior epigastric artery.
O It is bounded above and laterally
by the arched lower margin of fascia
transversalis.
O It is bounded
below and medially by the inferior epigastric vessels
END : SUPERFICIAL INGUINAL RING

O
Wtrictr is a triangular opening in the external oblique aponeurosis % inch
a[u,e
old.. nrpfialtry
tha Pubio tr
berc.lp-
o Normally loesn
o It is triang lr in
o The media supe
o The latera infer
i
e sYmPhYsis Pubis.
the Pubic tubercle.

I
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nfaffcil
nng
ANTERIOR
WAtL
1- External oblique aponeurosis along its whole length.
2- Strengthened laterally by fleshy fibres of internal oblique muscle

originating from the lateral % of the inguinal ligament.
POSTERIOR WALL
1. Fascia transversalis along its whole length.

2. Conjoint tendon (also known
as
inguinalfalx) along its medial ll2.
3. Reflected part of inguinal ligament along its medial ll4.
ROOF I Arched fibres of conjoint muscle (Internal oblique
muscle
Transversus
abdominis muscle).
FLOOR I Upper grooved surface of medial
of ineuinal lisament (which is the
lower free border of external oblique aponeurosis, attached to pubic

tubercle medially and ASIS laterally).
inal nng
Roof of the canal
Lateral
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COVERINGS OF
TIIE CORD :
1. Internal spermaticfoscia: From transversalis fascia at deep inguinal ring.
2. Cremasteric muscle andfascia.'From internal oblique muscle.

3. External spermaticfascia.' From external oblique aponeurosis at the
superficial inguinal ring.
nt slrcl.matic faeio
Crcoastric
Antcrior
m(sclc & (Ncia
Fxt -s1rcmrtic
&.ardrGnd'ffiffF
qEioira
iqidoc (dc{
EIE
fascia
El
Vr,
Sl)crrrutic cord
Porslcri<rc
CONTENTS OF TTIE CANAL

(A) Ilio-inguinal nerue (L1)
The ilioinguinal nerve is a branch of the lumbar plexus which lies within the
substance of the psoas maior muscle.
It emerges from the lateral border of the psoas major just below the
iliohypogastric nerve, and passes obliquely across the quadratus lumborum

and iliacus.
Above the iliac crest, the ilioinguinal nerve then pierces the transversus
abdominis & passes in the plane between the transyersus abdominis and the
internal oblique muscle.

It enters the inguinal canal by piercing the internal oblique muscle "once the
nerve enters the canal, it becomes only sensory).

The nerve lies infront of the cord and Ieaves the canal through the super{icial
inguinal ring to supply the skin of the inguinal region, upper medial part of the
thigh, anterior
t/3
ol the scrotum (or labia majora) and root of the penis.
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It shares in the motor supply to the internal oblique, transversus abdominis &
gives the main motor supply to the conjoint tendon before entering the canal.
(B) Spermatic cord
(Round ligament of the uterus in females).
* 4 Vessels .'
1. Testicular artery & Pampiniform plexus of veins.
2. Artery of the vas & vein of the vas (branch of inferior vesical a.).
3. Cremasteric artery & vein (branch of inferior epigastric a.).
4. Lymphatic
vessels.
* 2 Neraes :
l. Sympathetic nerve fibres along with the testicular artey.
2. Cremasteric
nerve (genital branch of genito-femoral nerve).
* 2 Structrres
1. Vas deferens.
2. Vestige of processus vaginalis.
Clomsificution of the eolntertts lraeord,ing to their position in the

cord.:
(A) Anterior contents:
O Pampiniform
O Lymphatic
plexus.
vessels.
(B) Posterior contents
O Testicular artey with sympathetic fibres along it

O Vas deferens and its vessetrs.
(C) Contents
within the coverings of the cord:
O Cremasteric verve and vessels.
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TIIE PROTECTIVE MECHANISMS OF TIIE CANAL :

l - The obliquity of the canal ( The flap valve mechanism | :
O
The internal and external rings do not lie apposite to each other (this
mechanism is absent in infants below 2 years).
O Therefore when the intra abdominal
pressure rises the ant. & post. walls of
the canal are approximated thus obliterating the passage.
2-The shutter mechanism of the internal oblique muscle :

O On straining, the lower arched fibres of the int. oblique muscle contracts
approximating the roof to the floor like a shutter.
3- The
ball valve mechanism :
@ Contraction of the cremasteric muscle helps the spermatic cord to plug the
both inguinal rings.
4- The slit valve mechanism :
O Contraction of the ext. oblique
m. approximates the 2 crura of the superficial
ring thus narrowing it a slit.
superior crus if the internal ring is attached to

the transversus abdominis by fascial slips, so that
contraction of the transversus abdominis draws the
internal rina laterally increasing the obliquity of the
5- The
cqnql.
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Hassellrach's (lnguinal) triangEe

DEFINITION :
@ It is a triangular area in the inner aspect of the lower part of the anterior
abdorninal wall.
O It is tho ste of dir" r

BOUNDARIES
I.
hcrnia-
Medially : Lateral border of rectus sheath.
2. Laterally : Inferior epigastric artery.

3. Inferiorly : Medial ll2 of inguinal ligament.
FLOOR
1. Fascia transversalis.
2. Reinforced medially by the conjoint tendon.
Inferior epig:rs-
Rcctus
abdominis
Inguinal ligarncnt
H asse lbach's
SUBDIVISIONS
( ngiunal) Tri an gle
O The Hasselbach's triangle is divided
to medial & lateral parts by the latpmL
urnbilioaf hg arnent (o[tilproted r"rlbitioaf ortpru).
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Ceneral Drinciples of tlernias

DEFINITION
H A hernia is a protrusion
of a viscous or part of a viscous usually within a
peritoneal sac through a defect in the abdominal wall.
ETIOTOGY
l- CongeniJal (Preforrned
a. Unobliterated
sac) :
processus vaginalis
oblique inguinal hernias.
b. Unobliterated physiological umbilical hernia of fetus (exomphalos).
2- Acquired:
a. Raised intra-abdominal pressure due to any cause.
b. Weak anterior abdominal wall (old age, repeated pregnancy).
COMPONENT
t- Sac
neck
H This is the peritoneal
pouch which bulges out through
the , l-*
abdominal wall defect.
H It
has a neck, body, and fundus.
?- Contents
<. Fundus
H Any abdominal viscus except the pancreas,

H The most common are intestine, omentum or both.
Intestlno
tOrnenturn
Gonsistency
Soft
Doughy
Guruling on reduction
0ccurs
llo
Ease o[ reduction
tirst Rart mole difficult
Lastpartmole difficult
Percussion
May be lesonant
0ull
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N.B : Special Contents :

a) Richter's hernia
H The content is part of the circumference of an

intestinal loop (common in femoral hernia).
b) Littre's hernia
The content is Mickle's diverticulum.
c) Maydl's hernia
H It contains 2 loops of intestine while an intermediate

in the abdominal cavity ( hernia in W ).
ll.B. : Sometimes, an extra [e]itoneal organ lifte the blailder,

GaeGUm 0t
left G0l0n may be adhetent t0 the [osteilo]
wall 0f me netnial sac flom outsidc a this is called
slidinq hernia.
3- Eoverings : Structures stretched over the sac.

