24- Abdominal Wall - Explains Flashcards
(285 cards)
1
Q
What is a Spigelian hernia?
A
An interparietal hernia occurring at the level of the arcuate line, usually between the internal and external oblique muscles, with equal distribution in both sexes.
2
Q
Where is the position of a Spigelian hernia?
A
Lateral to the rectus abdominis.
3
Q
What are the possible repair options for a Spigelian hernia?
A
Both open and laparoscopic repair, with open repair preferred in cases of strangulation.
4
Q
What is a lumbar hernia?
A
A rare hernia that occurs in the lumbar triangle bounded by the iliac crest, external oblique, and latissimus dorsi muscles.
5
Q
What is the most common cause of lumbar hernias?
A
Most lumbar hernias are incisional hernias following renal surgery.
6
Q
What is the recommended procedure for the repair of a lumbar hernia?
A
Direct anatomical repair with or without mesh reinforcement.
7
Q
What is an obturator hernia?
A
A hernia that occurs through the obturator canal, more common in females and usually located behind the pectineus muscle.
8
Q
How do obturator hernias typically present?
A
Most cases present acutely with obstruction, requiring laparotomy or laparoscopy for diagnosis and treatment.
9
Q
What is a Richter’s hernia?
A
A condition where part of the small bowel wall is strangulated within a hernia, typically involving the anti-mesenteric border.
9
Q
How do Richter’s hernias differ from typical intestinal obstructions?
A
Richter’s hernias do not present with typical features of intestinal obstruction as the lumenal patency is preserved.
10
Q
What is an incisional hernia?
A
A hernia that occurs through a site of surgical access into the abdominal cavity, often following surgical wound infection.
11
Q
What is the recommended technique to minimize the risk of incisional hernias after midline laparotomy?
A
Following the Jenkins Rule, a suture length four times the length of the incision with bites taken at 1cm intervals, 1cm from the wound edge.
12
Q
What is a Bochdalek hernia?
A
A typically congenital diaphragmatic hernia, with 85% of cases located in the left hemidiaphragm.
13
Q
What are some characteristics of Bochdalek hernias?
A
They are more common in males, associated with lung hypoplasia on the affected side, and may contain the stomach.
14
Q
How are Bochdalek hernias treated?
A
Treatment may involve direct anatomical apposition or placement of mesh. Severe cases in infants may require mechanical ventilation, but the mortality rate is high.
15
Q
What is a Morgagni hernia?
A
A rare type of diaphragmatic hernia that occurs through the foramen of Morgagni.
16
Q
Where is a Morgagni hernia usually located?
A
On the right side and tends to be less symptomatic.
17
Q
What may a more advanced Morgagni hernia contain?
A
Transverse colon.
18
Q
What is the incidence of pulmonary hypoplasia in Morgagni hernias?
A
Less common due to the small defects.
19
Q
What is the preferred treatment for Morgagni hernias?
A
Direct anatomical repair.
20
Q
What is an umbilical hernia?
A
A hernia that occurs through a weak umbilicus.
20
Q
When does an umbilical hernia usually present?
A
In childhood.
21
Q
Are umbilical hernias often symptomatic?
A
Yes, they are often symptomatic.
22
Q
What is the sex incidence of umbilical hernias?
A
Equal in both sexes.
22
At what age do 95% of umbilical hernias resolve?
By the age of 2 years.
23
When is surgery typically performed for umbilical hernias?
After the third birthday.
24
What is a paraumbilical hernia?
A hernia that occurs in adulthood through a defect in the linea alba.
25
Is paraumbilical hernia more common in males or females?
More common in females.
26
What are the risk factors for paraumbilical hernia?
Multiparity and obesity.
27
What is the traditional repair technique for paraumbilical hernia?
Mayo's technique, which involves overlapping repair. Mesh may be used unless small bowel resection is required due to acute strangulation.
27
What is a Littre's hernia?
A hernia that contains Meckel's diverticulum.
28
What is usually required in the treatment of Littre's hernia?
Resection of the diverticulum.
29
Can a mesh repair be performed for Littre's hernia?
A mesh repair may not be possible if small bowel resection is required due to acute strangulation.
30
What is a possible cause of right iliac fossa pain with pain radiating?
Appendicitis.
31
What are common symptoms associated with appendicitis?
Anorexia (loss of appetite) and a short history. Diarrhea and profuse vomiting are rare.
32
What condition often presents with a long history, signs of malnutrition, and changes in bowel habit?
Crohn's disease.
33
What condition mainly affects children and is associated with a higher temperature compared to appendicitis?
Mesenteric adenitis.
34
Which condition may present with right iliac fossa pain and can affect both the left and right sides?
Diverticulitis. A CT scan can help confirm the diagnosis.
35
What is Meckel's diverticulitis?
A congenital abnormality present in about 2% of the population, typically located 2 feet proximal to the ileocaecal valve. It may be lined by ectopic gastric mucosal tissue and can cause bleeding.
36
What condition usually produces upper quadrant pain but can also cause lower abdominal pain?
Perforated peptic ulcer.
37
What is a possible cause of right iliac fossa pain that may be associated with a hernia or bowel obstruction?
Incarcerated right inguinal or femoral hernia.
38
What condition is rare for right iliac fossa pain and is associated with bowel perforation secondary to caecal or colon carcinoma?
Bowel perforation secondary to caecal or colon carcinoma.
39
What are some gynecological causes of right iliac fossa pain?
Pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion/mittelschmerz.
40
What are some other possible causes of right iliac fossa pain?
TB (tuberculosis)/typhoid/herpes zoster/AAA (abdominal aortic aneurysm)/situs inversus.
