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Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modi- fication of the Halsted radical mastectomy and selective use of radiotherapy purchase 162.5mg avalide with mastercard. Chassin† Indications Preoperative Preparation Wide Local Excision Wide local excision requires no specific preoperative preparation order avalide 162.5 mg with amex. Patients receive an injection of technetium 99m in The diagnosis of melanoma is usually made by punch or nuclear medicine several hours before surgery order avalide 162.5 mg otc. Occasionally a shave biopsy will have Lymphoscintigraphy is performed to determine the drain- been performed avalide 162.5 mg online. Wide local excision is indicated for local age pattern and help guide incision placement. The width of the margin required is determined by Blue dye, if used, is injected on the operating table after the thickness of the lesion. Pitfalls and Danger Points Sentinel Lymph Node Biopsy Inadequate excision Failure to identify a positive sentinel lymph node due to Sentinel lymph biopsy is used to stage clinically node- technical problems or poor localization negative patients whose melanomas exhibit any of the fol- lowing characteristics: • Thickness ≥1. Often the diagnosis of melanoma will ered an indication for completion node dissection (see Chaps. Biopsy Contraindications The manner in which that diagnostic biopsy was done can Widespread metastatic disease may be a contraindication. Therefore, a Sentinel node biopsy is rarely indicated in known node- few words are in order about the unique considerations positive patients. For the extremities, this requires placing the long axis parallel to the long axis of the limb (rather than in a natural skin crease). For the torso, incisions parallel to the likely lymphatic drain- age pattern are often preferred; however, the skin is usually loose enough that a skin crease incision can be made. If the lesion is large, take a representative biopsy from the thickest (non-ulcerated) part of the lesion either by making a small incision or performing a punch biopsy. Wide Local Excision The margin is defined from the edge of the lesion or edge of the biopsy site if the lesion has been “biopsied away. Then plan the long axis of your excision site and draw Thus, even for extremity melanoma, lymphoscintigraphy may triangles at both ends to convert your circle into a lens- be helpful. The trunk can be divided into four quadrants by a advocated to allow closure without “dog ears” at the ends, vertical line down the middle and a transverse line at the level of but fatter excisions can be used if necessary. Generally the lymphatics drain to the regional following general guidelines into consideration. For the lymph node basin in their respective quadrant; thus, the skin of extremities, use an incision parallel to the long axis of the the left upper quadrant of the trunk will usually drain to the left extremity. Plan your excision first and ies from person to person, so lymphatic drainage in this region is worry about closure later. It is no longer con- and lymphoscintigraphy to localize the node is of crucial impor- sidered necessary to take the fascia with the excision. Sometimes a local rotation or tis- would not have been predicted based upon anatomic location. It also makes it easy to see and clip or ligate lym- primary or transposed local tissue closure is not feasible. Because blue dye travels through the lymphatic system rapidly, it is injected just before surgery. Sentinel Lymph Node Biopsy Use the gamma probe to identify the region of greatest radioactivity and make an incision over this spot (see Chap. Always make this incision in such a way that you can tinel lymph node biopsy are discussed in detail in Chap. The • Complex layered closure (if used) radius of the circle depends upon the thickness of the mela- • Flap closure (if used) noma, with 1 cm being adequate for thin melanomas • If split-thickness skin graft, document area grafted in (<1. As noted previously (see Operative Strategy ), intermediate-thickness melanomas generally are excised with 1–2 cm margins. Operative Technique Convert the circle to an elliptical or lens-shaped incision by outlining two triangles at apposing ends (Fig. Frequently, wide excision and sentinel node biopsy are done Align the long access of the resulting incision with the under the same anesthesia. It may be possible to position the regional lymphatics or the long axis of the limb (if arm or patient to allow both procedures to be done under the same leg). Melanomas of the head and neck present particular prep, for example, a melanoma of the anterior trunk which challenges (see references at the end). However, in many cases, it will be Incise the skin sharply and deepen the incision straight necessary