ABDOMEN EMRCS Flashcards

Question

Theme: Hernias A. Littres hernia B. Richters hernia C. Bochdalek hernia D. Morgagnihernia E. Spigelian hernia F. Lumbar hernia G. Obturator hernia Please select the type of hernia that most closely matches the description given. Each option may be used once, more than once or not at all. A 45 year old man has recurrent colicky abdominal pain. As part of a series of investigations he undergoes a CT scan and this demonstrates a hernia lateral to the rectus muscle at the level of the arcuate line.

Answer 1

The correct answer is Spigelian hernia This is the site for a spigelian hernia.

Answer 2

The clinical description of a painless grape-sized mass in the groin area with a cough impulse that disappears when lying down suggests a condition that involves a protrusion or herniation. Given these characteristics, the most likely diagnosis is: E. Saphenous varix Explanation: • Femoral hernia (A): Often presents as a groin mass and can have a cough impulse, but it tends to be more common in older women and can be painful. • Lymphadenitis (B): Typically presents with painful and swollen lymph nodes, often accompanied by signs of infection. • Inguinal hernia (C): More common in men, and the description matches this condition; however, the disappearance on lying down is more classically described with saphenous varix. • Psoas abscess (D): Usually presents with fever and back pain, not a typical groin mass. • Saphenous varix (E): A dilated saphenous vein at the saphenofemoral junction. It presents as a compressible, painless mass that can have a cough impulse and disappears when lying down, fitting the description perfectly. • Femoral artery aneurysm (F): Would be pulsatile and generally does not disappear when lying down. • Metastatic lymphadenopathy (G): Typically presents as a firm, non-tender, non-reducible mass. • Lymphoma (H): Presents with firm, non-tender lymph nodes that do not change with position. • False femoral artery aneurysm (I): Would be pulsatile and does not typically disappear when lying down. Conclusion: The most likely diagnosis for the described groin mass is a saphenous varix (E). This condition is characterized by a painless, compressible mass with a cough impulse that disappears on lying down, matching the patient’s symptoms.

Answer 3

The correct answer is Lymphadenitis The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes.

Answer 4

The correct answer is False femoral artery aneurysm False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall.

Answer 5

The correct answer is Meckels diverticulum This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration.

Answer 6

The correct answer is Mittelschmerz Typical story and timing for mid cycle pain. Mid cycle pain typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours.

Answer 7

The correct answer is Crohns disease Weight loss and chronic symptoms coupled with change in bowel habit should raise suspicion for Crohns. The presence of intermittent right iliac fossa pain is far more typical of terminal ileal Crohns disease. Both UC and Crohns may be associated with a low grade pyrexia. The main concern here would be locally perforated Crohns disease with a small associated abscess.

Answer 8

Femoral herniae account for <10% of all groin hernias. In the scenario the combination of symptoms of intestinal compromise with a mass in the region of the femoral canal points to femoral hernia as the most likely cause. Femoral canal The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both the femoral artery laterally and femoral vein medially. The canal lies medial to the vein. Borders of the femoral canal Laterally: Femoral vein Medially: Lacunar ligament Anteriorly : Inguinal ligament Posteriorly: Pectineal ligament

Answer 9

Profuse vomiting and diarrhoea are rare in early appendicitis Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions.

Answer 10

During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord structures results in chronic pain and usually a higher risk of recurrence. Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias. Types of surgery include: Onlay mesh repair (Litchenstein style) Inguinal herniorrhaphy Shouldice repair Darn repair Laparoscopic mesh repair Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g. repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically challenging to perform. Inguinal hernia surgery Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests on their relation to Hesselbach's triangle. Boundaries of Hesselbach's Triangle Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament

Answer 11

The correct answer is Application of a 'Bogota Bag' Application of a Bogota bag is safest as attempted closure will almost certainly fail. Repeat look at 48 hours to determine the best definitive option is needed.

Answer 12

The correct answer is Looped 1/0 PDS (polydiaxone) Mass closure obeying Jenkins rule is required and this states that the suture must be 4 times the length of the wound with tissue bites 1cm deep and 1 cm apart.

Answer 13

The correct answer is Re-inforced 1/0 Nylon Attempt at re-closing the wound is reasonable in which case 1/0 nylon (reinforced with drainage tubing) is often used. Abdominal wound dehiscence This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis. Traditionally, it is said to occur when all layers of an abdominal mass closure fail and the viscera protrude externally (associated with 30% mortality). It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers.

Answer 14

The correct answer is Bochdalek hernia Theme from 2011 exam The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development.

Answer 15

The correct answer is Morgagni hernia Morgagni hernia may contain the transverse colon. Unless there is substantial herniation, pulmonary hypoplasia is uncommon. As a result, major respiratory compromise is often absent.

Answer 16

The correct answer is Obturator hernia The groin swelling in obturator hernia is subtle and hard to elicit clinically. There may be pain in the region of sensory distribution of the obturator nerve. The defect is usually repaired from within the abdomen.

