Not another Lipoma!

The exclamation mark at the beginning of the post is warranted! I have written before about the God's scheming to keep surgeon's on their toes by making sure the intra operative findings completely differ from the initial clinical assesment as was the case during the mysterious hernia here.. I'm quite prepared to give this phenomenon a name maybe Techknowdoc's Law (on the lines of Murphy!)

A 40 something Koli (fisherfolk community) woman presented to us with a swelling over her left buccal surface not visible from the outside but fairly big on the inside. It was bothering her as it would interfere with her eating and brushing. Now that I have mentioned brushing, this lady would not use toothpaste but tobacco powder (an unfortunate but very common occurrence in rural India)

This simple piece of information was enough to make us suspicious and we did the usual palpations and tests.An ultrasound exam revealed an echopoor mass with some solid component and no conclusion was offered by the radiologist on the first exam. She also turned out to be hypothyroid which prompted us to think in terms of an aberrant thyroid mass (lingual thyroid is common too)

She was advised an MRI and a thyroid uptake scan both of which were not done as she was not in a position to afford expensive tests. A repeat ultrasound after 2 weeks showed that the mass was not shrinking after a course of antibiotics, and the neck scan revealed normal thyroid tissue and a reactive lymph node on the opposite side.

She was getting very restless and offered a blanket consent for removal. We decided to go ahead and operate. After preop preperations were complete, she was taken in the OT and was given local anaesthesia with an anaesthetist standby. As soon as we took the incision, a grand yellow soft mass popped out.

                                          

Once again, the infamous Lipoma (which has baffled us before - as seen in this post) had surfaced in the most unlikely of locations with the most unusual presentation. This was easily removed and the patient was sent home about 2 hours post the surgery! She walked in for a follow up after a week with the mouth wound completely healed and the histopathology report confirming a simple Lipoma. 

I guess the God's were giving us a break with this fortunate happy ending! This case will be prepared as a case report and sent to a medical journal for publication. Hopefully, it should end up published.

What else could a Lipoma be?

In a follow up to the post on What else could an Umbilical hernia be? a strikingly similar experience prompts this post.

A fairly large lady of middle eastern descent presented to us with a soft, non expansile, mobile, swelling over her left thigh just about where the groin fold meets the leg. She said she'd had it for years and it gave her no trouble other than cosmetic and she wanted it taken out for that specific purpose.

She underwent a Sonogram which confirmed our clinical diagnosis of it being a Lipoma. Happy with our findings we posted her for surgery under local anaesthesia (which is usually the case) in day care!

We started off, dissected around it, it looked like a lipoma and we dug deeper and higher. Down to the muscle layer, carefully avoiding the femoral vessels. Until we reached what we thought was the femoral canal. She was under local so we asked her to cough. No impulse. Asked her again. No impulse. No luck either as my finger was going all the way up through what was now confirmed as the femoral canal.
This was no lipoma. It was a full fledged femoral hernia!

Luckily the anaesthetist was close by and was able to reach us in 10 minutes. We carried out the repair completely and the lady is doing fine.

I wonder what else a lipoma could be? Until I find another presentation.....

What else could an Umbilical Hernia Be?

As a Surgeon, every time I settle down and think to myself that I've seen a case like this before and it should be routine, God intervenes and reminds me that nothing in surgery is as it seems. Least of all when you expect it to be.

We had a lady who presented with a fairly simple small swelling just around her umbilicus at the lower edge. She had had it for about a year. She was keen on getting it out and got the relevant investigations for the surgery ready.

We took her into the O.T. and gave her the necessary sedation and local anaesthesia and proceeded with the usual 'smiling' umbilical incision. On dissection, we noticed a very well circumscribed localised blob of fat = Lipoma. Could it be?? As simple as a Lipoma? No way.

We dissected further. It wasn't extending beyond the subcutaneous plane. I had not even reached the rectus sheath and it was almost out. I was just about ready to call it a Lipoma and then I reached the rectus sheath. It seemed to be growing out of it. I had to really dig deep into my long forgotten medical school knowledge bank kept at the back of my head somewhere in the pits of my cerebrum.

I showed it to my senior. He confirmed. It was a 'Fatty hernia of the Rectus'. Strange, I thought. That's something I've heard in relation to the Linea Alba. Extraperitoneal fat in the epigastrium is known, but paraumbilical at the rectus?? Anyway, that's what we left it as since there was no sac, so it couldn't be a hernia and it was only fat and the defect was less than a cm in size.

Strange!

Non Obese Fat.

Its been quiet for a while now, but you can always expect things to get interesting when you're working in surgery! This is an incident involving a lot of fat.

 

A man came to the clinic the other day with a very simple request. He had a swelling on his forehead that he wanted to get rid of. Fairly straightforward lipoma, I thought. We had a discussion and he was fine with everything and fixed a time for the surgery. He clearly was happy with what he heard because he then showed me his hands. He had the same type of swelling on both his forearms. He wanted to get those out too. Fine, I said. More for me to operate on!

 He then turned around and shifted through his hair and showed me one more at the back of the skull. I thought this would be a cyst (as is most likely in that area), but it too felt like a lipoma.
 
By now I was sure that there would be more so I just went out on a limb and asked him, "How many you have" (nothing to do with the ad really). He casually mentioned that he had many but he would like to get rid of only these 4. He then let me examine him completely (another reason why a complete physical is a must)

 I must have counted at least 50!!! Spread all over his body.....back, abdomen, legs, everywhere! It wasn't so much ugly as it was sad! For no fault of his own, he was bestowed upon with these fat deposits by someone higher up with a wierd sense of humour! He wasn't even overweight. He was in fact quite fit other than these little fat deposits all over his body.


The reason for him to get the 4 out was that they were the one's that could be seen. Everything else would be covered by his clothing so he was not bothered about them. He had even tried exercising and weight loss techniques for losing these fat buddies of his because someone had told him that they were fat, but forgot to explain that they had nothing to do with being overweight or obese!

 This is one fat problem you can't get rid of by going to the gym or walking it out!!

Would you be able to walk with these?

Over the past few weeks, it seems, I've been getting relatively common things in relatively uncommon places. Coming off from the fishbone story (read here, if you haven't already), I now have something as common as a lipoma in someplace as uncommon as the anteromedial aspect of both knees!

These were so huge that they actually prevented the patient from walking normally, sitting on a regular chair and even going to the washroom! Taking a closer look at the picture will show you that you can barely even see the knee joint. It's almost as if the lipoma's had pushed the knee joint away!

Anyway, an ultrasound and doppler were done to ascertain the feasibility of surgery and whether it would really help. Luckily, both sided did not have major vessels in the lipomatous mass and they were confirmed as lipomas.

The surgery was difficult, took two hours, and required a lot of patience. A large amount of skin was to be sacrificed in order to achieve closure and keep the dead space as minimal as possible. Suction drains were kept for draining the collection which was bound to happen. The surgery went off well and the patient was able to go home on the same evening. The best part is that she walked out of the hospital on her own and by her own admission feeling like the life had come back into her legs, thats how light she was feeling!!

The third day post op dressing revealed no real seroma formation or any degree of contamination or ooze. She came walking to the clinic, walked out, even thought about shopping for a bit before returning to her place of residence. Hopefully, the sutures should be out in a week and she will be absolutely normal.

Would you have been able to walk with these??

Till the next thing that comes in a totally unexpected place!!