Skin and Soft Tissue Disorders and Hernias Flashcards
Risk factors for melanoma
- FHx melanoma
- Sun exposure
- Previous dysplastic nevi or atypical moles
Physical exam s/s suggestive of malignant lesions
- Ulceration
- Bleeding
- Change in size
- Variation in pigmentation (5-10% of melanomas are not pigmented)
- ABCD rule (asymmetry, border irregularity, color variation, diameter, dark black color)
- Regional LN involvement
When to perform incisional biopsy on a skin lesion
- > 2-3cm
2. Contiguous w/important structures such as the face
Mgmt given skin biopsy results
- Benign skin lesions = no further tx
- Basal cell CA = Local excision b/c of recurrence may be locally invasive. If excision has negative margins then no further tx reqd. May ALSO use topical 5-FU or radiation
- SCC (Bowen’s disease) = Local excision w/1cm margin for tumors >4mm b/c recurrence is common. Lesions >10mm often involve local LN’s and LN dissection is req’d if nodes are palpable. 5-FU or radiation may ALSO be used here.
- In situ melanoma = excise to ensure 0.5-1cm margin
- Dysplastic nevus = req only minimal adequate excision (no margin req’d)
Factors affecting survival in melanoma
- TNM stage
- Ulceration in the primary lesion (33% reduction in survival)
- Lesions on face/trunk = worse prognosis
- Women do better than men
Mgmt of malignant melanoma depending on depth
- 0.7mm depth = local control w/1cm margin excision down to the fascial plane. CXR, CBC, LFT’s are appropriate. Follow up b/c recurrence in 5%
- 1.6mm depth = warrants 2cm margin with LN dissection if nodes are palpable b/c of 40% LN mets. DO NOT resect NONpalpable nodes b/c no added benefit and risk of lymphedema and wound complications. (If nodes are palpable then a sentinal LN biopsy is warranted)
- 4.5mm depth = poor prognosis with death most likely from metastatic disease. Excise w/2-3cm margin. Excise LN’s b/c of tendency to erode skin and become infected and painful. CT/MRI of brain necessary to r/o brain mets. Interferon CTX.
- Axillary LAD = regional LN dissection warranted. 75% chance recurrence in the next 5yrs in pts with mets. CXR, LFT’s, CT abd, MRI brain should be done to evaluate mets/staging. Interferon CTX increases survival by 40%
Tx of melanoma with distant mets
- Stage IV dz should be treated with systemic tx w/combo drugs OR dacarbazine
- SOLITARY lung/brain mets may be tx w/resection
- Rads may relieve pain from bone mets
Superficial, spreading (NOT invading) skin lesion often involving the face
Lentigo maligna melanoma. Mgmt involves local excision with narrow margins b/c of face involvement. Precursor = Hutchinson freckle. Mgmt of Hutchinson freckle involves observation
Malignant melamona on the sole of the foot
Poorer prognosis than other locations. Often are thicker. More common in dark-skinned people.
Subungual malignant melanoma
- Excision of a portion of the nail in continuity w/the lesion
- Re-excision following diagnosis involves amputation at the DIP joint
Anal melanoma traits
- Poor prognosis (100% 5yr mortality)
- Lesions occur at the dentate line
- thicker lesions req abdominoperineal resection of the anorectum (lower local recurrence)
- Regional LN dissection only indicated for positive inguinal nodes
Hx of malignant melanoma s/p resection, abd distention, N/V, SBO
Melanoma recurrence in peritoneal cavity causing SBO. Poor prognosis w/palliative tx possible for solitary lesions but most pts die
Slow growing firm painless mass on anterior thigh that is larger than benign tumors +/- regional adenopathy
Soft tissue sarcoma. a/w hx of therapeutic radiation exposure or axillary LN dissection, trauma w/persistent mass (misdiagnosed as hematoma)
Mgmt of sarcoma
- Excisional biopsy for masses 3cm. Large defect makes closure complex w/potential for seeding other compartments with tumor cells
- Core needle bx is accurate in dx in certain centers
- FNA is NONdiagnostic and thus NOT USEFUL
- Frozen section does NOT allow for reliable dx
Prognosis of sarcoma
- high rate of mets to liver, lung, bone, brain (req’s metastatic workup)
- Bone pain should prompt bone scan
Tx of sarcoma
- Total comprtmental resection = limb sparing and provides excellent local control. total compartment implies entire length of muscle, its origin/insertion, and investing fascia/deep fascia
- Radical amputation has the highest control but requires extensive rehab
