Abdomen and Trunk Flashcards
(60 cards)
1
Q
Difference between direct and indirect inguinal hernia?
A
- indirect: remnants of patent processus vaginalis, arise lateral to inferior epigastric vessels, through deep ring
- direct: result of weak posterior wall of inguinal canal, arise medial to vessels, not within spermatic cord
2
Q
Contents of spermatic cord
A
3 arteries: to vas deferens, testicular, cremasteric
3 nerves: ilioinguinal nerve (L1), to cremaster (genitofemoral), autonomic (T10)
3 others: vas deferens, pampiniform plexus, lymphatics to para-aortic nodes
3
Q
What would you tell patients about their recovery from inguinal hernia repair?
A
- mobilisation early
- keep wound clean, can bathe immediately
- 6 weeks off work if heavy lifting
- avoid prolonged coughing and constipation
4
Q
Complications of inguinal hernia repair
A
- urinary retention
- bruising
- pain (often severe, chronic in 5%)
- haematoma
- infection
- ischaemic orchitis (pampiniform plexus thrombosis)
- recurrence
5
Q
Differential of lump in the groin
A
L - lymph node/lipoma S - sapheno-varix/skin lesion H - hernia A - aneurysmal dilatation of femoral artery P - psoas abcess/bursa E - ectopic/undescended testis
6
Q
What level does serum bilirubin need to rise to before jaundice can be detected on clinical exam?
A
Normal is < 17 mmol/L
Has to be 3x as much >50 mmol/L to discolour sclera.
7
Q
How should obstructive jaundice be investigated?
A
- urine for bilirubin
- blood: FBC (anaemia, infection) U+Es (hepatorenal syn) LFTs, clotting
- radiological: USS (common bile duct dilation >8mm, stones, pancreatic mass) CT, ERCP, MRCP
8
Q
Causes of post-op jaundice
A
- pre-hepatic: haemolysis post transfusion
- hepatic: anaesthetics, sepsis, intra- or post-op hypotension
- post-hepatic: biliary injury
9
Q
Indications for forming a stoma
A
- feeding
- lavage
- decompression
- diversion: protect distal anastomosis, urinary post-cystectomy
- exteriorisation
10
Q
How would you prepare a patient for a stoma pre-op?
A
- psychosocial and physical prep
- explain indications and complications
- CNS in stoma care
- mark site with patient standing: within rectus muscle, away from scars, creases, bony point, waistline, easily accessible
11
Q
Complications of stoma formation
A
Specific - ischamia/gangrene - haemorrage - retraction - prolapse/intussuscption - parastomal hernia - stenosis - skin excoriation General - stoma diarrhoea + hypokalaemia - nutritional disorders - renal and gall-stones following ileostomy - pscyhosexual - residual disease e.g. crohns
12
Q
Difference between ileostomy and colostomy
A
Ileostomy: RIF, spouted, watery content
Colostomy: LIF, flush with skin, formed stool
13
Q
How would you rehabilitate a patient following stoma placement?
A
- normal diet
- change bag once or twice-a-day
- ileostomies need base plate changed every 5 days
- psychological and psychosexual support
14
Q
Hepatomegaly causes
A
- physiological: reidel’s lobe, hyperexpanded chest
- infections: viral (hepatitis, EBV, CMV), bacterial (TB, abcesss), protozoal (malaria, schistosomaisis)
- alcoholic liver disease: fatty, cirrhosis
- metabolic: Wilson’s, haemochromatosis, infiltration (amyloid)
- malignant: primary/secondary, lymphoma, leukaemia
- CCF: RHF, TR, Budd-Chiari
15
Q
Significance of arterial bruit or venous hum over liver?
A
Arterial bruit = alcoholic hepatitis or carcinoma
Venous hum = portal hypertension
16
Q
What is portal hypertension?
A
- portal vein pressure > 10 mmHg
- portal flow greatly reduced or reduced
- pre-hep, hep and post hep causes
17
Q
What is an incisional hernia?
A
Extrusion of peritoneum and abdo contents through a weak scar or accidental wound on abdo wall. Represents a partial wound dehiscence where the skin remains intact.
18
Q
Complications of incisional hernia
A
- intestinal obstruction
- incarceration (irreducible)
- strangulation (compromised blood supply)
- skin excoriation
- persistent pain
19
Q
Predisposing factors to incisional hernias
A
- pre-op: age, immunocompromised, obesity, malignancy, distension from obstruction or ascites
- operative: poor technical closure, drains placed through wound
- post-op: wound infection, haematoma, early mobilisation, atelectasis and chest infection
20
Q
Incisional hernia treatment options
A
- non-surgical: truss/corset, weight-loss, other risk factor management
- surgical: optimise risk factors first, dissect sac, close defect +/- mesh
21
Q
Pathogenesis of umbilical herniae?