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OBLIQTjE (INDIPIOD INGIJINAL HEI)NIA

ETIOLOGY & TYPES
I - Eonqenital hernia :
:
E[lDue to persistence patency of the whole processus vaginalis.
tEft
reaches down the scrotum from the
start.
[Ettre testis is inseparate from the hernial

Eg Aftfio{.g},. congenital,
sac and its contents.
it mag oq1pear irt adrlt lf,".
2- Infantile hernia
(operative finding only)
[ECombined inguinal hernial sac + infantile hydrocele (2 sacs).
EEat operation, the tunica is liable to be opened in mistake for the
true sac.
3-Adult [acquired I oblique inquinal hernia
E[lDue to raised intra abdominal pressure and weak

abdominal wall.
It may be :
a) Buhonoeele
O Ttre hernial
sac is limited to the inguinal canal and is seen as a bulge
or
swelling in the inguinal region and does not come out through the
external ring.
b) Funieular
O
1ftre hernia passes out through the external ring and starts to descend into
the scrotum, reaching only its neck.
e) Complete (serotal) hernia
O ttre hernia descends to the bottom of the scrotum, as a continuation of

funicular type.
O The testis is separate from the hernial
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sac and its contents.
PATHOLOGY
1. The defect : Stretched deep inguinal ring.
2. The sac
@ Congenital sac present within the cord contents.

@ Or acquired sac present within the cord coverings antero-lateral to the vas
and vessels.
3. The contents : Small intestine, omentum or both.

4. The coverings
In the inguinal reeion : Skin, superficial fascia, external oblique aponeurosis,
a)
cremasteric muscle and fascia and internal spermatic fascia.

b)
In
the scrotum
Skin, dartos muscle, Colles' fascia and the three cord
coverings.
CLINICAL PICTURE
c/o
@ Painless inguinal or inguinoscrotal swelling (unless complicated).

@ Before appearance of the hernia, the pt may complain of stitching pain
(Pre eruptive pain).
otB
General examinafion:
O May reveal other
features of weak mesenchyme like varicose veins,
varicocele, flat foot .... Etc.
O Chest examination : For COPD.

O P/R : For Benign prostatic hyperplasia "BPH".
local examination:
1. Site : Inguinal or inguino-scrotal (by scrotal neck test).
2. Size: Variable and * on lying flat & 6 on straining

3. Shape : Usually oblong.
4. Surface: Usually smooth
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5. Special chsracter
Rpluoittp a gare" prPonsils
6. Soecial tests
*prlrc
ot. cougl"
retuilhlp rrnless eo,mphaateA
: Internal and external ring tests.
7. Edse: well defined.
8. Consistencv: Soft or doughy.

9. Descent: Downwards, forwards and medially.
l0.Reduction
Backwards upwards and laterally.
DD : Inguino-serotal swellings
INVESTIGATIONS
speoialfu dire r
A fe;n*mlhcrr.ias.
1) To detect underlying cause of J abdominal pressure:

a. Chest x-ray & pulmonary function test.
b. Abdominal U.S.
c. Trans-rectal
U.S to detect B.P.H.
2) Routine pre operative investigations
a. Blood picture rrCBCrr

b. Blood chemistry.
c.
P.T
& P.T.T.
d. ECG.
TREATMENT : Th" -.tU o-umtire TTT i. .urg.rg.

GENERAL OPERATIONS FOR HERNIA
lll Herniotorng
H Excision of the hernial sac up to the neck.

H This is sufficient in children with congenital hernia when the
musculature is good & the only problem is preformed sac
t2l Herniorrhaphg
H Repair
of the defect by sutures with herniotomy (better) or withowt herniotomy.
[3] Hernioplastu "LicJrtenstein repair" :

H
Repair with mesh "Tension free repair".

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OPERATIONS FOR OIH
Pr eop er atio e pr qp ar o;tiort :

@ Treat first any predisposing factor as COPD, BPH.
Steps of tltc
Anesthesia
opuation "OPDR.ATIVE"
..
General / spinal or epidural / local anesthesia.
Posltlon: Supine.
Sterllization
lncision
Betadine from umbilicus to mid-thigh.
: I inch above & parallel to the medial 213 of the inguinal ligament.
Steps:
1. Divide skin, S.C tissue & Scarpa'sfascia.
2. Divide the exl oblique aponeurosis in lhe direction of
its fibers
(from the ext.
ring extending laterally till the int. ring).
3. ReJlect the ext oblique aponeurosis upwards to expose the conjoint tendon &
downwards to expose the superior surfoce of the inguinal ligament.
4.
Idenltfy the ilioinguinal nerve & reJlect it over the aponeurosis (injury of the
ilioinguinal nerve at this level causes hypothesia in the scrotum only without
any paralysis).
5.
The cord is delivered
& lifled over a gauze tape.
6. Divide the cremasteric muscle & inlernal spermaticfascia.

7. Dissect the sac by sharp & blunt dissection until its neck :
N.8; The sac is known by:

* Pcarlywhite in coloul. * Antero-lateral t0 thc uas.
The neck is known
by:
\\,
* The nalrowest Dart 0[ the sac.
* ExtlaDeritoneal fataround
it
* lateral t0 tlte inlerior eliuasHc uessels.

Open the sac at the frrrrfurs
Twist tlre soo
tlen tta
& reduce the contents.
sfrx
at tle de*4 rhg.
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lQ.Excise the redundant sac 'llctniotot

llB
llthe sac ls Ine Uoccssus uaginalis
tgi
* fransfixlon of the []oximal mrt& euerslon 0ItIe distal [an as in hydrocele.
I I. llenzlotoaa aloac is enoegh
an
wtgenilal lrprrria in irfants and olihben
12- Ilerrriorrhaphy :
O Done in adults with good musculature.
@ Herniotomy & repair of the weak posterior wall of the inguinal canal.
@ Repair is done by interrupted non- absorbable prolene sutures.
a) Shouldice
repqir
@ The fascia transversalis is opened in the length of the floor of inguinal

canal from the pubic tubercle to the internal ring; this creates 2 flaps.
O The lower flap is sutured to the undersurface of the upper flap.

O An0 then the upper flap is sutured to the shelving edge of the inguinal
ligament "is the natural exlension of thefascia transversalis below".
O La: rc+ab is do,rrs bg do.r.bts breasting oftlsfuscirtmnsrrersolis.

