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RIGHT ILIAC FOSSA MASS MASS By, Prof R.A.Pandyaraj, MS, FICS,FAIS,FMAS(Laproscopy). Head of surgery department, Govt. Royapettah Hospital.

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Presentation on theme: "RIGHT ILIAC FOSSA MASS MASS By, Prof R.A.Pandyaraj, MS, FICS,FAIS,FMAS(Laproscopy). Head of surgery department, Govt. Royapettah Hospital."— Presentation transcript:

1 RIGHT ILIAC FOSSA MASS MASS By, Prof R.A.Pandyaraj, MS, FICS,FAIS,FMAS(Laproscopy). Head of surgery department, Govt. Royapettah Hospital.

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3 BOUNDARIES;  TRANS TUBERCULAR LINE  MIDCLAVICULAR LINE  ILIAC CREST

4 CONTENTS; CONTENTS; Appendix Caecum Mesoappendix Terminal ileum Retro peritoneal tissue iliac nodes iliac arteries

5 APPROACH INSPECT PALPATE PERCUSS AUSCULTATE PV / PR OTHER MASS

6 PAIN Dullaching Colicky Continuous / intermittent Dullaching Colicky Continuous / intermittent

7 CLASSIFICATION RIF MASSANATOMICAL PARIETAL INTRA ABDOMINAL CLINICAL SOLIDCYSTIC ANATOMICAL Pariteal Intra abdominal intra peritoneal retro peritoneal CLINICAL solid mass cystic mass

8 ANATOMICAL PARIETAL INTRA ABDOMINAL INTRA ABDOMINAL 1.LIPOMA 2.DESMOID TUMOR 3.PYOGENIC ABSCESS 4.INTRA ABDOMINAL ABSCESS BURROWING THROUGH 1.ILIAC ABSCESS 2.APPENDICULAR ABSCESS 1.LIPOMA 2.DESMOID TUMOR 3.PYOGENIC ABSCESS 4.INTRA ABDOMINAL ABSCESS BURROWING THROUGH 1.ILIAC ABSCESS 2.APPENDICULAR ABSCESS

9 ANATOMICAL PARIETAL INTRA ABDOMINAL INTRA ABDOMINAL INTRA PERITONEAL

10 ANATOMICAL PARIETAL INTRA ABDOMINAL INTRA ABDOMINAL INTRA PERITONEAL RETRO PERITONEAL

11 CLINICAL SOLID CYSTIC APPENDICULAR MASS CARCINOMA CAECUM ILEO-CAECAL TUBERCULOSIS EXTERNAL ILLAC LYMPHADENITS RETRO PERITONEAL SARCOMA CROHN’S UNASCENDED KIDNEY ACTINOMYCOSIS APPENDICULAR MASS CARCINOMA CAECUM ILEO-CAECAL TUBERCULOSIS EXTERNAL ILLAC LYMPHADENITS RETRO PERITONEAL SARCOMA CROHN’S UNASCENDED KIDNEY ACTINOMYCOSIS APPENDICULAR ABSCESS PSOAS ABSCESS RT.OVARIAN CYST ILIAC ARTERY ANEURSYM APPENDICULAR ABSCESS PSOAS ABSCESS RT.OVARIAN CYST ILIAC ARTERY ANEURSYM

12 APPENDICULAR MASS ILEO CAECAL TB ILEO CAECAL TBCA.CAECUMAGE ANY AGE,COMMON IN YOUNGER AGE YOUNG& MIDDLE AGE MIDDLE & OLDER AGE PAIN SHORT DURATION, >3 DAYS,MIGRATING INITIALLY Colicky NO PAIN, MAY BE IN LATE STAGE FEVER HIGH GRADE LOW GRADE RECURRENTAbsent VOMITING+++++, IF OBSTRUCTED ++ IF OBSTRUCTED IF OBSTRUCTED ALTERED BOWEL HABITUS - DIARRHOEA ALTERED WITH CONSTIPATION +

13 MASS CHARACTERISTICS APPENDICULARMASS ILEO-CAECAL TB CA.CAECUMTENDER SOFT TO FIRM SOFT TO FIRM ILL DEFINED BORDERS ILL DEFINED BORDERS IRREGULAR & FIXED IRREGULAR & FIXED TYMPANIC NOTE TYMPANIC NOTE NON-TENDER FIRM TO HARD HIGHLY PLACED DOUGHY ABDOMEN NON-TENDERHARDFIXEDASCITESHEPATOMEGALY

14 INVESTIGATIONS Blood HB, TC,DC,ESR RFT X-Ray – Chest,Abdomen Erect Barium Enema USG Abdomen CT Scan Abdomen

15 APPENDICULAR MASS ILEO-CAECAL TB CA.CAECUM PLAIN XRAY LOCALISED ILEUS MULTIPLE AIR-FLUID LEVELS CALCIFIED TBNODES _ BARIUM STUDY NOT INDICATED PULLED UP CAECUM, NARROWED TERMINAL ILEUM WIDENING OF ILEO-CAECAL ANGLE IRREGULAR FILLING DEFECT, APPLE CORE SIGN USG MIXED ECHOGENIC LESION DILATED ILEUM THICKENED CAECUM SOLID CAECAL MASS HEPATOMEGALY,ASCITIS

16 APPENDICULAR MASS This is caused by inflammation and swelling of the appendix, caecum, omentum and distal part of the terminal ileum Treat conservatively with bowel rest, antibiotics, analgesics and fluids Consider interval appendicectomy if symptoms recur Treat conservatively with bowel rest, antibiotics, analgesics and fluids Consider interval appendicectomy if symptoms recur

