Note
The parotid gland is innervated by the auriculotemporal nerve, which is a branch of the mandibular division of trigeminal nerve, this branch provide sensory innervation and carries postganglionic parasympathetic nerve fibres to the parotid gland for secretomotor activity, these fibres originate in the otic ganglion associated with the mandibular nerve, the preganglionic nerve fibres comes from the glossopharyngeal nerve.
#Salivary
#Surgery
The parotid gland is innervated by the auriculotemporal nerve, which is a branch of the mandibular division of trigeminal nerve, this branch provide sensory innervation and carries postganglionic parasympathetic nerve fibres to the parotid gland for secretomotor activity, these fibres originate in the otic ganglion associated with the mandibular nerve, the preganglionic nerve fibres comes from the glossopharyngeal nerve.
#Salivary
#Surgery
Relationship of facial nerve to the parotid gland
◼️The facial nerve exists the skull through the stylomastoid foramen, it then directly enters the substance of the parotid gland.
◼️Within the parotid gland, the facial nerve usually divide into an upper and lower nerve trunks, which furthur divide and anastomose within the gland forming the parotid plexus of nerves which is also called Pes Anserinus plexus (see above fig).
◼️The Pes Anserinus divides the parotid glands into two parts, the superficial part (outside the plexus) and the deep part (Deep to Pes Anserinus).
◼️Five branches emerge from Pes Anserinus which include (1) Temporal, (2) Zygomatic, (3) Buccal, (4) Marginal, (5) Cervical, these provide motor innervation to the muscles of the face.
#Salivary
#Surgery
◼️The facial nerve exists the skull through the stylomastoid foramen, it then directly enters the substance of the parotid gland.
◼️Within the parotid gland, the facial nerve usually divide into an upper and lower nerve trunks, which furthur divide and anastomose within the gland forming the parotid plexus of nerves which is also called Pes Anserinus plexus (see above fig).
◼️The Pes Anserinus divides the parotid glands into two parts, the superficial part (outside the plexus) and the deep part (Deep to Pes Anserinus).
◼️Five branches emerge from Pes Anserinus which include (1) Temporal, (2) Zygomatic, (3) Buccal, (4) Marginal, (5) Cervical, these provide motor innervation to the muscles of the face.
#Salivary
#Surgery
Salivary glands
◼️There are about 1000 minor salivary glands which are located in the submucosa and mucosa that lines the tongue, buccal surfaces, and palate of the oral cavity, these glands opens directly via small ducts.
◼️The parotid gland is the largest of the three major pairs of salivary glands, it is located within a shallow triangular trench bordered by (1) sternocleidomastoid muscle behind, (2) Mandibular ramus infront, (3) The base of the triangle made by external auditory meatus and posterior part of zygomatic arch. (see fig)
◼️The parotid duct (Stensen's duct) leaves the anterior aspect of the gland midway between zygomatic arch and corner of the mouth, it traverse the face external to masseter muscle and turns medial to pierce the buccinator muscle and opens adjacent to the upper 2nd molar tooth.
◼️The parotid gland loops around the mandibular ramus, so that it is superficial, posterior and deep to it.
◼️The relationships of parotid gland will be discussed later.
#Salivary
#Surgery
◼️There are about 1000 minor salivary glands which are located in the submucosa and mucosa that lines the tongue, buccal surfaces, and palate of the oral cavity, these glands opens directly via small ducts.
◼️The parotid gland is the largest of the three major pairs of salivary glands, it is located within a shallow triangular trench bordered by (1) sternocleidomastoid muscle behind, (2) Mandibular ramus infront, (3) The base of the triangle made by external auditory meatus and posterior part of zygomatic arch. (see fig)
◼️The parotid duct (Stensen's duct) leaves the anterior aspect of the gland midway between zygomatic arch and corner of the mouth, it traverse the face external to masseter muscle and turns medial to pierce the buccinator muscle and opens adjacent to the upper 2nd molar tooth.
◼️The parotid gland loops around the mandibular ramus, so that it is superficial, posterior and deep to it.
◼️The relationships of parotid gland will be discussed later.
#Salivary
#Surgery
Note: "Serum amylase level and acute pancreatitis"
◼️Serum amylase, an enzyme produced by the exocrine pancreas and released into the circulation in excess amounts with inflammatory conditions of the pancreas, is an important laboratory marker for acute pancreatitis.
◼️In acute pancreatitis serum amylase level is more than 3 times the upper limit of normal value, it is important to understand that the level of amylase does not correlate with the severity of acute pancreatitis, infact, low levels of serum amylase occurs more often in severe cases of acute pancreatitis than in mild cases.