A
Defect through linea alba often due to obesity stretching.
- true umbilical herniae occur through umbilical scar, usually congenital
- paraumbilical herniae occur around scar
- neck of sac often tight, higher risk of strangulation
22
Q
Umbilical herniae in children
A
Minor defects common in neonates, often repair spontaneously.
Only repair if symptomatic
23
Q
Causes of acquired umbilical herniae in adults
A
- pregnancy
- ascites
- ovarian cysts
- fibroids
- bowel distension
24
Q
How would an umbilical hernia be repaired?
A
- optimise concurrent medical problems
- Mayo’s ‘vest-over-pants’ op
- dissect sac, reduce contents, excise sac, sublay extraperitoneal mesh below rectus, suture upper edge of rectus over lower edge with interrupted mattress non-absorbable sutures
25
Splenomegaly causes
- Infective: EBV, CMV, HIV, I.E. malaria
- Haematological: haemolytic anaemia, myeloproliferative disorders, sickle-cell, leukaemia (CML), lymphoma
- Portal hypertension: cirrhosis, vein thrombosis
- Systemic diseases: amyloidosism, sarcoidosis, RA (Felty's)
26
Causes of massive splenomegaly
- myelofibrosis
- CML
- malaria
27
Indications for splenectomy
```
Trauma
Hypersplenism:
- autoimmune thrombocytopaenia/haemolytic anaemia
- hereditary spherocytosis
- thrombotic thromovytopaenia
- sickle-cell/thalassaemia
- myelofibrosis, CML, Hodgkin's
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28
Functions of the spleen
- produces IgM
- filters micro-organisms esp encapsulated
- sequesters and removes old RBCs and platelets
- recycles iron
- pools platelets (30%)
29
Immunisations before splenectomy
- pneumococcal
- HIB
- meningococcal
- annual flu
- consider lifelong penicillin
- warn about risk of malaria
30
Blood film appearences post splenectomy
- increased platelet count and size
- increased neutrophils
- nucleated red cells with Howell-Jolly bodies and target cells
- increased leukocytosis to infection
31
Definition of severe exacerbation of IBD?
Truelove and Witts' classification
- GI: bloody stool >6x day
- Systemic: tachy >90, pyrexia >37.8
- Lab findings: Hb 30
32
Indications for surgery in IBD
- Acute severe UC: toxic megacolon (>6cm), perforation, severe GI bleeding
- Chronic UC: medical Mx failure, malignant transformation, maturation failure in children
- Crohn's: abscess, fistulae, stenosis causing obstruction, control acute/chronic bleeding
33
Hepatobiliary complications of IBD
- Liver: fatty change, hepatitis, cirrhosis, amyloidosis
| - Biliary system: gallstones, PSC, cholangiocarcinoma
34
Surgical options for UC
- subtotal colectomy with ileostomy +/- mucous fistula formation: op of choice for acute severe colitis, leaves distal sigmoid and rectum.
- panproctocolectomy: all colon + rectum + anus. Permanent thus only as patient choice or if no other option.
- restorative proctocolectomy: avoids permanent stoma: formation of ileal pouch anastomosed to anus, often covered by diverting loop ileostomy
35
Surgical options for Crohn's
- preserve as much small bowel as possible
- limited ileocaecectomy for distal ileal disease
- colonic defuctioning loop ileostomy may be needed for failure medical therapy
- occasionally subtotal colectomy with permanent end ileostomy
- pouch surgery generally contraindicated in Crohn's
36
What is a hydrocoele?
Excess accumulation of fluid in the processus vaginalis
37
Anatomical classification of hydrocoeles
- Vaginal: fluid in tunica vaginalis which surround testes but does not extend up cord
- Cord: fluid around spermatic cord, difficult to distinguish from inguinal hernia
- Congenital: sac communicates directly with peritoneum thus filled with peritoneum fluid
- Infantile: only obliterated at deep ring thus fluid around cord and testes but does not communicate
38
Hydrocoele treatment
- exclude malignancy
- watch and wait
- aspiration relieves symptoms but often reaccumulates
- Lord's plication
- Jaboulay's operation
39
What is a secondary hydrocoele?