O Finally
the fascial part of the conjoint tendon is sutured to the inguinal
ligament.
lniornol obliquc murclc
lcndon
Bctrlctad rpormatic cord
Deep sutura lino
nlorior epigastric vcssel:

Poritoneum
Elcvrtod .doca
ol
tronlvccelir {ascia
4
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b) Marcy
repair :
Th'e tmnsverctrs a[dotninis apoae,uotio arch is sutrrred hfefiodU to tt e
ilt
frti"
troot.
O The iliopubic tract "Thomson's
ligament', is the thickened lower part of
fascia transversalis.
c) Bassini repair :
The inguinal ligament is sutured to the
conjoint tendon & arched fibres of internal

oblique and transversus abdominis muscle.
@ Disadvantages
i.Tension atrophy of conjoint tendon
ii.
Interferes with the normal shutter mechanism.
iii. Union & healing is unlikely to occur befween the fleshy fibers of the
conjoint tendon & the fibrous tissue of the inguinal ligament in the
lateral part of the repair.
ln the above mentioned 3 methods of repair especially Bassini repair, it is
recommended to do a relaxing incision in the anterior rectus sheath
"Tannels s/lde release incision" to avoid sutures under tension which may
disrupt.
d) Lytle
repair :
O Narrowing
of the internal ring.
13- OR llernioplasty :
@ Done in patients with weak musculoaponeurotic boundaries or wide defect.
O Most surgeons prefer it now as it is tpnsio,ra frcp * recurrence is rare.

@ The interstices of the mesh will be impregnated with a dense sheet of
fibrous tissue.
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Where to put the mesh?
(A) Otilny mesh:

O On the fascia transversalis.
@ It is sutured to the transversus abdominis aponeurotic arch superiorly and
to the iliopubic tract arnd inguinal ligament inferiorly.
@ The mesh should extend 1-2 cm medial to the pubic tubercle to ensure
covering of the pyriform fossa which is a week part of the posterior wall of
the inguinal canal "postgraduate note".
O Some surgeons recommend application
of a mesh plug in the internal ring
with lateralization of the cord "Gilbert hernioplasA".

(B) Preperitoneal 6nnlage) hernioplasty :
O The mesh is placed between the fascia transversalis and the

peritoneum (space of Bogros').
@ This can be achieved by either
a) Open surgery "stoppo repair also known
as giant
prosthetic
reinforcement of the visceral sac (GPRVS)".
b) OR laparoscopic hernioplasty which is done by 2 techniques
* TAPP : Trans-abdominal pre-peritoneal repair.

* TEP : Totally extra peritoneal repair.
Types of mesh used

1- Prolene mesh
2- Vicryl mesh
! Strong & inert (most commonly used).
Used in cases of burst abdomen when there is big muscular defect.
3- Vypro mesh ( Vicryl + Prolene )
H Easily handled and sutured.

H Vicryt will be absorbed within 3 months leaving prolene
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WhiteKnightLove
only-
What's recent about hernioplasty
Prolene hernia system (PHS): This system consists of an anterior oval

prolene mesh connected to a circular posterior prolene mesh.
The anterior component is inserted on the fascia transversalis & the
posterior component is laid pre-peritoneal.
DIQECT INCL]INAL HIENIA

:
INCIDENCE
ETIOTOGY
* Common in old
males. * 50o bilateral.
a. Weakness of lower abdominal wall muscles with chronic increased intra

abdominal pressure.
b. Paralysis of conjoint tendon due to injury of the ilioinguinal nerve darring

appendectomy (only after muscle cutting).
PATHOLOGY
&
TYPES
l - Lateral Q4le "Commonesf' :

A Bulges through the lateral part of Hasselbach's triangle (made of fascia
transversalis only).
A Thus has a very wide neckand is less liable to complicate.

A Never descends to the scrotum.
2- Medial gpe (funieular form of Ogilrie) : "Rare"
A Passes through a defect in the conjoint tendon infront of fascia
transversalis in the medial half of the triangle.
A ttre edge of the defect is sharp & the neck is narrow )

A It may descend to the scrotum.
CLINICAL PICTURE
liable to complicate.
I As OIH with the following differences.
llemia
0blique inguinal homia
llirectinguinal
Ag.
Any age
Usually old age
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WhiteKnightLove
Side
Uni or bilateral
Usually bilateral
Shape
Oblong
llemisherical
Descent
Downwards, forwards and
Forward
medially
Descent to
Muy occur
Very rare
Upwards, backwards, and
Backwards
scrotum
Reducibility
laterally
Complications
More common
Less common
Internal ring test
Hernia does not protrude
Hernia protrudes
External ring test Impulse at the tip of the finger
Impulse at the side

of finger
Relation of neck
Lateral to the artery
Medial to the artery-
of sac to inferior
epigastric artery
(at operation)
(Ilntr*r.c,.lring tcst:
E Let the patient lies down.
E Reduce the hernia.
tr
Occlude the internal ring by the thumb of opposite hand (internal ring
is % inch above the mid point of inguinal ligament ).
E Then ask the patient TO STAND UP and cough :

O If hernia descends: direct hernia.
O If hernia descends after release of thumb : indirect hernia.
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b. ertP*nalrtng tcst, :
B Let the patient lies down & reduce the hernia.
tr
lntroduce the little finger into the inguinal through external ring and ask the
patient to cough.
the tip: indirect hernia.
E If impulse
is felt at
E If impulse
is felt at the
side: direct hernia.
This test is not done because :
a. Not a very sensitive test.

b. Painful.
c.
Can stretch the external ring
inguinal hernia can reach the scrotum.
N.B : lrhat is Z:.ur.orjs 3 fingers test

?s.
The patient lies down then the hernia is reduced,
ts 3 fingers are put as follows :

* One on the internal ring (for indirect hernia)
* One on the external ring (for direct hernia)
* And the third over the saphenous opening (for femoral hernia).
tg The patient is asked to cough and you will see which finger
the impulse first.
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WhiteKnightLove
receives
TREATMENT
: The only curutive TTT is surgery after correction
af any
predisposing factors.
0[efatiOnS: As for OIH with the following differences.

