Problem-based Learning in Surgery – For My Continuing Self-education and for Surgical Trainees – Part of Education for Health Development in the Philippines
Issue: Do you need to close the platysma in thyroidectomy?
While discussing with my surgical students on thyroidectomy technique (how I usually do it), I was challenged with this question or issue: should the platysma be closed routinely?
Search – found this article.
The impact of non-closure of the platysma muscle layer on the cosmesis of thyroidectomy scar – a randomised double-blind controlled trial
Background: The relevance of closing the platysma muscle layer after open thyroidectomy has received little interest in terms of research. The objective was to determine whether non-closure of the platysma muscle layer after open thyroidectomy impacts significantly on the cosmetic outcome of the resulting collar scar.
Methods: In this prospective randomised controlled clinical trial, patients were assigned randomly to have the platysma muscle layer closed or not closed. The primary endpoint was the cosmesis of the collar scar six weeks after surgery assessed using the patient and observer scar assessment scale (POSAS). Additional endpoints included operation time and early postoperative wound complications.
Results: Ninety-two patients were recruited, with 46 randomised to each group. The patient scar assessment subscale(PSAS) of the POSAS showed no significant difference in the scar cosmesis between the two groups six weeks after surgery (median PSAS: 16.5 vs 17.5; p = 0.514). The observer scar assessment subscale (OSAS) showed that the platysma muscle layer closure group had marginally better scars (median OSAS: 15 vs 17; p = 0.045). The size of the goitre did not make any significant difference in the scar cosmesis. There was no significant difference in the incidence of early postoperative wound complications as well as the median operation time.
Conclusion: Not closing the platysma muscle layer had no significant impact on the scar cosmesis six weeks after open thyroidectomy, with no significant difference in the incidence of early postoperative wound complications and the operation time.
I have done a lot of thyroidectomies – some with closure of the platysma and others without. I have not seen any difference in the quality of the neck incision scar caused by non-closure of platysma.
This study validates my observation.
So, should I close the platysma or not from hereon?
If there is no reason why I should not close it, I close it, not for cosmetic scar reason, but for the restoration and maintenance of functions that the platysma do, such as:
Aids facial expression by lowering the inferior lips.
August 25, 2022 – Had telemedical consult with a seaman – 38 years old / male – while he was docked in Japan. He had abdominal pain. With a background of an ultrasound report of cholecystolithiasis in June 30, 2021, my primary diagnosis was cholecystitis secondary to gallstones. I treated him with warm compress; antispasmodics; mefenamic acid and paracetamol (when antispasmodics were out of stock); and bland diet. He was able to tolerate pain when he sailed to Russia for 14 days. On the 14th day, with recurring abdominal pain, he decided to fly home to the Philippines without finishing his work contract.
Upon his return to the Philippines, he went right away to his province where a surgeon did a laparoscopic cholecystectomy on September 16, 2022 (no postop complications)
No repeat ultrasound preop – surgeon relied on ultrasound result of 2021 – allegedly with gallstones)
Operative finding: gallbladder polyps
One month postop (October 16, 2022) – with recurring abdominal pain, back pain, fever, headache, shortness of breath. Admitted to a hospital.
Finding: Low hemoglobin at 106 g/L.
October 14, 2022 – low hemoglobin
Ultrasound – hepatomegaly, splenomegaly, spleen with multiple varisized hypoechoic nodules
Technique: multiple axial tomographic sections of the abdomen were obtained. Contrast-enhanced images were obtained in the arterial, portal venous and delayed phases. No untoward reactions were observed.
Findings:
Spleen: enlarged (splenic index = 929). Numerous (>30) hypodense and hypoenhancing nodules are scattered in the parenchyma, measuring up to 2.2 cm. Splenic hilar vessels are unremarkable.
Liver: enlarged (right hepatic length = 19 cm), with smooth borders, and homogeneous parenchymal attenuation. No masses. Portal vein is dilated (1.4 cm).
Gallbladder and biliary tree: gallbladder surgically absent. Surgical clips are in the gallbladder fossa. Common bile duct (0.9 cm) is mildly dilated. Intrahepatic ducts are not dilated.
Pancreas: unremarkable. No masses or peripancreatic fluid collections.
Periportal/peripancreatic areas: there are rim-enhancing periportal and peripancreatic lymph nodes measuring up to 2.3 x 1.5 cm.
Gastrointestinal tract: stomach and bowels are unremarkable. No obstruction.
Peritoneal cavity: no free fluid.
Retroperitoneum: abdominal aorta is unremarkable. No enlarged retroperitoneal lymph nodes.
Adrenal glands: normal.
Kidneys: normal in size, position and configuration, with good excretory function. No masses, ectasia. There is a 0.5 cm calculus (513 HU) in the inferior calyx of the right kidney.
