Quick revision pearls – Surgery (Part 1)

Thyroid

1. Superior thyroid artery is a branch of external carotid. Inferior thyroid artery is a

branch of the thyrocervical trunk
2. Superior thyroid & middle thyroid veins drain into internal jugular vein. Inferior
thyroid vein drains into the brachiocephalic vein
3. Thyroglossal cyst represents persistence of the thyroglossal tract. Majority are
subhyoid in position. Surgery – Sistrunk surgery which consist of en bloc cystectomy
and excision of the central hyoid bone to minimize recurrence.
4. Follicular carcinoma can develop in long standing cases of multinodular goiter
5. Follicular adenoma is the commonest cause of a solitary thyroid nodule
6. FNAC cannot differentiate between follicular adenoma and carcinoma
7. Papillary carcinoma can develop after radiation exposure during childhood
8. Papillary carcinoma is the most common thyroid cancer and has the best prognosis
amongst all differentiated carcinomas. It is slow growing but can be multi-centric in
origin
9. Papillary carcinoma spreads via lymphatics to cervical lymph nodes.
10. Histo-pathological features of papillary carcinoma include Orphan Annie eyed nuclei,
intra-nuclear inclusions
11. Medullary carcinoma thyroid arises from parafollicular C cells and shows amyloid
material in histo-pathology
12. Calcitonin is a tumor marker for medullary carcinoma thyroid
13. Medullary carcinoma can be familial or sporadic. It can be a part of MEN (multiple
endocrine neoplasia) syndrome
14. MEN 1 – (Wermer’s syndrome) – 3 P’s
- Pituitary adenoma
- Parathyroid adenoma/ hyperplasia
- Pancreatic tumor
15. MEN II (A) – (Sipple syndrome)
- Medullary carcinoma thyroid
- Parathyroid adenoma/ hyperplasia
- Pheochromocytoma
16. MEN II (B)
- Meduallry carcinoma thyroid
- Parathyroid adenoma/ hyperplasia
- Marfanoid habitus
- Mucosal ganglioneuromas
17. Thyroid lymphoma is seen in 6th decade of life and can be treated with
chemotherapy with or without surgery. (Non hodgkins lymphoma)
18. Anaplastic carcinoma has the worst prognosis amongst thyroid cancers
19. Hemi-thyroidectomy is the treatment of choice for solitary nodules. Hemi-
thyroidectomy involves removal of one lobe + removal of isthmus.
20. Total thyroidectomy – 2 x total lobectomy plus isthumusectomy
21. Subtotal thyroidectomy – 2 x sub-total lobectomy plus isthumusectomy
 22. Near total thyroidectomy – total lobectomy plus isthumusectomy plus subtotal
lobectomy

23. Respiratory distress most commonly occurs due to laryngeal edema after thyroid
surgery

24. Hypoparathyroidism following thyroid surgery occurs because of either vascular

insult to the parathyroids or inadvertent removal of the glands during surgery. It
usually manifests 2-5 days after surgery.

25. Signs and symptoms of hypocalcemia –

- Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation in and
around the mouth and lips, and in the extremities of the hands and feet. This is often
the earliest symptom of hypocalcaemia.

- Carpopedal and generalized tetany

- Latent tetany

a. Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood
pressure cuff and maintaining the cuff pressure above systolic)
b. Chvostek's sign (tapping of the inferior portion of the zygoma will produce
facial spasms

Breast

26. Lymphatics of the breast drain into axillary and internal mammary lymph nodes.
Majority (85%) of the drainage is to the axillary lymph nodes
27. The following are the groups of axillary lymph nodes (lateral, anterior, posterior,
central, inter-pectoral (Rotter’s) and apical).
28. They are arranged in three levels in relation to the pectoralis minor [level 1 – lateral
to p. minor, level II – behind p. minor, level III – medial to p. minor]
29. Sentinel lymph node is the first lymph node draining the tumor bearing area of the
breast
30. Contact radiography; radiation exposure is 0.1 cGy and therefore it is a safe imaging
investigation. Sensitivity increases with age and as the breast becomes less dense.
31. Mamography is preferred in patients >40 years. In <40 years of age – USG is
preferred
32. Duct papilloma
- Commonest cause of bloody discharge from a single duct
- May be associated with a cystic swelling below the areola
- Treatment is microdochectomy (removal of affected duct)
33. Cone excision of major ducts (Hadfield’s procedure)
- Done when discharge cannot be localized to a single duct (usually in Duct ectasia)
- Patient should be warned that she will be unable to breast feed after the surgery

34. Poland syndrome is characterized by aplasia, the absence of glandular tissue in the
presence of a nipple and areola and is often accompanied by musculoskeletal
deformities of the chest wall and ipsilateral upper extremity.