◼️Serum amylase level may be elevated in other conditions, including (1)perforated peptic ulcer, (2)mesenteric infarction, (3) Renal failure, (4) Macro-amylasemia, in such cases serum lipase level or the pancreatic isoenzyme amylase are more specific for the diagnosis.
◼️A normal serum amylase level does not exclude the diagnosis of acute pancreatitis, it is almost immediately elevated with the onset of disease, and remains elevated for 3 to 5 days following the index event, meanwhile its being excreted into the urine, here urinary amylase level may be more beneficial in securing a diagnosis of acute pancreatitis.
#Pancreas
#Surgery
◼️Serum amylase, an enzyme produced by the exocrine pancreas and released into the circulation in excess amounts with inflammatory conditions of the pancreas, is an important laboratory marker for acute pancreatitis.
◼️In acute pancreatitis serum amylase level is more than 3 times the upper limit of normal value, it is important to understand that the level of amylase does not correlate with the severity of acute pancreatitis, infact, low levels of serum amylase occurs more often in severe cases of acute pancreatitis than in mild cases.
◼️Serum amylase level may be elevated in other conditions, including (1)perforated peptic ulcer, (2)mesenteric infarction, (3) Renal failure, (4) Macro-amylasemia, in such cases serum lipase level or the pancreatic isoenzyme amylase are more specific for the diagnosis.
◼️A normal serum amylase level does not exclude the diagnosis of acute pancreatitis, it is almost immediately elevated with the onset of disease, and remains elevated for 3 to 5 days following the index event, meanwhile its being excreted into the urine, here urinary amylase level may be more beneficial in securing a diagnosis of acute pancreatitis.
#Pancreas
#Surgery
Colon vascular supply
◼️The colon is supplied by both the superior and inferior mesenteric arteries which are branches of the aorta.
◼️The superior mesenteric artery (SMA) arise from the anterior surface of the aorta just below the celiac trunk at the level of the lower part of L1.
◼️SMA branches off the ileocolic artery (abscent in 20% of population) which supplies the terminal ileum and proximal ascending colon, it also gives the right colic and middle colic arteries that supply the distal ascending colon and transverse colon respectively.
◼️The inferior mesenteric artery arise from the aorta at about L3 vertebral level, it gives the left colic artery, several sigmoidal branches, and the superior rectal artery which supplies the proximal rectum.
◼️Each of these arteries communicate via anastomoses through the artery of Drummond, this circle of anastomoses is complete in only 15% to 20% of the population.
#Intestinal
#Surgery
◼️The colon is supplied by both the superior and inferior mesenteric arteries which are branches of the aorta.
◼️The superior mesenteric artery (SMA) arise from the anterior surface of the aorta just below the celiac trunk at the level of the lower part of L1.
◼️SMA branches off the ileocolic artery (abscent in 20% of population) which supplies the terminal ileum and proximal ascending colon, it also gives the right colic and middle colic arteries that supply the distal ascending colon and transverse colon respectively.
◼️The inferior mesenteric artery arise from the aorta at about L3 vertebral level, it gives the left colic artery, several sigmoidal branches, and the superior rectal artery which supplies the proximal rectum.
◼️Each of these arteries communicate via anastomoses through the artery of Drummond, this circle of anastomoses is complete in only 15% to 20% of the population.
#Intestinal
#Surgery
Differential diagnosis of a groin lump :
1) Indirect inguinal hernia.
2) Direct inguinal hernia.
3) Femoral hernia.
4) Enlarged cloquet lymph nodes.
5) Saphena varix.
6) Femoral aneurysm.
7) Encysted hydrocele of cord.
8) Hydrocele of canal of Nuck.
9) Hematocele of round ligament.
10) Ectopic testis.
11) Lipoma.
12) Psoas abscess.
13) Enlarged psoas bursa.
14) Ruptured adductor muscles.
#Hernia
#Surgery
1) Indirect inguinal hernia.
2) Direct inguinal hernia.
3) Femoral hernia.
4) Enlarged cloquet lymph nodes.
5) Saphena varix.
6) Femoral aneurysm.
7) Encysted hydrocele of cord.
8) Hydrocele of canal of Nuck.
9) Hematocele of round ligament.
10) Ectopic testis.
11) Lipoma.
12) Psoas abscess.
13) Enlarged psoas bursa.
14) Ruptured adductor muscles.
#Hernia
#Surgery
Strangulation of paraumbilical hernia is frequent which justify operation in nearly all cases, from the image above the fibrous rigid linea alba (black arrow) creates a narrow neck with a rigid edge that makes strangulation likely, in addition sometimes in large hernias loculations due to omental adhesions cause strangulation in a knuckle of intestine in an otherwise soft and non tender hernial sac.