Answer 17

The correct answer is Laparoscopic appendicectomy She is likely to have appendicitis. In women of this age there is always diagnostic uncertainty. With a normal vaginal exam laparoscopy would be preferred over USS.

Answer 18

Active observation This is mesenteric adenitis. Note history of flu like illness and temp > 38o c. The decision as to how to manage this situation is based on the abdominal findings. Patients with localising signs such as guarding or peritonism should undergo surgery.

Answer 19

The correct answer is Ultrasound scan abdomen/pelvis This patient is suspected of having an ectopic pregnancy. She needs an urgent β HCG and USS of the pelvis. If she were haemodynamically unstable then laparotomy would be indicated.

Answer 20

The pain or discomfort of IBS is typically migratory and variable in intensity. Pain at a fixed site is suggestive of malignancy. Abdominal bloating is an extremely common feature. Irritable bowel syndrome The diagnosis of irritable bowel syndrome is made according to the ROME III diagnostic criteria which state: Next question Recurrent abdominal pain or discomfort at 3 days per month for the past 3 months associated with two or more of the following: Improvement with defecation. Onset associated with a change in the frequency of stool. Onset associated with a change in the form of the stool. Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis Red flag features should be inquired about: Rectal bleeding Unexplained/unintentional weight loss Family history of bowel or ovarian cancer Onset after 60 years of age Suggested investigations are: Full blood count ESR/CRP Coeliac disease screen (tissue transglutaminase antibodies) Colonoscopy (if worrying symptoms, positive family history) Thyroid function tests Glucose (ensure not diabetic) The NICE criteria state that blood tests alone will suffice in people fulfilling the diagnostic criteria. We would point out that luminal colonic studies should be considered early in patients with altered bowel habit referred to hospital and a diagnosis of IBS should still be largely one of exclusion. Treatment Usually reduce fibre intake. Tailored prescriptions of laxatives or loperamide according to clinical picture. Dietary modification (caffeine avoidance, less carbonated drinks). Consider low dose tricyclic antidepressants if pain is a dominant symptom. Biofeedback may help.

Answer 21

The correct answer is Mesenteric vein thrombosis Mesenteric vein thrombosis may complicate severe intra abdominal sepsis and when it progresses may impair bowel perfusion. The serosa is quite resistant to ischaemia so in this case the appearances are usually patchy.

Answer 22

The correct answer is Acute Pancreatitis Although back pain and abdominal pain coupled with haemodynamic compromise may suggest ruptured AAA the 48 hour history and amylase >3 times normal go against this diagnosis.

Answer 23

The correct answer is Acute mesenteric embolus Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting. Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries. Types Acute mesenteric embolus (commonest 50%) Sudden onset abdominal pain followed by profuse diarrhoea. May be associated with vomiting. Rapid clinical deterioration. Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases. Acute on chronic mesenteric ischaemia Usually longer prodromal history. Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%. When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult). Mesenteric vein thrombosis Usually a history over weeks. Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow. Low flow mesenteric infarction This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise. The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards. Diagnosis Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease). Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful. SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic mesenteric ischaemia. MRI is of limited use due to gut peristalsis and movement artefact. Management Overt signs of peritonism: Laparotomy Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In the interim urgent bowel revascularisation via endovascular (preferred) or surgery. Prognosis Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures. Thrombophilia accounts for 60% of cases.

Answer 24

The correct answer is Indirect inguinal hernia This is likely to be an indirect hernia. In children these arise from persistent processus vaginalis and require herniotomy.

Answer 25

The correct answer is Indirect inguinal hernia This is likely to be an indirect hernia. In children these arise from persistent processus vaginalis and require herniotomy.

Answer 26

The correct answer is Femoral hernia A mass below and lateral to the pubic tubercle is indicative of a femoral hernia.

Answer 27

Psoas abscess Psoas abscesses may be either primary or secondary. Primary cases often occur in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may complicated intra abdominal diseases such as Crohns. Patients usually present with low back pain and if the abscess is extensive a mass that may be localised to the inguinal region or femoral triangle . Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed. Groin lumps- some key questions Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma) Scrotal lumps - some key questions Is the lump entirely intra scrotal Does it transilluminate (?hydrocele) Is there a cough impulse (?hernia) In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most convenient next investigation.

Answer 28

Fluid levels in the distal colon are nearly always pathological. In general contents of the left colon transit quickly and are seldom held in situ for long periods, the content is also more solid. Abdominal radiology Plain abdominal x-rays are often used as a first line investigation in patients with acute abdominal pain. A plain abdominal film may demonstrate free air, evidence of bowel obstruction and possibly other causes of pain (e.g. renal or gallbladder stones). Investigation of potential visceral perforation is usually best performed by obtaining an erect chest x-ray, as this is a more sensitive investigation for suspected visceral perforation. Features which are usually abnormal Large amounts of free air (colonic perforation), smaller volumes seen with more proximal perforations. A positive Riglers sign (gas on both sides of the bowel wall). Caecal diameter of >8cm Fluid levels in the colon Ground glass appearance to film (usually due to large amounts of free fluid). Sentinel loop in patients with inflammation of other organs (e.g. pancreatitis). Features which should be expected/ or occur without pathology In Chiladitis sign, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present. Following ERCP (and sphincterotomy) air may be identified in the biliary tree. Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48-72 hours.