40
What are some urological causes of right iliac fossa pain?
Ureteric colic/urinary tract infection/testicular torsion.
41
What is the typical location of abdominal pain in appendicitis?
Peri-umbilical (around the belly button), which then radiates to the right iliac fossa due to inflammation of the appendix.
42
Is marked and persistent vomiting common in appendicitis?
No, it is unusual. Patients may vomit once or twice, but persistent vomiting is uncommon.
43
Is diarrhea a common symptom of appendicitis?
No, diarrhea is rare. However, pelvic appendicitis or a pelvic abscess may cause some loose stools.
44
What is the typical temperature range in patients with appendicitis?
Mild pyrexia, usually around 37.5-38°C. Higher temperatures are more typical of conditions like mesenteric adenitis.
45
Is anorexia common in patients with appendicitis?
Yes, anorexia (loss of appetite) is very common. It is unusual for patients with appendicitis to feel hungry.
45
What are the signs on examination for appendicitis?
Generalized peritonitis if perforation has occurred or localized peritonism. Retrocecal appendicitis may have relatively few signs. Digital rectal examination may reveal a boggy sensation if a pelvic abscess is present or even tenderness with a pelvic appendix.
46
What diagnostic findings justify an appendectomy?
Raised inflammatory markers, compatible history, and examination findings.
47
What is the role of ultrasound in the diagnosis of appendicitis?
Ultrasound is useful in females when pelvic organ pathology is suspected. While the appendix may not always be visualized, the presence of free fluid should raise suspicion.
48
What is the treatment for appendicitis?
Appendectomy, which can be performed via open or laparoscopic approach. Metronidazole administration helps reduce wound infection rates. Patients with perforated appendicitis require abdominal lavage. Patients without peritonitis but with an appendix mass should receive broad-spectrum antibiotics and may require an interval appendectomy.
49
What should you be cautious about in older patients with suspected appendicitis?
Underlying caecal malignancy or perforated sigmoid diverticular disease.
50
What structures are divided in a midline incision?
Linea alba, transversalis fascia, extraperitoneal fat, peritoneum.
51
How can the bladder be accessed in a midline incision?
Through the extraperitoneal approach via the space of Retzius.
52
What structures are divided/retracted in a paramedian incision?
Anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum.
53
What is the location of a battle incision?
Similar to paramedian, but the rectus muscle is displaced medially and denervated.
54
What is the purpose of a Kocher's incision?
It is used for procedures like cholecystectomy and is made under the right subcostal margin.
55
Where is a Lanz incision made and what procedure is it commonly used for?
It is made in the right iliac fossa and is commonly used for appendicectomy.
56
What is a gridiron incision and where is it centered?
It is an oblique incision centered over McBurney's point and is typically used for appendicectomy.
57
What is the purpose of a Gable rooftop incision?
There is no specific information provided about this incision.
58
What is the location and purpose of a Pfannenstiel's incision?
It is a transverse supra-pubic incision primarily used to access pelvic organs.
59
What is the purpose of a McEvedy's incision and where is it made?
It is a groin incision commonly used for emergency repair of a strangulated femoral hernia.
60
What is the purpose of a Rutherford Morrison incision?
It is an extraperitoneal approach to the left or right lower quadrants, providing access to the iliac vessels. It is the preferred approach for first-time renal transplantation.
61
What are the most common causes of colonic obstruction?
Malignancy (60%) and diverticular disease (20%).
62
What percentage of colonic obstruction cases are due to volvulus?
5%
63
What is a potential differential diagnosis for colonic obstruction?
Acute colonic pseudo-obstruction.
64
What is a rare but recognized cause of colonic obstruction?
Intussusception, often due to tumors in the adult population.
65
What are the typical symptoms of a patient with large bowel obstruction?
Gradual onset of progressive abdominal distension, colicky abdominal pain, obstipation or absolute constipation.
66
What is a useful sign on examination for colonic obstruction?
Presence of caecal tenderness (assuming no overt evidence of peritonitis).
67
What imaging modality is commonly used as the first line investigation for large bowel obstruction in the UK?
CT scan
68
What is the surgical indication for prompt surgery in large bowel obstruction?
A caecal diameter of 12cm or more in the presence of complete obstruction, with a competent ileocaecal valve and caecal tenderness, indicating impending perforation.
69
What is the recommended treatment for right-sided lesions causing large bowel obstruction?
Right hemicolectomy or its extended variant, with the possibility of constructing an ileocolic anastomosis.
70
What are the treatment options for left-sided lesions causing obstruction?
Subtotal colectomy and anastomosis, left hemicolectomy with on-table lavage and primary anastomosis, left hemicolectomy with end colostomy formation, or colonic stent insertion.
71
What did the Cochrane review and meta-analysis conclude about the use of colonic stents?
Both reviews concluded that there was no benefit from using colonic stents over conventional surgical resection, with better outcomes observed in the surgical group.
72
What did the CREST trial suggest about the use of self-expanding metallic stents?
The trial suggested that self-expanding metallic stents can improve outcomes and avoid the need for a stoma.
73
How should rectosigmoid lesions causing obstruction be treated?
Generally, a loop colostomy is performed. For lesions in the distal sigmoid colon, a high anterior resection is usually performed, and the decision to restore intestinal continuity is made by the operating surgeon.
74
How is a fistula defined?
An abnormal connection between two epithelial surfaces.
75
What are the two types of fistulas mentioned in general surgical practice?
Diverticular disease and Crohn's disease.
76
What is the general rule for fistulas?
They will resolve spontaneously as long as there is no distal obstruction.
77
What is an enterocutaneous fistula?
