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Year 3 > Surgery > Flashcards

Surgery Flashcards

1
Q

What is the definition of an abdominal aortic aneurysm?

A

Dilation >3cm

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2
Q

What is the definition of any arterial aneurysm?

A

> 50% normal diameter of the artery

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3
Q

When should an AAA be considered for surgery?

A

> 5.5cm
Or larger than 4cm and >1cm/year increase
Symptomatic

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4
Q

How often should AAAs be monitored?

A

If 3.0-4.4 then 2 years

4.5-5.4 every 3 months

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5
Q

Describe management for small and large AAAs?

A

Small- monitoring, manage HTN, statins, stop smoking

Large- surgical open repair (with clamping, removal and prosthetic graft) or endovascular repair (EVAR, has improved survival, graft via femoral arteries)

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6
Q

What’s the difference in outcomes between open repair and EVAR for AAAs?

A

Both open repair and endovascular repair have similar long term outcomes.

Endovascular repair does have an improved short term outcome in terms of decreasing hospital stay and 30 day mortality, yet has a higher rate of reintervention and aneurysm rupture. After 2 years the mortality for both procedures is the same, therefore in young fit patients an open repair may be more appropriate .

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7
Q

In a 50yo man with a ruptured AAA, what is the repair of choice?

A

Open:
 open surgical repair is likely to provide a better balance of benefits and harms in men under the age of 70.
 EVAR provides more benefit than open surgical repair for most people, especially for women and for men over the age of 70

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8
Q

Following an EVAR for a ruptured AAA, a 70yo lady does not seem to be improving. What might have happened?

A

people can develop abdominal compartment syndrome after EVAR or open surgical repair of a ruptured AAA.
Assess people for abdominal compartment syndrome if their condition does not improve after EVAR or open surgical repair of a ruptured AAA.

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9
Q

Is there screening for AAA?

A

Yes, to men >65yo

Men screened for AAA have been shown to have an approximately 50% reduction in aneurysm-related mortality

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10
Q

What longer term complication can result from EVAR AAA repair?

A

Endoleak (endovascular leakage)
When seal around the aneurysm is incomplete so blood leaks into graft
Can eventually rupture. Needs monitoring with CT angio (NOT USS, won’t be able to tell if endoleak or aneurysm)

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11
Q

Where does intermittent claudication most frequently affect? (which muscles and artery)

A

Superficial femoral artery (which supplies entire lower leg, becomes popliteal, so calf muscle pain)
Pain due to build up of anaerobic metabolites and pain producing chemicals (substance P) due to inadequate arterial supply

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12
Q

Differentials for intermittent claudication?

A

Spinal stenosis (pain radiating down both legs, worse on walking, but not rapidly relieved by rest)
Sciatica (root compression)
MSK strain

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13
Q

6 Ps of acute arterial insufficiency

A

Pale, pulseless, parasthesia, perishingly cold, painful

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14
Q

What is ABPI?

A

Leg pressure / arm pressure (use the higher number of both)
Normal is >1.1
arterial disease if <0.9
May be falsely high if calcified vessels (diabetics, renal failure, very elderly)

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15
Q

How can you differentiate arterial and venous ulcers?

A

Venous: shallow with irregular borders and a granulating base, characteristically located over the medial malleolus

Arterial: small deep lesions with well-defined borders and a necrotic base. They most commonly occur distally at sites of trauma and in pressure areas (e.g the heel).

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16
Q

Definition of postural hypotension

A

Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.

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17
Q

If someone has intermittent claudication, what medication should you start them on? What surgery would you consider?

A 
Clopidogrel
Angioplasty (insert stent with balloon, inflate, leave stent)
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18
Q

Treatments for critical limb ischaemia?

A

Angioplasty (stent with balloon)
Bypass (e.g. femoropopliteal)
Amputation

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19
Q

What are varicose veins and what are risks?

A

Tortuous, twisted or lengthened veins
Result from valvular failure
Risks are prolonged standing times, pregnancy, obesity

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20
Q

What type of varicose veins are most?

A

Trunk (resulting from the long or short saphenous vein and their branches)
Another type is telangiectasia (intradermal <1mm vessels)

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21
Q

Describe primary, secondary and tertiary varicose veins?

