Upon encountering the torrential arte- spheric fssure cheap 100 mg kamagra gold fast delivery, where it joins its contralateral vessel via the rial bleeding from inadvertent laceration or perforation buy generic kamagra gold 100mg line, the anterior communicating artery buy cheapest kamagra gold. The anterior cerebral artery natural frst step is aspiration of blood with the appropriate- is of particular importance when performing extended su- size sucker and application of a cottonoid with pressure to prasellar approaches for tumors as they will likely be dis- the site of injury. In addition, direct manual com- pression on the cervical carotid artery ipsilateral to the side I Vascular Injuries to the Carotid Artery of injury can help to diminish the proximal pressure on the arteriotomy, potentially facilitating hemostasis. With endo- Vascular injury during transsphenoidal surgery can occur scopic surgery, the endoscopic view may become obscured during both the surgical approach as well as the resection by blood. The most efective management of vascular in- constant irrigation of the lens will facilitate visualization. If jury is prevention through detailed preoperative and intra- the endoscope is on a scope-holder, it is important to have operative technique. It is critical for the operative surgeon an extra set of hands to control the scope so that it can be re- to remain in the midline during the approach and have an moved and cleaned or moved above the rising pool of blood intimate knowledge of the relationship between the vas- or down toward the arteriotomy as needed. Entry into 7 Fukushima and Maroon describe a surgical technique the sphenoid sinus may be complicated by a carotid artery for intrasellar control and hemostasis of an injured carotid that bulges into the space or is actually exposed to the sinus artery. After temporary control with the aforementioned without any bony protection, a phenomenon seen in 4% of 4 method, they slowly replace the cottonoid with a piece of specimens. This can be layered methods to accurately assess the relationship among vascu- by taking another piece of Tefon, which has been dipped lar, bony, and soft tissue structures. Vascular abnormalities in semisolid methylmethacrylate, and applying it over the on these studies can then be followed by digital subtrac- frst piece. The edge of the im- these imaging modalities can be coupled to intraoperative pregnated Tefon can then be inserted under the bony ridge neuronavigation to ensure that a midline approach is ad- of the sellar foor to buttress the entire system, with the op- hered to beyond the vomer, an especially important tool in tion of adding a small titanium miniplate under the bony abnormal sphenoid sinus anatomy such as cases of honey- edge for even further reinforcement. This technique retains comb confguration, nonpneumatized sphenoid bone, and the advantage of controlling the hemorrhage specifcally at oblique sphenoid septum. Other predisposing surgical dif- the site of injury within the sella and ofering a permanent fculties include cavernous sinus invasion by the tumor, compressive construct that does not need to be removed, previous transsphenoidal surgery, radiation therapy, and thereby introducing risk of rebleeding. Even in situations be at higher risk for injury secondary to distortion of nasal of successful control of hemorrhage, postoperative vascular and sinus anatomy as well as a tendency to have tortuous 6 imaging, in particular angiography, is essential to rule out ectatic arteries that may protrude into the sella. In addi- vascular anomalies that may have developed regardless of tion, previous infammatory conditions in the vicinity of the type of vascular control attained. In addition, this may lower result of overpacking during initial attempts at hemostasis. Therefore, patients with postopera- cranial hemorrhage that may need to be addressed via a tive carotid stenoses and occlusions should receive defni- craniotomy. Pseudoaneurysms represent a dangerous and unstable I Endovascular Evaluation and Treatment vascular anomaly encountered after transsphenoidal sur- of Vascular Injuries gery. They are most often positioned medially, and their thin walls predispose them to rapid growth and frequent rup- The patient can be brought intubated from the operating ture. In some cases, the aneurysmal “wall” may be formed room directly to the angiography suite. The most common encountered internal carotid artery injuries after trans- presenting sign is epistaxis, which can be delayed. Even if the immediate postoperative angio- well as the lack of protection aforded from incomplete em- gram is normal in appearance, repeat angiography should bolization often mandate parent-vessel occlusion. Endovascular Carotid Occlusion The most commonly used and efective treatment for iat- rogenic injury to the internal carotid artery after transs- phenoidal surgery is endovascular carotid occlusion in the case of larger injuries that cannot be endovascularly re- constructed. The endovascular approach is simple