A fistula that links the intestine to the skin. It can be high output (>500ml) or low output (<250ml) depending on the source.
77
What are the four types of fistulas?
Enterocutaneous, enteroenteric or enterocolic, enterovaginal, and enterovesical.
78
What are the symptoms and characteristics of a colo-cutaneous fistula?
It tends to leak faeculent material.
79
What can cause the formation of an enterocutaneous or enterocolic fistula?
Spontaneous rupture of an abscess cavity onto the skin or iatrogenic input.
80
What is an enterovaginal fistula?
A fistula that goes from the intestine to the vagina.
81
What is an enterovesical fistula?
A fistula that goes from the intestine to the bladder. It can result in frequent urinary tract infections or the passage of gas from the urethra during urination.
82
What are some important rules to remember for fistula management?
Fistulas will heal if there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option.
83
How should the overlying skin be protected in cases of fistulas with skin involvement?
Using a well-fitted stoma bag to prevent skin damage, which can be difficult to treat.
83
What can be used to manage high output fistulas?
Octreotide, which can reduce the volume of pancreatic secretions and make the fistula more manageable.
84
What are common nutritional complications associated with high fistulas?
Nutritional complications, such as those seen in high jejunal or duodenal fistulas, may require the use of total parenteral nutrition (TPN) to provide nutritional support, along with the concomitant use of octreotide to reduce volume and protect the skin.
85
What should surgeons avoid when managing perianal fistulas with acute inflammation?
Probing the fistula, as this almost always worsens outcomes.
86
What is the recommended management option for perianal fistulas secondary to Crohn's disease?
Draining acute sepsis and maintaining drainage through the judicious use of setons, while implementing medical management.
87
Why is it important to delineate the anatomy of a fistula?
To understand the track and source of the fistula. For intra-abdominal abscesses and fistulas, barium and CT studies can be used. For perianal fistulas, surgeons should recall Goodsall's rule in relation to internal and external openings.
88
What are stomas?
They are created during abdominal procedures to bring the lumen or visceral contents onto the skin.
89
Which organ is most commonly involved in the creation of stomas?
The bowel.
90
Can other organs or their contents be diverted through stomas if needed?
Yes, depending on the situation, other organs or their contents may be diverted through stomas.
91
Why should small bowel stomas be spouted?
To prevent the irritant contents of the small bowel from coming into contact with the skin.
92
Do colonic stomas need to be spouted?
No, colonic stomas do not need to be spouted as their contents are less irritant.
93
Why is stoma siting important?
Stoma siting influences the patient's ability to manage their stoma and reduces the risk of leakage.
94
What can happen if there is leakage of stoma contents?
Leakage of stoma contents can lead to maceration of the surrounding skin and a loss of control of stoma contents.
95
What is the purpose of a gastrostomy stoma?
Gastric decompression or fixation, as well as feeding.
96
Where is the common site for a gastrostomy stoma?
Epigastrium.
97
What is the purpose of a loop jejunostomy stoma?
It is seldom used and may be used following emergency laparotomy with planned early closure.
98
Where can a loop jejunostomy stoma be located?
Any location according to need.
99
What is the purpose of a percutaneous jejunostomy stoma?
Usually performed for feeding purposes and is located in the proximal bowel, typically in the left upper quadrant.
100
What is the purpose of a loop ileostomy stoma?
Defunctioning of the colon, for example, following rectal cancer surgery.
101
Where is the common site for a loop ileostomy stoma?
Usually in the right iliac fossa.
102
What is the purpose of an end ileostomy stoma?
It is usually created following complete excision of the colon or when an ileo-colic anastomosis is not planned.
103
Where is the common site for an end ileostomy stoma?
Usually in the right iliac fossa.
104
What is the purpose of an end colostomy stoma?
It is created when a colon is diverted or resected, and an anastomosis is not primarily achievable or desirable.
105
Where can an end colostomy stoma be located?
Either in the left or right iliac fossa.
106
What is the purpose of a loop colostomy stoma?
To defunction a distal segment of the colon, with the distal lumen acting as a vent.
107
Where can a loop colostomy stoma be located?
It may be located in any region of the abdomen, depending on the colonic segment used.
108
What is the purpose of a caecostomy stoma?
It is considered a stoma of last resort when a loop colostomy is not possible.
109
Where is the common site for a caecostomy stoma?
Right iliac fossa.
109
Where can a mucous fistula stoma be located?
It may be located in any region of the abdomen, according to clinical need.
110
What is the purpose of a mucous fistula stoma?
To decompress a distal segment of the bowel following colonic division or resection, especially if closure of a distal resection margin is not safe or achievable.
111
What are some common causes of groin masses?
Herniae, lipomas, lymph nodes, undescended testis, femoral aneurysm, and saphena varix.
112
What can the history of a groin mass reveal?
Features relating to systemic illness and tempo of onset can provide clues to the underlying diagnosis.
113
What are some key questions to ask about groin lumps?
Is there a cough impulse? Is it pulsatile and expansile? Are both testes intra scrotal? Are there any leg lesions? Is there any history of anal cancer? Is the lump soft, small, and superficial?
114
What are some key questions to ask about scrotal lumps?
Is the lump entirely intra scrotal? Does it transilluminate? Is there a cough impulse?
115
How is the diagnosis of groin masses typically made?
In most cases, a diagnosis can be made clinically. If it is not clear, an ultrasound scan is often the next convenient investigation.
116
What is intra-abdominal pressure?
The steady state pressure concealed within the abdominal cavity.
117
What is the normal intra-abdominal pressure in critically ill adults?
5-7mmHg.
118
What are the pressures associated with intra-abdominal hypertension?
