Chest/Abdominal Wall Flashcards
A 55-year-old man presents for a large abdominal midline hernia repair. A component separation is planned with a posterior approach and a retrorectus mesh placement. Which of the following layers can be divided to provide further release and preserve the innervation to the rectus muscle?
A) Anterior rectus sheath
B) External oblique
C) Internal oblique
D) Transversalis fascia
E) Transversus abdominis
The correct response is Option E.
In the posterior component separation approach for ventral hernia repair, transversus abdominis release (TAR) can provide further mobility and preserve the innervation to the rectus muscle. The posterior approach reinforces hernia repair with a sublay mesh placed between the rectus muscle and posterior sheath. The Rives-Stoppa approach is associated with a 3 to 6% recurrence rate. To avoid disruption of the segmental nerves to the rectus, classical dissection was limited medial to the linea semilunaris. This, however, limited the space and reserved this technique for small- to medium-sized hernias. To extend this dissection laterally for use in larger defects, either the internal oblique or the transversus abdominis muscle can be divided. Division of the internal oblique divides the nerves to the rectus muscle. Division of the transversus abdominis can preserve these nerves. With this technique, the anterior rectus sheath is preserved as well as the external oblique and transversalis fascia.
A 65-year-old woman presents to the office with an ulcer on the right chest wall. She underwent right-sided mastectomy and adjuvant external beam radiation therapy for advanced breast cancer 5 years ago. Physical examination shows a 2-cm ulcer with surrounding radiation-damaged skin and no signs of acute infection. Which of the following is the most appropriate next step in management?
A) Biopsy of the wound
B) Excision of all radiation-damaged tissue and coverage with vascularized tissue
C) Excision of the ulcer and coverage with vascularized tissue
D) Hyperbaric oxygen therapy
E) Negative pressure therapy
The correct response is Option A.
Radiation causes production of reactive oxygen species, which causes injury to tissues and progenitor cells. Cytokine release results in chronic inflammation and ongoing tissue damage. Radiation therapy can cause soft-tissue ulcerations, osteoradionecrosis, and radiation-induced sarcomas. If a patient presents with a late ulcer after radiotherapy, malignancy needs to be ruled out. A biopsy of the ulcer edge should be performed.
Once malignancy has been ruled out, excision of all radiation-damaged tissue, rather than just the ulcer, will result in more durable reconstructive outcomes. Osteoradionecrosis of the chest wall presents as full-thickness chest wall ulcers and the involved ribs should be resected. The underlying pleura and lung may be adherent and, thus, limited lung resection may need to be performed. Reconstruction is performed with well-vascularized tissue, either local pedicled flaps or free flaps.
Negative pressure therapy utilizes subatmospheric pressure for local wound care. It provides local wound care by controlling exudate and, thus, keeping the wound clean. It is thought to promote wound healing by inducing cellular proliferation and increasing capillary blood flow. Malignancy in the wound is a contraindication to negative pressure therapy. Therefore, if suspected, malignancy should be ruled out prior to initiation of negative pressure therapy.
Hyperbaric oxygen is the administration of 100% oxygen in a pressurized chamber. This results in high tissue concentrations of oxygen, which promote neovascularization and wound healing. Hyperbaric oxygen has been shown to improve healing in soft-tissue radionecrosis and osteoradionecrosis. It can be used as an adjunct, especially when radical excision and reconstruction of radiation damaged tissue is not possible.
A 63-year-old man with a BMI of 35 kg/m2 presents with an incisional hernia. The patient underwent a midline exploratory laparotomy for trauma one year ago. Primary fascial closure was achieved with a running polypropylene suture that was performed at the time of the initial operation. CT scan shows intact rectus muscles, and the hernia defect is measured to be 10 cm at the widest, which is in the supraumbilical region. Which of the following is the most effective treatment to prevent hernia recurrence following repair?
A) Component separation with bridging mesh repair
B) Component separation with overlay mesh repair
C) Component separation with primary fascial closure
D) Component separation with retrorectus mesh repair
E) Primary fascial closure
The correct response is Option D.
Hernia repair is associated with a high rate of recurrence, approaching 20% in many studies. Recurrence rates are lowest when primary fascial closure of the abdominal wall is reinforced with mesh placement as an underlay.