to reposition the patient and re-prep and redrape to down to the deep fascia. Grasp one end of the specimen with provide optimum exposure for both portions of the operation. If this step is performed immediately rior) and submit it for pathological examination. We rarely use a subcuticular closure for this purpose, as the incision is gener- ally under some tension. This decision is best made at the initial part of the procedure and the incision outlined accordingly. Sentinel Lymph Node Biopsy Reposition and drape the patient, if necessary, to provide optimal exposure of the appropriate nodal basin as deter- mined by the lymphoscintigram. Use the sterile gamma probe to identify the region of greatest radioactivity and make an incision directly over this spot. Plan the incision so that it could be excised easily during a subse- quent lymphadenectomy, should this be required. If it is necessary to divide a lym- phatic trunk, secure it with clips or ties to minimize seroma formation. Any palpably or visibly abnormal nodes should be background (post-excision) count is less than 10 % of the removed. Take time to find the layers (without drainage) with interrupted 3-0 Vicryl and hottest spot on the node. Although the incidence of lymphedema is lower after senti- Available from: http://www. Sentinel lymph node biopsy for melanoma: critical assessment at its twentieth anniversary. The impact of biopsy technique on Axillary Lymphadenectomy 117 for Melanoma Carol E. Chassin† Indications Operative Strategy Malignant melanoma with positive sentinel node biopsy (see Fundamentally, axillary lymphadenectomy employs the Chaps. Adipose and lymphatic tissues inferior to the axillary nancies involving the skin of the upper extremity and vein are excised en bloc from the clavicle to the anterior shoulder, breast, and upper trunk border of the latissimus muscle. Adequate exposure requires For breast cancer, the standard completion axillary node dis- that the arm be flexed on the trunk to relax the major pectoral section is less radical than that described here. The long thoracic Preoperative Preparation and thoracodorsal nerves may be preserved if they are not involved with tumor. Pitfalls and Danger Points Nerve injury (lateral pectoral, long thoracic, or thoracodorsal Operative Technique nerve; brachial plexus) Injury to axillary vein See Chap. Exposing the Axillary Contents Incise the fascia overlying the lateral border of the major pec- toral muscle, and dissect it away from the undersurface of the muscle. Insert a Richardson retractor underneath the pecto- ral muscle and expose the coracobrachial muscle.

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Compared with an abdominal approach purchase avalide 162.5mg free shipping, this higher than rates associated with perineal repairs (Varma operation involves a shorter hospital stay and has lower et al buy 162.5 mg avalide with amex. The perineal approaches result in reduced mor- complication rates (10 %) 162.5 mg avalide sale, which include anastomotic bidity cheap avalide 162.5 mg online, pain, and hospital stay; however, recurrence rates are bleeding, pelvic abscess, and, rarely, an anastomotic leak; higher than those for abdominal operations. Furthermore, however, recurrence rates have been reported to be as high as the rectum is removed, suboptimal functional outcomes as 16–30 %. A Delorme procedure, circum- Abdominal approaches include rectopexy, with or with- ferential mucosal sleeve resection and imbrication of the out a segmental resection. Fixation of the rectum in the pel- muscularis layer with serial vertical sutures, can be per- vis with suture, first described by Cutait in 1959, aims to formed for short full-thickness rectal prolapse or mucosal correct the telescoping of the redundant bowel and causes prolapse. Recurrence rates are higher for this procedure fixation of the rectum from the resultant scarring and fibro- than for perineal rectosigmoidectomy, and the recurrence sis (Cutait 1959; Madoff and Mellgren 1999). The recur- rates for all perineal procedures are higher than for all rence rates for suture rectopexy are generally reported to be abdominal procedures. The second stage is gen- erally a restorative completion proctocolectomy with ileal Mucosal Ulcerative Colitis J-pouch-anal anastomosis and a diverting loop ileostomy. It is confined to the colonic the “J”-pouch configuration is the most widely used because mucosa and characteristically starts in the rectum and of its simplicity, suitability for fitting into the pelvis, and extends proximally without skip lesions. A stapled pouch- 50 % of cases have disease confined to the rectum, 30 % anal anastomosis is then performed 1–2 cm from the dentate have disease extending to the left colon, and 20 % have line. Backwash However, if the patient has a history