12-25mmHg.
119
What are the consequences of intra-abdominal pressures >15mmHg?
Microvascular hypoperfusion.
120
How is abdominal compartment syndrome defined?
Sustained intra-abdominal pressure >20mmHg coupled with new organ dysfunction/failure.
121
When can abdominal compartment syndrome occur?
It can occur either primarily without previous surgical intervention (e.g., following intestinal ischemia) or secondarily following a surgical procedure.
122
How is the diagnosis of abdominal compartment syndrome typically made?
Transvesical pressure measurements coupled with an index of clinical suspicion.
123
What is the recommended treatment if non-operative measures fail?
Laparotomy and laparostomy.
124
What are the non-operative measures for managing abdominal compartment syndrome?
Gastric decompression, improving abdominal wall compliance (e.g., with muscle relaxants/sedation), draining abdominal fluid collections, and considering fluid restriction/diuretics if clinically indicated.
125
What are the options for laparostomy?
The Bogota bag or VAC (Vacuum Assisted Closure) techniques, which are the most widely practiced.
126
What follows after laparotomy in the management of abdominal compartment syndrome?
Re-look laparotomy and attempts at delayed closure will be considered in due course.
127
What is Cullen's sign associated with?
Pancreatitis or other intraabdominal hemorrhage.
127
What is Rovsing's sign associated with?
Appendicitis.
128
What is Boas' sign associated with?
Cholecystitis.
129
What is Murphy's sign associated with?
Cholecystitis
129
What is Grey Turner's sign associated with?
Pancreatitis or other retroperitoneal hemorrhage.
130
What are the relative proportions of conditions presenting with abdominal pain?
Non-specific abdominal pain (35%), appendicitis (17%), intestinal obstruction (15%), urological disease (6%), gallstone disease (5%), colonic diverticular disease (4%), abdominal trauma (3%), perforated peptic ulcer (3%), and pancreatitis (2%).
130
What should non-specific abdominal pain be considered as?
A diagnosis of exclusion, and efforts should be made to exclude organic disease.
131
When should a CT scan be considered in cases of suspected perforated peptic ulcer?
If plain x-rays show no evidence of free air but clinical signs suggest otherwise.
131
What are some underlying medical causes of abdominal pain?
Pneumonia or diabetic ketoacidosis can contribute to abdominal symptoms in some patients.
132
What are some key points in the management of acute abdominal pain?
Early administration of adequate analgesia, the use of abdominal ultrasound for more information, and plain radiology as the main test for suspected perforated viscus.
133
What should be considered in cases of fever, raised white cell count, tachycardia, and peritonism?
Strangulated intestine.
134
What are the key investigations in suspected large bowel obstruction?
A water-soluble contrast enema or CT scan.
135
What can be used as a definitive diagnostic test when need for surgery is difficult to define and imaging is inconclusive?
Laparoscopy.
136
What can cause thrombosis of the splenic vein?
Pancreatitis, pancreatic carcinoma, iatrogenic trauma, and hypercoagulable diseases.
137
What complication can arise from splenic vein thrombosis?
The development of gastric varices.
138
What is the usual management for Mittelschmerz?
Conservative treatment.
138
What diagnostic tests should be performed in female patients presenting with abdominal pain?
Bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning.
139
Are esophageal varices common in splenic vein thrombosis alone?
No, esophageal varices are uncommon in splenic vein thrombosis alone.
140
How is the diagnosis of splenic vein thrombosis made?
By CT angiography.
141
What provides a reliable method of assessing suspected tubulo-ovarian pathology when diagnostic doubt persists?
Laparoscopy
141
What is the treatment for splenic vein thrombosis?
Splenectomy.
142
What is Mittelschmerz?
Mid-cycle pain in women, usually with a sharp onset, little systemic disturbance, and recurrent episodes. It usually settles within 24-48 hours.
143
What are the features and management of endometriosis?
It may present with asymptomatic cases or be associated with other pelvic organ pathology. Other cases may have menstrual irregularity, infertility, pain, and deep dyspareunia. Complex disease may require surgery, and in some cases, colonic and rectal resections may be necessary.
144
What are the symptoms, investigation, and treatment for ovarian torsion?
Symptoms include sudden onset of deep-seated colicky abdominal pain, associated with vomiting and distress. Ultrasound may show free fluid. Laparoscopy is usually performed for both diagnosis and treatment.
145
What are the symptoms, investigation, and treatment for ectopic gestation?
Symptoms include evidence of pregnancy without intrauterine gestation, often presenting as an emergency with evidence of rupture or impending rupture. Ultrasound may show no intrauterine pregnancy. Laparoscopy or laparotomy is performed, especially if the patient is hemodynamically unstable. Salpingectomy is usually performed.
146
What are the symptoms, investigation, and treatment for pelvic inflammatory disease (PID)?
Symptoms include bilateral lower abdominal pain associated with vaginal discharge, and dysuria may also be present. High vaginal and urethral swabs should be taken for investigation. Medical management is usually used.
147
What are inguinal hernias?
When the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal.
148
How are inguinal hernias classified?
They can be classified as direct or indirect, based on their relation to Hesselbach's triangle.
149
What are the boundaries of Hesselbach's triangle?
What are the boundaries of Hesselbach's triangle?
150
Where do direct hernias occur in relation to Hesselbach's triangle?
They occur within the triangle.
151
Where do indirect hernias occur in relation to Hesselbach's triangle?
They occur outside the triangle.
152
How are most inguinal hernias diagnosed?
Most cases are diagnosed clinically, with a reducible swelling at the level of the inguinal canal.
153
How can unclear cases be further investigated?