A

Primary- most common, from valvular failure
Secondary- from obstruction of deeper vein leading to varicose vein in superficial vein
Tertiary- arteriovenous fistula (high pressure flow causes engorgement in vein)

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22
Q

Varicose vein complications?

A

Haemorrhage and thrombophlebitis

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23
Q

Venous disease complications?

A

Venous ulcers, varicose eczema, lipodermatosclerosis, haemosiderin deposition, atrophe blanche (white scarring in lower leg from venous hypertension)

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24
Q

Surgical options for varicose veins?

A
  1. Laser ablation
  2. US guided foam sclerotherapy
  3. Open surgery
25
Q

Surgical options for varicose veins?

A
  1. Laser ablation (heat closes vein)
  2. US guided foam sclerotherapy (causes scarring in vein which closes it)
  3. Open surgery
26
Q

Causes of leg ulcers

A 
Venous, arterial, pressure 
Neuropathy (DM)
Vasculitis (SLE, RA, systemic sclerosis)
Sickle cell 
BCC, SCC
Sarcoidosis
27
Q

What is the pathophysiology of venous ulcers?

A

Varicose veins/previous DVT –> venous hypertension –> higher oncotic pressure leads to oedema –> oxygen and metabolites have to diffuse further from microcirculation to tissues –> ischaemia/inflam/reperfusion injury –> varicose eczema, lipodermatosclerosis, haemosiderin staining, ulceration

28
Q

Management for venous ulcers

A

4 layer compression bandaging (if arterial circulation okay)
Leg elevation
Improve mobility
Improve diet/obesity/smoking

29
Q

General complications of surgery

A

Haemorrhage, infection, damage to surrounding structures, wound dehiscence
Incisional hernia
Resp- pneumonia, atelectasis, ARDS

30
Q

Complications of anaesthesia

A

Local anaesthesia- haematoma, allergic, toxicity from inadvertent IV injection
Epidural- headache after dural puncture, spinal haematoma,
GA- PONV
CVS- MI
Resp- laryngospasm, atelectasis, LRTI
Hypothermia
Inadvertent trauma- corneal abrasions, diathermy pad burns, pressure sores

31
Q

What is Whipple’s

A

removal of the head of the pancreas, duodenum and GB

Rejoins the tail of pancreas directly to small intestine so bile flows straight in

32
Q

What is Hartmann’s

A

Removal of sigmoid colon +/- rectum with end colostomy formation in the acute setting (usually for perforated diverticular disease or an obstructing cancer). Rectal stump formed. Can reverse later on usually

33
Q

Complications of blood transfusion

A 
Acute: 
Haemolytic reaction 
ABO incompatibility 
Severe allergic reaction 
TRALI 
Febrile non-haemolytic TR 
Urticaria (give chlorphenamine 10mg IV and continue) 
Fluid overload 
Chronic: 
GvHD 
CMV, HIV, vCJD 
Iron overload 
Post-transfusion purpura (Platelet alloAbs) 
Infected cannula
34
Q

What is ARDS?

A

Acute resp distress syndrome. Rapid shallow breathing, hypoxia, diffuse pulmonary opacification on CXR (white out).

For various causes, pulmonary capillaries become more permeable and leads to leakage of protein fluid into alveolar interstitium –> interstitial oedema –> reduced lung compliance (stiff lungs)

35
Q

What are causes of ARDS?

A

Lung insults: aspiration, drowning, lung contusion, smoke inhalation
Systemic insults: multiple trauma with shock, severe acute pancreatitis, sepsis, air embolism, DIC, drug OD

36
Q

What are causes of ARDS?

A

Lung insults: aspiration, drowning, lung contusion, smoke inhalation
Systemic insults: multiple trauma with shock, severe acute pancreatitis, sepsis, air embolism, DIC, drug OD

37
Q

Complications of bowel surgery?

A

Anastamotic leak
Paralytic ileus (most commonly small bowel)
Pseudo-obstruction (adynamic large bowel with no mechanical obstruction, other causes are NOFF surgery and hypokalaemia)
Adhesions develop 1 weeks post surgery
Intra abdominal abscess
Peritonitis
Fistula

38
Q

What are the indications for different types of femur surgery

A

Fracture:
subcapital/transcervical: Hemiarthroplasty (or THR if young)
DHS if basicervical

Subtrochanteric: IM femoral nail

OA:
Hemi if old, THR if young

39
Q

Medications to stop pre surgery?