1- Herniotomy MAY BE NOT NEEDED in the lateral type as the neck is wide, so
invagination of the sac by the repair is enough (but herniotomy is needed in
the medial type).
2- Hernioplasty: Best.
ll.B: Pantaloon heruia
sometimes, tne mfient may naue 2 sacs at me same time; one sao [assing
tnlough the intctnal riltg toHiUuel anil the 0mc1[asses th]ougn
fie [osteriol
wall lllilec0.
with tne lnlefiot c[igast]icuessels between mc 2 sacs this hernia is oalleff

saddle-[ag
01
[antaloon hemia.
Qecurrent inguinal Hernia

INCIDENCE ; to"/o
ETIOLOGY
Operative eauses
1. Leaving part of the original
2. Missing
sac i.e failure to ligate the sac at its proper neck.
a second sac at operation e.g. (pantaloon hernia)
3. Failure to do the proper repair which suits the patient's condition

4.
Use of absorbable sutures.
Postoperative earrses :
t.
Poctop esotlw hop,nntonnot infeation : most irnpodant frotor.
2. Rapid return to hard work or job.
3.
Persistence of the predisposing factors.
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WhiteKnightLove
TREATMENT
l.
Correction of any predisposing factors.

2. Operation : Hernioplasty.
Slidino Hernia
DEFINITION
A This is a hernia where a viscous forms a part of the wall of the sac and not
part of the contents.
The commonest sliding organs are bladder, caecum, and sigmoid colon.
INCIDENCE
: Common in
1- Long standing hernia
2- Old males.
CLINICAL PICTURE
1. History of long standing hernia
2. Hernia is usually complete ( scrotal ) oblique inguinal hernia or direct

inguinal hernia in an old male.
3. Incomplete reduction of the hernia ( partia[y reducible )

4- urinary symptoms if sliding organ is the bladder as :
TTT
Double micturation.
Reduction of the hernia size after micruration.
Pressing the hernia couses a desire to micrurate.
* The sac is removed just distal to the stiding organ.

+ Reduce the sliding organ to abdomen.
+ Followed by hernioplasty.
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WhiteKnightLove
Anatomy of the femoral triangle & canal

Femoral triangle 56Searpa's triangle"
SITE
A Occupies the front of the upper 1/3 of the thigh just below the inguinal ligament.
BOUNDARIES
Laterallg : Medial border of sartorius muscle.

Mediallg : Medial border of adductor longus muscle.
Base : Poupart's ligament ( inguinal ligament ).
Apex : Meeting of sartorius and adductor longus muscles.
Floor : From medial to lateral :
1. Adductor longus muscle.
2. Pectineus muscle.
3. Psoas major muscle.
4. iliacus muscle.
Roof
1. Skin.
2. Superficial fascia consisting of fatty layer and membranous layer.

3. Deep fascia containing the saphenous opening covered by the cribriforrn fascia.
Corrtpailuanf
tntttndtZto tt
urt.uoll
po,st.
WhiteKnightLove
tt&.(i
CONTENTS
1) Femoral artery & its branches.
2) Femoral vein & its tributaries.
limsrl
3) Femoral sheath surrounding the upper
4 cm
br. of a.ni(o f@da, N.
(l% inch) of the femoral
vessels.
4) Femoral branch of genito-femoral nerve (infront of the femoral artery &

inside the femoral sheath)
5) Femoral nerve & its branches (outside the femoral sheath).

6) Deep group inguinal L.N.
7) Lateral cutaneous nerye of thigh (in the upper lateral angle of the triangle).
Femoral eanal
SITE
O It is the most medial compartment of the femoral sheath.

O The intermediate compartment is occupied by the femoral vein.
O The lateral compartment is occupied by the femoral artery.
SHAPE
&
S,IZE
Cone shaped lYz cm (% inch) long.
CONTENTS
Fat, lymphatic vessels and lymph node of Cloquet.
FUNCTION
Gives space for expansion of the femoral vein during increased venous
return with lower limb exerciseBoundaries of the femoral ring
rcmtrrer
canal).
Anteriorly: lnguinal ligament (Poupart's lisament). t
(Base of the femoral
irSuiod lagrrilcnt
l:csarr ligrnrcnt
pubk tutrcrclc
Posteriorly : Pectineal ligament (Cooper's ligament).

Medially : Lacunar ligament (Gimbernat's ligament).
Laterally : Femoral vein.
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WhiteKnightLove
fenmal canal
Femcral hernia
PATTIOTOGY
Defect: Femoral ring.

Sac
The sac of the femoral hernia pass downwards in the femoral canal then
forwards stretching the cribriform fascia of the saphenous opening then

upwards and laterally towards anterior superior iliac spine taking its
retort shape.
A ft does not continue inferiorly because of the strong attachment & fusion
of the deep and superficial fascia of the thigh below the saphenous
opening.
Contents
Omentum, bowel or only a part of the circumference of the bowel
(Richter's hernia).
Goverinqs
1. Skin.
2. Subcutaneous fat & Scarpa's fascia.
3. Stretched cribriform fascia.

4. Anterior layer of the femoral sheath:
ll.B : The nec[ 0I me sao is na]row, s0lemoral hernia ls
liaile t0 irleduclDllity
and srangulati0n.
CLINICAL PICTORE:
C/O I
ll.B
Painless swelling in upper part of thigh ( femoral triangle ).
: females ale Gommonly affGcted due to.
tll fleueateil Ueunanoy
,] Abdominal
t2l Small sized femoral ucin
Dressure.
wide lemoral fing.
t3I Wider rcluis.
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WhiteKnightLove
OIE : A swelling with thefoltowing criteria :
. Site: Femoral triangle.

. Size: Variable.
o Shape: Early rounded & then retort.
. Surface : Usually smooth .
o Special character: iD Expansile impulse on cough unless complicated.
* May be reducible or not.
. Edge: well defined.
o Consistencv: Soft or doughy.
o Descent : Downwards, forwards and then upwards and laterally.
o Reduclion : Usually irreducible but early it can be reduced
backward and upward.
D.D
1- Inguinal hernia.
A Femoral hernia is belor^r A lolrrolto the pubic tubercle.
A Inguinal hernia is abor,e I nrptiolto the pubic tubercle.
2- Swellings of the femoral triangle
A. Reducible femoral hernia
A
A
A
A
Saphena varix.
Femoral artery aneurysm.

Varicose aneurysm "A-V fistula".
Psoas abscess.
B. lrreducible femoral hernia :
A
A
INV :
Lipoma.
Ectopic testis
A lnguinal lymph node.

A Psoas bursa.
As inguinal hernia.
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WhiteKnightLove
TREATMENT
Surgery is the only line of treatment
(Steps
arefromMcGregor's)
1- Low (femoral) approach = Lockwood approach :

lnclslon : 1 inch below & parallel to the medial 213 of the inguinal ligament.
Steps:
A The coverings are divided to expose the sac.

A The sac is dissected up to the femoral ring.
A The sac is opened at the fundus, contents are
Llgatcd
Porlionsum
of
gac
ncck kgulnal
ligamenl
Lacunar
ligrmcnt
reduced finally the sac is transfixed.
A Repair of the defect is done by suturing the

inguinal ligament to the pectineal ligament.
Femoral
votn
Disadvantage:
a. Low transfixion of the sac.