They can be investigated using ultrasound or by performing a herniogram.
154
How are symptomatic or high-risk hernias usually treated?
They are usually treated surgically.
155
What is the treatment for first-time hernias?
An open inguinal hernia repair, where the hernia is reduced and the defect repaired. A prosthetic mesh may be used to reinforce the repair.
156
How are recurrent or bilateral hernias usually managed?
They are generally managed with a laparoscopic approach, deploying a mesh posterior to the deep ring.
157
How are inguinal hernias in children usually treated?
They are usually treated with herniotomy, especially in cases of neonatal hernias where there is a high risk of strangulation. Other hernias may be repaired on an elective basis.
158
How is diarrhea defined according to the World Health Organization?
Having more than 3 loose or watery stools per day.
159
What is considered chronic diarrhea?
Diarrhea that lasts for more than 14 days.
159
What is considered acute diarrhea?
Diarrhea that lasts for less than 14 days.
160
What are some possible causes of acute diarrhea?
Gastroenteritis, which may be accompanied by abdominal pain or nausea/vomiting. Diverticulitis, which classically causes left lower quadrant pain, diarrhea, and fever. Antibiotic therapy, especially with broad spectrum antibiotics. Clostridium difficile infection is also associated with antibiotic use.
161
What is a possible cause of constipation causing overflow diarrhea?
A history of alternating diarrhea and constipation may be given. This can lead to faecal incontinence in the elderly.
162
What are the most consistent features of chronic diarrhea?
Abdominal pain, bloating, and change in bowel habit.
163
How can patients with chronic diarrhea be divided?
Into those with diarrhea-predominant irritable bowel syndrome (IBS) and those with constipation-predominant IBS.
164
What are some additional features that may be present with chronic diarrhea?
Lethargy, nausea, backache, and bladder symptoms.
165
What are the common symptoms of ulcerative colitis?
Bloody diarrhea, crampy abdominal pain, weight loss, faecal urgency, and tenesmus.
166
What are the common symptoms of Crohn's disease?
Crampy abdominal pains, diarrhea (less commonly bloody than in ulcerative colitis), malabsorption, mouth ulcers, perianal disease, and intestinal obstruction.
167
What are the symptoms commonly associated with colorectal cancer?
Diarrhea, rectal bleeding, anemia, and constitutional symptoms (e.g., weight loss and anorexia).
168
What are the symptoms of coeliac disease in children?
Failure to thrive, diarrhea, and abdominal distension.
169
What are the symptoms of coeliac disease in adults?
Lethargy, anemia, diarrhea, weight loss. Other autoimmune conditions may coexist.
170
What are some other conditions associated with diarrhea?
Thyrotoxicosis, laxative abuse, appendicitis with pelvic abscess or pelvic appendix, radiation enteritis.
171
What diagnostic tests can be considered for chronic diarrhea?
Stool culture, abdominal and digital rectal examination. Colonoscopy may be performed (radiological studies are unhelpful). Thyroid function tests, serum calcium, anti-endomysial antibodies, and glucose.
172
What is abdominal wound dehiscence?
It occurs when all layers of an abdominal wound closure fail and the viscera protrude externally.
173
How is abdominal wound dehiscence classified?
It can be subdivided into superficial, where only the skin wound fails, and complete, implying failure of all layers.
174
What are some factors that increase the risk of abdominal wound dehiscence?
Malnutrition, vitamin deficiencies, jaundice, steroid use, major wound contamination (e.g., faecal peritonitis), and poor surgical technique.
175
What is the preferred method for wound closure to reduce the risk of dehiscence?
The mass closure technique, also known as the Jenkins Rule, is the preferred method.
176
What is the management approach when sudden full dehiscence occurs?
The management involves providing analgesia, intravenous fluids, intravenous broad-spectrum antibiotics, covering the wound with saline-impregnated gauze, and arranging for a return to the operating theater.
177
What is the surgical strategy to address abdominal wound dehiscence?
The underlying cause needs to be corrected, such as providing total parenteral nutrition (TPN) or using a nasogastric (NG) feeding tube if malnourished. The most appropriate strategy for managing the wound should be determined.
178
When is resuturing of the wound an option for managing abdominal wound dehiscence?
It may be an option if the wound edges are healthy and there is enough tissue for sufficient coverage. Deep tension sutures are traditionally used for this purpose.
179
What is a wound manager and when is it suitable for managing abdominal wound dehiscence?
A wound manager is a clear dressing with a removable front. It is particularly suitable when there is some granulation tissue present over the viscera or when there is a high-output bowel fistula in the dehisced wound.
180
What is a 'Bogota bag' and when is it applied in managing abdominal wound dehiscence?
A 'Bogota bag' is a clear plastic bag that is cut and sutured to the wound edges. It is only a temporary measure to be adopted when the wound cannot be closed, and it will require a return to the operating theater for definitive management.
181
What is a VAC dressing system and what should be ensured when using it for managing abdominal wound dehiscence?
A VAC dressing system can be safely used, but only if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this rule can result in the development of multiple bowel fistulae, creating a difficult management problem.
181
What are the important principles to appreciate regarding surgical complications?
The anatomical principles that underpin complications, the physiological and biochemical derangements that occur, the most appropriate diagnostic modalities to utilize, and the principles that underpin their management.
182
How can complications be minimized in surgery?
By anticipating likely complications and appropriate avoidance.
183
What are some points to consider in order to avert complications in surgery?