Primary fascial closure alone or with component separation results in a higher recurrence rate than primary fascial closure with mesh reinforcement. In this example, it is unlikely that primary fascial closure would be possible, given a 10-cm hernia defect. With regard to mesh placement, there are multiple planes at which the mesh can be placed. Using a bridging repair, the mesh is used to bridge across a fascial defect and is associated with the highest rates of recurrence. In a retrorectus repair, the mesh is placed deep to the rectus (Rives-Stoppa technique) or below the transversus abdominis (transversus abdominis release technique). This is performed underneath a primary fascial closure. Conversely, in an overlay repair, the mesh is secured superficial to the abdominal wall repair. Retrorectus placement of a mesh is associated with a significantly lower recurrence rate than placement of the mesh in another position.
A 46-year-old man presents with a midline 18-cm-wide ventral hernia 1 year after undergoing midline exploratory laparotomy for a bowel resection and right end ileostomy. Medical history includes significant weight loss through diet and exercise. His weight has been stable for 2 years. BMI is 29 kg/m2. He undergoes bilateral component separation with biologic mesh bridged between the rectus muscles and concomitant panniculectomy. Which of the following clinical characteristics will most likely increase the likelihood of hernia recurrence?
A) BMI greater than 24.9 kg/m2
B) Bridged biologic mesh hernia closure
C) Concomitant panniculectomy
D) Presence of an end ileostomy
E) Prior abdominal surgery
The correct response is Option B.
The patient presents after significant weight loss with a wide midline ventral hernia, right end ileostomy through his rectus muscle, and an abdominal pannus. Given the 18-cm waist of the hernia defect, he is being counseled that only a bridged repair with a biologic mesh will be possible rather than total muscular coverage for the midline defect. Hernia recurrence is a major problem for patients and can be associated with specific characteristics. When the technique of bilateral component separation and inlay biologic mesh repair is being performed, the most important predictor of recurrence is whether the rectus muscle and fascia will be able to be closed at midline, creating a total submuscular repair, or whether the mesh will be bridged. A bridged repair is associated with a 33% chance of recurrence at 3 years compared to 6.2% for total muscle coverage with fascial closure at midline.
With a BMI of 29 kg/m2, the patient remains overweight despite his prior stable weight loss. Surgical site occurrences are increased in the overweight patient with a 26.4% incidence versus 14.9% in patients with BMI less than 24.9 kg/m2. Similarly, skin dehiscence is significantly increased in the overweight patient (19.3% versus 7.2%), while hernia recurrence rates are not statistically significant (11.4% versus 7.7%). Concomitant panniculectomy was associated with an increase in surgical site occurrences and skin dehiscence, but hernia recurrence rates were not affected.
Similarly, patients with existing ileostomies or stomas complicated by parastomal hernias do have a significantly increased surgical site occurrence rate (34.1% with parastomal and midline hernia versus 18.7% with midline hernia only) but hernia recurrence rates are not affected. Prior abdominal surgery will be in the clinical history of all incisional hernia patients.
A 3-year-old child with pectus excavatum deformity is evaluated for surgical correction of the chest wall. The child has experienced mild respiratory insufficiency. Which of the following is the optimal timing of treatment for this patient?
A) Surgical correction between ages 2 and 5
B) Surgical correction between ages 6 and 12
C) Surgical correction between ages 13 and 17
D) Surgical correction at skeletal maturity
The correct response is Option B.
Pectus excavatum is the most common congenital chest wall deformity, occurring in approximately 1 in 400 live births. The condition is more common in males, and there is a positive family history in 30 to 40% of patients. The etiology is thought to be multifactorial and associated with increased incidence of congenital cardiac abnormalities, connective tissue disorders (e.g., Marfan and Ehlers-Danlos syndromes), and scoliosis. Treatment options have shifted from the traditional open technique involving sternal osteotomy and resection of abnormal costal cartilage to minimally invasive options such as the Nuss procedure and minimally invasive technique for repair of excavatum (MIRPE), which utilizes thoracoscopy and placement of intrathoracic retrosternal support bars to reposition the sternum and allow gradual remodeling over a period of 2 to 4 years. The ideal timing of repair is mid-adolescence, usually between ages 6 and 12.
