Skin and Soft Tissue

Melanoma

    • Dx:
      • ABC's of melanoma:
        • Asymmetry
        • Border
        • Color variance
        • Diameter > 6mm
        • Evolution or change in lesion
      • Types:
        • Superficial spreading
        • Nodular
        • Lentigo maligna
        • Acral lentiginous
        • Desmoplastic
      • Biopsy all suspiciou lesions.
        • < 1.5cm gets excision
        • >1.5cm gets punch to include normal skin. Do 2 areas and include thickest area.
    • Tx:
      • Margins:
        • Tis= 0.5mm
        • <1mm thick= 1cm
        • 1-2mm= 2cm
        • >2mm= 2cm
      • Sentinel lymph node biopsy is used for:
        • > 1mm thick
        • Ulceration
        • Clark level IV
        • Regression
        • Incomplete stage (shave biopsy)
        • Discuss as an option for all invasive melanoma because <1mm thick has <5% chance of nodal involvement.
      • Adjuvent Tx:
        • >4mm gets interferon alpha
        • Positive sentinel node gets:
          • Regional lymph node dissection
          • 1yr of interferon alpha
    • Subungual and digital melanomas can have Hutchinson's sign (pigment changes of cuticle.
      • worse prognosis.
      • Biopsy by removing nail.
      • Treat with amputation one joint proximal to tumor.
    • Head and face melanoma needs to have superficial parotidectomy when the parotid lights up as the sentinal lymph node or when doing regional lymph node dissection

Hernia

  • Inguinal hernias in woman are recommended to be repaired; men can have watchful waiting with 64% requiring surgery in 10yrs.
  • Types of surgical mesh
  • Shouldice technique= pure tissue repair
    • Incise transverses fascia and mobilize flap
    • Two layer closure of transverses fascia – tightens the internal ring
    • Join conjoint tendon to inguinal ligament in two running layers; 2nd layer includes rectus sheath and external oblique apaneurosis – closes floor
  • Bassini repair= similar to shouldice, but tightening internal ring and closing floor are each only one layer
  • Cooper ligament repair (McVay repair)= definitively repairs inguinal and femoral hernias
  • Cirrhotic umbilical hernia
    • Tx: medically optimize ascites, tips if needed, semielective repair.


Retroperitoneal Liposarcoma

      • Sx: large, invade adjacent organs
      • Dx: CT
      • Tx:
        • resection with grossly negative margins
        • chemo reserved for metastasis

Spleen

Ideopathic Thrombocytopenia Purpura (ITP)

    • thrombocytopenia alone, without underlying cause
    • Tx: start for bleeding or very low platelets
      • 1st line= steroid, IVIG
      • 2nd line= rituximab, thrombopoietin agonists (romiplostim, eltrombopag), splenectomy (often use trombopoietin agonist to improve platelet and then pts can decide on surgery)

Spontaneous atraumatic splenic rupture

    • From cancer, inflammatory state, drug related
    • Tx: splenectomy, IR, non-op

Splenic Cyst

    • Sx: pain, h/o infarct, abscess, parasite
    • Dx: CT, parasite assays
    • Tx:
      • aspiration confirms dx
      • splenectomy (can consider aspiration and sclerosis, especially for parasites)