Utilizing the World Health Organisation checklist prior to all operations, administering prophylactic antibiotics at the right dose, right drug, and right time, assessing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) and ensuring adequate prophylaxis, marking the site of surgery, using tourniquets with caution and respect for underlying structures, avoiding the use of adrenaline-containing solutions and monopolar diathermy in situations where end arteries occur, handling tissues with care to prevent devitalized tissue from serving as a nidus for infection, and being cautious of potential coupling injuries when using diathermy during laparoscopic surgery.
184
What is a favorite target for laparoscopic ports and surgical drains?
The inferior epigastric artery.
185
Why is understanding the anatomy of a surgical field important?
It allows for the appreciation of local and systemic complications that may occur during surgery.
186
What are some examples of nerve injuries that may occur following surgery in specific regions?
Accessory nerve injury during posterior triangle lymph node biopsy, sciatic nerve injury during a posterior approach to the hip, common peroneal nerve injury when the legs are in the Lloyd Davies position, long thoracic nerve injury during axillary node clearance, pelvic autonomic nerve injury during pelvic cancer surgery, recurrent laryngeal nerve injury during thyroid surgery, and hypoglossal nerve injury during carotid endarterectomy or repair.
187
What are some structures that may be at risk of injury during certain procedures?
The thoracic duct during thoracic surgeries like pneumonectomy or esophagectomy, parathyroid glands during difficult thyroid surgeries, ureters during colonic resections or gynecological surgeries, bowel perforation during the use of a Verres Needle to establish pneumoperitoneum, bile duct injury due to failure to delineate Calot's triangle carefully and careless use of diathermy, facial nerve during parotidectomy, tail of the pancreas when ligating the splenic hilum, testicular vessels during re-do open hernia surgery, and hepatic veins during liver mobilization.
188
What physiological/biochemical problem is associated with arrhythmias following cardiac surgery?
Susceptibility to hypokalemia (K < 4.0) in cardiac patients.
189
What physiological/biochemical problem is associated with neurosurgical electrolyte disturbance?
SIADH (syndrome of inappropriate antidiuretic hormone) following cranial surgery, causing hyponatremia.
190
What physiological/biochemical problem is associated with pulmonary edema following pneumonectomy?
Loss of lung volume makes these patients very sensitive to fluid overload.
191
What physiological/biochemical problem is associated with ileus following gastrointestinal surgery?
Fluid sequestration and loss of electrolytes.
192
What complications can arise from an anastomotic leak?
Generalized sepsis causing mediastinitis or peritonitis, depending on the site of the leak.
193
What complications can arise from a myocardial infarction following surgery?
In addition to direct cardiac effects, the decreased cardiac output may compromise grafts and other areas.
193
What baseline investigations are often helpful in acutely unwell surgical patients?
Full blood count, urea and electrolytes, C-reactive protein (trend rather than absolute value), serum calcium, liver function tests, clotting (remember to repeat if ongoing bleeding).
194
What special tests can be used for identifying specific complications?
CT scanning for identification of intra-abdominal abscesses, Doppler ultrasound of leg veins for identification of deep vein thrombosis (DVT), CTPA for pulmonary embolism, sending peritoneal fluid for U&E (if ureteric injury suspected) or amylase (if pancreatic injury suspected), and echocardiogram if pericardial effusion is suspected post-cardiac surgery and no pleural window is made.
195
What should be the guiding principle in the management of complications?
Safe and timely intervention.
196
What approach should be taken if an operation needs to occur in tandem with resuscitation?
Generally, a damage limitation type procedure rather than definitive surgery, which can be more safely undertaken in a stable patient the following day.
197
What is the recommended approach for laparotomies for bleeding?
The core principle of quadrant packing and subsequent pack removal should be followed, rather than plunging large clamps into pools of blood. This approach can worsen the situation and often leads to significant visceral injury, particularly when done by the inexperienced. If packing controls the situation, it is acceptable to leave packs in place and remove them the following day in the ICU.
197
What should be considered regarding thrombolysis in patients with recent surgery?
Recent surgery is a contraindication to thrombolysis, and in some patients, IV heparin may be preferable to a low molecular weight heparin as it is easier to reverse.
198
What are common causes of groin masses?
Herniae, lipomas, lymph nodes, undescended testis, femoral aneurysm, and saphena varix (more of a swelling than a mass).
199
What features in the history can provide clues to the underlying diagnosis of a groin mass?
Features relating to systemic illness and tempo of onset.
200
What key questions can help in assessing groin lumps?
Is there a cough impulse? Is it pulsatile and expansile (to distinguish between false and true aneurysm)? Are both testes intra-scrotal? Are there any lesions in the legs such as malignancy or infections (possibly lymph nodes)? Should the ano-rectum be examined for possible metastasis of anal cancer to the groin? Is the lump soft, small, and very superficial (possibly a lipoma)?
201
What key questions can help in assessing scrotal lumps?
Is the lump entirely intra-scrotal? Does it transilluminate (possibly hydrocele)? Is there a cough impulse (possibly a hernia)?
202
What is often the most convenient next investigation when the diagnosis is not clear clinically?
An ultrasound scan.
203
What is vomiting?
Reflex oral expulsion of gastric (and sometimes intestinal) contents, involving reverse peristalsis and abdominal contraction.
203
Where is the vomiting center located?
In a part of the medulla oblongata.
204
What are the three main categories of causes for malabsorption?
Intestinal causes, pancreatic causes, and biliary causes.
204
What triggers the vomiting center?
Receptors in several locations, including labyrinthine receptors of the ear (motion sickness), overdistention receptors of the duodenum and stomach, the trigger zone of the central nervous system (CNS) where many drugs (e.g., opiates) act, and touch receptors in the throat.
205
What are the common symptoms of malabsorption?
Diarrhea, steatorrhea (excessive fat in the stool), and weight loss.