- If the sarcoma is high grade (>15cm) then tx involves radical amputation + neoadjuvant CTX and Rads
- Childhood retroperitoneal pelvic rhabdomyosarcomas have clear advantage of CTX
Workup for lung mets in metastatic sarcoma
- CXR
- Chest CT w/contrast to characterize the new lesion
- Needle biopsy percutaneously
- PET scan of lung
Tx for lung mets in metastatic sarcoma
Thoracic wedge resection
Tx for liver mets in metastatic sarcoma
- Biopsy of liver lesion
- Hepatic wedge resection w/1cm margin
- Formal lobectomy
1cm tender groin LN
Lymphadeninits of groin/leg/foot
Acute onset tender testicle
- Torsion of the testis
- Viral orchitis
- Epididymitis
Acutely tender epididymis
Epididymitis d/t infection/trauma
Firm tender mass w/N?V and abdominal distension
Incarcerated/strangulated loop of intestine
Large, soft reducible mass in the scrotum separate from the testicle and c/o fullness in the inguinal canal
Bowel herniation into the scrotum
Firm tender mass with fever, leukocytosis, and acidosis
Segment of strangulated bowel resulting in cut off blood supply. If this persists then bowel necrosis will develop if not reduced. Strangulation is msot common in femoral hernias
Difference between direct and indirect inguinal hernias
Indirect hernias have an in-tact FLOOR of the canal while direct hernia has a weakness of the floor. Additionally, indirect originates lateral to the inferior epigastrics while the direct originates medial to the inferior epigastrics.
Conditions that increase the risk for hernia
- COPD
- Obesity
- Ascites
- BPH causing bladder outlet obstruction
- Colon/rectal obstruction d/t tumor, constipation, etc.
Risk factors for hernia strangulation. Reasons for surgical intervention of hernias
- Narrow neck of hernia
- Femoral hernia
- Risk of strangulation
- Local pain
- Enlargement
- Inability to lift
- Patient preference
Surgical repair options for groin hernia
- Bassini repair = Reconstruction of the posterior inguinal canal w/suturing of the superior abdominal wall layers (int obl, transv abd, transveralis fascia) to an inferior portion of the inguinal ligament and iliopubic tract. Limitation = high tension on the structure and may weaken over the years and recurr
- Cooper’s ligament repair = Bassini repair but inferior sutures are placed into Cooper’s ligament (periosteum of pubic ramus)
- Shouldice repair = attaching a reinforced transversalis fascia to the inguinal ligament in 2 layers
- Lichtenstein repair = prosthetic mesh used to approximate the abd wall structures to the inguinal ligment. This avoids tension on the fascial structures.
Cause of groin hernia formation
Weakness in the transversalis fascia
Risks involved in groin hernia repair
- Injury to genital branch of genitofemoral nerve
- Injury to ilioinguinal nerve
- Injury to iliohypgastric nerve
- Injury to lateral femoral cutaneous nerves (sensory defects)
- Testicular atrophy, edema, ischemia
- Recurrence
- Wound infection/hematoma
Anatomic structures to be most aware of in groin hernia repair incision
- Ilioinguinal nerve
2. Spermatic cord
Difference btwn adult and pediatric inguinal hernia
Pediatric hernias do not have a defect in the floor of the inguinal canal and are thus INDIRECT inguinal hernias. This represents a persistent patent processus vaginalis. Pediatric hernias have a high incidence of bilaterality and both are typically repaired. Repair is limited to high ligation of hte sac w/o abdominal wall repair b/c there is no wall defect
Anatomic borders of a femoral hernia
Anterior = iliopubic tract Posterior = cooper's ligament periosteum(pubic ramus) Medially = Pubic tubercle and its ligamentous attachments Laterally = femoral vein
What are possible contents of a sliding indirect groin hernia (aside from aforementioned nerves)?
- Bladder
- Cecum
- Sigmoid colon (Richter hernia)
- Meckel diverticulum (Littre hernia)
- Ovary
- Appendix
Indications to repair ventral hernias
- Risk of bowel incarceration/strangulation (higher risk with narrow neck hernias)
- progressive enlargement of defect making repair more difficult in the future
- Bowel obstruction
Risks a/w ventral hernia repair
- Must dissect bowel off the psoterior surface of the hernia sac and thus there is a risk for bowel injury
- Postoperative ileus
- Abdominal distention
- Pulmonary complications (atalectasis)
