- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
Chapter 63 / Skin Lesions 469
C h a p t e r 63
What are the most common skin cancers?
What is the most common fatal skin cancer?
What is malignant melanoma?
Skin Lesions
1.Basal cell carcinoma (75%)
2.Squamous cell carcinoma (20%)
3.Melanoma (4%)
Melanoma
A redundancy! All melanomas are considered malignant!
SQUAMOUS CELL CARCINOMA
What is it? |
Carcinoma arising from epidermal cells |
What are the most common |
Head, neck, and hands |
sites? |
|
What are the risk factors? |
Sun exposure, pale skin, chronic |
|
inflammatory process, immunosuppression, |
|
xeroderma pigmentosum, arsenic |
What is a precursor skin lesion?
What are the signs/symptoms?
How is the diagnosis made?
What is the treatment?
Actinic keratosis
Raised, slightly pigmented skin lesion; ulceration/exudate; chronic scab; itching
Small lesion—excisional biopsy Large lesions—incisional biopsy
Small lesion ( 1 cm): Excise with 0.5-cm margin
Large lesion ( 1 cm): Resect with 1- to 2-cm margins of normal tissue (large lesions may require skin graft/flap)
What is the dreaded sign of |
Palpable lymph nodes (remove involved |
metastasis? |
lymph nodes) |
What is Marjolin’s ulcer? |
Squamous cell carcinoma that arises in an |
|
area of chronic inflammation (e.g., chronic |
|
fistula, burn wound, osteomyelitis) |
470 Section II / General Surgery |
|
What is the prognosis? |
Excellent if totally excised (95% cure rate); |
|
most patients with positive lymph node |
|
metastasis eventually die from metastatic |
|
disease |
What is the treatment for |
Surgical resection |
solitary metastasis? |
|
BASAL CELL CARCINOMA |
|
|
|
What is it? |
Carcinoma arising in the germinating |
|
basal cell layer of epithelial cells |
What are the risk factors? |
Sun exposure, fair skin, radiation, chronic |
|
dermatitis, xeroderma pigmentosum |
What are the most common |
Head, neck, and hands |
sites? |
|
What are the signs/ |
Slow-growing skin mass (chronic, scaly); |
symptoms? |
scab; ulceration, with or without pigmen- |
|
tation, often described as “pearl-like” |
How is the diagnosis made? |
Excisional or incisional biopsy |
What is the treatment? |
Resection with 5-mm margins (2-mm |
|
margin in cosmetically sensitive areas) |
What is the risk of Very low (recur locally) metastasis?
MISCELLANEOUS SKIN LESIONS
What is an Epidermal Inclusion Cyst?
EIC Benign subcutaneous cyst filled with epidermal cells (should be removed surgically) filled with waxy material; no clinical difference from a sebaceous cyst
What is a sebaceous cyst?
Benign subcutaneous cyst filled with sebum (waxy, paste-like substance) from a blocked sweat gland (should be removed with a small area of skin that
includes the blocked gland); may become infected; much less common than EIC
What is actinic keratosis?
What is seborrheic keratosis?
How to remember actinic keratosis vs. seborrheic keratosis malignant potential?
What is Bowen’s disease of the skin?
What is “Mohs” surgery?
Chapter 64 / Melanoma 471
Premalignant skin lesion from sun exposure; seen as a scaly skin lesion (surgical removal eliminates the 20% risk of cancer transformation)
Benign pigmented lesion in the elderly; observe or treat by excision (especially if there is any question of melanoma), curettage, or topical agents
Actinic Keratosis AK Asset Kicker
premalignant
Seborrheic Keratosis SK Soft
Kicker benign
Squamous carcinoma in situ (should be removed or destroyed, thereby removing the problem)
Mohs technique or surgery: repeats thin excision until margins are clear by microscopic review (named after
Dr. Mohs)—used to minimize collateral skin excision (e.g., on the face)
C h a p t e r 64
What is it?
Which patients are at greatest risk?
What are the most common sites (3)?
Melanoma
Neoplastic disorder produced by malignant transformation of the melanocyte; melanocytes are derived from neural crest cells
White patients with blonde/red hair, fair skin, freckling, a history of blistering sunburns, blue/green eyes, actinic keratosis
Male female
1.Skin
2.Eyes
3.Anus
(Think: SEA Skin, Eyes, Anus)
472 Section II / General Surgery |
|
What is the most common |
Palms of the hands, soles of the feet |
site in African Americans? |
(acral lentiginous melanoma) |
What characteristics are |
Usually a pigmented lesion with an |
suggestive of melanoma? |
irregular border, irregular surface, or |
|
irregular coloration |
|
Other clues: darkening of a pigmented |
|
lesion, development of pigmented |
|
satellite lesions, irregular margins or |
|
surface elevations, notching, recent |
|
or rapid enlargement, erosion or |
|
ulceration of surface, pruritus |
What are the “ABCDs” of |
Asymmetry |
melanoma? |
Border irregularity |
|
Color variation |
|
Diameter 6 mm and Dark lesion |
What are the associated risk factors?
Severe sunburn before age 18, giant congenital nevi, family history, race (White), ultraviolet radiation (sun), multiple dysplastic nevi
How does location differ in |
Men get more lesions on the trunk; |
|
men and women? |
women on the extremities |
|
Which locations are |
Noncutaneous regions, such as mucous |
|
unusual? |
membranes of the vulva/vagina, anorectum, |
|
|
esophagus, and choroidal layer of the eye |
|
What is the most common |
Back (33%) |
|
site of melanoma in men? |
|
|
What is the most common |
Legs (33%) |
|
site of melanoma in women? |
|
|
What are the four major |
1. |
Superficial spreading |
histologic types? |
2. |
Lentigo maligna |
|
3. |
Acral lentiginous |
|
4. |
Nodular |
Define the following terms: |
|
|
Superficial spreading |
Occurs in both sun-exposed and |
|
melanoma |
non-exposed areas; most common |
|
|
of all melanomas (75%) |
|