Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• General Information:
  • What is a suture?
    • Any strand of material used to ligate blood vessels or to approximate tissues
  • How are sutures sized?
    • By diameter;:
      • Stated as a number of 0’s:
        • The higher the number of 0’s, the smaller the diameter:
          • For example a 2-0 suture has larger diameter than 5-0 suture
  • Which is thicker, 1-0 suture or 3-0 suture?
    • 1-0 suture
• Classification:
  • What are the two most basic suture types?
    • Absorbable and non-absorbable
  • What is an absorbable suture?
    • Suture that is completely broken down by the body:
      • Dissolving suture
  • What is a nonabsorbable suture?
    • Suture is not broken down:
      • Permanent suture
• Sutures:
  • Catgut:
    • What are “catgut” sutures made of?
      • Purified collagen fibers from the intestines of healthy cows or sheep
    • What are the two types of gut sutures?
      • Plain and chromic
    • What is the difference between plain and chromic gut?
      • Chromic gut is treated with chromium salts (chromium trioxide):
        • Which results in more collagen cross-links:
          • Making the suture more resistant to breakdown by the body
• Vicryl® Suture
  • What is it?
    • Absorbable, braided, and multi-filamentous copolymer of lactide and glycoside
  • How long does it retain its strength?
    • 60% at 2 weeks
    • 8% at 4 weeks
  • Should you ever use PURPLE-colored Vicryl® for skin closure?
    • No:
      • It may cause purple tattooing
• PDS®
  • What is it?
    • Absorbable, monofilament polymer of polydioxanone:
      • Absorbable fishing line
  • How long does it maintain its tensile strength?
    • 70% to 74% at 2 weeks
    • 50% to 58% at 4 weeks
    • 25% to 41% at 6 weeks
  • How long does it take to complete absorption?
    • 180 days (6 months)
• What is silk?
  • Braided protein filaments:
    • Spun by the silkworm larva:
      • Known as a nonabsorbable suture
• What is Prolene®?
  • Non-absorbable suture:
    • Used for vascular anastomoses, hernias, abdominal fascial closure
• What is nylon?
  • Non-absorbable “fishing line”
• What is monocryl?
  • Absorbable monofilament
• What kind of suture should be used for the biliary tract or the urinary tract
  • ABSORBABLE:
    • Otherwise the suture will end up as a nidus for stone formation

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• What is the most common:
  • Type of melanoma?
    • Superficial spreading:
      • 70% of the cases
  • Type of breast cancer?
    • Infiltrating ductal
  • Site of breast cancer?
    • Upper outer quadrant
  • Vessel involved with a bleeding duodenal ulcer?
    • Gastroduodenal artery
  • Cause of common bile duct obstruction?
    • Choledocholithiasis
  • Cause of small bowel obstruction (SBO) in adults in the United States?
    • Postoperative peritoneal adhesions
  • Cause of SBO in children?
    • Hernias
  • Cause of emergency abdominal surgery in the United States?
    • Acute appendicitis
  • Electrolyte deficiency causing ileus?
    • Hypokalemia
  • Cause of blood transfusion resulting in death?
    • Clerical error:
      • Wrong blood types
  • Site of distant metastasis of sarcoma?
    • Lungs:
      • Hematogenous spread
  • Position of anal fissure?
    • Posterior
  • Acute pancreatitis?
    • Gallstones
  • Chronic pancreatitis?
    • Alcohol
  • Cause of large bowel obstruction?
    • Colon cancer
  • Cause of fever less than 48 hours postoperative?
    • Atelectasis
  • Bacterial cause of urinary tract infection (UTI)?:
    • Escherichia coli
  • Abdominal organ injured in blunt abdominal trauma?
    • Liver:
      • Not the spleen
  • Benign tumor of the liver?
    • Hemangioma
  • Malignancy of the liver?
    • Metastasis
  • Pneumonia in the ICU?
    • Gram-negative bacteria
  • Cause of epidural hematoma?
    • Middle meningeal artery injury
  • Cause of lower GI bleeding?
    • Upper GI bleeding
  • Cancer in females?
    • Breast cancer
  • Cancer in males?
    • Prostate cancer
  • Type of cancer causing DEATH in males and females?
    • LUNG cancer
  • Cause of free peritoneal air?
    • Perforated peptic ulcer disease
  • Cause of death ages 1 to 44?
    • TRAUMA

