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Introduction Inguinal lymph node dissection (ILND) is performed for therapeutic and staging purposes in neoplasms such as melanoma, penile cancer, and Merkel cell carcinoma and less commonly for sarcomas, squamous cell carcinoma, and vulvar, anal, and rectal cancers. Elective ILND is performed in T1b or greater penile cancers. In most diseases, the presence of clinically positive inguinal lymph nodes is an indication for ILND. In the…
Introduction British surgeon Sir Berkeley Moynihan stated, “Surgery of cancer is not the surgery of the organs; it is the surgery of the lymphatic system.” This statement is especially true of breast cancer and melanoma, in which specific operations are carried out to remove regional lymph node metastases. Axillary lymph node dissection (ALND) was traditionally the standard of care for staging as well as treating these…
Introduction Several cancers, particularly breast cancer and melanoma, are similar in that regional lymph node metastasis greatly affects treatment, prognosis, recurrence rates, adjuvant therapy recommendations, and survival. Therefore accurate assessment and management of regional lymph node disease are of great interest in these patients. Historically, complete lymph node dissection was the standard of care for everyone with invasive breast cancer and melanoma. Although associated with high…
Introduction Nipple discharge is the third most common breast complaint for which women will see a physician. The majority of nipple discharge is benign. Nipple discharge can be characterized as physiologic or pathological. Physiologic nipple discharge is often bilateral, expressed from multiple ducts, and color can range from green to creamy. Pathological nipple discharge is spontaneous, unilateral, single duct, and bloody or serous ( Fig. 57.1…
Introduction The modern treatment of breast cancer, in simplified terms, sets forth the goal to cure the patient of breast cancer without diminishing patient quality of life, which for many patients is heavily reliant on breast reconstruction. Although some patients may decline surgery to reconstruct the breast, all patients undergoing mastectomy should be offered a referral to a board-certified plastic surgeon for potential reconstructive surgery, per…
Introduction Breast cancer is the most common cancer diagnosed and the second leading cause of cancer mortality in women. Major advances in recent years, including hormonal and monoclonal antibody therapy, have greatly improved outcomes in breast cancer patients. Historically, breast cancer has primarily been a surgically treated disease. In 1894, Halsted (per Dorland’s) and Myers described the landmark radical mastectomy. This operation removes the breast tissue,…
Introduction Compartment syndrome of any extremity is a limb-threatening condition that must be recognized and treated in a timely fashion. Left untreated, compartment syndrome can lead to not only limb loss or functional impairment of the affected limb but also systemic consequences such as renal failure, worsening acidosis, and death. Compartment syndrome is seen in both the upper and lower extremities, and the etiologies are similar.…
Introduction Arterial lines are invasive procedures performed under sterile technique in the emergency, critical care, and operative settings to closely monitor blood pressure. They are most commonly placed in the radial artery but can also be placed in the axillary, brachial, femoral, and dorsalis pedis arteries. Arterial lines are also useful to have in place when frequent blood draws and blood gas analyses are needed. You’re…
Introduction Successful and safe insertion of a central venous catheter requires an understanding of the anatomic relationships associated with the larger veins of the body. These catheters can be used for fluid resuscitation, blood draws, hemodynamic monitoring, parental nutrition, and blood product administration. When bedside ultrasonography is used, these key anatomic relationships are even better observed during catheter placement. Ultrasound can be used to assist in…
Introduction Resuscitative emergency thoracotomy can be a lifesaving procedure for patients in traumatic cardiac arrest. As a salvage maneuver, the associated mortality is high, and the search to clarify indications has sparked controversy since its first description. Patients who are pulseless with signs of life after penetrating thoracic trauma have the highest chance of survival after emergency thoracotomy ( Fig. 51.1A ). Additional indications include penetrating…
Introduction Chest tube placement may be a lifesaving maneuver. Chest tubes are generally inserted for pneumothorax, hemothorax, hemopneumothorax, empyema, chylothorax, bronchopleural fistula, and pleural effusion. Although there are no absolute contraindications to placement, caution is advised when considering placement in patients with coagulopathy or those who may be on antiplatelet agents or other anticoagulants. They are placed in emergent and nonemergent clinical situations, and depending on…
Introduction The well-trained airway expert has a key understanding of the anatomy and challenges that may cause possible complications during airway placement. There are several essential steps when considering an airway placement. The provider must understand the indications for intubation and have a standardized method of assessing the patient’s anatomy. With more complex airway placement encounters, the provider should be familiar with numerous difficult airway adjuncts…
Introduction Amputations above and below the knee are common surgical procedures performed by vascular, orthopedic, and general surgeons. The indications for these procedures include infection, irreversible acute ischemia, chronic progressive ischemia, trauma, intractable pain, neuropathy, and non-healing wounds. In developed countries, the primary indications for lower-extremity amputation are complications of peripheral vascular disease and diabetes mellitus. Preoperative Evaluation Recognition of the importance of amputation as the…
Introduction Infrainguinal arterial bypasses are major arterial reconstructions with the proximal anastomotic site below the inguinal ligament that are commonly used in the setting of chronic limb-threatening ischemia manifested by rest pain and/or tissue loss. The goal of these reconstructions is to provide inline arterial flow below the level(s) of the significant arterial stenosis or arterial occlusion. When a bypass is considered, it is imperative to…
Introduction Lower-extremity peripheral arterial disease (PAD) symptoms range from asymptomatic to claudication, which may be lifestyle limiting, to chronic limb-threatening ischemia consisting of rest pain and/or tissue loss. The usual minimum threshold for treatment is lifestyle-limiting claudication. However, this is considered on a case-by-case basis because this stage of PAD is not limb threatening. Chronic limb-threatening ischemia, as the name suggests, mandates treatment. Although the use…
Introduction Hemodialysis continues to be the predominant form of renal replacement. Arteriovenous fistulas (AVFs) are the preferred hemodialysis (HD) vascular access. Compared with arteriovenous grafts (AVGs) and tunneled central venous catheters (CVCs), they have lower complication and infection rates, reduced rates of vascular access thrombosis and access-related hospitalizations, and reduced overall health care costs. Both the 2006 Kidney Disease Outcomes Quality Initiative (KDOQI) and the 2008…
Introduction Mesenteric ischemia can be an acute or chronic process. Acute mesenteric ischemia is caused by embolism or thrombosis of one or more mesenteric blood vessels. Embolism is generally a result of a recent cardiac event or arrhythmia. Acute mesenteric ischemia patients have elevated lactic acid and often “pain out of proportion” to the physical exam. Urgent angiographic imaging should reveal filling defects in one or…
Video 43.1 Abdominal Aortic Aneurysm Introduction Aneurysms and dissections are the most common disease processes of the aorta. Several factors contribute to their formation and growth. Although most aneurysms are now treated through endovascular techniques, open surgical reconstruction of the aorta is still necessary in certain anatomic and physiologic constraints. Open aortic reconstruction was first described by Dubost et al in 1951 and has undergone continuous improvement…
Subclavian Artery Reconstruction Introduction Cervical reconstruction of arch branch vessels requires detailed understanding of neck and thoracic outlet anatomy. Revascularization of the subclavian arteries using a carotid subclavian bypass or transposition can be used to improve or preserve blood flow to the left subclavian and its branch vessels. Proximal occlusive lesions of the subclavian can be treated using these procedures avoiding open chest reconstruction and as…