Skin/Soft Tissue/Hernias Flashcards
What is “Bowen’s disease”?
SCC in situ
The margins required in excision of SCC are ____ cm, while for BCC it is _____ cm.
SCC: 1 cm
BCC: 0.2-0.4 cm
In the evaluation of malignant melanoma, the most significant finding in addition to histologic findings and TNM stage is the presence of
ulceration
What is the required margin for excision of MM?
if 1mm depth = 2cm
In MM with palpable lymph nodes, treatmetn with ______ may increase survival by as much as 40%
interferon
T/F: A Hutchinson freckle (what is it?) is malignant.
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.
T/F: Lentigo malignant melanoma has a more favorable prognosis than malignant melanoma.
True! More thick than deep
Treatment of distant metastatic melanoma?
systemic therapy with combination drugs or dacarbazine
If a subungual melanoma is found, what is the treatment?
amputation at the DIP!!!
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.
Women do better
face & trunk < extremity
**note, acral lesions have a poorer prognosis
Excisional biopsy is indicated for sarcomas of what size?
<3 cm (otherwise incisional biopsy)
What in the history can predispose to fibrosarcoma or lymphangiosarcoma?
hx of therapeutic radiation = fibrosarcoma
hx of axillary lymphadenectomy = lymphangiosarcoma
T/F: Neither FNA nor frozen section biopsies of a sarcoma aids diagnosis.
True. Core biopsy or excisional biopsy does.
T/F: Cell type of origin is a determinant of whether a sarcoma is low grade or high grade.
False! # of mitotic figures and degree of necrosis, as well as size (>15 cm) and if the lesion is symptomatic
Sarcomas of a muscle should be treated surgically with a total compartmental resection (radical local resection), which involves removing…
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! :)
A tender area in the lateral portion of the groin and an impulse that travels down the inguinal canal while coughing:
indirect inguinal hernia
Which of the 3 groin hernias goes posterior to the inguinal ligament? Which anterior?
posterior = femoral anterior = direct and indirect
Though femoral hernias are most likely to strangulate overall, out of direct and indirect hernias, which are more likely to strangulate?
indirect > direct
What are conditions that are associated with hernia development?
obesity, COPD, ascites, BPH (causes bladder obstruction), colon or rectal obstruction, pregnancy…
What is the repair of a pediatric inguinal hernia?
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)
What are the boundaries of the femoral canal?
anterior: iliopubic tract (reflection of inguinal ligament)
posterior: Cooper’s ligament
medial: pubic tubercle
lateral: femoral vein
What is a Littre hernia?
protrusion of a Meckel diverticulum into a hernia sac
What is a Richter hernia?
protrusion of a portion of the intestine wall into the hernia sac
The most common sliding hernias in indirect hernias involve what?
bladder, cecum, or sigmoid colon
A (larger/smaller) hernia is more dangerous.
Smaller = greater risk for strangulation if neck is small!
What are the borders of the femoral canal?
anterosuperiorly: inguinal ligament
posteriorly: pectineal ligament
medially: lacunar ligament
laterally: femoral vein
What is the most common complication following hernia repair?
hernia recurrence
Spigelian hernias are an uncommon type of ventral hernia that protrude through what?
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
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
1) Lichtenstein
2) Bassini
3) McVay
What is a Littre hernia?
it involves Meckels diverticulum
Which nerve is responsible for the cremasteric reflex?
genitofemoral
Which nerve supplies sensory innervation to superior scrotum and base of penis?
ilioinguinal
Which nerve supplies sensory innervation to scrotum, penis, anus, and motor innervation to pelvic muscles?
pudendal nerve
Placement of a stoma lateral to the rectus sheath results in (increased/decreased) parastomal herniation?
increased! as do conditions that increase intraabdominal pressure and midline incisions.
Stomas should be made with small bowel to decrease parastomal herniation
What is the treatment of an umbilical hernia in a patient with massive ascites?
umbilical hernia repair with peritovenous shunt (to decrease ascites and make repair more likely to last)
What is primary intention, secondary intention, and teritiary intention wound healing?
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
Malignant melanoma originates from cells in which layer of the skin?
stratum basalis! (layer of the epidermis); where melanocytes reside
Fournier gangrene is a necrotizing soft tissue infection (usually originating from a genitourinary or perianal source) that spreads how?
along fascial planes
tender scrotum with palpable crepitus and foul smelling dischage
What bugs are usually responsible for Fournier gangrene?
Polymicrobial! Most common aerobic organism = E coli while Bacteriodes is the most common anaerobe
Soft tissue masses greater than __ cm favor a diagnosis of malignant soft tissue tumor.
5-7cm
Treatment of a lipoma is generally unnecessary unless
the mass becomes painful or restricts movement
What are the layers of skin from superficial to deep?
Epidermis –> papillary dermis –> reticular dermis –> subcutaneous fat –> muscle
Contraindications to wound debridement:
1) presence of granulation/viable tissue, 2) pyoderma gangreonosum, 3) ischemic gangrene from peripheral arterial disease
What are two medications that can be used in unresectable mestastic melanoma?
Dacarbazine; ipilimumab (against a down regulatory receptor on activated T cells)
