B. Belingon Notes from case session slides, Beckys notes (Dr.

Nguyen)
Week 8 Breast and Soft Tissue M 08.19.13
A 66yr old female presents to w/ L breast mass. She noticed it 1 month ago during self breast exam. Hx of
breast cancer in a maternal aunt. She is on two antihypertensive medications. On exam of the L breast has a
3cm, firm, fixed painless mass in the upper outer quadrant. The skin and the nipples have no changes. There
is no axillary or supraclavicular LAD.
A 40 year old female presents to your office for her first routine screening mammogram. She denies
any history of fibrocystic changes. She has no history of breast cancer. She takes no prescribed or OTC
medications. She has had 2 breast biopsies which revealed fibrocystic changes. On examination she has firm
dense breasts but no discrete masses bilaterally. She has scars from the 2 previous breast biopsies. There are
no skin or nipple changes. There is no axillary or supraclavicular lymphadenopathy. The routine screening
mammogram shows dense breast tissue bilaterally. With these results of the screening mammogram she
wants to discuss her risk of breast cancer.
Fibrocystic changes: mass that gets tender and larger with menses cycle
Risk factors for breast cancer
o Personal history of breast cancer
o Family history of breast cancer
o Age
o Early menarche
o Late menopause
o Nulliparity
o Estrogen exposure
o BRCA-1, BRCA-2
Workup
o Mammogram to assess mass, axilla, and contralateral breast
o Core needle biopsy
Why not FNA? Thats more head, neck & axillary
Options for core needle biopsy: ultrasound, stereotactic
If its palpable mass, can biopsy outpatient or bedside
o Want to assess LN how?
Sentinel node biopsy
What if ultrasound and mammogram negative? Sentinel LN biopsy = inject
methylene blue dye into breast/tumor or areolar complex, dye will travel to first
draining node axillary incision to see if blue dye in axilla follow to LN,
then dissect out nodes that are blue
o If no dye available, can do technetium (radio-labeled colloid) and use
Geiger counter in OR to ID LN
o If sentinel node (+) axillary dissection
95% chance that other LN involved in sentinel node (+)
o If sentinel node (-) mastectomy or lumpectomy
Complications of axillary dissection
Lymphedema of extremity
o Lymphedema causing lymphsarcoma of upper extremity (very small
chance)
Injury of long thoracic n
o Staging: TNM
T: tumor size in cm (T1 <2, T2 2-5, T3 >5, T4 = invasion into surrounding structures)
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
Ultrasound determines solid vs cystic; useful in young pts
Treatment (Know management!)
o Lumpectomy vs mastectomy
Are these options equivalent in management of breast cancer? No
Radiation get recurrence if dont offer with lumpectomy
Mastectomy doesnt need radiation unless has metastasis into chest wall
o Use surgical resection or radiation for local disease
o Chemotherapy for systemic disease
Indications: metastatic disease, recurrence, nodal involvement
Two MC histologic types of breast cancer?
o Invasive ductal carcinoma
o Invasive lobular carcinoma
o Other invasive types? Inflammatory, tubular, medullary
A 42 year old female presents to your office with a left breast mass. She noticed the mass approximately 1
week ago during a routine self breast examination. She has a very strong family history of breast cancer.
Her mother and aunt expired from breast cancer at age 52 and 54 respectively. Her sister is undergoing
treatment for breast cancer. Her other sister expired from ovarian cancer at age 36. On examination the left
breast has a 2 cm, firm, fixed, painless mass in the upper outer quadrant. The skin and the nipples have no
changes. There is no axillary or supraclavicular lymphadenopathy.
Dx: BRCA 1/BRCA 2 mutation
o What % of all breast cancers are attributed to BRCA mutation?