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• What percentage of people in the United States will develop acute appendicitis?
  • Approximately 7%
• What is the acceptable percentage of normal appendices removed with the preoperative diagnosis of appendicitis?
  • Up to 20%:
    • It is better to remove some normal appendices than to miss a case of acute appendicitis:
      • Which could result in a ruptured appendix
• In what percentage of cases does an upper GI bleed stop spontaneously?
  • Around 80%
• What percentage of American women develops breast cancer?
  • 12%
• What percentage of patients with gallstones will have radiopaque gallstones on abdominal x-ray (AXR)?
  • Approximately 10%
• What percentage of kidney stones is radiopaque on AXR?
  • Approximately 90%
• At 6 weeks, wounds have achieved what percentage of their total tensile strength?
  • Approximately 90%
• What percentage of the population has a Meckel’s diverticulum?
  • 2%
• One unit of packed RBCs increases the hematocrit by how much?
  • 3%
• Additional 1 L/min by nasal cannula increases FIO2 by how much?
  • 3%

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• Prophylactic Mastectomy / Risk Reducing Mastectomy:
  • Rates are rapidly rising in the United States
• Prophylactic mastectomy:
  • May be associated with a 3.5% to 5% occurrence of occult carcinoma:
    • Depending on the indication for the operation
• SLNB at the time of prophylactic mastectomy:
  • May eliminate the need for ALND if occult disease is identified
• A recent meta-analysis reviewed 14 studies where SLNB was routinely performed for prophylactic mastectomy in patients undergoing bilateral mastectomy for unilateral cancer:
  • This study found metastatic disease in the SLNB of the prophylactic mastectomy:
    • In 0 to 4% of patients with contralateral cancer
  • The majority of metastatic disease was associated with:
    • Contralateral axillary tumor spread from the primary tumor:
      • Not an occult primary tumor
  • In patients who were found to have occult malignancy in the prophylactic mastectomy breast:
    • Less than 1% of sentinel lymph nodes were positive for metastatic disease
• Given the low rates of occult malignancy and axillary metastasis:
  • SLNB is not indicated for patients undergoing prophylactic mastectomy

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• Although there are no randomized data:
  • Multiple retrospective and observational studies:
    • Have evaluated SLNB in patients who have had previous breast or axillary operations
• Previous breast conservation or excisional biopsy:
  • Does not appear to affect the accuracy of the SLN biopsy
• Completion ALND:
  • Has been routinely recommended for all patients:
    • With local recurrence:
      • However, 60% to 90% of such patients:
        • Are node negative
  • Reoperative SLNB:
    • Has been shown to be accurate after local recurrence:
      • And spares some patients from an unnecessary ALND
• Successful identification of a sentinel node:
  • However, is inversely related to the number of nodes removed during the initial operation:
    • One study evaluating SLNB after previous axillary operations:
      • Reported successful sentinel lymph node identification in:
        • 68% of patients with less than nine nodes removed previously:
          • But only 38% in patients with nine or more nodes previously excised
  • Rates of extra-axillary sentinel node localization:
    • Range from 8% to 63% in patients:
      • With previous axillary operations
    • Patients who had a previous ALND:
      • Have the highest rates of extra-axillary localization:
        • Preoperative lymphoscintigraphy:
          • In addition to blue dye is recommended for SLNB after previous axillary operation to aid in localization and identification of extra-axillary drainage

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• Male breast cancer occurs in less than two per 100,000 men in the United States:
  • Accounts for less than 1% of all breast cancers
• Men are often diagnosed at a higher stage than women:
  • Approximately 40% of male patients:
    • Have more than three nodes involved with metastases at diagnosis
• Several small studies have examined the role of SLNB in male breast cancer:
  • They have shown its accuracy:
    • SLNB can spare a significant number of male patients;
      • The morbidity of ALND