A

5 days before- warfarin (start bridging plan)
1 week before- clopidogrel, NOACs
1 month before - COCP, HRT

Continue steroids (risk of Addisonian crisis) 
Continue aspirin 
SC insulin may be changed to VRIII
40
Q

What prophylaxis should be given for hepatobiliary/ colorectal/urology surgery?

A

Gentamicin + Metronidazole IV

41
Q

What prophylaxis should be given for orthopaedic surgery patients?

A

Co-amoxiclav

42
Q

When should you give VRIII for diabetic patients undergoing surgery?

A

If they are anticipated to miss more than 1 meal
If HbA1c is >69 and surgery is urgent

For emergency surgery:
If CBG >11mmol
If on insulin/tablet/known poor control

43
Q

When can a massive haemorrhage be declared?

A

> 150ml/min lost

50% of blood volume in 3hours

44
Q

Options for upper GI bleed treatment?

A
  1. Endoscopy (either adrenaline + thrombin/thermal coag/clips)
  2. Transcatheter arterial embolisation (go through arteries to zap bleeding one)
  3. Surgery
45
Q

What is a longer term treatment for bleeding varices?

A

TIPS: transjugular intrahepatic portosystemic shunts

46
Q

Name 2 XR signs that can be seen with peritonitis

A 
Psoas sign (loss of sharp border of psoas secondary to fluid in retroperitoneum) 
Rigler's sign: gas present in lumen and peritoneum so can see double wall
47
Q

What Abx for mild/mod no sepsis and ITU admitted peritonitis?

A

Mild/mod no sepsis: Co-amoxiclav and gentamicin

ITU: Tazocin

48
Q

Name the hernia layers

A

Anterior: aponeurosis of the external oblique
Posterior: transversalis fascia
Roof: transversalis fascia, internal oblique, and transversus abdominis
Floor: inguinal ligament and lacuna ligament medially

49
Q

Name the exact locations of the superficial and deep inguinal rings

A

Deep is located at the mid-point of the inguinal ligament (between ASIS and PT)
Superficial is located just superior to PT

50
Q

Borders of Hesselbach’s triangle

A

Medially: lateral border of rectus abdominus
Laterally: inferior epigastric vessels
Inferiorally: inguinal ligament

51
Q

Contents of inguinal canal

A

Spermatic cord
Round ligament
Ilioinguinal nerve
Genital branch of genitofemoral nerve

52
Q

Name two signs on physical examination of appendicitis?

A

Rovsing’s sign: press LIF, pain felt in RIF

Psoas sign: pain on extension of R hip (suggests inflamed appendix touching psoas major in retrocecal position)

53
Q

What are the recommendations for returning to normal activities post appendicectomy?

A

Avoid heavy lifting for 4 weeks
If work no heavy lifting then return in 2 weeks
Don’t drive until can move freely without discomfort and are safe to perform emergency stop
Tell insurance before you return to driving

54
Q

Difference between gallstones/biliary colic, cholecystitis and cholangitis?

A

Gallstones- no raised inflam markers
Cholecystitis- raised markers, positive Murphy’s sign
Cholangitis- raised markers + fever + jaundice (Charcot’s triad)

55
Q

How long should it be before you have a cholecystectomy?

A

Biliary colic: within 6 weeks ideally

Acute cholecystitis: ideally 72hrs, if not early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis)

56
Q

Complications of acute cholecystectomy

A

GB empyema
Gallstone ileus
Perforated GB –> peritonitis
Gangrenous cholecystitis

57
Q

What is PSC and PBC

A

Primary sclerosing cholangitis- chronic progressive fibrosis of intrahepatic and extra hepatic biliary ducts. Associated with IBD, especially UC. Complications include strictures, cholangitis, cholangiocarcinoma and end stage liver disease

Primary biliary cholangitis- progressive chronic disease of intrahepatic ducts only.

58
Q

Treatment for cholangitis

A

Abx- tazocin

ERCP with sphincterotomy

59
Q

Differentials for PR bleeding

A 
Diverticulitis 
Colonic Ca 
Anal fissure/haemorrhoids/fistula
Angiodysplasia 
Colitis 
IBD

Year 3 (7 decks)

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