Answer 29

The confirmatory test that should be performed prior to surgery for a 56-year-old lady presenting with a large bowel obstruction and abdominal distension is Gastrografin enema. Explanation: Gastrografin enema is a water-soluble contrast study that can help confirm the diagnosis of a large bowel obstruction by delineating the site and nature of the obstruction. It is preferred over barium enema in acute settings as it is less irritating to the peritoneum in case of perforation. Other options like abdominal ultrasound, rectal MRI scan, and endoanal ultrasound scan are less effective in identifying and confirming the nature and location of large bowel obstructions in acute settings. Correct Answer: E-Gastrograffin enema

Answer 30

Ketamine does not affect healing. All the other situations in the list carry a strong association with poor healing and risk of dehisence. Abdominal wound dehiscence Next question Administration of intravenous steroids Use of Ketamine as an anaesthetic agent This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis. Traditionally, it is said to occur when all layers of an abdominal mass closure fail and the viscera protrude externally (associated with 30% mortality). It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers. Factors which increase the risk are: * Malnutrition * Vitamin deficiencies * Jaundice * Steroid use * Major wound contamination (e.g. faecal peritonitis) * Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule) When sudden full dehiscence occurs the management is as follows: * Analgesia * Intravenous fluids * Intravenous broad spectrum antibiotics * Coverage of the wound with saline impregnated gauze (on the ward) * Arrangements made for a return to theatre Surgical strategy Correct the underlying cause (e.g. TPN or NG feed if malnourished) Determine the most appropriate strategy for managing the wound Options Resuturing of the wound This 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. Application of a 'Bogota bag' This is a clear plastic bag that is cut and sutured to the wound edges and is only a temporary measure to be adopted when the wound cannot be closed and will necessitate a return to theatre for definitive management. Application of a VAC dressing These can be safely used BUT ONLY if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem. Application of a wound manager This is a clear dressing with removable front. Particularly suitable when some granulation tissue is present over the viscera or where there is a high output bowel fistula present in the dehisced wound.

Answer 31

The most likely diagnosis for a 23-year-old lady who has suffered from diarrhea for 8 months, has lost 2 kg in weight, and has colonoscopy appearances of melanosis coli is laxative abuse. Explanation: Melanosis coli is a condition characterized by the dark pigmentation of the colon mucosa. It is most commonly associated with chronic use of anthraquinone-containing laxatives, such as senna or cascara. This pigmentation is due to the accumulation of pigment-laden macrophages in the lamina propria of the colon. It is not typically associated with infections, inflammatory bowel diseases, or ischemic colitis. Correct Answer: G. Laxative abuse

Answer 32

Ischaemic colitis The IMA is commonly ligated during and AAA repair and this may then render the left colon relatively ischaemic, thereby causing mesenteric colitis. Treatment is supportive and most cases will settle with conservative management.

Answer 33

The correct answer is Campylobacter jejuni infection Severe abdominal pain tends to favour Campylobacter infection.

Answer 34

Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically either intestinal volvulus or intestinal infarction. They seldom cause intussusception. Cystic fibrosis may lead to the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an intussusception. Intussusception- Paediatric Intussusception typically presents with colicky abdominal pain and vomiting. The telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of "red current jelly" stools. Recognised causes include lumenal pathologies such as polyps, lymphadenopathy and diseases such as cystic fibrosis. Idiopathic intussceception of the ileocaecal valve and terminal ileum is the most common variant and typically affects young children and toddlers. The diagnosis is usually made by abdominal ultrasound investigation. The decision as to the optimal treatment is dictated by the patients physiological status and abdominal signs. In general, children who are unstable with localising peritoneal signs should undergo laparotomy, as should those in whom attempted radiological reduction has failed. In relatively well children without localising signs attempted pneumatic reduction under fluroscopic guidance is the usual treatment.

Answer 35

In a Hartmans procedure the sigmoid colon is removed and an end colostomy is fashioned. The bowel remains in continuity and no absorptive ability is lost. An ileo-colic bypass leaves a redundant loop of small bowel in continuity, where the contents will stagnate and bacterial overgrowth will occur. Therefore this is recognised cause of malabsorption. Malabsorption Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats) Intestinal causes of malabsorption coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency) Pancreatic causes of malabsorption chronic pancreatitis cystic fibrosis pancreatic cancer Biliary causes of malabsorption biliary obstruction primary biliary cirrhosis Other causes bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) short bowel syndrome, lymphoma

Answer 36

The correct answer is Pseudomyxoma peritonei Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source. Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy. Pseudomyxoma Peritonei Rare mucinous tumour Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites) Incidence of 1-2/1,000,000 per year The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity Treatment Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C. Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse. In selected patients a second look laparotomy is advocated and some practice this routinely.

