1. Surgery
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01. Reconstruction after segmental mandibulectomy
02. Neck dissection: choice of selective versus radical
03. Glossectomy
04. Obstructing sigmoid colon carcinoma: colonoscopic image
05. Total mesorectal excision for rectal cancer: cylindrical excision
06. Skin sparing mastectomy with axillary dissection
07. Blue lymphatic channel and lymph node in sentinel node mapping in breast cancer
08. Laparoscopic nephrectomy for renal cell carcinoma: procedure
09. Postchemotherapy lymph node dissection for metastatic testicular cancer
10. Glottic cancer: laryngofissure preresection
11. Completion of pneumonectomy for mesothelioma: surgical field
12. Pneumonectomy specimen in mesothelioma
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2. Reconstruction after segmental mandibulectomy
Figure If the patient has good dentition and desires the ability to chew after surgery, then the best reconstructive option after segmental resection of the mandible is the placement of an osteocutaneous free flap into the defect with stabilization using a reconstruction plate. The most common donor sites for this type of reconstruction are the fibula and the scapula. Both donor sites allow for a significant bone segment and a skin paddle to fill the mucosal defect caused by the tumor resection. The fibula osteocutaneous free flap is shown in this instance.

3. Neck dissection: choice of selective versus radical
Figure The type of neck dissection performed by the surgeon depends on the reason for the neck dissection. Selective neck dissections are usually performed electively when there is no obvious lymphatic disease in the neck but when a significant chance of occult disease exists based on the tumor site or size. As such, they are believed to be staging procedures only [6], not sufficient treatment, should disease be found pathologically [7]. Modified radical and radical neck dissections are generally used to treat gross disease in the neck, and the extent of the surgical resection in these operations depends on the amount and location of the lymphatic metastases. Whenever possible oncologically, the most conservative procedure is preferred. References: [6]. Patel SG, Shah JP, . TNM staging of cancers of the head and neck: striving for uniformity among diversity. CA Cancer J Clin [7]. Byers RM, Clayman GL, McGill D, et al. Selective neck dissections for squamous cell carcinoma of the upper aerodigestive tract: patterns of regional failure. Head Neck

4. Glossectomy
Figure 2-7. Glossectomy. More extensive lesions or those with significant submucosal extension may require a more significant glossectomy, from partial glossectomy to hemiglossectomy and subtotal glossectomy. Again, the key to the procedure is wide excision with good visualization of the tumor margins. Care should be exercised to protect the lingual and hypoglossal nerves, if oncologically possible. For most T1 and T2 lesions, this can be accomplished transorally and the tongue closed primarily. However, the neck must be addressed with a separate simultaneous neck dissection. This procedure is discussed in greater detail later in the chapter, but gross disease in the neck mandates a complete neck dissection, while a neck without disease but at risk for metastases (N0 or elective neck) is usually treated with a selective neck dissection.

5. Obstructing sigmoid colon carcinoma: colonoscopic image
Figure 1-8. Obstructing carcinoma of the sigmoid colon. A, Colon-oscopic view. B, Apple core lesion seen on full column barium enema. C, Surgical specimen demonstrates annular constriction or “napkin-ring” appearance.

6. Total mesorectal excision for rectal cancer: cylindrical excision
Figure Situation after a cylindrical excision during abdominal perineal rectum amputation. This photo shows a wide cylindrical excision of a ventrally localized distal rectal tumor. To obtain adequate circumferential margins the dorsal vaginal wall is resected en bloc with primary repair afterward. One can easily recognize that these large wounds, which in the Dutch situation have received preoperative radiotherapy (5 × 5 Gy), are at great risk for complications in wound healing. Discussions on closing these wounds with vital, previously not irradiated tissue (eg, primary muscle flap: m. gracilis, rectus abdominis) are ongoing.

7. Skin sparing mastectomy with axillary dissection
Figure Skin sparing mastectomy with axillary dissection [11]. The use of skin sparing mastectomy allows the patient to retain the native skin envelope and, combined with immediate reconstruction, the envelope is filled with an implant, expander, or tissue flap (latissimus or transverse rectus abdominis muscle [TRAM]). A circumareolar incision may be used or some surgeons will use a small elliptical incision around the nipple areolar complex. Through this incision the usual boundaries for a mastectomy are adhered to at the time of surgery with proper retraction. If a patient has had an excisional biopsy, all scars should be included within the elliptical incision (or if remote from this, a separate excision of the scar is planned) [12]. The major concern about skin sparing mastectomies is the local recurrence rate. In several retrospective studies, the incidence varies from 0% to 7% and is not statistically different from conventional mastectomy. Patients need to be selected appropriately so negative margins are achieved with this more minimal skin approach. References: [11]. Carlson GW, Bostwick J, Styblo TM, et al. Skin sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg [12]. Stradling BL, Ahn M, Angelats J, Gabram SG, Skin-sparing mastectomy with sentinel lymph node dissection: less is more. Arch Surg

