Skin/Soft Tissue/Hernias

Question 1

What is “Bowen’s disease”?

Answer 1

SCC in situ

Question 2

The margins required in excision of SCC are ____ cm, while for BCC it is _____ cm.

Answer 2

SCC: 1 cm
BCC: 0.2-0.4 cm

Question 3

In the evaluation of malignant melanoma, the most significant finding in addition to histologic findings and TNM stage is the presence of

Answer 3

ulceration

Question 4

What is the required margin for excision of MM?

Answer 4

if 1mm depth = 2cm

Question 5

In MM with palpable lymph nodes, treatmetn with ______ may increase survival by as much as 40%

Answer 5

interferon

Question 6

T/F: A Hutchinson freckle (what is it?) is malignant.

Answer 6

False! This is a large macular brown lesion on the cheek (lentigo maligna) that is not malignant in and of itself, but which may be a precursor of lentigo malignant melanoma.

Question 7

T/F: Lentigo malignant melanoma has a more favorable prognosis than malignant melanoma.

Answer 7

True! More thick than deep

Question 8

Treatment of distant metastatic melanoma?

Answer 8

systemic therapy with combination drugs or dacarbazine

Question 9

If a subungual melanoma is found, what is the treatment?

Answer 9

amputation at the DIP!!!

Question 10

Individuals with melanomas located on the face or trunk have a (better/worse) prognosis than those with lesions on the extremity, and (men/women) do better overall.

Answer 10

Women do better
face & trunk < extremity
**note, acral lesions have a poorer prognosis

Question 11

Excisional biopsy is indicated for sarcomas of what size?

Answer 11

<3 cm (otherwise incisional biopsy)

Question 12

What in the history can predispose to fibrosarcoma or lymphangiosarcoma?

Answer 12

hx of therapeutic radiation = fibrosarcoma

hx of axillary lymphadenectomy = lymphangiosarcoma

Question 13

T/F: Neither FNA nor frozen section biopsies of a sarcoma aids diagnosis.

Answer 13

True. Core biopsy or excisional biopsy does.

Question 14

T/F: Cell type of origin is a determinant of whether a sarcoma is low grade or high grade.

Answer 14

False! # of mitotic figures and degree of necrosis, as well as size (>15 cm) and if the lesion is symptomatic

Question 15

Sarcomas of a muscle should be treated surgically with a total compartmental resection (radical local resection), which involves removing…

Answer 15

the entire length of the muscle, its origin and insertion, and its investing fascia, including the deep fascia
**not a wide excision!
WITH adjuvant radiotherapy/brachytherapy! :)

Question 16

A tender area in the lateral portion of the groin and an impulse that travels down the inguinal canal while coughing:

Answer 16

indirect inguinal hernia

Question 17

Which of the 3 groin hernias goes posterior to the inguinal ligament? Which anterior?

Answer 17

posterior = femoral
anterior = direct and indirect

Question 18

Though femoral hernias are most likely to strangulate overall, out of direct and indirect hernias, which are more likely to strangulate?

Answer 18

indirect > direct

Question 19

What are conditions that are associated with hernia development?

Answer 19

obesity, COPD, ascites, BPH (causes bladder obstruction), colon or rectal obstruction, pregnancy…

Question 20

What is the repair of a pediatric inguinal hernia?

Answer 20

high ligation of the sac (no abdominal repair is needed because there is no abdominal wall defect present). Exist because of a patent processus vaginalis (communication between the peritoneal cavity and the inguinal canal)

Question 21

What are the boundaries of the femoral canal?

Answer 21

anterior: iliopubic tract (reflection of inguinal ligament)
posterior: Cooper’s ligament
medial: pubic tubercle
lateral: femoral vein

Question 22

What is a Littre hernia?

Answer 22

protrusion of a Meckel diverticulum into a hernia sac

Question 23

What is a Richter hernia?

Answer 23

protrusion of a portion of the intestine wall into the hernia sac

Question 24

The most common sliding hernias in indirect hernias involve what?

Answer 24

bladder, cecum, or sigmoid colon

Question 25

A (larger/smaller) hernia is more dangerous.

Answer 25

Smaller = greater risk for strangulation if neck is small!

Question 26

What are the borders of the femoral canal?

Answer 26

anterosuperiorly: inguinal ligament
posteriorly: pectineal ligament
medially: lacunar ligament
laterally: femoral vein

Question 27

What is the most common complication following hernia repair?

Answer 27

hernia recurrence

Question 28

Spigelian hernias are an uncommon type of ventral hernia that protrude through what?

Answer 28

attachment of internal oblique and transversus abdominus to the rectus sheath (= linea semilunaris)

Note, the hernia passes between internal oblique and transversus abdominus, POSTERIOR to the external oblique

Question 29

Name the names of hernia repairs described:

1) tension-free with flat overlying anterior mesh
2) “tension” repair with conjoint tendon approximated to inguinal ligament
3) conjoint tendon approximated to pectineal ligament

Answer 29

1) Lichtenstein
2) Bassini
3) McVay

Question 30

What is a Littre hernia?

Answer 30

it involves Meckels diverticulum

Question 31

Which nerve is responsible for the cremasteric reflex?

Answer 31

genitofemoral

Question 32

Which nerve supplies sensory innervation to superior scrotum and base of penis?

Answer 32

ilioinguinal

Question 33

Which nerve supplies sensory innervation to scrotum, penis, anus, and motor innervation to pelvic muscles?

Answer 33

pudendal nerve

Question 34

Placement of a stoma lateral to the rectus sheath results in (increased/decreased) parastomal herniation?

Answer 34

increased! as do conditions that increase intraabdominal pressure and midline incisions.
Stomas should be made with small bowel to decrease parastomal herniation

Question 35

What is the treatment of an umbilical hernia in a patient with massive ascites?

Answer 35

umbilical hernia repair with peritovenous shunt (to decrease ascites and make repair more likely to last)

Question 36

What is primary intention, secondary intention, and teritiary intention wound healing?

Answer 36

primary: edges approximated by suture
secondary: wound allow to granulate (results in wider scar formation)
tertiary: wound left open for cleaning and observation for several days and then the edges are approximated

Question 37

Malignant melanoma originates from cells in which layer of the skin?

Answer 37

stratum basalis! (layer of the epidermis); where melanocytes reside

Question 38

Fournier gangrene is a necrotizing soft tissue infection (usually originating from a genitourinary or perianal source) that spreads how?

Answer 38

along fascial planes

tender scrotum with palpable crepitus and foul smelling dischage

Question 39

What bugs are usually responsible for Fournier gangrene?

Answer 39

Polymicrobial! Most common aerobic organism = E coli while Bacteriodes is the most common anaerobe

Question 40

Soft tissue masses greater than __ cm favor a diagnosis of malignant soft tissue tumor.

Answer 40

5-7cm

Question 41

Treatment of a lipoma is generally unnecessary unless

Answer 41

the mass becomes painful or restricts movement

Question 42

What are the layers of skin from superficial to deep?

Answer 42

Epidermis –> papillary dermis –> reticular dermis –> subcutaneous fat –> muscle

Question 43

Contraindications to wound debridement:

Answer 43

1) presence of granulation/viable tissue, 2) pyoderma gangreonosum, 3) ischemic gangrene from peripheral arterial disease

Question 44

What are two medications that can be used in unresectable mestastic melanoma?

Answer 44

Dacarbazine; ipilimumab (against a down regulatory receptor on activated T cells)