Urinary bladder: suboptimally distended precluding assessment of its walls. No lithiasis.
Prostate gland: unremarkable.
Osseous structures: unremarkable.
Lung bases: unremarkable.
Impression:
Numerous splenic nodules in the setting of splenomegaly, considerations include metastasis from an undetermined primary versus splenic sarcoidosis
Periportal and peripancreatic lymphadenopathy; inflammatory versus neoplastic
Dilated portal vein
Hepatomegaly
Non-obstructing nephrolithiasis, right
Representative images of the splenic nodules. All hypoenhancing in all phases. Spleen is enlarged (splenic index = 929)Periportal and peripancreatic lymph nodes
October 24, 2022 – upon receipt of the CT scan of the whole abdomen – after a telemedical consultation with me, I gave a primary diagnosis was splenic sarcoidosis. Bases: ultrasound and CT scan findings, fever, headache, shortness of breathe, abdominal pain, low hemoglobin. With explanation and informed consent, decided to try him on steroids right away.
October 24, 2022 – Prescribed Prednisone 5 mg / tab(Sig. Three tabs 2x a day with milk x 7 days) – Started on October 24, 2022 evening
October 24, 2022 – With fever and sobra nag chill now
October 25, 2022 – Doc Roy is feeling better as of now… nawala na yong panghihina ng katawan nya … Salamat po
October 25, 2022 – Afternoon report — so far this entire day wala syang fever... but yong headache same pa rin…masakit kapag pumitik
October 26, 2022 – -Temperature reading is normal for this day; little headache; – still coughing with little sipon; abdominal pain – no more; shortness of breath – no more
October 27, 2022 -Temperature is normal for the entire day; abdominal pain- none; shortness of breath – none; still coughing; with little headache
October 28, 2022 -Temp is normal for the entire day; Abdominal pain- at around 5am there is little pain .. can rate as 2 out of 10, then rest of the hour is good. Pain is gone; Shortness of breath – none; with little cough and sipon
October 29, 2022 – Temp Reading is normal; shortness of breath- none; abdominal pain – none; with little cough and sipon
Update for Today (Oct 30, 2022) – Abdominal pain – none – Temp reading is normal for the entire day – shortness of breath – none – Normal activity for the entire day
Will do monitoring ultrasound of the abdomen (upper abdomen) and CBC on the 15th day of Prednisone.
November 12, 2022 (3 weeks on Prednisone)
Repeat Ultrasound – still with the splenic nodules. However, patient remained asymptomatic (no recurrence of fever, abdominal pain, etc). However, he complained of blurring of vision. Recommended to consult an ophthalmologist.
Still with low hemogloginOctober 15, 2022 – low hemoglobinJanuary 2, 2023 – compared to November 2022 – from hypoechoic splenic nodules to anechoic splenic nodules. Still on prednisone – started Oct 24, 2022 (more than 2 months now).February 6, 2023 – compared to January 2, 2023 – splenic cysts smaller at 1.5 cm. Still on prednisone – started Oct 24, 2022 (more than 3 months now).November 2023 – decreasing size of nodules and decreasing solid nodulesFebruary 24, 2024 – 1.2 cm largest – cysicMay 10, 2024 – 1.2 cm largest splenic nodule with Prednisone to one tab a day for one month now.
October 2022 to May 2024 – more than one year on Prednisone with progressive decrease in size from 2.9 cm to 12 cm with change in nature – less solid – more cystic.
How is sarcoidosis of the spleen treated?
The first line of treatment for patients with sarcoidosis is corticosteroids, which reduce inflammation associated with sarcoidosis and can prevent further damage to the organs.
How long does it take to get rid of sarcoidosis?
There is no cure for sarcoidosis, but most people do very well with no treatment or only modest treatment. In some cases, sarcoidosis goes away on its own. However, sarcoidosis may last for years and may cause organ damage.Jan 30, 2019 (Mayo Clinic)
How long do you take steroids for sarcoidosis?
When necessary, oral steroids are generally prescribed for six to twelve months. In most cases, a relatively high dose is prescribed at first, followed by a slow taper to the lowest effective dose. Symptoms, especially cough and shortness of breath, generally improve with steroid therapy.
Thyroid nodule – 2 cm discrete – did a needle evaluation and aspiration biopsy – obtained 2cc of dark brown colloid fluid with complete disappearance (collapse) of a palpable mass – diagnosis: colloid cyst – placed her on high-dose of levothyroxine. There was re-appearance of the mass 2 weeks post needle aspiration.
No significant reduction of the nodule at 1.5 cm after 6 months. Repeat needle aspiration – 1.1 cc of colloid fluid with complete collapse of the mass. Still no response 3 months after 2nd aspiration. Changed brand of levothyroxine. Eventually, completely responded after 24 months of levothyroxine (note: there was no effect on the change of brand).