of low rectal cancer or ileitis (inflammation of the most distal terminal ileum sec- dysplasia, a mucosectomy and hand-sewn ileoanal anasto- ondary to reflux of stool from the cecum (Gordon and mosis may be performed (Lovegrove et al. Prior to Nivatvongs 2007)) may occur in up to 10 % of patients and the third operation, closure of the diverting loop ileostomy, resolves after surgery. The progression of the disease may the integrity of the anastomosis is assessed with a pouchos- be insidious, acute, or fulminant. Typically, patients include chronic disease refractory to medical management, have excellent outcomes following this procedure, averag- complications of medical management, dysplasia or can- ing approximately six to ten bowel movements per day with cer, fulminant colitis, growth retardation (in children), or good control and no urgency. The goal of surgery is to cure the patient Patients with all other surgical indications may be candi- from disease and, whenever possible and desirable, to dates for a two-stage procedure: restorative proctocolec- restore intestinal continuity. This procedure may be per- tomy and ileoanal pouch anastomosis with diverting loop formed in one to three stages. Prior to largely depends on the patient’s current nutritional status, offering a restorative proctocolectomy with ileoanal pouch medical fitness, recent use of immunosuppressant medica- anastomosis, the surgeon must have diligently excluded any tions, and sphincter function. This confirmation can be achieved by of Truelove and Witts and is defined as colitis with more a detailed history and examination to exclude any perianal than six bloody stools per day, fever (temperature >37. In approximately 40 % of patients, there is a are malnourished, receiving high-dose steroids (>40 mg/ disparity in diagnosis between general and specialist pathol- day) or tumor necrosis factor inhibitors, or who have inde- ogists; thus a preoperative review of previous colonoscopic terminate colitis (The Standards Practice Task Force of The biopsies by a gastrointestinal expert pathologist is important American Society of Colon and Rectal Surgeons 2005 ). It is important at this first operation that the presacral alternate procedure is a total proctocolectomy and continent space be preserved and the integrity of the stapled rectosig- ileostomy (“Kock pouch”) which is constructed from 45 cm moid stump be assured. If there is any question about this of distal terminal ileum with intussusception of the ileum seal, the staple line may be oversewn, or a mucous fistula just back into the pouch to create a nipple valve. This procedure is often has not gained widespread acceptance because of its intricate well suited for a laparoscopic approach. In addition to mini- construction and its high rate of complications, namely, val- mizing scars, pain, and disability, the laparoscopic method vular dysfunction requiring revisions. In this setting, the authors recommend delay of the pouch anastomosis have been demonstrated in the elderly, completion proctectomy and ileoanal pouch reconstruction with physiologic age, rather than chronological age being a to allow a period of observation for the clinical evolution of determining factor (Takao et al. If after 6–12 months, there is no evidence of Crohn’s disease, an ileoanal pouch reconstruction can be offered to Obesity the patient after an informed discussion. Pouch failure rates Ileoanal pouch reconstruction is feasible in patients with a for indeterminate colitis may be as low as those for ulcer- body mass index >30 kg/m2; however, it is associated with ative colitis or slightly higher (2–10 %) (Delaney et al. Furthermore, it is the authors’ experience that obesity decreases the ease and likelihood of pouch reach. Accordingly, treatment focuses on safely alleviating Laparoscopy has been shown to be safe and effective, disease symptoms and restoring quality of life while attempt- and in most cases superior for two- and three-stage restor- ing to maintain continuity of the intestinal tract. Surgery is indicated for complications of disease (nondrainable abscesses, per- Pouch That Does Not Reach foration, chronic bleeding and anemia, stricture formation, There are several maneuvers that can be performed if there fulminant colitis, and the development of dysplasia or adeno- is inadequate pouch length to perform a tension-free pouch- carcinoma) and failure of medical management (including anal anastomosis. First, it is important to ensure complete dependence on high doses of immunosuppressive agents and mobilization of the small bowel mesentery up to and ante- steroids) (Standards Practice Task Force of The American rior to the duodenum. Second, a slightly more proximal por- Society of Colon and Rectal Surgeons 2007 ). Third, superficial inci- colitis should