206
What are some examples of intestinal causes of malabsorption?
Coeliac disease, Crohn's disease, tropical sprue, Whipple's disease, Giardiasis, and brush border enzyme deficiencies (e.g., lactase insufficiency).
207
What are some examples of pancreatic causes of malabsorption?
Chronic pancreatitis, cystic fibrosis, and pancreatic cancer.
208
What are some other causes of malabsorption?
Bacterial overgrowth (e.g., in systemic sclerosis, diverticulae, blind loop), short bowel syndrome, and lymphoma.
208
What are some examples of biliary causes of malabsorption?
Biliary obstruction and primary biliary cirrhosis.
208
What are the typical symptoms of intussusception in pediatric patients?
Colicky abdominal pain and vomiting.
209
What are some recognized causes of intussusception?
Lumenal pathologies such as polyps, lymphadenopathy, and diseases like cystic fibrosis.
210
What can happen as a result of the telescoping of the bowel in intussusception?
Mucosal ischemia and bleeding, which may lead to the passage of red "current jelly" stools.
211
What is the most common variant of intussusception, and who does it typically affect?
Idiopathic intussusception of the ileocecal valve and terminal ileum, which typically affects young children and toddlers.
212
How is the diagnosis of intussusception usually made?
Abdominal ultrasound investigation.
213
What factors influence the treatment approach for intussusception?
The patient's physiological status and abdominal signs.
213
What is the usual treatment approach for relatively well children without localizing signs?
Attempted pneumatic reduction under fluoroscopic guidance.
214
When is laparotomy typically recommended for treatment?
In unstable children with localizing peritoneal signs or when attempted radiological reduction has failed.
215
When is pneumatic reduction not performed?
When there are concerns about impending perforation or if there is a small bowel intussusception.
216
What is the role of plain abdominal x-rays in patients with acute abdominal pain?
They are often used as a first-line investigation to assess for causes such as free air, bowel obstruction, and other sources of pain (e.g., renal or gallbladder stones).
217
What is the preferred imaging modality for investigating potential visceral perforation?
An erect chest x-ray, as it is more sensitive for suspected visceral perforation compared to recumbent films.
218
What are some features on abdominal x-rays that are usually abnormal?
Large amounts of free air (indicating colonic perforation), positive Rigler's sign (gas on both sides of the bowel wall), a caecal diameter >8cm, fluid levels in the colon, and a ground glass appearance (usually due to large amounts of free fluid).
219
What is a sentinel loop on an abdominal x-ray, and what does it suggest?
A loop of bowel seen in patients with inflammation of other organs (e.g., pancreatitis), indicating the presence of nearby pathology.
220
What are some features on abdominal x-rays that can be expected or occur without pathology?
Chiladitis sign, where a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression of free air; identification of air in the biliary tree following ERCP (and sphincterotomy); and free intra-abdominal air following laparoscopy or laparotomy, which usually dissipates after 48-72 hours.
221
How is the diagnosis of IBS made according to the ROME III criteria?
Recurrent abdominal pain or discomfort for at least 3 days per month for the past 3 months, along with two or more of the following: improvement with defecation, onset associated with a change in stool frequency, and onset associated with a change in stool form.
222
What are some additional features that may support the diagnosis of IBS?
Lethargy, nausea, backache, and bladder symptoms.
223
What are some red flag features that should be inquired about during evaluation for IBS?
Rectal bleeding, unexplained/unintentional weight loss, family history of bowel or ovarian cancer, and onset of symptoms after 60 years of age.
224
What are the suggested investigations for IBS?
Full blood count, ESR/CRP, coeliac disease screen (tissue transglutaminase antibodies), colonoscopy (if worrying symptoms or positive family history), thyroid function tests, and glucose (to ensure not diabetic).
225
What do the NICE criteria state regarding diagnostic tests for IBS?
Blood tests alone are sufficient for diagnosis in individuals fulfilling the diagnostic criteria.
226
What is the recommended treatment approach for IBS?
Reducing fiber intake, tailored prescriptions of laxatives or loperamide based on clinical presentation, dietary modifications (such as caffeine avoidance and reducing carbonated drinks), considering low-dose tricyclic antidepressants if pain is a dominant symptom, and biofeedback may be helpful.
226
Where is the femoral canal located in relation to the femoral sheath?
It lies at the medial aspect of the femoral sheath.
227
What does the femoral sheath contain?
Both the femoral artery laterally and the femoral vein medially.
228
What are the borders of the femoral canal?
Laterally: Femoral vein, Medially: Lacunar ligament, Anteriorly: Inguinal ligament, Posteriorly: Pectineal ligament.
228
What are the contents of the femoral canal?
Lymphatic vessels and Cloquet's lymph node.
228
What lies medially to the femoral canal?
The femoral vein.
229
What is the physiological significance of the femoral canal?
It allows the femoral vein to expand, facilitating increased venous return from the lower limbs.
230
What is the pathological significance of the femoral canal?
It is a potential space where femoral hernias can occur, and the relatively tight neck of the canal puts them at high risk of strangulation.
231
What are some common presentations of upper gastrointestinal bleeding?
Haematemesis (vomiting blood) and/or melaena (dark, tarry stools), along with epigastric discomfort and sudden collapse.
232
Which presentation of upper gastrointestinal bleeding is associated with higher mortality?
Patients presenting with haematemesis (vomiting blood) have a higher mortality compared to those with melaena alone.
233
What are the presenting features of oesophageal bleeding due to oesophagitis?
Small volume of fresh blood, often streaking vomit, and melaena is rare. It usually ceases spontaneously and is often preceded by symptoms of gastroesophageal reflux disease (GORD).