8. Blue lymphatic channel and lymph node in sentinel node mapping in breast cancer
Figure 1-9. Blue lymphatic channel and blue lymph node. When using blue dye for mapping, it is important to identify the lymphatic channel, which is then carefully followed with dissection to the appropriate blue lymph node(s). On average, 1.9 (range 1–8) sentinel lymph nodes are found in breast sentinel lymph node surgery [9]. If no blue lymphatic channels or blue or hot lymph nodes are identified during the sentinel lymph node procedure, standard of care dictates a complete axillary dissection. Some surgeons perform a frozen section of the sentinel lymph node(s) that have been removed during the procedure to ensure that, in fact, lymph nodes have been retrieved, or to perform a complete axillary dissection at the same operative procedure should the sentinel lymph node be positive on frozen section (< 1% false-positive rate in this setting). There is a 5% to 15% false-negative rate for a frozen section performed intraoperatively of sentinel lymph nodes, and patients need to be advised that there is a chance they may need to return for a complete axillary dissection should tumor cells be found on hematoxylin and eosin staining 3 to 5 days later in the final pathologic analysis. References: [9]. Hansen NM, Grube BJ, Giuliano AE, The time has come to change the algorithm for the surgical management of early breast cancer. Arch Surg

9. Laparoscopic nephrectomy for renal cell carcinoma: procedure
Figure 3-8. Laparoscopic nephrectomy. Laparoscopic surgery for solid renal masses is now recognized as a viable minimally invasive alternative to open extirpative renal surgery. The perioperative benefits of the laparoscopic approach have been well established. Several studies comparing patients undergoing laparoscopic radical nephrectomy with a similar cohort undergoing open radical nephrectomy demonstrated that the laparoscopic group had less postoperative discomfort, better cosmesis, a shorter hospital stay, and a significantly more rapid return to regular activities [24],[25],[26],[27],[28].Laparoscopic radical nephrectomy may be performed via an intraperitoneal or retroperitoneal approach. Advantages to the intraperitoneal approach include a greater working space, easy identification of adjacent landmarks, and use of a muscle-splitting incision for specimen extraction. Advantages to the retroperitoneal approach include early identification of the renal hilum and lower incidence of postoperative ileus. Laparoscopic radical nephrectomy may be performed on tumors greater than 4 cm or on centrally located tumors not amenable to partial nephrectomy. This procedure usually necessitates three small port site incisions less than 1 cm each and a 5- to 6-cm incision for extraction of the intact specimen. This extraction incision may be longer for larger tumors. Laparoscopic surgery for localized renal cell carcinoma to date has not been associated with an increased risk for tumor spillage, port site, intra-abdominal or retroperitoneal recurrences, or metastatic disease. Short-term data has revealed an actuarial long-term disease-free rate and cancer-specific survival rate comparable to open renal surgery. Longer follow-up will reveal the true 5- and 10-year survival rates in this cohort of patients [24],[25],[26]. Laparoscopic partial nephrectomy may be performed on renal lesions that would conventionally be managed with an open partial nephrectomy. While initial experience with this technique was limited to small exophytic lesions, recent advances in suturing instrumentation and topical hemostatic agents now aid the surgeon in performing safe removal of endophytic lesions and more complex renal reconstruction, including repair of the collecting system if necessary [29]. The same oncologic principles used in open nephron sparing surgery are followed with the laparoscopic approach. The renal hilum is controlled, if necessary, and laparoscopic ultrasound is routinely used to confirm tumor depth and map out renal vasculature.Laparoscopic radical nephrectomy may also have a role in patients with advanced or metastatic renal cell carcinoma. Recently, centers have reported patients undergoing cytoreductive laparoscopic radical nephrectomy in preparation for immunotherapy. One study reported that laparoscopic cytoreductive laparoscopic nephrectomy allowed patients to receive adjuvant therapy with interleukin-2 a month sooner than after open radical nephrectomy [30]. The combination of improved performance status after surgery and earlier delivery of adjuvant immunotherapy may result in improved outcomes for these high-risk patients. References: [24]. Dunn MD, Portis AJ, Shalhav AL, et al. Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol [25]. Ono Y, Kinukawa T, Hattori R, et al. Laparoscopic radical nephrectomy for renal cell carcinoma: a five-year experience. Urology [26]. McDougall EM, Clayman RV, Elashry OM, Laparoscopic radical nephrectomy for renal tumor: the Washington University experience. J Urol [27]. Eraky I, El-Kappany H, Shamaa M, Laparoscopic nephrectomy: an established routine procedure. J Endourol [28]. Kavoussi LR, Kerbl K, Capelouto CC, et al. Laparoscopic nephrectomy for renal neoplasms. Urology [29]. Schiff JD, Palese M, Vaughan ED, et al. Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience. BJU Int [30]. Walther MM, Lyne JC, Libutti SK, Linehan WM, Laparoscopic cytoreductive nephrectomy as preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell carcinoma: a pilot study. Urology