and can be performed immediately after the diagnostic images are obtained. Controlled endovascular embolization is more reliable than direct surgical packing of the internal carotid artery and permits balloon test occlusion to minimize isch- emic risks. The patient is brought to the angiography suite and placed in a supine position on the angiography table. Both groins are prepped and draped in a sterile fashion, and the bilateral common femoral arteries are accessed with a 19- gauge needle. The needles are exchanged for arterial sheaths that are attached to a continuous heparinized saline fush. A guide catheter is advanced through each sheath over a guide- wire into each internal carotid artery. Depending on the he- modynamic stability and hemorrhagic state of the patient, weight-based systemic heparin is dosed intravenously. The arrow points to the pseudoaneurysm of the into the high cervical segment of the internal carotid artery cavernous carotid artery. With the balloon infated 32 Managing Carotid Injury During Transphenoidal Surgery 331 until occlusion of the injured vessel, biplane angiography is of the vessel must occur both above and below the injury, performed over the cranium after injection of contrast into thereby “trapping” the perforation. Place- In formal balloon test occlusion cases, neurophysiologic ment adjacent to a branch vessel ensures that blood fow testing is performed on the patient at sequential time inter- is not static in the vicinity of the coil mass, decreasing the vals and with controlled drops in mean arterial pressure to chance for thrombus formation, propagation, and emboli. Indications and timing for cerebral blood fow based on imaging during angiography treatment are based on the severity of the symptoms, which is used to estimate the patient’s tolerance to subsequent ca- can include decreasing visual acuity, external ophthalmo- rotid occlusion. In patients for whom balloon test occlusion plegia, proptosis, hemorrhage, cortical venous drainage, in- fails, either through neurophysiologic testing or cerebral tolerable bruit/headache, and ischemia related to vascular blood fow imaging, surgical bypass remains a subsequent steal phenomenon. Venous drainage can extend anteriorly into the oph- ography performed through the vertebral artery can dem- thalmic veins, inferiorly into the pterygoid venous plexus, onstrate collateral supply to the anterior circulation via posteriorly into the petrosal sinuses, superiorly into the retrograde fow through a patent posterior communicating cortical veins via the sphenoparietal sinus, and across the artery. Often, a When vessel occlusion is required, endovascular emboli- mixed venous drainage pattern is seen. Also note the internal carotid artery angiogram after parent-vessel coil emboliza- artifact produced by the cottonoids packed into the sphenoid in the tion spanning from the ophthalmic segment to the petrous segment operating room. Note no anterograde fow of con- modalities of treatment, including carotid occlusion, which approaches, it is typical to inject contrast through an arterial runs the risk of recurrence by not obliterating the fstula. Endovascular therapy can be performed transarterially or A principal risk involved with the transvenous approach transvenously. Specifc manual maneuvers can be employed includes perforation of the relatively thin-walled venous to visualize the morphology of a high-fow fstula. The use of detachable platinum coils or transsphenoidal surgery does not lend itself to such a mor- liquid embolic material such as acrylic (N-butyl cyanoacry- phologic change. Often, the fow into a traumatic venous thrombosis may occur during catheterization. However, care must thalmic vein or intracranial hemorrhage from shunting into be taken not to decrease the pressure gradient between the cortical venous structures. Often, a formal balloon test occlusion does not most commonly via the ipsilateral jugular vein and infe- need to be performed, as anterograde fow through the ip- rior petrosal sinus. Both detachable coils and liquid embolic silateral internal carotid artery is already diverted fully into agents have been used successfully. Often, the sphe- nopalatine artery can be safely embolized after knowledge of the surrounding anastomoses so as not to jeopardize fow to collateral branches to the ophthalmic artery or menin- geal branches to the carotid artery supplying the trigeminal nerve. With the application of the transsphenoidal approach to the resection of tumors that spread outside the sellar com- partment, injuries to arteries within the intradural com- partment may occur. A commonly displaced or encased intradural artery by suprasellar extension of a tumor is the anterior cerebral artery. Iatrogenic perforation or laceration of this artery while dissecting adherent tumor from its wall is particularly devastating, as parent-vessel occlusion will often result in an ipsilateral stroke. Another possibility is avulsion of a small perforator from the anterior cerebral or anterior communicating artery (Fig.