Answer 37

The description of the clinical presentation suggests a condition that involves a mass effect on the retroperitoneal structures, specifically causing hydronephrosis and medially displaced ureters. This is characteristic of retroperitoneal fibrosis. Key Points: • Symptoms: Dull lower back pain, abdominal discomfort, hypertension. • Examination: Lower abdominal fullness. • Imaging: • Ultrasound: Hydronephrosis. • Intravenous urography: Medially displaced ureters. • CT scan: Periaortic mass. Diagnosis: • Retroperitoneal fibrosis (G): This condition involves the development of fibrotic tissue around the abdominal aorta and other retroperitoneal structures, leading to ureteral obstruction, displacement, and associated symptoms. Answer: G. Retroperitoneal fibrosis

Answer 38

The clinical presentation of a 48-year-old woman with abdominal distension, cachexia, ascites, and a significantly elevated CA19-9 level strongly suggests a diagnosis related to an intra-abdominal malignancy. CA19-9 is a tumor marker commonly associated with pancreatic cancer, but it can also be elevated in other gastrointestinal malignancies. Key Points: • Symptoms: Abdominal distension, cachexia, ascites. • Tumor Marker: Elevated CA19-9. Likely Diagnosis: • Metastatic adenocarcinoma of the pancreas: Pancreatic cancer often presents with these symptoms and is commonly associated with elevated CA19-9 levels. Answer: A. Metastatic adenocarcinoma of the pancreas

Answer 39

The correct answer is Ruptured abdominal aortic aneurysm Back pain is a common feature with expanding aneurysms and may be miss classified as being of musculoskeletal origin.

Answer 40

The correct answer is Acute mesenteric embolus Sudden onset of abdominal pain and forceful bowel evacuation are features of acute mesenteric infarct.

Answer 41

The correct answer is Acute on chronic mesenteric ischaemia This man is likely to have underlying chronic mesenteric vascular disease. Only 15% of emboli will occlude SMA orifice leading to entire small bowel infarct. The background history of weight loss also favours an acute on chronic event. Mesenteric vessel disease Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries. Types Acute mesenteric embolus (commonest 50%) Sudden onset abdominal pain followed by profuse diarrhoea. May be associated with vomiting. Rapid clinical deterioration. Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases. Acute on chronic mesenteric ischaemia Usually longer prodromal history. Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%. When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult). Mesenteric vein thrombosis Usually a history over weeks. Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow. Thrombophilia accounts for 60% of cases. Low flow mesenteric infarction This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise. The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards. Diagnosis Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease). Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful. SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic mesenteric ischaemia. MRI is of limited use due to gut peristalsis and movement artefact. Management Overt signs of peritonism: Laparotomy Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In the interim urgent bowel revascularisation via endovascular (preferred) or surgery. Prognosis Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures.

Answer 42

The correct answer is Intussusception Intussusception should be considered in toddlers and infants presenting with screaming attacks. The child often has a history of being unwell for one to three days prior to presentation. The child may pass bloody mucus stool, which is a late sign. Examination of the abdomen is often normal as the sausage mass in the right upper quadrant is difficult to feel.