35. Breast abscess –

- Commonly seen in lactating mothers

- Most likely case is Staphylococcus, which is transmitted from the child’s nasopharynx
- Treatment during the cellulitic stage – appropriate antibiotic
- Along with antibiotics (antibiotic of choice is amoxy plus clavulanic acid) – analgesics,
breast support, manual evacuation of breast milk
- If pus is formed – repeated USG guided aspirations or incision and drainage
36. Mondor’s disease
- Thrombophlebitis of the superficial veins of the breast and chest wall

37. Fibroadenoma (it is most common benign breast tumors younger female population)

• Usually found in women younger than 35 years.

• Rounded in outline mostly 2-3 cm in size and very movable (Breast mouse). They are
well-circumscribed, but not encapsulated.
• Mammographic appearance is: Popcorn appearance.
• Treatment is excisional biopsy

38. Phyllodes tumor (Cystosarcoma Phyllodes)

 • Phyllodes tumor or cystosarcoma phyllodes arise from periductal stroma and show
increased cellularity of the stromal components.
• Commonly seen after 40 years.
• It is a fibroepithelial tumor of unpredictable behavior. Although usually benign but it
has malignant potential.
• Local recurrence is likely.
A wide local excision is Treatment of choice.
For a recurrent or large tumour simple mastectomy can be done.

39. Risk factors for breast carcinoma

- Increasing age
- Women with positive family history of breast cancer
- Early menarche
- Late menopause
- Diet low in phytoestrogens
- High intake of alcohol
- Nulliparity
- Long term exposure to HRT
- History of previous irradiation

Protective factors

- Breast feeding
- First child at early age

40. Only about 5 – 10% of breast cancers are caused by inheritance of germline
mutations; most important of which are BRCA – 1 and BRCA – 2.
41. BRCA 1 gene is located on long arm of chromosome 17 (17q) and is associated with
- Ovarian
- Colorectal
- Prostate cancer
42. BRCA 2 is located on chromosome 13 (13q) and is associated with Male Breast
Cancer.

43. Modified Radical Mastectomy

- This surgical procedure removes the entire breast parenchyma including the
nipple-areolar complex along with pectoralis fascia and axillary tail of Spence
 - The pectoralis muscles (minor and major) are left intact unless part of it needs
to be resected to obtain clear margins.
- An ipsilateral axillary dissection is included.
- Minimum 10 axillary lymph nodes should be dissected

44. Complications
- Seroma formation (most common complication)
- Flap necrosis/ wound infection
- Injury to the Intercostobrachial (Sensory) Nerve: (most commonly nerve
injured) It will result in a permanent numbness in the lateral aspect of the
axillary and the inferior aspect of the arm.
- Injury to the Long Thoracic (Motor) Nerve: winging of scapula
- Injury to the Thoracodorsal Nerve: Leads to palsy of the latissimus dorsi muscle.
- Lymphedema: This is a complication which occurs less frequently with the
standard axillary dissections. However, it is commonly seen when an axillary
dissection is combined with axillary radiation. Long standing can develop
angiosarcoma (Stewart Treves syndrome)

45. Breast conservation surgery

Absolute Contraindications

1. Pregnancy is an absolute contraindication to the use of breast irradiation.

2. Women with two or more primary tumors in separate quadrants of the breast or
with diffuse malignant-appearing microcalcifications are not considered candidates
for breast conservation treatment.
3. A history of prior therapeutic irradiation to the breast region.
4. Persistent positive margins after two surgical attempts

Relative Contraindications
 1. Collagen vascular disease is a relative contraindication to breast conservation
treatment because published reports indicate that such patients tolerate irradiation
poorly
2. Large tumor to breast ratio

46. Breast Reconstruction After Mastectomy

- Most commonly used flap – TRAM (transverse rectus abdominus
myocutaneous flap_
- Best flap - DIEP

47. The axillary lymph node involvement by breast cancer is the most established and
reliable prognostic factor for subsequent metastatic disease and survival.

48. Hormone therapy in pre-menopasal hormone receptor positive breast cancer patient
– Tamoxifen (most common side effect – hot flashes)
49. Luminal A cancer – ER, PR positive & Her 2 neu negative – most common and best
prognosis.
50. Basal cancer (Triple negative) – worst prognosis