10. Postchemotherapy lymph node dissection for metastatic testicular cancer
Figure Postchemotherapy retroperitoneal lymph node dissection (RPLND). RPLND is another operation for metastatic testicular tumors. This procedure is performed for residual retroperitoneal tumor after administration of chemotherapy for metastatic testis cancer. The metastatic tumor can be very adherent to the great vessels and other structures; thus, proper tissue planes are difficult to determine. Specialized vascular techniques are sometimes necessary to completely resect the retroperitoneal tumor, but complete resection of all tumor is essential to ensure a good outcome. Surgeons who attempt postchemotherapy RPLND should be experienced with the procedure. It is very difficult to predict the degree of difficulty of the procedure based on preoperative clinical parameters.

11. Glottic cancer: laryngofissure preresection
Figure 2-3. Laryngofissure preresection (A), laryngofissure postresection (B), and laryngofissure closure (C). More extensive early glottic cancers require a more aggressive excision, while still maintaining the basic laryngeal function. A tracheotomy is undertaken to protect the airway in the perioperative period. A transverse skin incision over the thyroid cartilage then allows exposure of the strap musculature. These muscles are divided in the midline, and the thyroid cartilage is exposed; the perichondrium is elevated off the cartilage on the side of the tumor. The cartilage is divided in the midline and posterior to the tumor, and a full-thickness excision is performed of cartilage, soft tissue, and underlying vocal cord. A small amount of adjacent false vocal cord can be excised, if necessary. The periosteum is closed over the defect and the neck closed. This operation is very effective for control of cancer for appropriate lesions (95% local control), but requires a tracheotomy, perioperative swallowing rehabilitation, and a hospital stay of several days. It is uniformly associated with a weak voice that improves slowly over the first year, but rarely regains its former strength and clarity.

12. Completion of pneumonectomy for mesothelioma: surgical field
Figure 7-8. Completion of surgery. A, View of the surgical field after removal of a specimen. The operative mortality rate ranges from 5% to 15%, with the major morbidity at approximately 25% (primarily arrhythmias). Other complications may include empyema, bronchopleural fistula, cardiac herniation, and bleeding [6],[7].B, To prevent herniation of intestinal viscera, the diaphragm is reconstructed with a thick Gortex (WL Gore & Associates, Inc., Newark, DE) patch. Similarly, to prevent cardiac herniation, which can lead to cardiac arrest because of torsion of the great veins, the pericardium is reconstructed with a thin Gortex patch. Fenestrations are placed to prevent tamponade. Sites of first recurrence after extrapleural pneumonectomy (EPP) are local in 35% of patients, abdominal in 26%, the contralateral thorax in 17%, and other distant sites in 8%. Long-term survival rates after EPP remain disappointing, with the median survival times ranging from 9.3 to 17 months for the majority series. The majority of patients were pathologic stage II or III in these two series. Most recently, Sugarbaker et al.[6] reported a 17-month median survival time overall in a series heavily weighted with stage I patients. Those stage I patients with epithelial histology without nodal positivity and with negative margins (n= 31 of 183) who had a multimodality approach had 2- and 5-year survival rates of 68% and 46%, respectively. Otherwise, survival of stage I was 30% at 5 years. In the series by Rusch [8], the 2- and 5-year survival rates patients with stage I disease (n= 16 of 131) were 65% and 30%, respectively [9]. References: [6]. Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg [7]. Rusch VW, Indications for pneumonectomy. Extrapleural pneumonectomy. Chest Surg Clin North Am [8]. Rusch VW, Pleurectomy/decortication in the setting of multimodality treatment for diffuse malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg [9]. Rusch VW, Venkatraman ES, Important prognostic factors in patients with malignant pleural mesothelioma, managed surgically. Ann Thorac Surg

13. Pneumonectomy specimen in mesothelioma
Figure 7-7. Pneumonectomy specimens. Radical extrapleural pneumonectomy (EPP) classically has been described for pure epithelial tumor (stage I) that is technically resectable and encapsulated by the parietal pleura. EPP is the en bloc removal of the parietal and visceral pleura, lung, hemidiaphragm, and pericardium, with reconstruction of the hemidiaphragm and the pericardium. It is usually the only cytoreductive procedure possible when a thick tumor rind obliterates the pleural space. A, EPP surgical specimen from the patients whose studies are seen in Figures 23-3 and B, Cross-section of the specimen seen in A reveals the fusion of the parietal and visceral pleura, with encroachment in the fissures and trapping of the lung.