Pcc'tinoal
ligrmonl
b. If the bowel was strangulated, resection is difficult

to be done from this approach.
c. Injury to the abnormal obturator artery.

Q.
What ls the a[no]mal
o[tu]atot artery P
Usually the obturator artery and the inferior epigastric artery each gives
a small pubic branch which anastomose at the back of the pubis.
ln 30% 0I rco[le tfie Rubic branch 0Ithe lnferior e[igastlic ls ucry large talfing the
[lace of the ohtu]atfi artery a is ftnown as abno]mal obturator artery which [asses
down in relation t0 tnc lemoral ring t0 reach mB obturatol lommen as lollorus
(a) lt may stick to the side of the femoral vein (safe position).
(b) lt may pass along the free edge of lacunar ligament only in 10% (i.e.
in 3%) of all cases (dangerous posifion) as it may be injured during

the low approach.
2- High (inguinal) approdch = Lotheissen's approach:
A lncision is similar to that of inguinal hernia.

A Ttre external oblique aponeurosis is incised & the cord is drawn aside.
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WhiteKnightLove
Transversalis fascia is incised in the floor of the canal medial to the inferior
epigastric vessels exposing the peritoneum and the neck of the sac.
A llhe sac is opened at the fundus, contents are reduced finalty the sac is
transfixed.
Repair of the defect is done by suturing the conjoint tendon to the

pectineal ligament and then the pectineal ligament to the inguinal
ligament "C-C & P-P".

Advantages:
A High transfixion of the sac at its neck proper.
A If the bowel was strangulated, resection can be done from this approach.
A If the hernia is strangulated or irreducible, the lacunar ligament can be

divided under vision and an abnormal obturator artery can be ligated under
vision.
A Associated inguinal hernia can be dealt with

Disadvantages:
McEvedy approach
A Weakens the inguinal canal.
High approach
ao*
approach
3- The pre-peritoneal approach = McEvedy's approach

lnclsion
A A vertical incision is made just over the femoral hernia to a point about 8 cm
above the inguinal ligament.
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WhiteKnightLove
Steps:
A Skin is retracted & the anterior rectus sheath is exposed "in
this position the
anlerior rectus sheath is formed by the aponeurosis of the 3 muscles af the

anlerior abdo minal walPt
A The sheath is incised
I cm medial to the lower % of linea semilunaris.
A the rectus muscle is retracted medially exposing fascia transversalis.
A The fascia transversalis is incised and dissection is carried down between

the fascia transversalis infront & the peritoneum behind.
A The hernial
sac is identified as a funnel shaped protrusion of the
peritoneum entering the femoral canal.
A Herniotomy and repair
as above.
Advantages:
A Avoids opening of the inguinal canal.

A High transfixion of the sac at its neck proper.
A If the bowel was strangulated, resection can be done from this approach.
A If the hernia is strangulated or irreducible, the lacunar
ligament can be
divided under vision and an abnormal obturator artery can be ligated under
vision.
Disadvantages:
A Retraction of the rectus muscle medially carries the risk of injury of

its never supply leading to incisional hernia.
Hernioplasty can be done via any of these 3 approaches instead of repaEr"
Nyhus classification of groin hernia (post graduate)
O Type I : Indirect hernia without dilatation of the internal ring

O Type 2 : Indirect hernia with dilated internal ring
O Type 3a : Direct hernia with posterior wall defect
O
Type 3b : Indirect hernia with posterior wall defect (combined hemia)
O Type 3c : Femoral hernia

@ Type 4 : Recurrent hernia
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WhiteKnightLove
IJMBILIEAL HEANTA
TYPES
1- Congenital umbilical
kernia
2- Infantile umbilical hernia
3- Adult umbilical hernia (para-umbilical hernia)
(t) Congenital Urnbilical llernia (Exornphalos)

ETIOLOGY
@ Unobliterated physiological umbilical hernia of the fetus.
It is normal for the intestines to protrude from the abdomen, into

the umbilical cord at the 4th week of pregnancy, after which they
return to inside the fetal abdomen at the loth week.
ExomRhalos minor
Defect
txomRhalos maior
Small ( < 5cm ) at the centre of Large
(,
5cm ) at the center of
the abdominal wall usually
the umbilicus.
above the umbilicus.
Peritoneum
Peritoneum
Contents
Usually intestine
Many viscera +/- liver
Coverings
Wharton's jelly and a layer of
Only a layer of amniotic
amniotic membrane.
membrane & there is danger
Sac
of rupture of the sac followed

by peritonitis.
Treatment
Cord is twisted & the contents

are reduced and returned to
the abdomen, the sac is excised
and defect is repaired in layers
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WhiteKnightLove
Look down
OTTIER CONGENITAL ANOMALIES ASSOEIATED IUITH
EXOMP}IAIOS
O Congenital heart disease,

O Cteft palate.
O Musculoskeletal abnormalities.
@ Dental malocclusion
D.D. I
Gastroschisis.
@ Is a type of inherited congenital abdominal wall defect in which the

intestines and sometimes other organs develop outside the fetal abdomen
through an opening in the abdominal wall.
SCREENING
O Elevated maternal alpha fetoprotein at the beginning of the 2nd trimester.

@ tn utero fetal U.S.
TTT OF
A.
EXOTTTPNALOS TTTA'OR
If the sac is intact t
Primary repair is always dfficult because
@ There is no room in the abdomen to accommodate the contents.
O Will
be under tension
MANAGEMENT
Circulatory & respiratory compromise.
1. Attempts to dry the sac by painting with cicatrizing agents until

creeping epithelialization occurs is a prolonged procedure often
punctured by septic episodes "Cuschieri".
2. The extruded organs are placed in a sterile silastic bag "silo bug"
which is twisted daily to the let the abdominal cavity accommodate
the contents to be followed later by definitive repair.
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WhiteKnightLove
B.
If the sac has ruptured )
Urgent operation because of
@ Rist< of infection.
O Risk of perforation.
O Heat & fluid
loss.
MANAGEMENT
O Skin flaps are used for closure & release incisions in the flanks
(Z) lntantile Urnbilical

ETIOLOGY
are needed.
llernia
1. Weakness of the umbilical scar from infection (omphalitis).
2. Increased intra abdominal pressure from coughing or constipation.

PATTIOLOGY
*
*
*
The defect is exactly at the umbilicus.