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Moreover buy kamagra gold 100mg without a prescription, since multiple organs can be involved in the context of systemic diseases generic 100mg kamagra gold with visa, collecting multiple representative portions of target organs with syndrome- based approach (Table 45 cheap kamagra gold online amex. Influenza-associated myocarditis is a good example to show the difficulty of identifying influenza virus in the heart tissue even with prominent histopathologic changes of myocarditis, while the evidence of infection is usually present in the respiratory tissues [81]. In general, antigens and nucleic acids in tissue samples can be well preserved in paraffin-embedded blocks if formalin fixation does not exceed 2 weeks. It is highly recommended to embed tissue samples in paraffin no longer than 72 h after adequate formalin fixation. While biopsy procedure is usually performed under a strin- gent sterile condition, autopsy is not. In addition, delay of postmortem examination will facilitate colonization by normal flora or contamination by environmental organisms and interfere subsequent diagnostic assays. Therefore, autopsy should be performed as soon as possible (preferably within 12 h after death) to minimize these postmortem confounding factors. Summary Diagnosis with pathologic techniques provides histomorphologic correlation for a specific infectious agent with the disease it causes and is essential for identifying the cause of death. It helps identify or confirm the etiology of an outbreak caused by a novel pathogen, especially from severe or fatal cases. It is crucial for management of clinical patient with unknown etiology of infection, control and prevention for emerging disease outbreak, epidemiologic surveillance, and study of pathogenesis. Tissue samples, especially postmortem specimens, should be collected adequately and promptly. Because immune mechanisms can greatly amplify the host response, the actual numbers of pathogens present in tissues can be relatively small. This means that many sections may need to be examined before a pathogen is identified. If the tissue specimens are not obtained from relevant lesions or areas with histopathologic changes, the subsequent tests performed on such specimens can all result in false- negative outcomes. Timing of tissue sampling, as mentioned earlier, is another cru- cial element that can affect test results. Delayed autopsy procedure increases the chance of tissue autolysis and postmortem contamination, which can significantly interfere with histopathologic evaluation and all related pathologic tests. A negative result cannot exclude the possibility of an infection caused by certain organisms because duration of illness, modalities of treatment, tissue sampling and fixation may affect the outcome of these assays. Therefore, a correlation of the test results with clinical history, epidemiological information, and other laboratory assays is highly recommended for a more accurate interpretation involving in patient care and public health management. Shieh W-J, Guarner J, Paddock C et al (2003) The critical role of pathology in the investigation of bioterrorism-related cutaneous anthrax. Madea B, Saukko P, Oliva A, Musshoff F (2010) Molecular pathology in forensic medicine— introduction. Drosten C, Günther S, Preiser W et al (2003) Identification of a novel coronavirus in patients with severe acute respiratory syndrome. Brandtzaeg P (1998) The increasing power of immunohistochemistry and immunocytochemistry. Tao Q (1994) Double-immunostaining method using biotin-conjugated primary antibodies from the same species. Krenacs T, Krenacs L, Raffeld M (2010) Multiple antigen immunostaining procedures. Kellam P (2001) Post-genomic virology: the impact of bioinformatics, microarrays and pro- teomics on investigating host and pathogen interactions. Palacios G, Druce J, Du L et al (2008) A new arenavirus in a cluster of fatal transplant- associated diseases. Ye Y, Mar E-C, Tong S et al (2010) Application of proteomics methods for pathogen discovery. Stratton , and Yi-Wei Tang Introduction Biomarkers are continuously being sought in the field of diagnostic microbiology for the laboratory diagnosis and assessment of microbial infections. A set of clinical and laboratory criteria necessary for an ideal diagnostic marker of infection have previously been proposed by Ng and his colleagues [1 ]. According these criteria, an ideal biomarker should possess at a minimum the following characteristics: (a) bio- chemically, a biomarker should be stable and remain significantly deregulated in the body fluid compartment for at least 12–24 h even after commencement of appropri- ate treatment that may allow an adequate time window for specimen collection or storage without significant decomposition of the active compound until laboratory processing; (b) its concentration should be determined quantitatively and the method of measurement should be automatic, rapid, easy, and inexpensive; (c) the collection of a specimen should be minimally invasive and require a small volume (e. Cui (*) Jiangsu Provincial Center for Disease Control and Prevention , Nanjing , China e-mail: cui_lb@163. Needless to say, serum, plasma, and other body fluid specimens are generally available for clinical testing. Theoretically, a characteristic profile