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)