The neck of the peritoneal sac is wide.
Coverings : Extra peritoneal fat & umbilical scar.
CHNIEAT PICTURE:
1. Umbilical protrusion with cough or crying.
2. Edge of the defect can be palpated as firm ring.
TREATMENT :
1- Reassurance of the parents as in most cases the defect closes
spontaneously within 2 years.
2- Operation : Anatomical repair with prolene sutures if the defect

is more than 2 fingers or when hernia persists after the age of 2
years.
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Aault Urnbilical Ilernia

(Pararrrnbilical Hernia)
(S)
ETIOLOGY
Obese
& multiparous females.
PATTIOLOGY
O More common
above the umbilicus because linea alba is thinner
and wider above umbilicus than below.
The defect:
Small defect in the linea alba so there is increased incidence of

i
rred ucibility and strangulation.
The sac : Narrow neck, and commonly multilocular sac due
Multiple defects in linea alba.
Adhesions between the omentum & the fundus of the sac.
The contents : Usually omentum,
CLINICAL PICTURE
c/o
Iess commonly intestine.
1. Painless paraumbilical swelling.
2. Dyspepsia due to traction on the omentum.
otD
. Site : Paraumbilical swelling

. Size : Variable and {r on straining & * o., lying flat
. Shape : Usually rounded.
. Surface : Smooth or lobular due to multilocular sac.
. Special character: Expansile impulse on cough.
. Edge: w'ell defined.
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WhiteKnightLove
to:
Consistency: Soft or doughy.

Reducibilitv
Usually partially irreducible due to presence
of adhesions between the omentum & the fundus of the sac
or between the contents itself.
.
INV I
Doatfotg* to
ernnine,
f,ttprc is dtuafioation of ttz
reoJi. o,t
not
As before.
TREATMENT : Surgery
is the only line of treatment.
tlliRtical transuelse incision is made ouel the hernia.

Sac is dlssected down to me neclr
Sac is orcncd al
its necklueto adhcsions atthe fundus.
Gonlents are dealtwith and rcduccd t0 Ue a[domen 0] exclsed.

Sac is cxcised.
V Ahu ercisio?r of tls

I - Mayo's Repair
soc, olocure of
tlz
d#r,^r is doaz bg :
The detect is closed by overlapping the upper flap over the lower
flap of anterior rectus sheath.

Disadvantages of Mayo's repair:
Peritoneum of the upper flap is in contact
with anterior rectus sheath causing
irritation & exudation of fluid which

predisposes to infection.
2- Anatomical repair : Each layer is sutured separately.
3- IlernioplastJr : Methods of mesh application :

a- On lay : Anterior to the rectus sheath.
b-
In lay :
Between the rectus muscle & the posterior rectus sheath.
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WhiteKnightLove
Advantages of in lay mesh
Less incidence of infection.
@ Less incidence of seroma formation.
Better action.
N.B : True adult umbilical hernia is usually seen in patients with
or
ascites
chronic liver disease, the umbilicus is flat or everted.
Epigastric tlernia
( Fattv
PATTIOLOGY
l- Fatty
&
hernia of the linea alba

TYPES
hernio- of the linea o,lbo. :
H The hernia starts as a protrusion
of the extraperitoneal fat
through a defect in the supraumbilical part of the linea alba.
2- True etrfigastric hernia

H As the protrusion
enlarges the extraperitoneal fat pulls a small
peritoneal sac through the defect which may contain intestine or

omentum.
N.B : The
defect in the linea alba is known as foramine of
Egr6s through which paramedian vessels and nerves pass.
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WhiteKnightLove
CLINIEAL PICTURE
l-
Soft epigastric swelling, frequently irreducible, gives as expansile

impulse on cough.
2- Associated symptoms : Dyspepsia
& epigastric pain may
be due to
traction on the lesser omentum or the stomach.
TREATMENT
Ej Exclude first peptic ulcer or gallbladder disease by endoscopy or

abdominal U.S if there is continuous dyspepsia & epigastric pain.
El Repair: (1) Hernioplasty.

(2) Anatomical repair.
(3) Mayo's repair ( vertical ).
Divarication of Qecti
DEFINITION
I Separation of the recti due to stretching of linea alba

by chronic increased intra-abdominal pressure.
C/O : * Common in patients with CLD & ascites.
On raising the shoulders, the linea alba bulges as a
longitudinal ridge and the fingers can be dipped into the

abdomen between the two recti.
TREATMENT
l.
Abdominal belt is satisfactory
2. Very rarely Keel repair
is needed.
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WhiteKnightLove
HIENIA
(VIN-fEAL HIPNIA)
TNOISTONAL
DEFINITION
EJ
Incisional hernia is a hernia that develops at the site of a previous

abdominal incision, usually within 1 year after the operation.
TYPES
1. Cicatricial
H Due to defective closure & muscular defect

2. Paralytic due to injury of nerues & muscular paralysis :
H Direct hernia following appendectomy with muscle cutting
incision duo to injury of the ilioinguinal nerve.
H Incisional hernia following Kocher's incision due to damage of

intercostal nerves 8, 9 & 10.
H Lumbar hernia following lumbar (Morris') incision due to

damage of subcostal nerve.
ETIOLOGY
A- Preoperatiae factors :
l- Obesity.
2- Poor health condition as D.M, cirrhosis, steroid therapy.
3- Respiratory problems : Chronic bronchitis or asthma.
B- Operatiae fo.ators
1. Muscle cutting incisions instead of muscle splitting incisions.
2. Rough surgical technique.

3.
Use of absorbable sutures in abdominal closure specially midline
4. Insertion of drains though the main wound.

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WhiteKnightLove
5. Injury of nerves (paralytic incisional hernia).
C- Post operutiae factors:

1. Poor recovery from anaesthesia.
2. Persistent increase of intra-abdominal pressure.

3. Post operative wound hematoma or infection.
CLINICAL PICTURE
H Painless swelling with
expansile impulse on cough at site of previous
operation.
H A defect is detected in the cicatricial

TREATMENT I
type only
Surgery is the only line of TTT
1- Hernioplasty: Best.
2- Anatomical repair : Each layer is sutured separately.
3- Keel "Mainglot" repair:
H The sac is dissected "not opened" & inverted inside the abdomen.
H The defect is closed by a series of interrupted sutures.
H Disaduenleee: The non obstructive adhesions may become obstructive.
BIJPST ABDOMEN
( ITIDOA{INAL
DEFINITION
DEHISCENOE)
Complete disruption of an abdominal incision in the early post

operative period.
ETIOLOGY I As incisional hernia.
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WhiteKnightLove
PATTIOLOGY
&
TYPES
l-
Complete bu.rst :
H If intestine prolapses out of the wound, it is called evisceration.
H If the intestine doesn't prolapse out of the wound, it is called wound
dehiscence.
2- Pq.rtial bu,rst :
V fne deep layers burst but the skin is intact.

CTINICAL PICTURE
1. Onset 6-8th post operative day.
2. Warning sign ( RED sign ) : Serosanginous discharge
soaks the
dressings.
3. The pt. feels as if something
gives way followed by disruption of the
abdominal wall.
ll.B : Beware 0f burst a[domen in a [atient witn ente]ic anastomosls,
as tnere may be underlying lealmge.
TREATMENT : By urgent surgical closure.

