Surgery

Question 1

Laparoscopy Complications

Answer 1

Laparoscopy: complications

Complications of laparoscopy include:
general risks of anaesthetic
vasovagal reaction (e.g. bradycardia) in response to abdominal distension
extra-peritoneal gas insufflation: surgical emphysema
injury to gastro-intestinal tract
injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

Question 2

Laparoscopy Complications - Example Question

Answer 2

You are asked to review a 65-year-old woman who has become breathless on the surgical ward. Earlier in the day she had a laparoscopic cholecystectomy for gallstone disease. A chest x-ray has already been obtained:

PASSMED SEE IMAGE SURGICAL EMPHYSEMA GINGKO LEAF SIGN

What complication has developed?

	Pneumothorax
	Intestinal perforation resulting in pneumoperitneum
	> Subcutaneous emphysema
	Pulmonary embolism
	Acute respiratory distress syndrome

This radiograph demonstrates subcutaneous (surgical) emphysema which is a known complication of laparoscopic surgery. If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the ‘ginkgo leaf’ sign.

Question 3

Atelectasis

Answer 3

Atelectasis

Atelectasis is a common post operative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.

Question 4

Atelectasis - Example Question

Answer 4

A 72-year-old man is admitted to hospital for an elective knee replacement. The surgery is completed successfully and induction, maintenance and emergence of anaesthesia proceeds without any problem. Several hours after the operation however, the patient’s saturations start to drop, reaching a level of 91% when the patient is started on oxygen via face mask. He also starts coughing up small mucous plugs.

His background history includes mild COPD that is treated with tiotropium and hypertension which is treated with ramipril and amlodipine. There is no relevant family history and he has smoked 15 cigarettes a day for 30 years.

What is the most likely diagnosis?

	> Basal atelectasis
	Pneumococcus pneumoniae
	Streptococcus pneumoniae
	Pulmonary embolism
	Pneumothorax

The most likely diagnosis in this scenario is basal atelectasis - a condition where mucous trapped in the bronchial tree results in small airway obstruction. There is often segmental lung collapse due to the basal atelectasis. Management is with chest physiotherapy and saline nebulisers to encourage production of the mucous.

Question 5

Post-Cholecystectomy Syndrome

Answer 5

= a recognised Cx of cholecystectomies

Sx:
- dyspepsia
- vomiting
- pain
- flatulence
- diarrhoea
Occur in up to 40% patients post surgery

Pathology behind syndrome isn’t completely clear, however there is some association w remnant stones and biliary injury.
Pain is often due to sphincter of Oddi dysfunction and the development of surgical adhesions

Mx:

• difficult
• involves low-fat diet and intro of bile acid sequestrations such as CHOLESTYRAMINE and bind to excess bile acids and thus preventing lower GI signs
• PPIs do play a role if pt complains of dyspeptic like Sx

Question 6

Gastric Bypass in Menstruating patients

Answer 6

The duodenum is the primary site of absorption for both IRON and CALCIUM

All gastric bypass operations bypass the duodenum

Nearly all menstruating women will therefore require iron supplementation

Question 7

Fitness to Fly - Surgery

Answer 7

Travel should be avoided for 10d following abdominal surgery
Laparoscopic surgery - can fly after 24h
Colonoscopy - can fly after 24h
Following application of a plaster cast majority of airlines restrict flying for 24h on flights <2 hours or 48h for longer flights (air can get trapped beneath the cast)