There was complete clinical response after 2 years of levothyroxine (from 2017 to 2019). She has a maintenance of levothyroxine thereafter.
Last check up – Sept 2022 (3 years after complete response) – there was NO clinical evidence of recurrence. She is on levothyroxine maintenance.
INSIGHTS:
The response of colloid cyst is variable. From experience, some responded completely within one month. Some longer – 6 months. In this patient, it responded after 2 years on levothyroxine.
Lesson: Be patient on medical suppressive therapy as long as one is certain (at more than 90% probability) it is colloid cyst or colloid adenomatous goiter or BENIGN. Do not jump into recommending operation. Just have close surveillance.
Advised self-monitoring (monthly breast self-examination) and check-up with me.
Saw her regularly ranging from 3 months to 6 months to 12 months.
In October 2009, she palpated a right breast lump. I examined her – 3-cm right upper outer quadrant mass, solid, tender. I did a needle biopsy – suspicious for malignancy.
Did a wide excision followed by frozen section – result: “fibrocystic changes with focal severe ductal hyperplasia. Largely infarcted tumor with suspicious mucinous neoplasm along non-infarcted periphery.” I stopped at wide excision and did not proceed to axillary dissection because of the uncertain frozen section biopsy.
Final histopath result: “infarcted breast neoplasm consistent with mucinous carcinoma. Size of mass noted on histopath – 2cm.
An infarct is a coagulative necrosis of (breast-) tissue, caused by ischemia. This may be spontaneous or occurring after a procedure such as needle biopsy. – RARE though.
ERA/ PRA / HER-2-NEU was requested but not done because pathologist said specimen of the carcinoma “too small.”
Patient and I agreed to just have a close surveillance. She did not want total mastectomy and axillary dissection.
She had regular (average yearly except during the COVID19 PANDEMIC) ultrasound and at times, mammography on top of regular breast specialist examination.
2009 to 2022 – 13 years already in remission – with regular breast self-exam and symptom-based surveillance, there is no clinical evidence of recurrence (mucinous carcinoma). [2022 – 65 years old – 13 years in remission]
INSIGHTS
Patient-centered care management
Respected her decision to stop at wide excision or partial mastectomy with no more total mastectomy and axillary dissection (as is commonly practiced in the community). It seems at 13 years postop in 2022, she made the right decision.
Partial or subtotal mastectomy may be sufficient for some patients with cancer. Usually, this can be an option for small breast cancer with no evidence of axillary node spread.
Whatever decision is made at a certain point in time in the medical consultation (with physician respecting patient’s preferences and needs), there must be continuous follow-up and check-up. In this patient, she first consulted me in 2005. Regular check-up was being done and a mass was detected in 2009 (4 years after). Because of this regular check-up, the breast cancer was discovered in its early stage. In this patient also, after she decided not to have the traditional total mastectomy and axillary dissection, she went for a close monitoring and check-up with me. I am still closely monitoring her. Hopefully, there won’t be any recurrence in the future. Above shows the importance of regular check-up with a breast specialist.
“Masakit po right side pag inaplayan ng pressure parang maga din bantayan ko lang po if Pimple ba pero day 3 po ito”
3 days already
No redness; no unusual skin changes on the nose; no evident swelling; no pain inside the nose; no fever. Pain tolerable but annoying.
My diagnosis: Non-specific nose pain at the moment. Recommendation: Observe for a few more days. Analgesic (paracetamol) if pain becomes intolerable.
Insight:
I had experienced this kind of symptoms before probably twice in my life. The nose pain spontaneously disappeared after a few days without antibiotics and without pain killers. No development of pimples.
I could not discern the exact cause – maybe inflammation of the nose cartilage. I will just label it as “Non-specific external nose pain.”
Follow-up:
2 to 3 days after last consult, the pain completely disappeared. The total duration was about 5 to 6 days.
ROJoson TPORs (Thoughts, Perception, Opinion and Recommendations)
Mammography with BIRADS Zero
BIRADS 0 – means need additional test.
PM, 42-year-old Filipino female, consulted me in 2009 for breast concern. She had a mammography done in 2008 which showed descriptive findings of “multiple nodules in both breasts; benign calcifications in the right breast; and a radiologist impression of BIRADS Zero.
When I examined her (physical examination) in 2009, there was no palpable dominant breast mass. My primary clinical diagnosis was FIBROCYSTIC CHANGES.
I did not order for ultrasound anymore as recommended by the radiologist. I considered the multiple nodules mentioned by the radiologist as fibrocystic changes.
She came back to me for a check after one year in 2010 (2 check-ups at 3-month interval). My findings were still the same.
Then, she did not follow up with me until 2022.
In 2022, October, my findings were still the same – FIBROCYSTIC CHANGES.
