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ulcerative growth

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(1)presentation

a.particulars
Mrs.Nasima,75 years old woman from Bakhrabad ,comilla presented with an ulcerated growth over lateral side of left mid leg for 3 months. initially it started as itchy papule 5years back and presented as an fast growing lesion for last 3 months and was never treated.she is diabetic but now controlled but normotensive and non asthmatic

b.on examination
On inspection
• There is an ulcerated growth over lateral side of mid 1/3rd of left leg
• Measuring about 4×4 cm
Initially was small but attained the current size in last 3 months(size)
• Cauliflower /irregular in shape(shape)
• Surface is ulcerated (surface)
• Border is irregular(spread/extent)
• there is colour change around the lesion,
but There is no scar, visible engorged vein, oedema and abnormal hair distribution (skin condition)

 


On palpation
• Temparature is normal
• Non tender
• Margin is indurated
• Edge is raised,everted
• Floor contains moist necrotic material
• Base is indurated and fixed with underlying sractures(cant be moved on contraction of underlying muscle)
• Foul smelling straw coloured haemorrhagic discharge
• Distal pulse sensation and joint movements are well intact and draining lymphnodes ,left inguinal nodes are enlarged.these are
• painless
• firm to hard
• Descrete
• Examination of oral cavity ,chest and abdomen revealed normal findings

c.My provisional diagnosis is non specificis (malignant ulcer)due to SCC over lateral side of mid leg (left)with secondary left inguinal lymphadenitis/reactive lymphadenitis

d.Differentials
• 1.Marjolins ulcer(long history due to chronic infection)
• 2.BCC(typical site and edge raised and rolled)
(2)Investigations:
a.For confirmation of diagnosis
1.Local part
• Discharge for CS
• Local part Xray
• Excision biopsy(small lesion)

marking for wedge

wedge taken

ulcer base after wedge taken

• Incision biopsy(large lesion)/wedge biopsy
2.LN
• Biopsy
b.For detection of distant Extension
Examination of oral cavity
• Examination of chest
• Chest Xray
• USG-WA

c.For diagnosis of Co morbidities/end organ damage

d.For Fitness

e.For follow up /prognosis

f.For planning

 

(3)Confirmatory diagnosis

invasive  SCC  of leg (grade II) stage III

(4)management
• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

incision biopsy/wedge biopsy on 28/11/2014

 

 

histopathology report

 

 

definitive surgery-excision of growth and reconstruction by skin graft

OPERATION NOTE:

date:26/12/2014 time:3:30-4:45PM

venue:Shefa Hospital,Muradnagar,Comilla

name of operation:

excision of growth and reconstruction by skin graft

indication: non specificis (malignant ulcer)due to invasive SCC over lateral side of mid leg (left) (grade II) stage III with reactive lymphadenitis

anaesthesia:local

procedure:(Bakhrabad procedure)

with all aseptic precaution an elliptical incision was given over front of right thigh measuring about 3 x 2 sq.cm by no.12 BP blade(elliptical incision was given so that skin would have been closed rather than keeping open as done in split skin graft to avoid chance of further growth of SCC as the patient had propensity to develop SCC) very thinthickness skin was excised with scissor dissection and wound was closed immediately with 2/0 cutting proline and duely dressed before going to cancerous wound(opposite limb was choosed to prevent contamination/easy spread of malignant cell from pathological wound)

skin was prepared with multiple windows to be grafted and it was cut into two pieces (to get enough coverage)

gloves and drapps and gauzes, dressing and other instruments were changed before starting recepient site

a rim of 1cm free margin around the ulcer was excised and base was excised up to deep fascia

and skin was grafted with 3/o round body vicryl (to lessen the hazard of stich off)

after proper haemostasis graft was covered by vaseline or supratulle and 10 layers of non adhesive dressing was applied

findings:few necrotic material friable tissue along with granulation tissue were  found in base but adequate blood supply was present in all margins and base

surgeons:Dr.Tanvir Rahman,Dr.Shofiul Alam Babul

advice:dressing of donor site after 7 days

dressing of recepient site after 10-14 days

 

elliptical incision in donor site

 

excision of thin part of skin

excision from both ends

first suture between distal corner of wound apex of triangular graft to fix the graft

 

grafting in progress

grafted wound

key points of Bakhrabad Procedure(6 Cs)

1.contralateral(other limb is selected as donor site)

2.cutting(excision) of skin rather than splitting

3.cutting(division of graft to make the graft well fitted to recepient wound)

4.closure: closure of donor site rather than keeping it open as in split graft

5.closure: closure of donor wound before starting recepient wound

6.change:change the gloves and drapps and gauzes, dressing and other instruments before starting recepient site

 

(5)Follow up

 

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