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GS42 General Surgery and Thoracic Surgery Liver Toronto Notes 2019
Clinical Features
• extrusionofmasswithincreasedintra-abdominalpressure • difficultyinbowelregulation
■ tenesmus, constipation, fecal incontinence
• permanentlyextrudedrectumwithexcoriation,ulceration,andconstantsoiling • maybeassociatedwithurinaryincontinenceoruterineprolapse
Treatment
• TypeI
■ conservative: gentle manual reduction of prolapsed area, especially in children ■ mucosectomy with excision of redundant mucosa, mostly in adults
• TypeII
■ conservative: reduce if possible
■ surgery: abdominal, perineal, and transsacral approaches
Anal Neoplasms
ANAL CANAL
Squamous Cell Carcinoma of Anal Canal (Above Dentate Line)
• mostcommontumourofanalcanal(75%)
• anuspronetohumanpapillomavirus(HPV)infection,thereforeatriskforanalsquamousintra-
epithelial lesions (ASIL)
■ high grade squamous intra-epithelial lesion (HSIL) and low grade squamous intra-epithelial lesion
(LSIL) terminology used
• clinicalfeatures:analbleeding,pain,mass,ulceration,andpruritus;25%asymptomatic
• treatment:chemotherapy±radiation±surgery
• prognosis:80%5-yrsurvival
Malignant Melanoma of Anal Canal
• 3rdmostcommonsiteforprimarymalignantmelanomaafterskin,eyes • aggressive,distantmetastasescommonattimeofdiagnosis
• treatment:wideexcisionorAPR±chemoradiation
• prognosis:<5%5yrsurvival
ANAL MARGIN
• clinicalfeaturesandtreatmentasforskintumourselsewhere
• squamousandbasalcellcarcinoma,Bowen’sdisease(SCCinsitu),andPaget’sdisease
Liver
Right hepatic vein
VII
VIII
VI
V
I. Posterior (caudal) segment
II. Lateral segment (lateral superior area)
III. Left anterior lateral segment (lateral inferior area)
Figure 24. Anatomy of liver
Inferior vena cava Right hepatic vein
Inferior vena cava
Middle hepatic vein
Middle hepatic vein Left hepatic vein
IVa
I
IVa IVb
VIII
V
Hepatic artery proper Portal vein
Left hepatic vein II
II
Bile duct
IVa. Medial segment (medial superior area)
IVb. Medial segment (medial inferior area) V. Anterior medial segment
(anterior inferior area)
Hepatic artery proper
III
III IVb
Portal vein Bile duct
VI. Right anterior Iateral segment (posterior inferior area) VII. Posterior lateral segment (posterior superior area) VIII. Posterior medial segment (anterior superior area)
© Dennis Wei 2009