1. Cover the prolapsed bowel by a sterile dressing.
2.
I.V. fluids, antibiotics, Ryle's tube suction.
3. In operating theater, the protruded intestinal loops are washed

with saline and returned to the abdomen.
4. The abdominal wall
is closed as one layer using strong prolene
(TENSION SUTURES) as they are retained for at least 3 weeks.
5. Abdominal binder
is used postoperative.
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WhiteKnightLove
Qare Forms of Hernias

1- Gluteal hernia : Through the greater sciatic notch.
2- Sclatic hernia : Through the lesser sciatic notch.
3- Obturator hernia : Through the obturator foramen.
4- Lumbar hernia
5- Spigelian hernia
Through the 2 lumbar triangles

:
H flernia through the linea semilunaris at the level of arcuate line.

H It is very liable to strangulate.
H Abdominal swelling best diagnosed by CT scan
H The ttt is hernioplasty and better to be done early.
The r.ore homiso
Ttrc comlrron hernice

Splgellan
Epigostric
Obturaior
Incisionol
lnguinol
Umbllicoi
Fernorcl
Lumbar
Gluteal
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WhiteKnightLove
Lumhar tlernia
H A hernia that occurs through the inferior
(coilmoasd or superior
lumbar triangles-
Bound,aries of tlw inferior lumbar (Petit) triangl,e :
H Medially by the latissimus dorsi muscle.

H Laterally by the external abdominal oblique muscle.
H lnferiorly by the iliac crest.
El The floor of the inferior lumbar triangle is the internal oblique
muscle.
Boundll.;ries of the superior lurnbqr (Grgnfeltt) trianglc
H Medially by the quadratus lumborum muscle.

H Laterally by the internal abdominal oblique muscle.
H Superiorly by the l2th rib.
H The floor of the superior lumbar triangle is the fascia transversalis
H The roof is the external oblique muscle.
Superior lumbar
triangle and
transversalis fascia
External
oblique
lnternal oblque
lnferior
lumbar
traingle
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WhiteKnightLove
eomrrlications of tlernia
I- Irreducibility
DEFtrNITION
@
Irreducibility means failure to return the contents into the abdomen.
CAUSES:
O,A.dhesions between the contents and the sac or between the contents
themselves.
CLINIEAL PIETURE
O The best person to reduce the hernia is the patient himself, failure
to do so, it is considered irreducible.
EOMPLICATIONS
O Irreducibility predisposes to obstruction & strangulation.
TTT : Urgent surgery.

Ct
fleduction
[v taxis is comraindicated: As it may tead to
1. Reduction of strangulated loop to the abdomen.
2. Rupture of the hernia.

3. Reduction of the sac between the layers of the abdominal wall
(reduction- en bisac).
It- Obstruction f In cases of nterocele only ) :

DEFINITION
O Occlusion of the intestinal lumen from without or from within

without affecting its blood supply.
ll.B: lncarcelated hernia mcans o[sUuctcd hemia [yfaeces.
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WhiteKnightLove
CLINICAL PICTURE
The 4 Cardinat symptoms of I.O:
@ Abdominal colics.
@ Vomiting.
Absolute constipation.
O Abdominal
COMPLICATIONS
@
distension.
:
Obstruction predisposes to strangulation.
INV I
As strangulated hernia "See later".
TTT I Urgent surgery.
ItI- Slran{ulalion f lttost serious complication ) :

INCIDENCE
H The most common hernia liable to strangulate is

femoral hernia then paraumbilical hernia.
H The mosl common hernia seen strangulated
is
oblique inguinal hernia as it is the commonest form
of hernia.
H It
is the most common cause of I.O in developing countries.
EAUSES
1. Presence of a constricting agent as deep or superficial inguinal ring in
OIH or sharp
edge of lacunar ligament in femoral hernia.
H Constriction of the contents leading to interruption of their blood supply.

H If the conslriction is not relieved, gangrene occurs in few hours.
2. Narrowing of the neck of the sac by adhesions.
3.
[t may follow other complications
as
irreducibility or obstruction.
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WhiteKnightLove
PATTIOLOGY : The strangulated loop witt suffer thefottowing sequelae :
l- Pressrlre on the veins & irnpeded venous con$esdon
H The strangulated loop becomes congested and distended with gas & fluid.
H lncreased congestion causes haemorrhage in the wall &
lumen of the affected loop.
2- Pressure on the arteries & irnpaired arterial supply:
H Ischemia & infarctions of the mucosa.

H The devitalized loop exudates its contents (fluid, blood & bacteria)
into the hernial sac which now contains dark highly toxic fluid.
H Bacterial translocation occurs & predisposes to septic shock.

3. GanXirene <lccurs at dre site of consfficdon.
4- Perforadon &
peritonitis are the terrninal events.
CLINICAL PICTURE
c/o :
1- Acute pain in the hernia.
2- Sudden enlargement of the hernia.

3- Irreducibility.
4- Symptoms of intestinal obstruction as
@ Abdominal colics.
Vomiting.
@ Absolute constipation.
@ Abdominal distension.
5- Finally perforation occurs with generalized abdominal pain of peritonitis.
1- Strangulated omentum. 2- Littre's
hernia.
l5l
WhiteKnightLove
3- Richter's hernia.
olE
GENERAL
1. Fever.
2. Shock in neglected
ABDOMINAL
or even septic shock).
cases (hypovolaemic
Inspection : Abdominal distension.
Palpation : Abdominal rigidity in cases of perforation & peritonitis.

Percussion : Hyper-resonance on percussion.
Auscultation :
l"
accentuated intestinal sounds
: The hernia is :
1- Irreducible. 2- Tender
& later silent
abdomen.
LOCAL
3- Tense
4- Giving no expansile impulse on cough.

5. Showing signs of acute inflammation.
il.B:
Clinical differentiation between obstluction &stmngulation is difficult
*Thus it is safer to consider any obstructed hernia as

strangulated hernia until proved otherwise.
DIT 'ERENCE BETWEEN OBSTRUETED
& STRANGULATED
NERNIA
Obstructed hernia
Strangulated hernia
Not toxic
Toxic " Feverish "
Expansile impulse
Present
No
Tense:
Not tense
Tense
Overlying signs of inf.
Absent
Present
Percussion :
Resonant
Dull
General
Local
152
WhiteKnightLove
Auscultation:
Accentuated int.
Silent.
sounds
Ryle insertion
Relives pain
Doesn't
INV : TLC
Normal
Leucocytosis
INV
1. Serum electrolytes (Na & K), KFTs & LFTs
2. CBC : Leucocytosis.
3. ABGs : Metabolic acidosis.
4. Plain x-Ray abdomen erect & supine :

O Multiple fluid levels & distended loops.
TREATMENT
Urgent surgery after resuscitation
Preoperative preparation "resuscitation"
1. NPO & nasogastric tube suction : 9distension & vomiting.
2. l.Y fluids & correction of any electrolytes disturbance.