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• DCIS is noninvasive:
  • By definition, is unable to metastasize:
    • However, studies have shown that up to 15% of patients with pure DCIS:
      • Have isolated tumor cells (ITCs) or micrometastasis on nodal evaluation
    • However, these small tumor deposits:
      • Likely have little prognostic significance:
        • They may represent only cell clusters displaced by biopsy
• In patients with DCIS detected by core biopsy:
  • There is a 15% to 20% associated risk:
    • Of an invasive component when excised
• Patients undergoing mastectomy for DCIS:
  • Should be offered SLNB:
    • Since it would not be feasible to perform following mastectomy:
      • If invasive carcinoma is subsequently identified
• ASCO consensus guidelines recommend that:
  • Patients with DCIS who undergo breast-conserving operation should not routinely have SLNB:
    • However, SLNB could be discussed with patients undergoing breast conservation:
      • Who have a core biopsy diagnosis of DCIS and:
        • A large area of DCIS on imaging (2 cm to 5 cm)
        • High-grade DCIS
        • Comedonecrosis
        • When a physical examination or imaging:
          • Shows a discrete mass
    • These findings have been associated with an increased risk of invasive cancer:
      • And SLNB at the time of the initial operation could avoid a second operation

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• The lymph node that is the most likely to harbor metastatic disease:
  • Is the sentinel lymph node
• In a landmark study published in 1994:
  • A vital blue dye:
    • Was used to identify the first node in the lymphatic chain to harbor metastatic tumor
  • An axillary dissection was then completed:
    • The pathologists evaluated the sentinel lymph node separately from the remaining axillary contents:
      • The sentinel node was identified with a specificity of 96% in 174 consecutive patients with various stages of breast cancer
• As the sentinel node technique was further explored:
  • Additional studies demonstrated that SLNB could be reliably preformed using:
    • Radiolabeled colloid
    • Vital blue dye:
      • Methylene blue
      • Isosulfan blue
      • Blue patent
    • Both techniques:
      • Radiolabeled colloid and vital blue dye
• The American Society of Clinical Oncology (ASCO):
  • 2014 Sentinel Lymph Node Biopsy Early-Stage Breast Cancer Update:
    • Evaluated the performance of SLNB and reported that:
      • False negative rates of the procedure ranged from:
        • 4.6% to 16.7%
      • An overall accuracy of:
        • 93% to 97.6%
    • Factors that increase the false negative rate of SLNB are:
      • Obesity
      • Tumor location
      • Failure to localize a lymph node on lymphoscintigraphy
      • Patient age
      • Surgeon experience
• When radiolabeled sulfur colloid is used:
  • 0.4 mCi to 2 mCi of technetium-99m (99mTc)-labeled particles:
    • Measuring 50 to 200 nm in diameter are injected into the breast:
      • From 30 minutes to 24 hours before SLNB
    • Higher doses:
      • Are often used if the patient is injected the day prior to the operation
  • After injection:
    • The area is massaged gently for approximately 5 minutes:
      • To improve the lymphatic drainage
  • Patients may undergo static scintigraphy images:
    • To aid localization
• In the operating room:
  • A gamma probe is used to identify the radioactive node
    • “Hot” nodes:
      • Nodes that qualify as sentinel lymph nodes are those that have:
        • Counts greater than 10% of the ex vivo counts of the most radioactive lymph node
• Using a threshold of more than 10% of the hottest node:
  • Has been validated and correctly identifies:
    • 98% of sentinel lymph nodes
• 99mTc-labeled sulfur colloid and lymphoscintigraphy:
  • Can identify alternate lymphatic drainage:
    • And are particularly useful in patients with previous axillary operations
• Most surgeons find the use of both radioisotope and blue dye to be more successful than one method alone:
  • However, either may be used alone in experienced hands
• If vital blue dye is used:
  • 3 ml to 5 mL of solution is injected:
    • Followed by at least 5 minutes of massage is used:
      • To improve lymphatic drainage
• With either technique:
  • A transverse incision is then made:
    • Along the inferior margin of the hair-bearing region of the axilla