undergo a total abdominal colectomy with end sions on the anterior and posterior aspects of the small ileostomy (Standards Practice Task Force of The American bowel mesentery along the course of the superior mesen- Society of Colon and Rectal Surgeons 2007 ). Fourth, selective division of anemia, malnutrition, and sepsis rapidly resolve following mesenteric vessels to the apex of the proposed J-pouch can colectomy. Last, division of the ileocolic vessels can be mended in select patients who demonstrate minimal mucosal performed. Finally, when the ileum will not reach the pelvic inflammation, adequate rectal compliance, absence of ano- floor despite these maneuvers, it may be necessary to staple rectal disease, and good sphincter function. Otherwise, the the distal rectum and perform an abdominal colectomy and diseased rectum may be removed or left in place with appro- end ileostomy with Hartmann’s pouch. Isolated sigmoid or left-sided tis, the diagnosis of Crohn’s or ulcerative colitis is equivocal colon disease can be treated with a segmental colectomy, even after a thorough endoscopic and histopathologic evalu- whereas disease limited to the rectum can be treated with ation. The preferred approach for these patients is a total abdominoperineal proctectomy with end colostomy. If a diagnosis of ulcerative colitis rence rate compared to proctocolectomy with ileostomy. Wexner In the presence of pancolitis, a proctocolectomy with end are the most common presenting symptoms (Beck et al. Thorough physical examination and standard ing a proctectomy and permanent stoma, an intersphincteric preoperative laboratory tests should be performed. Because resection has been found to improve perineal wound healing, anemia is common in colon cancer patients, it is important to a difficult and morbid complication of this procedure check hemoglobin level prior to surgery. Whenever possible, all patients should undergo a full colonic evaluation prior to surgery. The majority of patients will have undergone a colonos- Premalignant and Malignant Conditions copy; however, confirmation of a complete examination is important as the risk of synchronous carcinomas or adeno- Polyps mas within the colon may be as high as 10 % in the general population (Standards Practice Task Force of the American Adenomas are the most common colorectal polyps and are Society of Colon and Rectal Surgeons 2012). The risk of invasive cancer increases with polyp size planned and endoscopic localization is unreliable (all loca- and histology (degree of villous component) (Stein and Coller tions except for the cecum and distal rectum). Most adenomatous polyps are endoscopically excised, whenever possible, a pathologic diagnosis of colon cancer and if histopathologic examination excludes the presence of should be preoperatively obtained. Preoperative imaging to assess for local invasion or metas- tases should be performed. The mesenteric resection should be complete and criteria are not met, there is a risk of either residual tumor or en bloc with the bowel segment.

Overzealous ventilation in the early postoperative period in sedated patient may also lead to wound disruption buy avalide 162.5mg cheap. Steroids and chemotherapy are two important drugs in this group buy avalide 162.5 mg online, which impair and delay the normal healing process to cause burst abdomen and incisional hernia 162.5 mg avalide amex. The surgeon must keep this in mind while closing the abdominal wound and through-and-through tension suture should be applied purchase avalide 162.5mg with amex. Interrupted far and near single layer mass closures are particularly recommended in peritonitis cases, operations on pancreas, obese patients who are vulnerable to burst abdomen and subsequent incisional hernia. Nowadays polypropylene or polyamide sutures are quite competent to prevent burst abdomen. So when drainage is required, it should be employed through a separate stab incision. In many cases there is no warning of this catastrophe, but patients may have complained of ‘something has given way’ or unusual soakage of the abdominal dressing with serosanguineous fluid. It is the most pathognomonic sign of this condition and it signifies that some intraperitoneal contents are lying extraperitoneally and the muscle sutures have already given way. Wound dehiscence actually starts a few days earlier, as at this stage the sutures of the deep layers have already given way. These usually occur if an occult dehiscence has been overlooked for more than 24 hours. Alternatively a boggy swelling may be noticed in the abdominal wound in case of such occult dehiscence. The abdominal wound should be immediately covered with a sterile towel wrung out of warm saline. A nasogastric tube should be inserted to decompress the stomach and intravenous fluid therapy should be