234
What are the presenting features of oesophageal bleeding due to cancer?
Usually a small volume of blood, except as a pre-terminal event with erosion of major vessels. Other associated symptoms may include dysphagia (difficulty swallowing) and constitutional symptoms such as weight loss. Recurrence may occur until the malignancy is managed.
235
What are the presenting features of Mallory Weiss tear?
Typically, brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Melaena is rare, and the bleeding usually ceases spontaneously.
236
What are the presenting features of varices-related upper gastrointestinal bleeding?
Usually a large volume of fresh blood. Swallowed blood may cause melaena. It is often associated with haemodynamic compromise. While it may stop spontaneously, re-bleeds are common until appropriately managed.
237
What are the presenting features of gastric cancer-related gastric bleeding?
It may be frank haematemesis (vomiting blood) or altered blood mixed with vomit. Patients may have prodromal features of dyspepsia and constitutional symptoms. The amount of bleeding can vary, but erosion of a major vessel can lead to considerable hemorrhage.
237
What are the presenting features of Dieulafoy lesion-related gastric bleeding?
There are often no prodromal features prior to haematemesis and melaena (dark, tarry stools), but this arteriovenous malformation can produce significant hemorrhage that may be difficult to detect endoscopically.
238
What are the presenting features of diffuse erosive gastritis-related gastric bleeding?
Patients usually experience haematemesis, epigastric discomfort, and there is usually an underlying cause such as recent NSAID usage. Large volume hemorrhage can occur, leading to significant hemodynamic compromise.
238
What are the presenting features of gastric ulcer-related gastric bleeding?
Small, low volume bleeds are more common and may present as iron deficiency anaemia. However, erosion into a significant vessel can lead to considerable hemorrhage and haematemesis.
239
What are the common causes of major hemorrhage in the duodenum?
A posteriorly sited duodenal ulcer is the most common cause, but ulcers at any site in the duodenum can present with haematemesis, melaena, and epigastric discomfort. Periampullary tumors may also cause bleeding, although they are rare. In patients with previous abdominal aortic aneurysm surgery, aorto-enteric fistulation remains a rare but important cause of major hemorrhage with high mortality.
240
What are the initial steps in the management of upper gastrointestinal bleeding?
Admission to the hospital for careful monitoring, cross-matching blood, and checking blood parameters such as FBC (full blood count), LFTs (liver function tests), U+E (urea and electrolytes), and clotting.
241
What blood type is likely to be given to patients with ongoing bleeding and hemodynamic instability?
O negative blood (universal donor) may be given pending cross-matched blood.
242
Why is early control of the airway vital in certain cases, such as a drowsy patient with liver failure?
Early control of the airway is vital to ensure proper oxygenation and ventilation.
243
What treatment should patients with suspected varices receive prior to endoscopy?
Patients with suspected varices should receive terlipressin, a medication that helps reduce bleeding, prior to endoscopy.
244
When should upper gastrointestinal endoscopy ideally be performed for patients admitted with upper gastrointestinal hemorrhage?
Ideally, all patients admitted with upper gastrointestinal hemorrhage should undergo upper GI endoscopy within 24 hours of admission. For unstable patients, it may be done immediately after resuscitation or in tandem with it.
245
What are the treatment options for varices?
Varices can be treated with banding or sclerotherapy. If active bleeding makes these options impossible, a Sengstaken-Blakemore tube or Minnesota tube can be inserted.
246
What treatment should patients with erosive esophagitis/gastritis receive?
Patients with erosive esophagitis/gastritis should receive a proton pump inhibitor to reduce acid production.
247
What is the typical course of Mallory Weiss tears?
Mallory Weiss tears typically resolve spontaneously without any specific treatment.
247
What treatment should bleeding points receive?
Identifiable bleeding points should be treated with a combination of adrenaline injection and either thermal or mechanical treatment. Continuous infusion of a proton pump inhibitor should also be given to reduce re-bleeding rate.
248
When might surgery be indicated for upper gastrointestinal bleeding?
Surgery may be indicated for patients over 60 years of age, those with continued bleeding despite endoscopic intervention, those with recurrent bleeding, and those with known cardiovascular disease and poor response to hypotension.
249
What is the surgical management for duodenal ulcer with brisk bleeding?
Laparotomy, duodenotomy, and under-running of the ulcer. The bleeding site is almost always posteriorly sited and may have invaded the gastroduodenal artery, which is occluded using large bites above and below the ulcer base.
250
What is the surgical management for gastric ulcer with bleeding?
Under-running of the bleeding site.
251
What surgical procedures may be performed for antral ulcer or lesser curve ulcer involving the left gastric artery?
Partial gastrectomy or under-running of the ulcer.
252
When may total gastrectomy be considered for gastric ulcer with persistent bleeding?
Total gastrectomy may be considered if bleeding persists even after other interventions.
253
How can the need for admission and timing of endoscopic intervention be predicted?
The Blatchford score can be used, which considers a patient's Hb (hemoglobin), serum urea, pulse rate, and blood pressure. A score of 0 is low risk, while any other score is considered high risk and requires admission and endoscopy.
254
Is pre-endoscopic proton pump inhibition necessary?
The necessity of pre-endoscopic proton pump inhibition is contentious. While it does not impact mortality or morbidity, it may reduce the stigmata of recent hemorrhage at endoscopy. Some still administer PPI to patients prior to endoscopic intervention.
255
What should be done following endoscopy for acute upper gastrointestinal bleeding?
Calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a low rebleeding rate of 4% and a very low risk of mortality, identifying patients suitable for early discharge.