Answer 43

Sickle cell crisis Sickle cell anaemia is characterised by severe chronic haemolytic anaemia resulting from poorly formed erythrocytes. Painful crises result from vaso-occlusive episodes, which may occur spontaneously or may be precipitated by infection. Consider this diagnosis in all children of appropriate ethnic background. Appendicitis History of migratory pain. Fev er. A n o r e x ia . Evidence of right iliac fossa tenderness. Mild pyrexia. Differential white cell count Pregnancy test C-Reactive protein A m y la s e Urine dipstick testing Appendicectomy Mesenteric adenitis Usually recent upper respiratory tract infection. High fever. Generalised abdominal discomfort- true localised pain and signs are rare. Full blood count- may show slightly raised white cell count Urine dipstick often normal Abdominal ultrasound scan - usually no free fluid Conservative management- appendicectomy if diagnostic doubt Mittelschmerz Only seen in females Mid cycle pain Usually occurs two weeks after last menstrual period Pain usually has a supra-pubic location Usually subsides over a 24-48 hour period. Full blood count- normal Urine dipstick- normal Abdominal and pelvic ultrasound- may show a trace of pelvic free fluid Manage conservatively if doubt or symptoms fail to settle then laparoscopy Fitz-Hugh Curtis syndrome Disseminated infection with Chlamydia. Usually seen in females. Consists of evidence of pelvic inflammatory disease together with peri- hepatic inflammation and subsequent adhesion formation. Abdominal ultrasound scan- may show free fluid High vaginal swabs - may show evidence of sexually transmitted infections Usually medically managed- doxycycline or a z it h r o m y c in Abdominal aortic aneurysm (ruptured) Sudden onset of abdominal pain radiating to the back in older adults (look for risk factors). Collapse. May be moribund on arrival in casualty, more stable if contained haematoma. Careful clinical assessment may reveal pulsatile mass. Patients who are haemodynamically stable should have a CT scan Unstable patients should undergo immediate surgery (unless it is not in their best interests). Those with evidence of contained leak on CT should undergo immediate surgery Increasing unruptured aneurysmal size is an indication for urgent surgical intervention (that can wait until the next working day) Perforated peptic ulcer Sudden onset of pain (usually epigastric). Often preceding history of upper abdominal pain. Soon develop generalised abdominal pain. On examination may have clinical evidence of peritonitis. Erect CXR may show free air. A CT scan may be indicated where there is diagnostic doubt Laparotomy (laparoscopic surgery for perforated peptic ulcers is both safe and feasible in experienced hands) Intestinal obstruction Colicky abdominal pain and vomiting (the nature of which depends on the level of the obstruction). Abdominal distension and constipation (again depending upon site of obstruction). Features of peritonism may occur where local necrosis of bowel loops is occurring. A plain abdominal film may help with making the diagnosis. A CT scan may be useful where diagnostic uncertainty exists In those with a virgin abdomen and lower and earlier threshold for laparotomy should exist than in those who may have adhesional obstruction Mesenteric infarction Embolic events present with sudden pain and forceful evacuation. Acute on chronic events usually have a longer history and previous weight loss. On examination the pain is typically greater than the physical signs would suggest. Arterial pH and lactate Arterial phase CT scanning is the most sensitive test Immediate laparotomy and resection of affected segments, in acute embolic events SMA embolectomy may be needed.

Answer 44

The correct answer is Spontaneous bacterial peritonitis The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumoniae, due to the loss of immunoglobulins and opsonins in the urine.

Answer 45

Laparoscopy results in fewer adhesions. When talc was used to coat surgical gloves it was a major cause of adhesion formation and withdrawn for that reason. A Nobles plication is an old fashioned operation which has no place in the prevention of adhesion formation. Use of an anastamotic stapling device will not influence the development of adhesions per se although clearly an anastamotic leak will result in more adhesion formation Surgical complications Complications occur in all branches of surgery and require vigilance in their detection. In many cases anticipating the likely complications and appropriate avoidance will minimise their occurrence. For the purposes of the MRCS the important principles to appreciate are: The anatomical principles that underpin complications The physiological and biochemical derangements that occur The most appropriate diagnostic modalities to utilise The principles which underpin their management This is clearly a very broad area and impossible to cover comprehensively. There is considerable overlap with other topic areas within the website. Avoiding complications Some points to hopefully avert complications: World Health Organisation checklist- now mandatory prior to all operations Prophylactic antibiotics - right dose, right drug, right time. Assess DVT/ PE risk and ensure adequate prophylaxis MARK site of surgery Use tourniquets with caution and with respect for underlying structures Remember the danger of end arteries and in situations where they occur avoid using adrenaline containing solutions and monopolar diathermy. Handle tissues with care- devitalised tissue serves as a nidus for infection Be very wary of the potential for coupling injuries when using diathermy during laparoscopic surgery The inferior epigastric artery is a favorite target for laparoscopic ports and surgical drains! Anatomical principles Understanding the anatomy of a surgical field will allow appreciation of local and systemic complications that may occur. For example, nerve injuries may occur following surgery in specific regions. The table below lists some of the more important nerves to consider and mechanisms of injury Nerve Mechanism Accessory Posterior triangle lymph node biopsy Sciatic Posterior approach to hip Common peroneal Legs in Lloyd Davies position Long thoracic Axillary node clearance Pelvic autonomic nerves Pelvic cancer surgery Recurrent laryngeal nerves During thyroid surgery Hypoglossal nerve During carotid endarterectomy Ulnar and median nerves During upper limb fracture repairs These are just a few. The detailed functional sequelae are particularly important and will often be tested. In addition to nerve injuries certain procedures carry risks of visceral or structural injury. Again some particular favorites are given below: Structure Mechanism Thoracic duct During thoracic surgery e.g. Pneumonectomy, oesphagectomy Parathyroid glands During difficult thyroid surgery Ureters During colonic resections/ gynaecological surgery Bowel perforation Use of Verres Needle to establish pneumoperitoneum Bile duct injury Failure to delineate Calots triangle carefully and careless use of diathermy Facial nerve Always at risk during Parotidectomy Tail of pancreas When ligating splenic hilum Testicular vessels During re-do open hernia surgery Hepatic veins During liver mobilisation Again many could be predicted from the anatomy of the procedure. Physiological derangements A very common complication is bleeding and this is covered under the section of haemorrhagic shock. Another variant is infection either superficial or deep seated. The organisms are covered under microbiology and the features of sepsis covered under shock. Do not forget that immunocompromised and elderly patients may present will atypical physiological parameters. Selected physiological and biochemical issues are given below: Complication Physiological/ Biochemical Problem Arrhythmias following cardiac Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients) surgery Neurosurgical electrolyte disturbance SIADH following cranial surgery causing hyponatraemia Ileus following gastrointestinal Fluid sequestration and loss of electrolytes surgery Pulmonary oedema following Loss of lung volume makes these patients very sensitive to fluid overload pneumonectomy Anastamotic leak Generalised sepsis causing mediastinitis or peritonitis depending on site of leak Myocardial infarct May follow any type of surgery and in addition to direct cardiac effects the decreased cardiac output may well compromise grafts etc.