Incomplete involution of the mammary ridge during embryonic development is most likely to result in which of the following?
A) Amastia
B) Gynecomastia
C) Inverted nipple
D) Poland syndrome
E) Polymastia
The correct response is Option E.
The breast develops as the result of bilateral thickening of ectoderm along the milk line, or mammary ridge, from the axillary to the inguinal region. Mammary buds begin to develop as growths within the epidermis and invade the deeper mesenchyme. Much of the ridge disappears as the embryo develops as the result of apoptosis, except for the primary buds in the pectoral regions. Failure of regression of the mammary ridge can result in accessory breasts (polymastia) or accessory nipples (polythelia). Accessory breast tissue occurs in 1 to 2% of live births and commonly occurs in the axillae.
Amastia is the complete absence of the mammary gland. This occurs due to either the failure of the mammary ridge to develop or the complete involution of the mammary ridge.
Gynecomastia is defined as benign enlargement of the male breast. While pathologic cases can exist, it is most typically due to a normal response of the breast tissue to circulating levels of estrogen.
Inverted nipples are due to failure of the mesenchyme to proliferate above the level of the skin.
Poland syndrome can have the following components: hypoplasia of the breast and nipple, absence of the sternocostal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, abnormalities of the chest wall, and anomalies of the upper extremity. Many etiologies have been hypothesized, with the most widely accepted being an interruption of the embryonic blood supply to the upper limb.
A 22-year-old woman presents for consideration of aesthetic breast surgery to address asymmetry. Physical examination shows a unilateral hypoplastic breast with a constricted, elevated base and a herniated nipple-areola complex. Which of the following is the most likely diagnosis?
A) Amastia
B) Micromastia
C) Poland syndrome
D) Tuberous breast
E) Virginal mammary hypertrophy
The correct response is Option D.
A tuberous breast is classically defined as hypoplastic with a constricted and elevated base, insufficient inferior skin, and a herniated nipple-areola complex.
Amastia would manifest without a nipple. Poland syndrome is classically described as missing the pectoralis muscle with variable breast and nipple effects. A constricted base and herniated areola are not usually associated with Poland syndrome. Hypertrophy would likely present with a broader base and increased volume. Micromastia would not manifest with a herniated areola.
A newborn is noted to have a lesion of the midline of the lower back consisting of a protruding membrane which covers meninges, cerebrospinal fluid (CSF), and neural structures. Which of the following is the primary goal of surgical repair?
A) Hydrocephalus mitigation
B) Increase in lower extremity strength
C) Infection prevention
D) Prevention of tethered cord syndrome
E) Restoration of bowel or bladder function
The correct response is Option C.
Meningomyelocele is the most common neural tube defect. It involves dorsal herniation of the meninges and spinal cord through the vertebrae and may produce motor and sensory nerve deficits. It is often diagnosed prenatally by elevated maternal serum alpha fetoprotein and ultrasonography. Treatment of larger defects often involves both neurosurgery and plastic surgery teams. After repair of the neural placode, the goals of soft tissue reconstruction are to cover and protect the neural element, prevent infection, and avoid any cerebrospinal fluid leak. Ideally this is performed within the first 24 to 48 hours of life. Larger defects are often best reconstructed with muscle flaps, fasciocutaneous flaps, or a combination of both. Many different flaps have been described, but considerations for adequate vascularity (such as inclusion of perforator blood vessels within geometrically designed flaps) and closure without tension are paramount.
While hydrocephalus is a common finding in patients with meningomyelocele, it is treated with cerebrospinal fluid shunting if required.
Meningomyelocele repair does not regain or improve neural abilities that are not present at birth, such as bowel and bladder function, and lower extremity motor and sensory function.
Symptoms related to tethering of the spinal cord may develop as the patient grows in as many as 20 to 50% of children who undergo meningomyelocele repair shortly after birth and many may require surgery to release the scar tissue attached to the cord. However, this condition is not prevented by meningomyelocele repair.
A 5-year-old male has a cerebrospinal fluid leak and a 3 x 3-cm area of wound dehiscence involving the posterior trunk following tethered cord repair. Which of the following is the most appropriate method to reconstruct the wound?