  • Blunt and sharp dissection:
    • Is used to identify a lymphatic track or blue-stained or “hot” node
  • Following removal of the sentinel lymph node:
    • The surgeon should palpate the axilla for any additional suspicious nodes and remove these as well
  • Although most patients have one sentinel lymph node:
    • Multiple nodes may be identified and should be removed
  • Care should be taken to remove only the targeted lymph node or nodes:
    • Separating them carefully from investing axillary fat:
      • As excessive dissection and tissue removal:
        • May increase rates of postprocedure seroma or lymphedema remove these as well
• Complications following SLNB are less frequent than complications following ALND:
  • Especially with respect to:
    • Lymphedema, sensory loss, and mobility
• Patients following SLNB:
  • Report improved quality of life and a more rapid return to work:
    • However, the International Cooperative Group Trial:
      • Reported lymphedema and seroma in:
        • 7% of patients treated with SLNB
      • Wound infection and hematoma rates:
        • Were both 1%
      • Shoulder or arm pain and decreased abduction are:
        • Also occasionally seen with SLNB.
• Both methylene blue and 1% isosulfan blue dye:
  • Are commonly used to identify sentinel lymph nodes:
    • Isosulfan blue has a documented risk of allergic reaction, resulting in:
      • Rash, urticaria, and hypotension:
        • In as many as 3% of patients
      • Anaphylaxis:
        • In less than 1%
  • Although methylene blue is less costly and has a lower risk of anaphylaxis:
    • It is associated with skin necrosis in up to 10% of patients:
      • When injected intradermally or subcutaneously
    • For this reason, it should be diluted 1:2 in saline:
      • And an intradermal injection should be avoided
  • Multiple studies have tried to prove the superiority of one or other of these dyes:
    • They appear equivalent
• Debate remains about the location of injection:
  • Peritumoral, subareolar, subdermal, and intradermal injection sites have all been used
  • Studies have shown that there is little difference between areolar injections and peritumoral injections:
    • But a randomized controlled trial:
      • Suggested that areolar intradermal injections:
        • Have the highest rates of localization and decreased harvest time of the first sentinel lymph node
  • In tumors that are large and in the upper outer quadrant of the breast:
    • Peritumoral injection is probably superior
  • In patients who undergo nipple-sparing mastectomy:
    • Subareolar injection should be avoided
  • Skin tattooing:
    • Can occur with intradermal injection
• Patients with early-stage invasive breast cancer (clinically T1 and T2):
  • Who do not have clinically positive lymph nodes (cN0):
    • Should undergo SLNB
• The ASCO reviewed the literature and created guidelines for the use of SLNB:
  • The current ASCO guidelines for SLNB are displayed in the second table
• SLNB is widely applicable:
  • But there are some circumstances:
    • In which it is contraindicated
    • And others in which its utility is questionable
  • Given the dermal and pervasive lymphatic involvement in inflammatory carcinoma:
    • An ALND should be performed in patients with inflammatory cancer:
      • These patients have lymphatic vessels largely obstructed by tumor emboli:
        • Making sentinel node localization unreliable with high false negative rates:
          • Even after neoadjuvant chemotherapy (NAC)
  • Patients with large or locally advanced breast cancers (clinically T3 / T4):
    • Have historically:
      • Not been offered SLNB
    • Small case series have shown a large variability in:
      • The accuracy (85% to 98%) and a false negative rate (3% to 18%) of SLNB for patients with large tumors:
        • And these patients made up a small group in large, randomized sentinel lymph node clinical trials
    • Clinically node-negative patients with large tumors:
      • Also have high rates of positive SLNB as well as additional involved nonsentinel lymph nodes:
        • Ranging from 40% to 80%
      • Although many practitioners perform SLNB for patients with clinically T3 tumors;
        • Current ASCO guidelines argue that there is still insufficient evidence to support the practice

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