CS Skin and Soft Tissue

1. Inject radioisotope (Tc-99 sulfur colloid) intradermally in a four-quadrant fashion surrounding the lesion or previous biopsy site.
2. Obtain lymphoscintigram.
3. Three to 4 h later (or next morning), take the patient to the operating room.
4. Inject 1–3 mL of isosulfan blue intradermally in a four-quadrant fashion surrounding the lesion and gently massage.
5. Use handheld gamma probe to identify the node and make an incision over that spot.
6. Orient the incision so it can be easily incorporated into a future complete lymphadenectomy incision if necessary.
7. Record 10 s count in vivo and excise the node and then record 10 s ex vivo count.
8. Scan the nodal basin from which it was excised and continue to excise nodes until the focal basin radioactivity is less than 10% of the hottest node excised.
9. Inspect for any grossly abnormal nodes; excise if found.
10. Close the incision.
11. Perform wide local excision of primary

1. Elliptical / vertical incision centered over femoral triangle.
2. Raise flaps.
3. Divide and ligate the greater saphenous vein distally.
4. Identify the femoral vessels.
5. Reflect the lymph nodes off the femoral vessels.
6. Ligate/clip tributaries of the greater saphenous vein as they are encountered.
7. Suture ligate the greater saphenous vein at the saphenofemoral junction.
8. Identify the inguinal ligament and detach the specimen.
9. Take abdominal wall fatty tissue 5 cm above the inguinal ligament.
10. Ensure hemostasis.
11. Detach the proximal sartorius muscle and swing medially to cover the defect over the femoral vessels.
12. Secure the sartorius to the external oblique aponeurosis / inguinal ligament with interrupted 3-0 PDS horizontal mattress sutures in a staggered fashion.
13. Place closed suction drains adjacent to the sartorius.
14. Approximate subcutaneous tissues with interrupted 3-0 Vicryl.
15. Close the skin with a subcuticular stitch / staples / other.
16. Apply dressing and compressive Ace bandage to the lower extremity.

1. Curvilinear incision crossing the inguinal ligament (Option: combined incisions transverse incision above inguinal crease and longitudinal incision in femoral triangle).
2. Flaps to expose the femoral triangle and aponeurosis of the external oblique.
3. Identify and preserve the spermatic cord in males.
4. Incise fascia overlying the medial border of the adductor longus muscle to the crossing of the sartorius.
5. Sweep the nodal tissue laterally.
6. Ligate and divide the saphenous vein at the apex of the femoral triangle (Option: preservation of the greater saphenous vein).
7. Incise fascia overlying the sartorius and sweep the nodal tissue off.
8. Clean anterior surfaces of the femoral vessels.
9. Ligate and divide the saphenous vein at the saphenofemoral junction (Option: preservation of saphenofemoral junction).
10. Identify and preserve the branches of the femoral nerve.
11. If pelvic dissection:
• Detach the inguinal ligament from the anterior superior iliac spine and reflect medially / separate transverse incision above the inguinal ligament and divide abdominal wall.
• Dissect the nodal tissue along the external and common femoral vessels and obturator nerve, preserving the nerve, vessels, and ureter.
12. Obtain hemostasis.
13. Reconstruct inguinal ligament.
14. Transpose the sartorius muscle medially.
15. Place closed suction drains

1. Measure desired margin around the lesion
(depending on Breslow depth, 1–2 cm).
2. Orient incision in skin line or directed longitudinally along the limb.
3. Excise down to but not including the fascia
while maintaining perpendicular orientation
to the skin.
4. Orient the specimen.
5. Elevate flaps to facilitate closure, if needed.
6. Ensure hemostasis.
7. Close in layers

1. Preoperative coordination with radiology and nuclear medicine for breast lesion and axillary node localization
2. Peri- or subareolar blue dye injection and breast massage
3. Partial mastectomy incision placement with consideration of potential need for later mastectomy
4. Intraoperative utilization of localization techniques in addition to palpation
5. Axillary sentinel LN identification via dual tracer method
6. Removal of all axillary nodes wtih gamma rdiation count >10% of LSN
7. Aggressive hemostasis with electrocautery
8. Inspection of specimen radiograph for biopsy clip, calcifications and margin status

1. Preprocedural localization of nonpalpable lesions
2. Plan incision on lesion depth and lcoation, wiht consideration of future mastectomy incision
3. Excise localized lesion with grossly normal 1cm margins
4. Orient specimen and send to MMG to ensure wire, clip and lesion / calcifications are in specimen
5. Palpate cavity for any suspicious tissue
6. Ensure hemostasis and close
7. Postoperative MMG (1-3 weeks postop) to confirm complete excision of lesion prior to initiation of radiation therapy

1. Orient elliptical incision to include nipple-areolar complex , previous biopsy site and overlying skin
2. Use electrocautery and gentle traction to develop the connective tissue plane superficial to the breast parenchyma in creation of the skin flaps
3. Dissection borders : superiorly - clavicle, medially - sternum , laterally - lat dorsi, inferiorly - anterior rectus sheath
4. Remove the breast from pec muscle, including pectoralis fascia
5. Perform sentinel lymph node biopsy utilizing the same incision
6. Ensure hemostasis, place drains and close

1. patient positioned in supine position with leg flexed and externally rotated in frog leg position
2. An oblique, slightly S-shaped icncision is created medial to ASIS And coursing to a point 1-2cm below apex of the femoral triangle. Ellipse of skin over palpble mass included in the incision
3. Progressively thicker flaps raised laterally to the sartorius muscle, medially to adductor longus, and superiorly to a line from pubic tubercle to ASIS
4. Lymph node bearing tissue excised over femoral nerve, artery and vein and off external oblique aponeurosis
5. A deep dissection can be performed by creating a separate incision in external oblique aponeurosis or by dividing the inguinal ligament
6. The peritoneum and ureter are retracted medially to expose the iliac fossa . The iliac nodes are dissected off the common and external iliac vessels . Obturator nodes are dissected off posterior surface of external iliac vein
7. After closure over a deep drain, sartorius is mobilized and transposed to sit over the exposed femoral vessels
8. A superficial drain is placed and incision is closed

1. midline laparotomy
2. thorough exploration to verify resectability
3. complete exposure of sarcoma and surrounding structures
4. Resection of mass wtih en bloc resection of contiguous organs and vessels as needed
5. Placement of metal clips in resection bed
6. Reconstructino (bowel, major vessels) as needed
7. Abdominal closure

1. Preoperative MRI assess tumor size and proximity to surrounding structures, and core needle biopsy to detrmine histologic subtype and pathologic grade . Review in MDRT to determine optimal multimodal therapy
2. Surgical incision oriented along longitudinal axis of extremity, unless this compromises options for complex soft tissue reconstruction
3. STS is completely removed en bloc wtih a margin of uninvolved soft tissue and adjacent facial layers
4. Nerve and vessels critical to limb function are preserve.d Segment of vessel encased by tumor can be removed when vascular reconstruction is feasible
5. Orient pathologic specimen and assess margin of resection. Consider delayed reconstruction if margin status uncertain
6. Place metallic clips wtihin the srugical site as markers for adjuvant radiation
7. Close the skin and SQ tissues over surgical drains. Consider PT / OT eval following surgery