Vaginal hydrocoele can be due to local pathology:
- testicular tumours
- torsion
- orchitis
- trauma
- following inguinal hernia repair
40
Epididymal cyst treatment
- leave alone if not troublesome, esp in young men
- very large or painful cysts can be removed
- occasionally total epididymal excision indicated to prevent frequent recurrence of painful cysts
41
Aetiology of varicoceles
- dilated tortuous 'varicose' veins in pampiniform plexus
- occur in 15% young men around puberty
- if suddenly appear in older men, exclude underlying retroperitoneal disease including left renal carcinoma
42
Why are 98% of varicoceles left-sided?
Left testicular vein:
- is more vertical where it connects to the renal vein
- is longer than the right
- frequently lacks terminal valve
Also, the left renal vein can be compressed by colon
43
Varicocele treatment
Transfemoral radiological embolisation of testicular vein
Surgical ligation of veins
- Palomo op: high retroperitoneal approach
- Inguinal approach
- Laproscopic
44
Causes of a right iliac fossa mass
- from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
- from bowel: caecal Ca, Crohn's mass, TB mass, appendicular mass/abscess
- from gyane organs: ovarian tumour, fibroid uterus
- from male repro organs: undescended testis, ectopic testis
from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
- from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
45
Investigations for a RIF mass
- USS
- CT
- IV contrast CT
46
Causes of a left iliac fossa mass
- from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
- from bowel: diverticular mass, colon Ca, faecal mass
- from gyane organs: ovarian tumour, fibroid uterus
- from male repro organs: undescended testis, ectopic testis
from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
- from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
47
Major indications/causes for kidney transplant
End stage renal failure due to:
- DM
- Hypertensive renal disease
- Glomerulonephritis
- PCKD
48
How is 'matching' of transplanted kidneys performed?
- ABO
| - HLA: DR > B > A
49
Stages of transplant rejection
- Hyperacute: within hrs from preformed antibodies
- Accelerated acute: 1-4 days from secondary immune response (T mem cell activation)
- Acute: 5 days-2 weeks from cell-mediated immunity
- Chronic: humoral mechanisms most important
50
Signs of renal transplant rejection?
- graft tenderness
- reduced urine output
- rising creatinine
51
Causes of ascites?
- CLD
- RHF
- Intra-abdominal malignancy
- Hypoalbuminaemia
- Nephrotic syndrome
- TB
- Chylous ascites
52
Differential of epigastric mass
- from skin and soft tissues: sebaceous cyst, sarcoma, lipoma, hernia
- from GI tract: stomach Ca, hepatomegaly, pancreatic Ca, pancreatic pseudocyst
- from vascular system: AAA, retroperitoneal lymphadenopathy
53
Causes of dysphagia
Mechanical
- Lumen: FB, oesophageal web
- Wall: Ca, oesophagitis, Barrett's, stricture
- Outside wall: retrosternal goitre, lung Ca, pharyngeal pouch
Coordination abnormalities
- Motility disorder: spasm, achalasia
- Neuromuscular disease: MG, bulbar palsy (MND), CVA
54
Enlarged kidney differential
```
Congenital
- cystic disease
- horseshoe kidney
- hypertrophic single kidney
Acquired
- Renal: cysts, tumours, hydronephrosis, pyonephrosis, perinephric abcess, renal vein thrombosis
- Systemic: DM, amyloidosis, SLE
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55
Beck's triad
For renal cell Ca
- haematuria
- loin mass
- loin pain
56
Classification of breast disease
Malignant
- Ductal Ca (70%)
- Lobular Ca (20%)
- Other: mucinous, tubular, medullary (10%)
Benign
- Congenital: extra nipples, hypoplasia
- Aberrations of normal dev and involution (ANDI): fibroadenomas, cysts, sclerotic/fibrotic lesions
- Non-ANDI: infective, lipomas, fat necrosis
57
Indications for mastectomy
- patient preference
- clinical evidence of multifocal/multicentric disease
- large lump in small breast tissue
- nipple involvement
58
Preparing a patient for breast surgery
```
Physical
- mark site
- explain procedure + post op drain
- expect numb skin in axilla and upper arm (T1) as intercostal nerve is divided
- anaesthetic work-up including CX (pul mets)
Psychological
- breast care nurse
- fully explanation of reasons for op
- reconstruction options discussion
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59
When should post-mastectomy drain be removed?
Often two placed (axilla and at breast)
- 3-5 days, until drainage <50 ml in 1 day
- patients can be sent home with drains and district nurse support
60
Types of breast reconstruction
Timing
- immediate
- delayed
Technique
- Tissue expansion (implants): subcutaneous or submuscular
- Autologous tissue: transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, superficial IEP, latissimus dorsi flap.