started immediately. Once the anaesthetist approves and the patient’s condition becomes stable immediate operation should be undertaken. The abdominal wound is covered with sterile packs and the surrounding skin is cleansed and painted with antiseptic solution. Any protruding contents of the abdomen are gently washed with normal saline and pushed into the abdomen with warm wet mop. The anaesthetist is asked to relax the abdominal muscles by giving muscle relaxants. All layers of the abdominal wound are approximated by through-and-through interrupted sutures of braided nylon or polypropylene passed through, a soft rubber tube or plastic tube. The sutures are started about an inch (2 to 3 cm) away from the edge of the wound. Mattress sutures are used and passed through soft rubber or plastic tubes before tying, so that these sutures cannot cut out through the skin and to minimise tension on the suture line. One must be very careful to see that no portion of the bowel is being trapped in the wound and then these sutures are tightened. The usual technique is to apply all the sutures first and then they are tied one after another from above downwards. Very occasionally there may be gross abdominal distension and it will be difficult to appose the wound margins. In these cases decompression of the bowel by retrograde milking of the intestinal contents into the stomach and nasogastric aspiration may ease the process of closure of the wound. After the abdominal wound is sutured, it is supported by strips of adhesive plaster covering about anterior 2/3rds of the circumference of the abdomen. Gastric decompression and intravenous fluids are rigidly continued until the peristalsis of bowel can be properly heard. Early ambulation is not much encouraged after this operation, but movements of the legs are encouraged. Healing is usually satisfactory, which seems to be due to improvement in collagen metabolism. The outcome is better if it is detected earlier and treated immediately, while the wound is still clean and prolapse of intestine has not occurred. Ventral Hemia or Postoperative Hemia) An incisional hernia is one which occurs through an acquired scar in the abdominal wall caused by a previous surgical operation, or an accidental trauma. Scar tissue is inelastic and can be stretched easily if subjected to constant strain. Kocher’s subcostal incision for cholecystectomy often inflicts injury to the 8th, 9th and 10th intercostal nerves; Battle’s pararectal incision for appendicectomy; McBurney’s incision for appendicectomy may injure the subcostal or ilioinguinal nerve. So careful closure of the wound is extremely important to prevent incisional hernia. There may be some oozing of serosanguineous discharge through the laparotomy wound, but this is more of a signal of wound dehiscence or burst abdomen rather than of incisional hernia. A portion of the muscles may also be destroyed by infection which are resolved afterwards by fibrosis. Sometimes attacks of subacute intestinal obstruction may occur leading to abdominal colic, vomiting, constipation and distension of the abdomen. Strangulation, though uncommon, is liable to occur at the neck of a small sac or in a locule of a large hernia. These cases must be differentiated with (differential diagnosis) : (i) A deposit of tumour. There is a wide gap in the musculature which is easily recognized and whose margin is smooth and regular. These are : (a) If the patient is obese, weight should be reduced by dieting if an elective operation has to be performed. After reducing the hernia a belt is fitted with a suitable pad so that the hernia does not get an opportunity to come out. If such treatment is continued for a long time without giving a chance of hernia to come out, there is a possibility of cure. Moreover this treatment may be applied to those type I cases where operation is contraindicated due to the general condition of the patient. In fact majority of the cases of incisional hernia need operation sometime or the other. The unhealthy skin is gradually dissected off the sac, which is nothing but a redundancy of peritoneum. If the sac is loculated and very adherent it is better to open the sac around its neck. Any adhesions involving the bowel should be separated as far as practicable before the hemial contents are returned to the abdomen. These layers are sutured individually without tension with non-absorbable sutures. Now the anterior rectus sheath is sutured in the midline if possible by overlapping. To reduce tension one may have to make release incision vertically on the lateral part of the rectus sheath. With non-absorbable sutures it is pleated so that it projects into the abdominal cavity. A few layers of sutures are applied one after the other till the healthy margins of the muscles and aponeurosis are brought close.