should be potential biomarkers for disease diagnosis and prog- nosis. A number of studies have been conducted to demonstrate this theory and promising results have been seen in a number of altered physiological states includ- ing various cancers, heart disease, pregnancy, diabetes, injury, and infection. In contrast, viral nucleocapsid and spike protein targets seem to co-opt downregu- lated miR-223 and miR-98 respectively. They found that the expres- sion of let-7e, miR-29a, and miR-886-5p were increased in response to mycobacterial infection at 48 h [51]. However, technical issues must be addressed before they are accepted among the current stan- dard methods [54 ]. Other disadvantages of this method include low throughput and potential environment hazards of radiolabeling. Then, a primer consisting of an oligo(dT) sequence with a universal primer-binding sequence at its 5¢-end or a uni- versal primer complementary to the 3¢-end of the linker is used to prime reverse transcription [ 53]. The basis for this type of TaqMan probe detec- tion has been reviewed by Benes and Castoldi [53]. This method also has a considerably larger dynamic range compared to microarray analysis. Therefore, Tm normalization of the full set of probes is absolutely required since the hybridization is usually carried out at one temperature. Conventional denaturing urea–acrylamide gel electrophoresis combined with a commercialized kit (e. Sepsis Diagnosis and monitoring of sepsis can be difficult because many of its signs and symptoms can be caused by other noninfectious disorders. The current gold stan- dard for diagnosing septicemia is the blood culture, which generally takes several days or longer. To date, these biomarkers have not demonstrated sufficient sensitivity and/or specificity to guide clinical management. Upregulation of miR-155, miR-223, miR-146a and downregulation of miR-125b, miR-144, and miR-142-5p have been observed in human monocyte-derived dendritic cells by Ceppi et al. Moreover, miR-150 levels were significantly reduced in plasma samples of sepsis patients and correlated with the level of disease severity.

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Systematic review and meta-analysis on management of hemodialysis catheter-related bacteremia purchase 100 mg kamagra gold amex. Clinical presentation purchase generic kamagra gold on line, etiology buy kamagra gold 100mg on line, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Changing profile of infective endocarditis – results of a one-year survey in France in 1999. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States. Impact of regional comorbidity on infective endocarditis in a southeastern United States medical center. Infective endo- carditis in patients receiving chronic hemodialysis: clinical features and outcome. Clinical out- comes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis. Staphylococcus aureus bloodstream infection and endocarditis – A prospective cohort study. Cross-sectional association of kidney function with valvular and annular calcification: the Framingham heart study. Association between cardiac valvular calcification and myocardial ischemia in asymptomatic high-risk patients with end- stage renal disease. Differences in associated factors between aortic and mitral valve calcification in hemodialysis. Valvular calci- fication and its relationship to atherosclerosis in chronic kidney disease. Mitral annular calcification predicts mortality and coronary artery disease in end stage renal disease. Cardiac valve calcifica- tion in haemodialysis patients: role of calcium-phosphate metabolism. Infective endocarditis in mainte- nance hemodialysis patients: fifteen years’ experience in one medical center. Prospective surveillance for pri- mary bloodstream infections occurring in Canadian hemodialysis units. Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients. Update on emerging infections: news from the Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections–United States, 2001, 2008, and 2009. Incidence of bloodstream infection among patients on hemodialysis by central venous catheter. Risk and prognosis of Staphylococcus aureus bacteremia among individuals with and without end-stage renal disease: a Danish, population-based cohort study. In vitro resistance to thrombin-induced platelet microbicidal protein in isolates of Staphylococcus aureus from endocarditis patients correlates with an intravascular device source. Infective endocarditis in patients with end-stage renal disease: clinical presentation and outcome. Mortality risk fac- tors in chronic haemodialysis patients with infective endocarditis. Invasive methicillin- resistant Staphylococcus aureus infections among patients on chronic dialysis in the United States, 2005–2011. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Are bioprostheses associated with better outcome than mechanical valves in patients with chronic kidney disease requiring dialysis who undergo valve surgery? Long-term survival of dialysis patients with bacterial endocarditis undergoing valvular replacement surgery in the United States. Epidemiology and clinical outcomes of infective endocarditis in hemodialysis patients. National agenda for prevention of healthcare-associated infections in dialysis centers. Approach to prophylactic measures for central venous catheter-related infections in hemodialysis: a critical review. Use of a Staphylococcus aureus conjugate vaccine in patients receiving hemodialysis. A new full course of treatment should only start if valve cultures are positive, the choice of antibiotic being based on the susceptibility of the latest recovered bacte- rial isolate. One of the most persistent problems in the failure of antibiotic therapy is the low compliance in the implementation of protocols, often related to their complexity. In this chapter, we present the antibiotic protocols used by our team (La Timone Hospital, Marseille, France), based on a more than 20-year endocarditis team expe- rience. Three sets of blood cultures should be drawn at 30 min intervals before initiation of antibiotics. If it is not possible, we use a treatment by amoxicillin 3 g/day orally for 1 year to decrease the incidence of recurrence. Some authors rely on antibiotic susceptibilities of isolated strains but this may neglect slower clones resis- tant betalactamines. There is no current evidence that alternative therapies are safer or more efficient. Staphylococcus Aureus Staphylococcus aureus is a major killer in endocarditis, with a fatality rate greater than 20 % in most series. Failures with this protocol were associ- ated with positive blood cultures after 24 h of treatment and the presence of intracar- diac abscesses. The addition of rifampin must be take place when the blood cultures are positive after 24 h of treatment and in cardiac abscesses. Adding the gentamicin aims to quickly sterilize blood culture in the case of posi- tive persistence. Dramatic reduction in infective endocarditis-related mortality with a management- based approach. Sudden death in patients with infective endocarditis: findings from a large cohort study. Treatment of Staphylococcus aureus endocarditis with high doses of trimethoprim/sulfa- methoxazole and clindamycin-preliminary report. Investigation of blood culture-negative early prosthetic valve endocarditis reveals high prevalence of fungi. Treatment of Q fever endocarditis: comparison of 2 regimens containing doxycycline and ofloxacin or hydroxychloroquine.

On the other hand order kamagra gold 100mg with mastercard, a 4-mm thick ulcerated melanoma carries a 5-year survival rate of 45% discount kamagra gold 100mg with visa. In practice buy discount kamagra gold, once the word ‘cancer’ has been used, patients take in little further information. Psychosocial aspects The diagnosis of melanoma can have significant psychosocial im- pact, particularly because there is a widespread awareness among the public that it may be lethal. Psychosocial distress impairs ability to cope, quality of life and possibly even survival. Providing general information on coping strategies and cognitive behavioural therapy (such as relaxation training) to patients with high levels of psycho- social distress improves quality of life and general health status of melanoma patients, underpinning the need for psychological sup- port following diagnosis. Metastatic melanoma Eighty per cent of metastases develop within 5 years of diagnosis. Lympho-oedema is a common post-operative complication and requires compression hosiery. Surgical excision is the mainstay of treatment for meta- static disease, as systemic chemotherapy and immunotherapy have little effect. Radiotherapy has some role in the palliation of bone and excision, hyfrecation or carbon dioxide laser ablation or regional cerebral metastases. Metastasis to the regional lymph nodes presents with palpable lymphadenopathy and is treated by lymph node Loco-regional metastases block dissection (Fig. The prognosis from regional lymph node Satellite and in-transit metastases present as papules and nodules metastasis depends on the number of lymph nodes involved. For ex- in the skin and subcutaneous tissues between the site of the original ample, a patient with a non-ulcerated primary melanoma and a single melanoma and the regional lymph nodes. They are treated by surgical metastatic lymph node has almost a 60% chance of cure. Surgical excision of distant metastases • Regional lymph nodes • Solid organs is central to effective palliative care, and improves survival for iso- • Satellite metastases (skin or subcutaneous tissues • Skeleton lated pulmonary, cerebral or gastrointestinal metastases (Fig. Many of these responses are not clinically Melanoma – management and prognosis 45 Box 10. These may be non-specific (fatigue) or specific (haemoptysis, headache, oedema) • Examine original site for satellite and in-transit recurrence • Examine for regional lymphadenopathy, distant lymphadenopathy and hepatomegaly • Complete skin examination for further primary skin malignancies and premalignant lesions • Reinforce photoprotection • Promote self-examination (see Fig. As there was no disease - comprehensive and include examination of primary site for elsewhere, this lesion was treated by surgical excision. Investigations at follow-up visits are usually guided by the history and physical ex- Follow-up amination. Follow-up for patients with melanoma enables earlier detection of metastatic disease and of new skin cancers, so that prompt, poten- Future directions tially curative, surgical intervention can be provided (Box 10. Follow-up also provides the opportunity to offer education and New chemotherapy agents introduced over the