5-10%
o Only 5-10% of breast cancers can be attributed to BRCA gene mutations
Still RF with greatest risk of development of breast cancer
o Autosomal dominant Chrom 17q/13q respectively
o Suspect if 2 or more relatives develop ovarian OR breast cancer before age 50
o BRCA 1
90% lifetime risk of breast CA; 40% lifetime risk of ovarian CA; Also risk of colon/
prostate CA
o BRCA 2
85% risk of breast CA; 20% risk of ovarian CA
Men have 6% risk of breast CA if have the BRCA 2 mutation
Also risk of colon/prostate/pancreatic/GB/Bile duct/Stomach/Melanoma CA
Workup
o Mammogram
o Core needle biopsy or excisional biopsy
Risk management strategies???
o If BRCA (+) and no breast or other cancer
Prophylactic mastectomy and reconstruction
Prophylactic oopherectomy and hormone replacement therapy (if done with child-
bearing)
Intensive surveillance for breast and ovarian CA
Chemoprevention
Tamoxifen S/E: incr risk of uterine cancer (can give raloxifene), incr risk of
DVT
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
A 66 year old female presents to your office with a left breast mass. She noticed the mass approximately
1 month ago during a routine self breast examination. She has a history of breast cancer in a maternal
aunt. She is on two antihypertensive medications. On examination the left breast has a 3cm, firm, fixed,
painless mass in the upper outer quadrant. The skin and the nipples have no changes. There is no axillary or
supraclavicular lymphadenopathy.
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
Dx: Breast cancer
o Types: Lobular Carcinoma in Situ (LCIS), Ductal Carcinoma in Situ (DCIS), Infiltrating Lobular
Carcinoma, Infiltrating Ductal Carcinoma
Workup
o Complete H&P
o Imaging
Clusters of microcalcifications can be
indicative of DCIS
o Tissue diagnosis
Palpable masses
core needle, excisional biopsy
Non-palpable masses
Ultrasound core needle biopsy
Needle localization biopsy
Stereotactic biopsy
Treatment
o Radical mastectomy
Removes breast, pectoralis major , pectoralis minor, and axillary lymph nodes
o Modified radical mastectomy
Removed breast and axillary lymph nodes
o Simple (Total) mastectomy
Removes breast only
o Lumpectomy
Removes tumor only
o Two goals of treatment
Locoregional control
Modified Radical Mastectomy
Lumpectomy with XRT (Breast conservation therapy)
Systemic control
Axillary node dissection
Sentinel lymph node biopsy
Chemotherapy for positive nodes or high risk tumors
Tamoxifen
o What two nerves must you avoid?
Long thoracic n serratus anterior winged scapula
Thoracodorsal n latissimus dorsi cant abduct arm
A 69 year old female presents to your office with a right breast mass.
She noticed the mass approximately 6 months ago during a routine
self breast examination but has not sought advice until now. She has
a history of breast cancer in her mother and her maternal aunt. On
examination the right breast has a 3 cm, firm, fixed, painless mass in
the upper outer quadrant. The skin over the mass has induration and
erythema (peau d orange). The nipples are normal. There is no
axillary or supraclavicular lymphadenopathy.
Dx: Inflammatory breast cancer
o Advanced breast cancer: Rapid progression, aggressive
behavior from onset
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o < 3% of all breast cancers, but 7% of all breast cancer
mortality
o Median survival is 3-4 years
o Diffuse erythema and peau dorange
Skin inflammation caused by lymphatic invasion/occlusion by cancer cells
Workup
o Punch biopsy
Treatment
o Neoadjuvant chemoradiation because of aggressive nature of cancer
o Surgical resection
A 62 year old female presents to your outpatient clinic with redness and itching of the right nipple. On
examination the entire right nipple has erythematous, flaky, scaly changes which are similar to eczema in
appearance. There is also a 2 cm firm, fixed, slightly tender breast mass just deep to the nipple-areolar
complex. The right nipple appears flatter against the chest wall compared to the left nipple. There are no
other breast lesions. There is no axillary or supraclavicular lymphadenopathy. A diagnostic mammogram
shows a thickened right nipple with an underlying 2 cm, solid, spiculated breast mass.
Dx: Pagets disease of the nipple
o Presents as chronic eczematous eruption of the nipple.
o Usually associated with extensive DCIS and may be associated with invasive cancer.
o Biopsy and treat accordingly
Treatment
o Surgical therapy for Paget's disease may involve lumpectomy, mastectomy, or modified radical
mastectomy, depending on the extent of involvement and the presence of invasive cancer.
40 year old female presents to your office with intermittent bloody discharge from the right nipple. She
performs regular monthly self breast examination and denies a mass. She has no family history of breast
cancer. She is on no medications. On examination both breasts have no masses, nipple or skin changes.
