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• It is clear that patients with pathologically negative sentinel lymph nodes:
  • Do not require completion ALND:
    • But the management of patients with ITCs and micrometastatic disease in sentinel lymph nodes:
      • Has extensively been debated
• Micrometastatic disease is defined as:
  • Tumor deposits spanning:
    • 0.2 mm to 2.0 mm:
      • Within lymph nodes
• ITCs are:
  • Groupings of cells not greater than 0.2 mm or 200 cells:
    • In a single lymph node cross section
• According to the American Joint Committee on Cancer (AJCC) staging guidelines:
  • Patients with ITCs are N0(i+)
  • Patients with micrometastases in one to three axillary lymph nodes are N1mi
• ACOSOG Z0010:
  • Is one of the largest trials to prospectively evaluate the significance of small metastases in sentinel nodes
  • Hematoxylin and eosin (H&E) tumor-free sentinel nodes:
    • From patients with early breast cancer were evaluated in a central laboratory with:
      • Immunohistochemistry (IHC)
  • Micrometastatic or ITC disease:
    • Was found in 11% of 3,326 sentinel lymph nodes
  • With a median follow-up of 6.3 years:
    • Occult sentinel lymph node metastases:
      • Were not associated with differences in overall survival, disease-free survival, or recurrence:
        • When compared with patients with IHC-negative lymph nodes
• A subset analysis of NSABP-32:
  • Looked retrospectively at patients with occult metastatic disease:
    • Including patients with micrometastatic or isolated tumor cells
  • In patients who were sentinel node negative:
    • 16% had occult metastases detected on further evaluation:
      • 11% of occult metastases were isolated tumor-cell clusters, 4% were micrometastases, and less than 1% of patients had macrometastatic deposits seen on additional sectioning of the lymph node
  • Log-rank tests indicated that patients with occult metastasis:
    • Had worse overall survival (95% versus 96%), disease-free survival (87% versus 89%), and distant disease-free interval (90% versus 93%):
      • When compared with patients without occult metastases
    • Although statistically significant:
      • These differences were not felt to be clinically relevant
  • There was no improvement in overall or disease-free survival:
    • When patients with occult metastasis underwent completion ALND

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• Randomized clinical trials support the use of SLNB without ALND:
  • For node-negative patients
• These studies demonstrated very low axillary recurrence rates:
  • In patients with negative sentinel lymph nodes:
    • Regardless of receptor status
    • Type of breast operation
    • Patient age
• The ASCO guidelines state:
  • That women with early-stage breast cancer without sentinel nodal metastases:
    • Should not undergo ALND
• The first use of SLNB without ALND was a prospective observational study in 1994:
  • Which evaluated 125 patients with SLNB alone
• NSABP B-32:
  • A phase III trial involving 80 centers in Canada and the United States
  • Prospectively randomized 3,989 sentinel lymph node–negative patients to SLNB plus ALND or SLNB alone
  • Patients were stratified based on age, tumor size, and surgical approach
  • Regional recurrence was rare in both patients who underwent SLNB alone and those who had a completion ALND and was not statistically significantly different
  • Of the 22 regional events in both groups:
    • 10 breast cancer recurrences were in the axilla:
      • For a rate of less than 1%
    • Two of these recurrences occurred in patients who were treated with ALND and eight in patients who underwent SLNB alone
    • There was no difference in overall or disease-free survival between groups:
      • And there were fewer complications in the SLNB-alone group
  • The results of NSABP B-32:
    • Have also been seen in other studies
• Guided by this strong evidence:
  • SLNB alone has replaced ALND for sentinel node–negative patients

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• In patients with PHPT and calcium oxalate kidney stones:
  • Surgery for primary hyperparathyroidism (PHPT):
    • Can reduce stone formation by up to 90%

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• What is a taper-point needle?
  • Round body:
    • Leaves a round hole in tissue:
      • Spreads without cutting tissue
  • What is it used for?
    • Suturing of soft tissues other than skin:
      • For example:
        • GI tract, muscle, nerve, peritoneum, fascia

• What is a conventional cutting needle?
  • Triangular body with the sharp edge toward the inner circumference:
    • Leaves a triangular hole in tissue
  • What are its uses?
    • Suturing of skin

• What is a simple interrupted stitch?

• What is a vertical mattress stitch?
  • Simple stitch is made;
    • The needle is reversed, and a small bite is taken from each wound edge:
      • The knot ends up on one side of the wound
• What is the vertical mattress stitch also known as?
  • Far–far, near–near stitch:
    • Oriented perpendicular to wound
• What is it used for?
  • Difficult-to-approximate skin edges:
    • Everts tissue well

• What is a simple running (continuous) stitch?
  • Stitches made in succession without knotting each stitch

• What is a subcuticular stitch?
  • Stitch (usually running) placed just underneath the epidermis:
    • Can be either absorbable or non-absorbable:
      • Pull-out stitch if non-absorbable

• What is a purse-string suture?
  • Stitch that encircles a tube perforating a hollow viscus:
    • For example:
      • Jejunostomy tube
      • Gastrostomy tube:
        • Allowing the hole to be drawn tight and thus preventing leakage

• What are metallic skin staples?

• What is a staple removal device?

• What is a gastrointestinal anastomosis (GIA) device?
  • Stapling device that lays two rows of small staples in a hemostatic row:
    • And automatically cuts in between them

• What is a Lembert stitch?
  • It is a second layer in bowel anastomoses
  • Technique:
    • The needle is inserted perpendicular to the epidermis, approximately 8 mm distant to the wound edge.
    • With a fluid motion of the wrist, the needle is rotated superficially through the dermis, and the needle tip exits the skin 2 mm distant from the wound edge on the ipsilateral side.
    • The needle body is grasped with surgical forceps in the left hand and reloaded onto the needle driver.
    • The needle is then inserted perpendicular to the skin on the contralateral side of the wound edge, 2 mm distant from the wound edge.
    • The needle is again rotated superficially through its arc, exiting 8 mm from the incised wound edge.
    • The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges

• What is a Connell’s stitch?
  • The first mucosa-to-mucosa layer in an anastomosis:
    • Basically, a running U stitch
  • The Cushing and Connell suture technique:
    • Is often used to close the incisions in hollow organs such as the stomach, urinary bladder, and uterus
  • In the Cushing suture technique:
    • The suture penetrates into the submucosa without penetrating the organ lumen
    • The suture runs from both sides of the incision:
      • Parallel to each other
  • The Connell suture technique is almost identical to the Cushing suture technique:
    • These two suture techniques are separated according to the tissue they penetrate during suture passage
    • While the Cushing suture technique is also passed through the submucosa, Connell suture technique is used to pass through the lumen
  • While applying these techniques, the following steps are followed:
    • A directionally opposed suture passage is made parallel to the incision.
    • Suture passage is made from the other side of the incision in the same direction as the incision, parallel to the first passage
    • The beginning of the suture line is fixed with a knot.
    • Starting from the back of the knot, a suture passage is made in the direction of the incision
    • A passage is made from the other side of the incision parallel to the first pass and in the same direction
    • When the suture is pulled, the tissue becomes inverted and the knot is buried under the skin
    • A suture passage is made in the direction of the incision
    • A passage is made from the other side of the incision parallel to the first pass and in the same direction
    • The last two steps are repeated throughout the incision
    • After the incision line is crossed, End of suture line is fixed by repeating first three steps

• What is a suture ligature (a.k.a. “stick tie”)?
  • Suture is anchored by passing it through the vessel on a needle before wrapping it around and occluding the vessel:
    • Prevents slippage of knot-use on larger vessels

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• 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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