Friday, April 25, 2014

Excision of swellings

A.LIPOMA

Indication

  • Large size (cosmesis/patients wish)
  • Recent rapid increase in size (sarcomatous change) 
  • Symptomatic naevo/neurolipomas
  • causing pressure symptoms based on site.
Surgical procedures
  • Incision: A linear incision over the summit of the swelling is placed and flaps raised on both sides of the incision.
  • Layers opened: skin and some part of the subcutaneous tissue till the capsule of the swelling is encountered.
  • Dissection : using an artery forceps or a moquito forceps( if a small swelling) , a plane is created between the raised flaps and the capsule of the swelling.Pressure is given at the base of the swelling to deliver out of lipoma.A small vessel may be encountered as the base is being dissected that should be identified and cauterised or ligated.The specimen should be sent for hisptopathological evaluation.
Closure
  • The cavity left after the excision can be closed by few interrupted vicryl sutures to close the subcutaneous layer. The excess skin is removed. The skin is closed with 2.0 ethilon vertical mattress suture. Sometimes a drain may have to be kept to drain the cavity.Remove suture after 7-10days.
B.SEBACEOUS CYST

Indication : Infection , cosmesis

Surgical procedure: 
  • Elliptical incision around the summit of the swelling encircling the punctum.
  • Layers opened:
  1. Incision should be superficial. Care should be taken not to cut open the cyst wall.
  2. The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of the surrounding skin around the punctum.
  • Dissection 
  1. A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.
  2. An Allis forceps may be applied to the punctum and the elliptical skin to get a traction. Flaps need to be raised gradually on either sides of the incision and then deliver the cyst in toto.(huh?)
  3. If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst wall in piece meal is made.
Closure: Single layer closure of the skin. suture removed after 7-10 days.

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