A) Gluteal muscle flap and skin advancement flap
B) Latissimus muscle turnover flap and skin advancement flap
C) Local fascial flap and skin advancement flap
D) Skin advancement flap
E) Split-thickness skin graft
The correct response is Option C.
The most appropriate method to reconstruct the wound is a local fascial flap and skin advancement flap. The major principle of tethered cord and myelomeningocele repair is to obtain a well-vascularized layer of soft tissue coverage between the dural and skin closures. The fascia overlying the paraspinous muscles can be turned over as flaps to cover the underlying dural repair. This vascularized soft tissue layer will minimize the risk of cerebrospinal fluid leak by reinforcing the dural repair. In addition, the fascial flaps will prevent contact with cutaneous bacteria and subsequent meningitis if either the dural repair or skin repair breaks down. A split-thickness skin graft over the dura would not adequately protect the spinal cord. Closing the skin directly over the dural repair using skin advancement flaps would place the child at risk for meningitis in the event of a cerebrospinal fluid leak or if wound breakdown occurred along the incision line of the widely undermined skin flaps. The use of a regional gluteal or latissimus muscle flap to cover the dural repair is unnecessary because local tissue (paraspinous muscle fascia) is available. Harvesting the gluteal or latissimus muscles also may cause significant donor site morbidity in a child already at risk for ambulatory problems from a neurological deficit.
A 58-year-old man comes to the office with recurrent rectal cancer four years after undergoing low anterior resection with adjuvant radiotherapy. Open abdominoperineal resection is planned. Which of the following closure methods will most reliably reduce the incidence of perineal wound complications?
A) Gracilis flap closure
B) Negative pressure wound therapy
C) Primary closure
D) Rectus abdominis flap closure
E) Split-thickness skin grafting
The correct response is Option D.
Several retrospective studies and one randomized trial have shown that when compared to primary closure, the rectus abdominis myocutaneous flap reduces wound healing complications after abdominoperineal resection (APR). Gluteal and gracilis flaps have been used for reconstruction after APR; however, the data supporting their use is not as robust. Split-thickness skin grafting and negative pressure wound therapy are inappropriate for reconstruction of the APR due to the size of the wounds and the risk of evisceration.
A 65-year-old man presents with an infection of the sternum following aortic valve repair. After sternal debridement, there is a 10-cm-wide, deep wound from the clavicle to the upper abdomen. Which of the following is the most appropriate flap to reconstruct the wound?
A) Latissimus dorsi
B) Omentum
C) Pectoralis major
D) Pectoralis minor
E) Serratus
The correct response is Option B.
The most appropriate flap to reconstruct the wound is omentum. Because of the large extent of the wound, the only flap listed that can adequately fill the defect and eliminate the dead space is the omentum. Pectoralis major flaps would not adequately fill the defect, particularly the inferior aspect of the wound. Pectoralis minor flaps are not used for sternal reconstruction and would not provide adequate tissue. The latissimus dorsi flap would not be able to fill the large sternal wound. Serratus flaps can be used for posterior chest wounds, but would not be able to reconstruct the large anterior chest wound
A 75-year-old woman with a history of right mastectomy and irradiation therapy presents with a sarcoma that requires radical resection and partial sternectomy. A photograph is shown. A pedicled flap is planned to repair the defect. Which of the following arteries supplies the most appropriate flap in this situation?
A) Deep inferior epigastric
B) Internal mammary
C) Lateral thoracic
D) Thoracoacromial
E) Thoracodorsal
The correct response is Option E.
The most appropriate pedicled flap for this particular defect is a latissimus flap, shown in the photograph, supplied by the thoracodorsal artery. The latissimus flap is a Mathes/Nahai type V flap that can be transferred on its dominant pedicle (thoracodorsal artery) or on multiple segmental paraspinal perforators. The internal mammary artery terminates as the superior epigastric artery, which would provide blood supply for a superiorly based vertical rectus flap. The rectus flap is a Mathes/Nahai type III flap, with two dominant pedicles. However, this pedicle is not available because of the radical resection and prior irradiation. The lateral thoracic artery is one of two dominant pedicles supplying the serratus anterior muscle (Mathes/Nahai type III). This flap is an option, but it would not provide enough bulk necessary for the defect in this situation. The deep inferior epigastric artery (DIEA) supplies the DIEA perforator flap, which would be an option as a free tissue transfer but not as a pedicle flap for this situation.