Answer 46

The correct answer is Ectopic pregnancy The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy.

Answer 47

The correct answer is Pelvic inflammatory disease The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.

Answer 48

The correct answer is Mittelschmerz Mid cycle pain is very common and is due to the small amount of fluid released during ovulation. Inflammatory markers are usually normal and the pain typically subsides over the next 24-48 hours.

Answer 49

Correct Answer: When it does occur is most common at 15 days Explanation: A burst abdomen, also known as wound dehiscence, typically occurs within the first week after surgery, usually around 7-10 days postoperatively. This timeline is crucial as the wound strength is at its lowest during this period due to the inflammatory phase of wound healing. Here is an analysis of the other statements: • Is seen in 1-2% of modern laparotomies: True. The incidence of burst abdomen is around 1-2% in modern surgical practice. • Is more common in faecal peritonitis: True. Faecal peritonitis increases the risk of wound dehiscence due to infection and increased intra-abdominal pressure. • Is less common when a ‘mass closure’ technique is used: True. Mass closure techniques, which involve taking large bites of tissue including fascia, are associated with a lower incidence of burst abdomen compared to layered closure techniques. • Is similar in incidence regardless of whether 1/0 polydiaxone or 1/0 polypropylene are used: True. Studies have shown that the type of suture material (whether absorbable like polydiaxone or non-absorbable like polypropylene) does not significantly affect the incidence of wound dehiscence. Thus, the incorrect statement is that wound dehiscence is most common at 15 days, which is not accurate as it typically occurs earlier in the postoperative period.

Answer 50

Vitamin C toxicity causes osmotic diarrhoea. Diarrhoea World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days Acute Diarrhoea Gastroenteritis Diverticulitis Antibiotic therapy Constipation causing overflow Chronic Diarrhoea May be accompanied by abdominal pain or nausea/vomiting Classically causes left lower quadrant pain, diarrhoea and fever More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Ulcerative colitis Crohn's disease Colorectal cancer Coeliac disease Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist

Answer 51

The annual probability of strangulation is up to 3% and is more common in indirect hernias. Elective repair poses few risks. However, emergency repair is associated with increased mortality, particularly in the elderly. Inguinal hernia surgery Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests on their relation to Hesselbach's triangle. Boundaries of Hesselbach's Triangle Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament

Answer 52

Thrombosis of the splenic vein may complicate pancreatitis, pancreatic carcinoma, iatrogenic trauma and hypercoagulable diseases. Diagnosis is made by CT angiography. The treatment of choice for a patient with gastric varices secondary to splenic vein thrombosis is: Splenectomy Explanation: • Splenic vein thrombosis can lead to isolated gastric varices due to increased pressure in the short gastric veins, which drain into the splenic vein. This can cause episodic epigastric discomfort and the development of varices. • Splenectomy is the treatment of choice because it removes the source of increased pressure, thereby alleviating the gastric varices and preventing further episodes of bleeding. Other options are less appropriate in this context: • Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is typically used for portal hypertension involving the portal vein and is not specifically indicated for isolated splenic vein thrombosis. • Surgical bypass of the splenic vein is not a standard treatment for this condition. • Gastrectomy is an overly aggressive approach for managing varices caused by splenic vein thrombosis. • Stapling of the gastro-oesophageal junction is not a treatment for gastric varices and does not address the underlying cause of the varices in this scenario. Therefore, the correct answer is Splenectomy.

Answer 53

The clinical sign that matches the described scenario of acute retrocaecal appendicitis indicated when the right thigh is passively extended with the patient lying on their side with their knees extended is: C. Psoas stretch sign Explanation: • Psoas stretch sign (also known as the psoas sign) is used to identify inflammation of the appendix, particularly when it is retrocaecal. This sign is elicited by passively extending the right thigh with the patient lying on their left side. Pain elicited during this maneuver suggests irritation of the psoas muscle by the inflamed appendix, indicating retrocaecal appendicitis. Therefore, the correct answer is C. Psoas stretch sign.

