Skin/Soft Tissue Surgery

Question 1

What does basal cell carcinoma look like?

Answer 1

Raised waxy lesion or non-healing ulcer in upper face, doesn’t spread; tx local excision with 1 mm margins

Question 2

What does squamous cell carcinoma look like?

Answer 2

Non-healing ulcer in lower face, spreads to LN; tx local excision with 1 cm margins and LN excision

Question 3

What are the SCC risk factors?

Answer 3

draining fistulas, arsenic exposure

Question 4

What is a dysplastic nevus?

Answer 4

Atypical mole, precursor of malignant melanomas, requires close observation

Question 5

What do you see with melanomas?

Answer 5

ABCDE
A-asymmetric B- irregular borders C- colors D- diameter >5mm E-evolving
Px is related to depth, highly metastatic and will be found in weird places

Question 6

What are the worrisome melanoma features?

Answer 6

ulcerated (1/3 reduction in survival) and depth >4 mm (pt will likely die from mets)

Question 7

How do you treat melanoma with metastasis?

Answer 7

Tx radiation and chemotherapy (interferons)

Question 8

What is lentigo maligna melanoma?

Answer 8

Superficial, spreading melanoma on the face, good prognosis overall, tx excision with narrow margin

Question 9

What is acral lentiginous melanoma?

Answer 9

Melanoma on pale areas of dark-skinned patients (sole of feet, palm of hand), worst prognosis due to depth

Question 10

How does a sarcoma present?

Answer 10

Present as a firm, painless mass; px depends on size, grade, and distant metastasis
No LN involvement since sarcomas spread hematogenously

Question 11

What are some melanoma subtypes to be aware of?

Answer 11

subungual melanoma (under fingernail or toenail)
mucosal melanoma (bad prognosis, tx APR with palpable LN excision)
melanoma + SBO (presents as abd distention, nausea and vomiting due to metastatic melanoma in abd cavity, tx with ex lap and excision)

Question 12

How do you manage sarcomas?

Answer 12

Dx incisional biopsy parallel to resection margins, chest CT for mets, tx resection with 1 cm negative margins
tx high-grade sarcomas with radical amputation with post-op radiation therapy
Common mets in lung and liver

Question 13

What are the hernia surgery indications?

Answer 13

All abdominal hernias due to possibility of strangulation, except sliding esophageal hernias (tx PPIs) and umbilical hernias in pts <2 yo (simple observation)
Can cause SBO or strangulation (presents as firm/tender mass with fever, increase in WBC, metabolic acidosis)

Question 14

How do you manage umbilical hernias?

Answer 14

2cm fix, fix if it doesn’t regress before kindergarten regardless

Question 15

What is an indirect hernia?

Answer 15

Through internal ring lateral to inferior epigastric vessels, due to patent processus vaginalis; most common hernia overall
In kids, high incidence of bilaterality, repair is limited to high ligation of sac without abdominal wall repair

Question 16

What is a direct hernia?

Answer 16

Medial to inferior epigastric vessels, due to weakening abdominal wall; more common in elderly

Question 17

What is a femoral hernia?

Answer 17

Below inguinal ligament into femoral triangle, more common in women, highest risk of strangulation
Other types include : sliding hernia and ventral hernia

Question 18

What are the four places in the body you can bleed out?

Answer 18

Abdomen, retroperitoneal space (pelvis), pleural space (x2), and the thighs

Question 19

What are the common skin cancers?

Answer 19

Basal cell carcinoma (50%), squamous cell carcinoma (25%), malignant melanoma (15%); management is full-thickness incisional biopsy at border of the lesion