There is no axillary or supraclavicular lymphadenopathy. With firm palpation you express a small amount
of bloody discharge from a single lactiferous duct in the right nipple.
Dx: Intraductal papilloma
o Benign lesion of the terminal duct
o Generally <5mm in diameter but may be as large as 5cm
o Causes bloody discharge
o Rarely undergo malignant transformation
o Confirmed with ductogram
Screening with mammogram starts at age 40
Controversy on how often to do mammogram after age 40 do ductogram
Ductogram shows single lesion in left duct
Treatment is excision of terminal duct with papilloma (even though low risk of malignancy)
A 25 year old female presents to your office with a left breast mass. She has no family history of breast
cancer. Her only medication is oral contraceptives. The left breast shows a discrete, round, mobile,
nontender mass in the upper outer quadrant. Both breasts have no nipple or skin changes. There is no
axillary or supraclavicular adenopathy.
Dx: Fibroadenoma
o Common throughout reproductive years
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o Majority are small, benign, and asymptomatic
o Confirm diagnosis with U/S guided biopsy
Treatment is observation
o Excisional biopsy if concerned or growing
o Removal for large or bothersome lesions, or cant rule out malignancy
o If not excised, get repeat U/S in 3 mos and follow
Very rapidly growing tumor = Phyllodes tumor locally invasive, excise w 1 cm margin
A 42 year old female undergoes a routine annual screening mammogram. She denies any breast complaints.
She has no family history of breast cancer. She takes no prescribed or OTC medications. On examination
the breasts are normal bilaterally. There are no discrete masses. The skin and the nipples have no changes.
There is no axillary or supraclavicular lymphadenopathy. The screening mammogram shows a 2 cm deep
cluster of microcalcifications in the right upper lateral breast.
What is the classification system used for MMG interpretation of breast lesions?
o BIRADS classification - Breast Imaging Reporting and Data System
0 - Incomplete (needs additional evaluation)
1 - Negative
2 - Benign
3 - Probably Benign
4 - Suspicious
5 - Highly suggestive of malignancy
Mammogram
o False positive rate 10%
o False negative rate 7%
o Suspicious findings
o Solid mass with or without stellate features
o Asymmetric thickening of breast tissue
o Clustered microcalcifications
o Presence of fine stippled calcium in and around a suspicious
lesions is suggestive of breast cancer
Stippling: creation of a pattern simulating
varying degrees of solidity or shading by using small
dots
Present in as many as 50% of non-palpable cancers
A 35 year old female undergoes wide local excision for a presumed fibroadenoma. Three days
postoperatively the pathologist calls you to state that your patient indeed has a fibroadenoma but she also has
an adjacent area of lobular carcinoma in situ.
Whats important about LCIS? Its a MARKER for increased risk of breast CA.
o Risk of breast cancer is equal in BOTH breasts
It is a risk factor for what type of breast CA?
o Invasive ductal carcinoma
Whats the treatment of LCIS?
o Prophylactic mastectomy
Removing LCIS doesnt remove risk of dev breast cancer in other breast vs DCIS MUST
remove because pre-cancerous
o Tamoxifen
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
Can give some chemotherapy agents to pregnant women that do not cross barrier
o Close observation
A 28 year old female delivers a healthy 9 pound term infant by spontaneous vaginal delivery. The mother
breast feeds the infant. With breast feeding the mother notices a small breast mass in the left upper outer
quadrant. On examination there is a 3 cm mobile, ballotable mass in the left upper outer quadrant. There
are no skin or nipple changes. There is no axillary or lymphadenopathy. The diagnostic mammogram shows
a 3 cm, round, hypoechoic, fluid filled, sharply circumscribe d mass in the left upper outer quadrant.
Dx: Galactocele
o Breast cyst filled with milk
o Dilated, obstructed breast duct
o From inspissated secretions
o Only occurs in lactating women
o Differentiate from mastitis or abscess
Treatment is aspiration if does not resolve spontaneously
o If do U/S guided drainage and cyst recurs more than
twice need to excise
How to differentiate between abscess and galactocele?
o Abscess = pain, signs of inflammation
o Galactocele = can cause pressure/pain if very large
A 45 year old male who is an avid marathon runner comes to your
office with a painless mass in the left thigh. The left anterior thigh shows a 6 cm painless, firm, fixed mass
deep in the muscles of left anterior medial thigh. The left leg shows no warmth, induration, erythema or
pain. There are no inguinal, femoral or obturator hernias. The left femoral, popliteal, dorsalis pedis and
posterior tibial pulses are strong. The left leg has normal motion and sensation.