#Hernia
#Surgery
#Hernia
#Surgery
This is a polypropylene mesh used for hernioplasty, this provides structural support to a weak defect, it gained widespread popularity especially with inguinal hernias (Lichtenstein tension-free hernioplasty), it can be used for recurrent paraumbilical hernias or those with very large defect.
#Hernia
#Surgery
#Hernia
#Surgery
Mayo's operation, indicated for small defects on paraumbilical hernias, the operation simply proceed with transverse elliptical incision near the umbilicus, the subcutaneous fat is dissected to reveal the anterior rectus sheath and the neck of the hernia which is incised, the contents are delt with appropriately and then the sac is dissected out and the peritoneum sutured, then the defect is strengthened with overlapping of the aponeuroses on each side of the umbilicus and fixed with sutures the overlap should be 5 to 7.5 cm.
#Hernia
#Surgery
#Hernia
#Surgery
Paraumbilical hernia
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
#Hernia
#Surgery
◼️It is protrusion of a hernial sac in a weak point at the linea alba above or sometimes below the umbilicus.
◼️It can attain massive size.
◼️It is 5 times more common in females.
◼️Obesity, flabbiness of abdominal muslces and repeated pregnancy are important aetiologic factors.
◼️The neck of this hernia is remarkably narrow when compared to the size of the sac or volume of its contents, thus it is liable for strangulation and require operation.
◼️In longstanding cases the sac may become lobulated due to omental adhesions rendering it irreducible, in addition intertrigo due to friction of adjacent skin surfaces and trophic ulcers are troublesome complications.
◼️Dragging pain due to traction and transient intestinal colic due to partial intestinal obstruction may occur.
#Hernia
#Surgery
Umbilical hernia
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
#Hernia
#Surgery
◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.
#Hernia
#Surgery
Enlargement of femoral lymph nodes Vs femoral hernia
◼️Presence of enlarged lymph nodes elsewhere helps to differentiate between this condition and femoral hernia.
◼️If Cloquet lymph nodes alone are enlarged (thick black arrows) it may be impossible to differentiate between it and femoral hernia,, inless there is other clues such as infected wounds or abrasions in the corresponding limb or perineum.
#Hernia
#Surgery
◼️Presence of enlarged lymph nodes elsewhere helps to differentiate between this condition and femoral hernia.
◼️If Cloquet lymph nodes alone are enlarged (thick black arrows) it may be impossible to differentiate between it and femoral hernia,, inless there is other clues such as infected wounds or abrasions in the corresponding limb or perineum.
#Hernia
#Surgery
Saphena Varix Vs femoral hernia
◼️Saphena varix is enlargement of the terminal end of long saphenous vein.
◼️It is differentiated from femoral hernia by :
¶ Saphena varix is usually associated with other signs of varicose veins.
¶ Saphena varix usually disappear completely while the patient lies flat, while a femoral hernia will usually be still palpable.
¶ A fluid thrill is felt with the saphena varix when the patient cough or when the long saphenous vein is tapped below the varix.
¶ Saphena varix may be associated with a venous hum which is heard when the stethoscope is placed on the varix.
#Hernia
#Surgery
◼️Saphena varix is enlargement of the terminal end of long saphenous vein.
◼️It is differentiated from femoral hernia by :
¶ Saphena varix is usually associated with other signs of varicose veins.
¶ Saphena varix usually disappear completely while the patient lies flat, while a femoral hernia will usually be still palpable.
¶ A fluid thrill is felt with the saphena varix when the patient cough or when the long saphenous vein is tapped below the varix.
¶ Saphena varix may be associated with a venous hum which is heard when the stethoscope is placed on the varix.
#Hernia
#Surgery
Femoral Vs inguinal hernia
◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.
◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.
◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.
◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.
#Hernia
#Surgery
◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.
◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.
◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.
◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.
#Hernia
#Surgery
Pathology of femoral hernia
◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
#Hernia
#Surgery
◼️This device is called a retort, it is used in chemisty for distillation of fluids, water is placed in the distended part and heated, so on water will be dripping out of the funnel part,, it is the best example to describe a femoral hernia.
◼️The femoral hernia descend through the inelastic rigid femoral canal (corresponding to the funnel of retort "black arrow") and emerge from the saphenous opening.
◼️Once it bypass the saphenous opening the hernia distend in the loose areolar tissue of the groin (corresponding to the distended part of the retort "white arrow").
◼️Note that sometimes the distension is considerable that the bulbous extremity of the hernia lie above the inguinal ligament.
◼️The funnel of the retort (black arrow) reflect how the hernia is so narrowed at the femoral canal, this is why femoral hernias are the most liable hernia to strangulate.
#Hernia
#Surgery