last 30years have psychological support and to reinforce self-examination techniques, not shown any benefit over dacarbazine, even in multiple combina- as up to 5% of patients develop a second primary melanoma, rep- tions, underlining the highly chemoresistant nature of melanoma. In some areas, follow-up is neously regress has led to significant interest in immunotherapy, Table 10. So far, vaccines have Further reading produced low response rates and have not improved survival. Final version of the American Joint Com- mittee on Cancer staging system for cutaneous melanoma. A tant for patients at high risk of metastasis and those with advanced national clinical guideline. Diagnostic procedures • The great majority of diagnostic and curative surgical procedures Punch biopsy can be carried out under local anaesthetic in the ambulatory care Incisional biopsy setting. Excisional biopsy • Surgical specimens must always be sent for histological investi- Curative procedures gation. Curettage and cautery * ✓* Excision with narrow margins ✓ • Suspected melanomas should be excised in their entirety with an Excision with wide margins elliptical excision. Mohs’ micrographic surgery ✓ ✓ • A punch or incisional biopsy can be used to establish a diagnosis in lesions suspected to be non-melanoma skin cancer or pre- *Avoid unless operator experienced and lesion small (< 1 cm) and low-risk – cancer. The resultant defect can be closed with a suture or packed and left to heal by secondary intention. Operators should be aware of im- Surgical procedures are carried out for both diagnosis and treat- portant structures, such as nerves and blood vessels, beneath the ment of skin cancer (Table 11. With suitable precautions, frail, elderly and anticoagulated patients can be Incisional biopsy treated safely. The choice of procedure depends on the site and type An elliptical excision is performed from the centre of the lesion to of lesion and the goal of the surgery. It is essential to form a clinical normal perilesional skin, down to the level of the subcutaneous fat differential diagnosis before performing a diagnostic procedure, as (Fig. The defect is normally closed with monofilament skin histological results should always be interpreted in the clinical con- sutures. If the histological diagnosis is at odds with the clinical impres- tological diagnosis, as they provide a larger, full-thickness sample of sion, then this must be resolved by discussion between clinician and the lesion and perilesional skin. Negative biopsy results in the face of compelling clinical evidence of cancer or pre-cancer should be treated with caution, Shave biopsy and further biopsies or complete excision of the lesion should be The most superficial layers of a lesion are shaved off using a blade or considered. Shave biopsies are appropriate for benign lesions that are protuberant above the skin surface, such as intradermal naevi. They are not suitable for diagnosis of lesions thought to be melanoma or other invasive skin cancer, since they may compromise subsequent histological measurement of tumour thickness. Selecting the appropriate diagnostic procedure Pigmented lesions Suspected melanomas should be excised in their entirety with an elliptical excision taking 1–2-mm margins of normal perilesional skin. An example would be a large removed (yellow) along with the tumour to ensure areas of subclinical spread lesion on the sole of the foot. Negative biopsy results in the face of compelling clinical evidence of skin cancer should be treated with caution. Curative procedures The goal of treating skin cancer is to remove the tumour in its entirety together with any micro-metastases with acceptable cosmetic results and minimal functional morbidity. Conventional excisional surgery remains the most common means of treating skin cancer surgically, although curettage and cautery can be used in certain situations. Surgical excision Excisional surgery for skin cancer is generally performed by derma- tologists and plastic surgeons who are part of a skin cancer multidis- ciplinary team. The benefits of excisional surgery over non-surgical treatments such as radiotherapy are that it can be completed in one visit, the whole lesion is available for histological analysis, and exci- sion margins can be analysed to ensure the tumour is completely excised. Multiple in complete excision of the primary lesion and vary with the type and cycles of curettage and cautery are required to ensure subclinical extensions are adequately treated. For melanoma, the entire lesion will usually have been excised in the primary diagnostic excision. Definitive treatment bulkier area of a lesion scooped out, after which the periphery of the with wider excision is then necessary. The size of wider lateral excision defect is scraped until all abnormal tissue is removed. Modern dis- margins varies from 1 to 3 cm, according to the Breslow thickness of posable curettes comprise an extremely sharp ring attached to an er- the melanoma (Box 1. The surgical defect may be closed directly, it difficult to feel the difference between normal and abnormal tissue with a skin flap or with a skin graft (Fig. A skin flap is the use of compared with traditional spoon-shaped curettes, which allowed for adjacent skin to cover the defect, whereas a skin graft is the use of skin cleavage through a tissue plane.