17 APPENDICULAR MASS OSCHNER REGIMEN Approach AOSCHNER REGIMEN Initial conservative treatment followed by interval appendicectomy six to eight weeks later Approach B Immediate appendicectomy following inflammatory mass resolution Approach C An entirely conservative approach without interval appendicectomy in patients with appendiceal mass

18 APPENDICULAR MUCOCELE Appendicular mucocele is a rare lesion (0.2 ‐ 0.3% of surgical appendicectomy specimens) It is a descriptive term denoting an obstructive dilatation of the appendicular lumen by mucinous secretions Appendicular mucocele is a rare lesion (0.2 ‐ 0.3% of surgical appendicectomy specimens) It is a descriptive term denoting an obstructive dilatation of the appendicular lumen by mucinous secretions

19 MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA ACCOUNT FOR 60 ‐ 70% OF ALL MUCOCELES LESS COMMON CAUSES: RETENTION CYST MUCOSAL HYPERPLASIA CARCINOID APPENDICOLITH ENDOMETRIOSIS ADHESIONS VOLVULUS MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA ACCOUNT FOR 60 ‐ 70% OF ALL MUCOCELES LESS COMMON CAUSES: RETENTION CYST MUCOSAL HYPERPLASIA CARCINOID APPENDICOLITH ENDOMETRIOSIS ADHESIONS VOLVULUS

20 ‐ High Correlation Of Synchronous Or Metachronous Colorectal Adenomas And Carcinomas (Up To 20%) ‐ Association With Mucin‐secreting Tumors Of The Ovary ‐ Pseudomyxoma Peritonei (Avoid Iatrogenic Rupture Of The Mucocele)TREATMENT Appendicectomy Is Used For Simple Mucocele Or For cystadenoma Right Hemi‐colectomy Is Recommended For Cystadenocarcinoma ‐ High Correlation Of Synchronous Or Metachronous Colorectal Adenomas And Carcinomas (Up To 20%) ‐ Association With Mucin‐secreting Tumors Of The Ovary ‐ Pseudomyxoma Peritonei (Avoid Iatrogenic Rupture Of The Mucocele)TREATMENT Appendicectomy Is Used For Simple Mucocele Or For cystadenoma Right Hemi‐colectomy Is Recommended For Cystadenocarcinoma MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA

21 TREATMENT

22 ILEO-PSOAS ABSCESS Cough with expectorant,evening raise of temperature,haemoptysis, Attitude of flexion,spine tenderness,gibbus Cross fluctuation No line of separation/space between mass&iliac spine Cough with expectorant,evening raise of temperature,haemoptysis, Attitude of flexion,spine tenderness,gibbus Cross fluctuation No line of separation/space between mass&iliac spine

23 CROHN’S DISEASE INFLAMMATORY DISEASE INVOLVING ILEUM, CAECUM, COLON PTS.PRESENT WITH DIARRHOEA, FEVER, MULTIPLE FISTULA (PERIANAL), WITH SIGNS OF INTESTINAL OBSTRUCTION COBBLESTONE APPEARANCE, PSEUDOPOLYPS, SKIP LESIONS STRING SIGN OF KANTOR ( NARROWING OF TERMINAL ILEUM ) INFLAMMATORY DISEASE INVOLVING ILEUM, CAECUM, COLON PTS.PRESENT WITH DIARRHOEA, FEVER, MULTIPLE FISTULA (PERIANAL), WITH SIGNS OF INTESTINAL OBSTRUCTION COBBLESTONE APPEARANCE, PSEUDOPOLYPS, SKIP LESIONS STRING SIGN OF KANTOR ( NARROWING OF TERMINAL ILEUM )

24 COBBLESTONE APPEARANCE

25 ILEO-CACEAL TB ABDOMINAL TUBERCULOSIS INTESTINALULCERATIVEHYPERPLASTICSTRICTOROUSMIXED EXTRA INTESTINAL PERITONEUMACUTECHRONICMESENTRY SOLID ORGANS GENITO- URINARY SYSTEM

26 ABDOMINAL TUBERCULOSIS

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28 ILEO-CAECAL TB ILEO CAECAL REGION IS MORE COMMONLY INVOLVED ??????? RICH LYMPHATICS IN PEYER’S PATCHES ALKALINE MEDIUM ILEOCECAL VALVE PRECIPITATES STASIS TERMINAL ILEUM IS MAXIMUM AREA OF RESORPTION RICH LYMPHATICS IN PEYER’S PATCHES ALKALINE MEDIUM ILEOCECAL VALVE PRECIPITATES STASIS TERMINAL ILEUM IS MAXIMUM AREA OF RESORPTION

29 TREATMENT CATEGORY I – ATT IN CASE OF COMPLICATIONS – LIMITED RESSECTION – RIGHT HEMICHOLECTOMY

30 CALCIFIED TB MESENTRIC NODES

31 MESENTERIC-CYSTMESENTERIC-CYST

32 CARCINOMA CAECUM

33 APPLE CORE APPEARANCE IN CA.CAECUM APPLE CORE APPEARANCE IN CA.CAECUM

34 INTUSSUSCEPTION

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36 COMPLICATIONS

37 RT.TUBO-OVARIAN MASS Menstrual h/o; menorrhagia,polymenorrhagia,dysmenorrhea Leucorrhea,dyspareunia, Lower border not felt, Per vaginal; rt.fornix tenderness, Menstrual h/o; menorrhagia,polymenorrhagia,dysmenorrhea Leucorrhea,dyspareunia, Lower border not felt, Per vaginal; rt.fornix tenderness,

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