Dx: Soft Tissue Sarcoma (Liposarcoma)
o Tumors arising from connective tissue (mesenchyme) and named for tissue of origin
Liposarcoma, fibrosarcoma, rhabdomyosarcoma, leiomyosarcoma, osteosarcoma,
chondrosarcoma, synovial sarcoma, angiosarcoma, neurofibrosarcoma, malignant fibrous
histiocytoma
o Can be extremity, truncal, or retroperitoneal
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o
o RF: radiation, lymphedema, occupational exposures
o Clinical suspicion based on size, absence of trauma to explain the mass, firmness, and lack of
surrounding inflammation
Workup
o NEVER do excisional biopsy
o Core needle or incisional biopsy
Treatment
o Wide local excision with 2 cm margins
o XRT
Prognosis
o Staging based on size (< 5 vs. > 5cm), tumor grade, and metastasis
o Large tumors or high grade at increased risk of metastasis (esp lung)
o Retroperitoneal tumors most likely to recur regionally
Case scenario: Mass encompassing SFA and SFV if can, amputate, but wont affect LT survival
dont leave behind cancer isolate vessels proximal and distal, excise mass en bloc vascular surgery
will reconstruct artery and vein
A 57 year old construction worker comes to your office with a crusty lesion on the left ear. He is a roofer who
wears a baseball cap but rarely applies sunscreen. He has had the lesion for 6 months and it has grown
progressively larger over that time. The vital signs are normal. On the left
ear he has a 7 mm lesion with a crusty center and pearly rolled edges that
have underlying telangectasia.
What is the most common skin cancer?
o Basal cell carcinoma > squamous cell > melanoma
Which skin cancer is responsible for most skin cancer deaths?
o Melanoma
Basal cell carcinoma
o Most common form of skin cancer
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o Pearly papules or nodules with
telangectasias
May be pruritic and occasionally bleed
Ulcerated center with rolled up borders
o Slow local growth, rarely metastasize
Squamous cell carcinoma
o Second most common skin cancer
o Arises from epithelial keratinocyte
Skin most common, also mouth, esophagus, vagina,
lung, cervix, salivary glands
o Hyperkeratotic, flesh colored, raised papule or nodule. +/-
ulceration
o Can invade or metastasize (<5% risk of mets)
Skin cancer treatment
o Biopsy for diagnosis
o Local excision with negative margins
0.5 to 1 cm for low risk SCC
0.3 to 0.5 cm for low risk BCC
Mohs surgery for higher risk tumors
o Mohs microsurgery
Layer by layer resection with frozen sections until all margins are negative
Squamous cell carcinoma in a chronic wound = Marjolins ulcer

A 33 year old fair-skinned white male who works as a lifeguard on Padre Island presents to your office with
a lesion on the left anterolateral lower leg. The patient is in the sun most of the day and wears a baseball
cap but he rarely applies sunscreen. The lesion is 1 cm in diameter. The lesion is painless, multicolored
and asymmetric with irregular borders. There is no erythema, warmth, induration, ulceration or drainage
associated with the lesion. There are no clinically palpable nodes in the neck, the axillae or groins.
Dx: Melanoma
o Aggressive skin cancer
o ABCDEs
Asymmetry
Border irregularity
Color change
Diameter increase
Enlargement or elevation
o Risks factors: fair skin, multiple nevi, history, UV B exposure, sunburns, tanning beds
Workup
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o Best way to biopsy a suspected melanoma
Punch biopsy is ideal
Goal is to obtain the deepest portion of lesion
Excisional biopsy is another good option for smaller lesions
Shave biopsy does not assess depth of invasion
o Staging depth
Clark based on layers
Breslow based on depth of invasion
TNM based on thickness
T stage = MOST prognostic indicator = depth of invasion
o (For breast cancer, its nodal involvement)
5-year survival superficial melanoma 96%
Treatment
o Wide local excision
o Lymph node dissection for intermediate depth/+ nodes
o Interferon for positive nodes/metastatic disease
A 45 year old male undergoes a left inguinal herniorraphy under general anesthesia. He is discharged to
home 6 hours after the operation. The next morning the patients wife contacts your office to say he has a
high fever. You tell the wife to take the patient to the Emergency Department at Santa Rosa Medical Center
immediately. The vital signs are temp 104, P 120, RR 28 and BP 108/56. The patient is lethargic. The lungs
are clear. The heart has tachycardia. The abdomen is soft and slightly distended with decreased bowel
sounds. The wound has erythema, induration, warmth and serous drainage. Blisters and erythema extend
into normal skin that surrounds the incision.