Answer 54

The correct answer is Grey-Turner's sign Grey-Turners sign occurs in patients with severe haemorrhagic pancreatitis. In this situation the major vessels surrounding the pancreas bleed. The pancreatitis process also results in local fat destruction, this results in blood tracking in the tissue planes of the retroperitoneum and appearing as flank bruising.

Answer 55

Murphy's sign Invariably present when patients are assessed in the emergency department! This sign occurs because the inflamed gallbladder irritates the parietal peritoneum in this manoeuvre.

Answer 56

Non specific abdominal pain is a commonly recorded diagnosis for patients presenting with acute abdominal pain. Following careful diagnostic work up, a proportion of patients may be identified with disorders such as coeliac disease and the diagnosis of non specific abdominal pain should not be used lightly. Acute abdominal pain Acute abdominal pain is a common cause of admission to hospital. The relative proportions of conditions presenting with abdominal pain is given below: 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%) Pancreatitis (2%) (Data derived from Irvin T. Br. J. Surg 1989 76:1121-1125) Non specific abdominal pain should really be a diagnosis of exclusion and if care is taken in excluding organic disease the proportion of cases labeled such should decline. It should also be appreciated that a proportion of patients may have an underlying medical cause for their symptoms such as pneumonia or diabetic ketoacidosis. Key points in management Early administration of adequate analgesia (including opiates). Abdominal ultrasound is safe, non invasive and cheap and yields significantly more information than plain radiology. However, plain radiology is still the main test for suspected perforated viscus, especially out of hours. In up to 50% cases with perforated peptic ulcer, the plain x-rays may show no evidence of free air. If clinical signs suggest otherwise, then a CT scan may be a more accurate investigation, if plain films are normal. Plain film radiology usually cannot detect <1mm free air, and is 33% sensitive for detection of 1-13mm pockets of free air (Stoker et al. Radiology 2009 253: 31-46). Think of strangulated intestine when there is fever, raised white cell count, tachycardia and peritonism. In suspected large bowel obstruction a key investigation is either a water soluble contrast enema or CT scan. Where need for surgery is difficult to define and imaging is inconclusive the use of laparoscopy as a definitive diagnostic test is both safe and sensible.

Answer 57

Obese patients with ileus following major abdominal surgery are at increased risk of intra abdominal compartment syndrome.The risk is increased by the use of prosthetic meshes, which some surgeons favor following a major vascular case as they may reduce the incidence of incisional hernia. They prevent abdominal distension and may increase the risk of intra abdominal hypertension in the short term. Although colonic ischaemia may occur following major aortic surgery it would not typically present in this way. Abdominal compartment syndrome Background Intra-abdominal pressure is the steady state pressure concealed within the abdominal cavity. In critically ill adults the normal intra abdominal pressure = 5-7mmHg Intra abdominal hypertension has pressures of 12-25mmHg Changes >15mmHg are associated with microvascular hypoperfusion Abdominal compartment syndrome is defined as sustained intra abdominal pressure >20mmHg coupled with new organ dysfunction / failure It may occur either primarily without previous surgical intervention e.g. Following intestinal ischaemia or secondarily following a surgical procedure Diagnosis is typically made by transvesical pressure measurements coupled with an index of clinical suspicion. Management Once the diagnosis is made non operative measures should be instituted including: Gastric decompression Improve abdominal wall compliance e.g. muscle relaxants/ sedation Drain abdominal fluid collections. Consider fluid restriction/ diuretics if clinically indicated. In those whom non operative treatment is failing; the correct treatment is laparotomy and laparostomy. Options for laparostomy are many although the Bogota bag or VAC techniques are the most widely practised. Re-look laparotomy and attempts at delayed closure will follow in due course.

Answer 58

The correct answer is Latex T Tube drain Latex is used for this indication as it will encourage track formation.

Answer 59

The correct answer is Redivac suction drain Suction drains are commonly used following mastectomy and axillary surgery to prevent haematoma formation. Not all surgeons routinely drain the axilla.