3. I.V antibiotics
4. I.V.
: 3'd generation cephalosporins
& metronidazole.
H2 blockers to avoid stress peptic ulcer.
5. Fluid chart.
Operative management:
1. The incision must explore the neck & the fundus of the sac.
2. Dissect & open the sac (at the fundus ):

x To avoid escape of lhe toxic
fluid to the peritoneal cavity.
3. Evacuate the toxic fluid.
4. Hold the contents & divide constriction ring
on your finger or hernia
director.
5. Deliver the loop outside to avoid strangulated inner loop in

cases of Maydle's hernia.
r53
WhiteKnightLove
6. Deal with the contents according to viability.

a. Omentum
Must be resected
b. lntestinal loop
as
viability can't be guaranteed.
llon-uiaile lootl
UiaDle looE
Normal luster
Lusterless
Pink
Grey or black
Pulsating mesenteric arteries
Not pulsating (thrombosed)
Contracts if pricked or pinched
No response
i- Viable loop : Returned

ii- Doubtful loop :
to abdomen.
Eg Hot packs are applied for maximum 10-15 minutes & ask
the anesthesiologist to increase pure oxygen inhalation for
few minutes & then see if it
iii- trangrenous loop :

Snall intestinc : Resutiort 6 |'t
is viable or not.
anastotnosk
@ Good blood supply of the small intestine.
O Small intestine is less contaminated.

O Has complete serosa & musculosa & good blood supply.
154
WhiteKnightLove
Rt orloa E
Lilt
oalor,
uuum:
Rt lrsriorlrototry
I il*ban*e:se
anastornosis.
Erteltottzatiott rcseotiott
O The gangrenous part is excised.

O The proximal segment is exteriorized
as colostomy.
O The distal segment is closed

(Hartman's pouch) or
f*tenb.isaAin
sutured to the skin (mucus

fistula).
/1
H a,r
ll.B : Primary anastomosis 0[ an
t, an ]
2*rodun.
unue[aled left G0l0n is benel auoided due
t0:
l- Poor blood sw[ly 0l the left colon.
2- iligher Gontamination than small intestine.
3- The selosa is not Gom0lete.
4- The
outcr longitudinal muscle layel is conuerted t0 3 tenia coli & Is
absent in[etween [musculosa is not G0m[letcl.
7. Finally herniorrhaphy using prolene sutures but mesh is

contraindicated.
IU- Intlammation : fExtremely rare)

O Contents as inflamed appendix or Meckel's diverticulum.
U- RUptUfg
Common in patients with CLD & ascitis.
UI- Hydrocele of the hernial Sac : Look scrotum & testes.
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WhiteKnightLove
Differential Diagnosis of Inguinal

Swellings
1) Inguinal hernia : Direct & oblique "Bubonocele"
2) Femoral hernial.
3) Undescended testis or ectopic
testis.
4) Inguinal Iymphadenopathy.
5) External iliac artery or common femoral artery aneurysm.
6) Saphena varix.
7) Lipoma.
8) Iliopsoas abscess.
9)
Psoas bursa.
Differential Diagnosis of scrota! swellings

[
l- Testis
I II I Chronic
) Acute
*Acute epidydmo-
* Testicular tumours.
orchitis.
2- F;pididyrnis
* Spermatocele
* Torsion testis.
*Acute epididymitis
* Haematocele
* Pyocele
* Syphilitic gumma* T.B. * Bilh. *Filariasis.

* Epididymal cysts
* Vaginal hydrocele.
* Clotted or calcified
haematocele.
* Encysted hydrocele of
4- Sperrnadc
cord
the cord
156
WhiteKnightLove
Differential Diagnosis of inguirto-scrotal

swellings
1. Complete (Scrotal type) of OtH.
2. Varicocele.
3. Congenital & infantile hydrocele.
4. Lipoma of the cord.
5. Ilydrocele of the hernial
sac of a complete OIH-
6. Endemic funiculitis.
t57
WhiteKnightLove

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'It is more blessed to give than to receive.

Freely you have received; freely give.

Anatomy & embryologyMaldescended testes.

10. Congenital & infantile hydrocele

1. Anatomy of the inguinal canal.

Burst abdomen14. Rare forms of hernia & lumbar hernia.

" " 101

'It is more blessed to give than to receive.

Alftre thyroid gland appears

proliferation (bilobed diverticulum)

Attris part forms tlp

istlmxs Athl- mqiot P*t of eanJr loba

['uUer <:rrl urn I illpar

t d i -su 1r1>ca: r's

lrYr-()i (l Car-I i I ?)ge (C1. )

(.1'i(:r)trt r:Jr'l i l:tge

Freely you have received; freely give.

2- 4th pltarttnqeal oottr,h :

A Gives the ultimo-branchial

body that unites with the above part during its

the loth week.

Anatomy cf the thyroid Sland :

$ A small pyramidal lobe (*uy

be absent) projects from the isthmus

thyroidae (remnant of the thyroglossal tract)

SITE & SHAPE

lfne normal thyroid gland is about 20-25 qms-

Each lobe measures

'It is more blessed to give than to receive.

The isthmus lies opposite the

*True fibrous capsule : from the C.I of the gland itself

suspensory ligament of Berry

ls thickening in the pretracheal fascia that fixes the

[r.i roitl ( J !:lurl

Freely you have received; freely give.

RELATIONS OF TTIE THYROID GLAND:

Arttero lnteral srrrfuee :

2. Superior belly of omohyoid in its upper part.

4. Sternomastoid muscle overlapping the lower part.

Larynx ( Cricoid & thyroid cartilages & -c_ricothyroid muscle

'It is more blessed to give than to receive.

l. Superior thntroid, arteru :

2. Inferior Jhqroid. arteru

H Arises from the thyrocervical trunk which is a branch of the first

3. Thuroid itnrl- arteru

H Might be found from the arch of the aorta or the innominate

Freely you have received; freely give.

vein to be ligated & divided during thyroidectomy.

3. Inferior thuroid roeil$:

innominate vein of the corresponding side.

'It is more blessed to give than to receive.

Upper deep cervical tymph nndes.

2. Lower deep cervical lymph nodes.

2. Pretracheal lymph nodes (Delphic).

Upper deep eenvical

Lower deep cervical

Freely you have received; freely give.

A: Zhe su".erior thuroid aessels ane related to tlte

t2 This nerve is motor to the cricothyroid

& inferior constrictor

muscle of the pharynx

When the nerve injured

it leads to loss of high pitched voice ( hstir,ss

of toico = moaotoaorrs taotcs).