Dx: Necrotizing soft tissue infection
o Rapidly progressing infection
DDx: consider in POD1 pts
o Spreads along the fascial plains necrosing
blood vessels and making the overlying tissue
ischemic
o Causes
Hemolytic strep, aka flesh eating bacteria
Clostridium
Polymicrobial
Characteristics
o High fever
o Sepsis
o Edema outpacing erythema
o Can rapidly lead to septic shock and MOF
Treatment
o Prompt recognition
o IV antibiotics!!!
o Wide surgical debridement!!!
A 65 year old female who lives in a nursing home presents to the Emergency Department at Santa Rosa
Medical Center with 24 hour history of acute abdominal distension, nausea, vomiting and obstipation. Her
past medical history is significant for Alzheimers disease only. She has not lost weight and her weight is 60
kg. She has never had an abdominal operation. Her vital signs are temp 100, P100, RR 20 and BP 98/62. She
appears in pain but she cannot voice her site of pain. The lungs are clear. The heart has a regular rate and
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
rhythm with a II/VI holosystolic murmur heard loudest at the second intercostal space left sternal border.
The abdomen is soft but distended, diffusely tender with occasional rushing bowel sounds. There is a right
infrainguinal mass which is tender and poorly reducible. The skin over the mass is normal. The rectal exam
shows no masses or tenderness and is guaiac negative.
Dx: Femoral hernia
o Uncommon (3% of hernias)
o Herniation through the femoral canal into the thigh (medial to femoral vein)
o More common in women
o Usually incarcerated
o Can require abdominal and groin approach to repair
A 25 year old male presents with painful masses in the left axilla. He states that this has been a chronic and
now debilitating problem. The vital signs are temp 100.7, P 98, RR 18 and BP 130/88. On examination he has
multiple painful, indurated, erythematous abscesses and fistulous tracts in the left axilla.
Dx: Hidradenitis Suppurativa
o Skin disease affecting apocrine sweat glands
o Commonly in axilla, groins, and/or buttocks
o Can be small and isolated or large clusters of abscesses and
sinuses
o Periods of inflammation with drainage
Flare-ups can be triggered by stress, perspiration,
hormonal changes, humid heat, clothing friction
o Can become secondarily infected
Treatment is supportive
o Antibiotics for infection
o Surgery as a last resort
Primary excision
Excision with secondary closure
Skin grafting
A 26 year old male with a history of type II diabetes mellitus complains of pain,
mass and drainage from the sacral area. On examination the patient is obese and
quite hirsute. The vital signs are temp 101, P 110, RR 20 and BP 110/70. The sacral
region shows multiple painful, indurated, erythematous, warm masses. There are
also a few sinus tracts with dark thick hairs arising from the base of the sinus
tracts.
Dx: Pilonidal cyst
o Caused by infected hair follicle in the sacrococcygeal area
o Painful fluctuant mass in acute phase
o Common in hirsute, obese, young males
o Can rupture and lead to a chronic sinus
Treatment
o I&D, antibiotics in acute setting
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
o Excision for chronic
(20% recurrence)
-----------------------------
EXTRA CASES IN PPT
BREAST
A 45 year old female is involved in a high speed motor vehicle accident and strikes her left breast on the
steering wheel. She develops a 3 cm hematoma in the left breast that is treated non operatively. She returns
to your outpatient trauma clinic in 2 weeks with fever and breast pain. The vital signs are temp 102, P
110, RR 20 and BP 120/60. The left breast has warmth, induration, pain and erythema in the upper outer
quadrant. There is a 3 cm fluctuant mass. The nipple has no lesions or inversion. You order a diagnostic
mammogram which shows a 3 cm collection with an air fluid level.