Answer 60

Wallace Robinson drain These tube drains are often used in abdominal surgery to drain abscess cavities. Debate might occur around the use of low pressure vs no suction in this setting so this option is deliberately omitted. Surgical drains Drains are inserted in many surgical procedures and are of many types. As a broad rule they can be divided into those using suction and those which do not. The diameter of the drain will depend upon the substance being drained, for example smaller lumen drain for pneumothoraces vs haemothorax. Drains can be associated with complications and these begin with insertion when there may be iatrogenic damage. When in situ they serve as a route for infections. In some specific situations they may cause other complications, for example suction drains left in contact with bowel for long periods may carry a risk of inducing fistulation. Drains should be inserted for a defined purpose and removed once the need has passed. A brief overview of types of drain and sites is given below CNS Low suction drain or free drainage systems may be used for situations such as drainage of sub dural haematomas. CVS Orthopaedics and trauma In this setting drains are usually used to prevent haematoma formation (with associated risk of infection). Some orthopaedic drains may also be specially adapted to allow the drained blood to be auto transfused. Gastro-intestinal surgery Surgeons often place abdominal drains either to prevent or drain abscesses, or to turn an anticipated complication into one that can be easily controlled such as a bile leak following cholecystectomy. The type of drain used will depend upon the indication. Following cardiothoracic procedures of thoracic trauma underwater seal drains are often placed. These should be carefully secured. When an air leak is present they may be placed on suction whilst the air leak settles Drain types Type of drain Features R e d iv a c Suction type of drain Closed drainage system High pressure vacuum system Low pressure drainage systems Consist of small systems such as the lantern style drain that may be used for short term drainage of small wounds and cavities Larger systems are sometimes used following abdominal surgery, they have a lower pressure than the redivac system, which decreases the risks of fistulation May be emptied and re-pressurised Latex tube drains May be shaped (e.g. T Tube) or straight Usually used in non pressurised systems and act as sump drains Most often used when it is desirable to generate fibrosis along the drain track (e.g. following exploration of the CBD) Chest drains May be large or small diameter (depending on the indication) Connected to underwater seal system to ensure one way flow of air Corrugated drain Thin, wide sheet of plastic, usually soft Contains corrugations, along which fluids can track

Answer 61

Following perforated appendicitis fluid is most likely to accumulate in the pelvis. Fluid may accumulate in the hepatorenal pouch although this is less common. Gravity favors the pelvis as the site of most collections. The incidence of these is higher with laparoscopic rather than open surgery.

Answer 62

The correct answer is Mesenteric cyst Theme from April 2012 Exam Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected.

Answer 63

The correct answer is Appendix abscess The high fever and diarrhoea together with vomiting all point to a pelvic abscess. The presence of pelvic pus is highly irritant to the rectum, and many patients in this situation will complain of diarrhoea.

Answer 64

The correct answer is Mesenteric adenitis High fever and mild abdominal signs in a younger child should raise suspicion for mesenteric adenitis. The condition may mimic appendicitis and many may require surgery.

Answer 65

Octreotide is a useful agent in reducing the output from pancreatic fistulae. Prokinetic agents will increase fistula output and should be avoided. Fistulas A fistula is defined as an abnormal connection between two epithelial surfaces. There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally. In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn's. As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae. The four types of fistulae are: Enterocutaneous These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis. Suspect if there is excess fluid in the drain. Enteroenteric or Enterocolic This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease. Enterovaginal Aetiology as above. Enterovesicular This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Management Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 66

The correct answer is Inguinal herniotomy Infants usually suffer from a patent processus vaginalis (a congential problem). As a result a simple herniotomy is all that is required. A mesh is not required as there is not specific muscle weakness.

Answer 67

The correct answer is Lichtenstein repair An open Lichtenstein repair using mesh is appropriate. There is a 0.77% recurrence rate with this technique. A Shouldice repair is an acceptable alternative if the surgeon is experienced

Answer 68

The correct answer is Laparoscopic hernia repair Laparoscopic hernia repairs are specifically indicated where there are bilateral hernias or recurrence of a previous open repair. Next question Inguinal hernia surgery Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests on their relation to Hesselbach's triangle. Boundaries of Hesselbach's Triangle Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament

Answer 69

The correct answer is Pfannenstiel's This patient needs an emergency cesarean section.

Answer 70

Correct Answer: A. Kocher’s Explanation: In this scenario, the patient likely requires an urgent cholecystectomy and possible exploration of the common bile duct due to gallstones causing jaundice and a dilated common bile duct. • Kocher’s incision: This is a right subcostal incision that provides excellent access to the gallbladder, common bile duct, and liver. It is commonly used for open cholecystectomy and biliary surgeries. Other incisions are less appropriate for this particular situation: • Lanz: Typically used for appendectomies. • Rooftop: Commonly used for extensive upper abdominal surgeries, such as pancreaticoduodenectomy. • Pfannenstiel’s: A low transverse incision used for pelvic surgeries, particularly gynecological and obstetric procedures. • Midline: Provides good access to most abdominal structures but is not specifically tailored for biliary surgery. • Paramedian incision: Less commonly used nowadays; offers good access to certain abdominal organs but not typically for biliary surgery. • McEvedy: Used for femoral hernia repairs. Therefore, the most appropriate incision for this procedure is Kocher’s.

Answer 71

The correct answer is Rooftop A pancreatectomy is usually performed through a roof top incision. This provides excellent access to the upper abdomen. Abdominal incisions Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Kocher's Lanz Gridiron Gable Pfannenstiel's McEvedy's Rutherford Morrison Incision under right subcostal margin e.g. Cholecystectomy (open) Incision in right iliac fossa e.g. Appendicectomy Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Rooftop incision Transverse supra pubic, primarily used to access pelvic organs Groin incision e.g. Emergency repair strangulated femoral hernia Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

ABDOMEN EMRCS Flashcards

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