then complete staging for mets CXR CT scan LFTs brain MRI Melanoma metastases

Then complete staging for mets cxr ct scan lfts brain

This preview shows page 18 - 19 out of 170 pages.

then complete staging for mets (CXR, CT scan, LFTs, brain MRI) Melanoma × metastases : Tx radiation and chemotherapy (interferons) Lentigo maligna melanoma : superficial, spreading melanoma on the face, good prognosis overall, Tx excision w/ narrow margin Acral lentiginous melanoma : melanoma on pale areas of dark-skinned pts (sole of feet, palm of hand), worst prognosis due to depth Subungual melanoma : melanoma under fingernail or toenail, Tx DIP amputation Melanoma on face : Tx excision w/ smaller margins for cosmetic purposes, consult plastic surgery Melanoma in anus : all mucosal melanomas have bad prognosis, Tx APR w/ palpable LN excision Melanoma × SBO : presents as abd distention, nausea and vomiting due to metastatic melanoma in peritoneal cavity; Tx ex lap w/ excision –––––––––––––––– SARCOMAS –––––––––––––––– Sarcomas : present as firm, painless masses; Px depends on size, grade, and distant metastases (no LN since sarcomas spread hematogenously) Sarcoma management : Dx incisional biopsy parallel to resection margins, chest CT for mets, Tx resection w/ 1 cm negative margins High-grade sarcomas : Tx radical amputation w/ post-op radiation therapy Sarcoma × lung mets : get chest CT to characterize lesion and look for others needle biopsy for confirmation Tx thoracic wedge resection Sarcoma × liver mets : biopsy for confirmation Tx hepatic wedge resection or formal lobectomy ––––––––––––––––– HERNIAS ––––––––––––––––– Hernia surgery indications : all abdominal hernias due to possibility of strangulation, except sliding esophageal hernias (Tx PPIs) and umbilical hernias in pts <2 yo (simple observation) Umbilical hernia management : <2cm watch, >2cm fix, fix if it doesn’t regress before kinder - garten regardless Hernia × SBO : presents as abdominal distention, nausea, and vomiting due to incarcerated or strangulated hernia; Tx emergent hernia repair Hernia × strangulation : presents as firm/tender mass w/ fever, WBC, metabolic acidosis; Tx emergent hernia repair Indirect hernia : through internal ring lateral to inferior epigastrics vessels, due to patent processus vaginalis; most common hernia overall (even in women and elderly) Indirect hernia in kids : high incidence of bilaterality, repair is limited to high ligation of sac w/o abdominal wall repair Direct hernia : medial to inferior epigastric vessels, due to weakening abdominal wall; more common in elderly Femoral hernia : below inguinal ligament into femoral triangle, more common in women, highest risk of strangulation (50% of all strangulations) Sliding hernia : involves other viscera as part of the hernia wall (e.g. bladder, cecum, sigmoid colon), important to recognize sliding hernias as not to injure any contained structures Ventral hernia : hernia through incision site at linea alba; Tx primary closure (small) or mesh repair (large) Rare hernia causes : anything that increases abdominal pressure obesity, COPD, ascites, BPH
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