A 52-year-old woman with cancer of the right breast undergoes mastectomy and axillary node dissection, complicated by mastectomy flap necrosis requiring skin grafting. She completes adjuvant chemoradiation. One year later, she comes to the office with a fungating mass growing through the skin graft. Imaging demonstrates involvement of the fourth and fifth ribs with an anticipated skeletal defect of 4 × 4 cm. A photograph is shown. Which of the following is the most appropriate treatment for the skeletal reconstruction?
A) High-density porous polyethylene
B) Methyl methacrylate with mesh
C) 2.4-mm Titanium plate
D) No skeletal reconstruction
E) Vascularized rib
The correct response is Option D.
The principles of management of this recurrent right breast cancer include radical resection of all involved tissues (including ribs) and reconstruction with well vascularized flaps. In this case, a right latissimus muscle flap and skin graft was used for reconstruction. No alloplastic material was placed or skeletal thoracic cage reconstruction performed. This is common in these types of patients, because excessive fibrosis caused by the radiation to the chest wall prevents loss of respiratory efficiency through paradoxical motion which otherwise occurs in patients who have more than four ribs involved or a defect larger than 5 cm.
A 56-year-old man is evaluated because of gynecomastia. Physical examination shows mild, diffuse breast enlargement with no visible inframammary fold or ptosis. Which of the following is the most appropriate surgical correction of this patient’s condition?
A) En bloc resection of skin and breast tissue with free nipple grafting
B) Open excision of breast tissue with mastopexy
C) Subcutaneous mastectomy with nipple preservation
D) Suction-assisted lipectomy
E) Superior periareolar excision with skin excision
The correct response is Option D.
The treatment of gynecomastia is based on the degree of breast enlargement and the extent of ptosis that is noted on examination. Grade 1 gynecomastia is minimal breast hypertrophy without ptosis. Grade II gynecomastia is moderate hypertrophy without ptosis. Grade III gynecomastia is severe hypertrophy with moderate ptosis. Grade IV gynecomastia is severe hypertrophy with severe ptosis. The treatment of mild to moderate gynecomastia without ptosis is suction-assisted lipectomy. Direct periareolar excision with skin excision and subcutaneous mastectomy are not indicated for gynecomastia without ptosis. Mastopexy and free nipple grafting techniques are indicated for gynecomastia with severe ptosis.
The postoperative CT scan shown is obtained to evaluate a wound dehiscence in a patient who underwent left-sided unilateral reduction mammaplasty for asymmetry six weeks ago. Which of the following upper extremity deformities is most likely to be found in this patient?
A) Contralateral radial club hand
B) Contralateral “pouce flottant” thumb
C) Ipsilateral brachysyndactyly
D) Ipsilateral radial head subluxation
E) Ipsilateral type IV Wassel preaxial polydactyly
The correct response is Option C.
Assessment of the chest CT shows right-sided absence of the pectoralis major and minor muscles and breast hypoplasia. The patient suffers from Poland syndrome, which is a congenital disorder of unknown etiology with the prevailing theory being hypoplasia of the subclavian artery or its branches during the sixth week of embryogenesis. Variability exists in physical findings with the most common being: anterior axillary fold and pectoralis major sternal head absence, breast gland thinning, rib and cartilage hypoplasia, and ipsilateral brachysyndactyly. After local wound care and antibiotic therapy, the patient had resolution of her symptoms.
A type IV Wassel preaxial polydactyly is the most common congenital thumb duplication but is not associated with Poland syndrome. Radial club hand is more common than ulnar club hand, but has no association with Poland syndrome. Both are congenital hand deformities, but unrelated to the pathological condition mentioned. Radial head subluxation is also known as “nursemaid’s elbow.” Nursemaid’s elbow is a common injury of early childhood. It is sometimes referred to as “pulled elbow” because it occurs when a child’s elbow is pulled and partially dislocates. There is no connection between Poland syndrome and increased incidence of radial head subluxation. Type IV Manske modification of the Blauth classification thumbs (the “pouce flottant” thumb) have rudimentary elements and are attached to the hand by a small skin bridge. These thumb anomalies are not associated with Poland syndrome.