ROJoson TPORs (Thoughts, Perceptions, Opinions and Recommendations) on mammography with BIRADS Zero notation
I personally believe that radiologists should not place BIRADS Zero after a mammography without an accompanying ultrasound. They should read and interpret the mammography based on their objective findings on the films. They should place presence or absence of signs or signals for cancer (cluster of microcalcifications; stellate mass density; mass density with ill-defined border; etc.). If they find something that they are not certain of the diagnosis, then they say so, such as suspicious or suggestive for something. They should not place any recommendation on what to do next such as ultrasound, needle biopsy, etc. Let the clinicians decide on what will or should be done next after getting the report of the radiologists.
In this patient, after I got the mammography report and findings, I examined the patient’s breasts. My diagnosis thereafter was a fibrocystic changes with a 98% probability (see record above – 2009). I did not order ultrasound anymore. Just monitoring and check-up.
In 2022, 13 years after my initial breast findings and clinical diagnosis in 2009 were still the change.
This anecdote illustrates I am correct in my evaluation.
It also illustrates the importance of clinical correlation in the interpretation of diagnostic report (in this case, mammography).
Furthermore, it illustrates that I need not order for an ultrasound in 2009 and I do not have to follow the recommendations of the radiologist.
I reiterate my TPOR:
I personally believe that radiologists should not place BIRADS Zero after a mammography without an accompanying ultrasound. They should read and interpret the mammography based on their objective findings on the films. They should place presence or absence of signs or signals for cancer (cluster of microcalcifications; stellate mass density; mass density with ill-defined border; etc.). If they find something that they are not certain of the diagnosis, then they say so, such as suspicious or suggestive for something. They should not place any recommendation on what to do next such as ultrasound, needle biopsy, etc. Let the clinicians decide on what will or should be done next after getting the report of the radiologists.
“Start the subcostal incision approximately 1 cm to the left of the linea alba, about two fingerbreadths below the costal margin (~4 cm). Extend the incision laterally for 10-15 cm, depending on the patient’s body habitus.”
ROJoson reactions (TPORs):
I don’t know why the subcostal incision has to be 1 cm to the left of the linea alba. I usually place the medial side of the incision up the midline or a little to the right of midline.
10-15 cm (4 to 6 inch) incision right away (depending on patient’s habitus)? I don’t make an outright 10-15 cm for open cholecystectomy. I usually draw an oblique line below the subcostal before incision is made and place marks by inches starting from the medial side of the incision. I usually start with 2-inch incision or less regardless of patient’s habitus. If I need to extend, then I extend inch by inch by half-inch by half-inch. What will usually determine the need for extension of the incision will be the following: the thickness of the subcutaneous fat; the depth of the gallbladder and its cystic duct (deep into the liver bed and deep down; presence of viscera intervening with exposure; etc.
Here is an illustration.
These are my usual practices.
I will continue to look at the practices of other surgeons.
How surgeons should react and respond when there is / are surgical complications (to prevent / mitigate against severe anxiety and depression)
Surgical complications are at times (always a potential) inevitable and unpredictable no matter how careful and mindful you are to avoid them. Be ready to manage them when they come and timely at that with the goal that the complications do not end up as a cause of more severe disability and not to say, death. The first requirement though is to try your very best in avoiding the complications at all cost. A clear conscience on this is your best prevention and mitigation against anxiety and depression on the complications.
[ROJ-Medical Notes]: Open cholecystectomy – rectus sparing vs rectus cutting postop pain
Problem-based Learning Issue:
Which has more postop pain – rectus sparing vs rectus splitting?
Conclusion 1 : Use of rectus sparing subcostal incision was found more feasible in open cholecystectomy in terms of severity of postoperative pain as compared to rectus cutting incision.
There are at least other 3 papers that show rectus muscle splitting or retracting carry less pain than rectus muscle cutting. (see below).
I – rectus sparing; II – rectus cutting———- Conclusion: Use of rectus sparing subcostal incision was found more feasible in open cholecystectomy in terms of severity of postoperative pain as compared to rectus cutting incision. H
I – rectus sparing; II – rectus cutting———- Conclusion: Use of rectus sparing subcostal incision was found more feasible in open cholecystectomy in terms of severity of postoperative pain as compared to rectus cutting incision.
Cost-effective analgesics after a cholecystectomy? Open and Lap Cholecystectomy?
One regimen reported in the NET: 2019
Open cholecystectomy – rectus sparing vs rectus cutting
“Ketorolac at the dose of 30mg 12 hourly for first twenty four hours and at the time of discharge, oral panadol 500 mg 8 hourly for 3 days”
I – rectus sparing; II – rectus cutting———- Conclusion: Use of rectus sparing subcostal incision was found more feasible in open cholecystectomy in terms of severity of postoperative pain as compared to rectus cutting incision. H
Problem-based Learning in Surgery 