Dx: Breast abscess
o 80% of breast infections are related to lactation
o Develop as mastitis but can progress to abscess
o Staph aureus is the most common pathogen
o Have to rule-out cancer in any non-lactating woman with a breast abscess
Treatment
o Aspiration and Abxs vs. I&D
A 65 year old female slipped on her wet kitchen floor and struck her left breast on edge of the kitchen table
6 weeks ago. She had a large ecchymosis on the left upper outer breast which slowly resorbed. She now
presents to your outpatient clinic with a mass in the left upper outer breast. There is a 3 cm firm, fixed,
slightly painful mass in the left upper outer breast. The skin of the breast has some retraction over the mass.
There are no nipple changes, discharge or inversion. The screening mammogram shows 3cm dense solid
breast mass in the left upper outer quadrant.
Dx: Fat necrosis
o Traumatic injury leads to inflammatory response and fat necrosis
o Simulates a mass and can cause dimpling and nipple retraction
o Have to rule-out cancer unless clear preceding trauma identified
SOFT TISSUE
A 66 year old male undergoes elective sigmoid resection for adenocarcinoma. He receives two perioperative
doses of cefoxitin for wound prophylaxis. On the seventh postoperative day he complains of fever and wound
pain. The vital signs are temp 101, P100, RR 18 and BP 150/84. The abdomen is soft and slightly distended
with decreased bowel sounds. The midline incision has erythema, induration, pain and warmth.
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
Dx: Surgical site infection
o SSI most common complication after surgery
o Risks increase with contaminated procedure
o Usual organisms are staph
o Gram negatives for bowel cases
Treatment
o Open incision
o Local wound debridement and care
o Antibiotics
A 65 year old male undergoes an emergent sigmoid resection and colostomy for perforated diverticulitis.
The midline wound is left open to heal by secondary intension. He has a history of chronic alcohol abuse and
malnutrition. He has a history of hypertension and diabetes mellitus. He has a history of benign prostatic
hypertrophy and chronic constipation. He does surprising well and is discharged from the hospital after
10 days with a wound VAC to be changed by home health care services every 3 days. He returns to your
outpatient clinic for regular routine follow up examinations. Two months after operation the patient calls
your office to state that he had a coughing spell and then noted a bulge in the lower aspect of the wound. You
examine the patient in the office and note that the midline wound is nearly completely closed but there is a
mass in the lower aspect of the wound.
Dx: Incisional hernia
o Delayed fascial dehiscence
o Primary repair has 20-50% failure rate
o Open vs. laparoscopic
o Mesh repair preferred
Prolene
PTFE
Biologic
A 62 year old male undergoes elective sigmoid resection for volvulus. He receives two perioperative doses of
cefoxitin for wound prophylaxis. He has a history of diabetes mellitus and hypertension, both of which are
under good control. On the sixth postoperative day he complains of low grade fever and wound drainage. He
describes the drainage as pink tinged and cloudy in appearance. The vital signs are temp 100.5, P 100, RR
18 and BP 120/84. The abdomen is soft and slightly distended with decreased bowel sounds. The wound has
slight erythema, induration and pain. There is separation of the upper aspect of the wound. There is cloudy,
pink-tinged drainage from the upper aspect of the wound. A small segment of small bowel may be evident in
the base of the separated wound.
Dx: Fascial dehiscience
o Disruption of fascia within days of surgery
o Reoperation indicated for evisceration, bowel exposure, or intra-abdominal infection
o Occurs in 2-20% of abdominal surgery but infection increases the risk 4-fold
o Risk factors
Age, infection, malnutrition, diabetes, tension, COPD, steroids
Other hernias:
Indirect inguinal hernia through canal
Direct inguinal hernia through floor
Umbilical around umbilicus
Littre contains a Meckels diverticulum
B. Belingon Notes from case session slides, Beckys notes (Dr. Nguyen)
Richter part of bowel wall into hernia
Spigelian into rectus sheath at semilunar line
Obturator through obturator canal into medial thigh (Howship-Romberg sign)
Sliding one wall of the sac made up by an organ