Abdominal surgery Flashcards by Hannah Gibson

Lateral abdo wall layers + their continuous spermatic + scrotal structure

Skin – epidermis, dermis, SC fat
Camper’s fascia – Dartos muscle
Scarpa’s fascia – Colle’s superficial perineal fascia
External oblique – inguinal ligament – external spermatic fascia
Internal oblique – cremasteric fascia
Transversus abdominis – posterior inguinal wall
Transversalis fascia – internal spermatic fascia
Preperitoneal fat
Peritoneum – tunica vaginalis

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Midline abdo wall layers

Skin 
Superficial fascia 
Rectus abdominis muscle 
Arteries 
Transversalis fascia 
Peritoneum

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Arterial blood supply to liver, spleen + gallbladder?

Liver = left + right hepatic 
Spleen = splenic
Gallbladder = cystic (branch of right hepatic)

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Arterial blood supply to stomach + duodenum?

Lesser curvature = right + left gastric
Greater curvature = right gastroepiploic (branch of gastroduodenal), left gastroepiploic (branch of splenic)
Fundus = short gastric (branch of splenic)
Duodenum = gastroduodenal + pancreaticoduodenal

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Arterial supply to pancreas, small + large intestine?

Pancreas = pancreatic branch of splenic + pancreaticoduodenal
Small intestine = superior mesenteric branches (jejunal, ileal, ileocolic)
Large = super mesenteric branches (right + middle colic) + inferior mesenteric branches (left colic, sigmoid + superior rectal)

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What tests should be done in an acute abdomen to reach a diagnosis?

ALP, ALT, AST, bilirubin 
Lipase/ amylase
Urinalysis 
bhCG 
Troponin 
Lactate

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What tests should be done in an acute abdomen to prepare pt for OR?

CBC, electrolytes, creatinine, glucose
INR/ PTT
CXR if cardiac/ pulmonary disease
ECG if cardiac hx or >70

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Surgical options for bariatric sugery

Combination of malabsorptive + restrictive:
Laparoscopic Roux-en-Y gastric bypass (most common, most effective, most complications)
Restrictive laparoscopic sleeve gastrectomy (only for severe obesity)
Laparoscopic adjustable gastric banding (modest weight loss)
Malabsorptive only: biliopancreatic diversion with duodenal switch

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Complications of bariatric surgery

Obstruction at enteroenterostomy 
Staple line dehiscence 
Dumping syndrome 
Cholelithiasis due to rapid weight loss 
Band abscess

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Complications of gastric surgery

Aklaline reflux gastritis 
Afferent loop syndrome 
Dumping syndrome 
Blind-loop syndrome 
Postvagotomy diarrhea

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What is afferent loop syndrome?

Accumulation of bile + pancreatic secretions cause obstruction + distention
Causes postprandial distention, RUQ pain, bilious vomiting
Manage with surgery

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What is dumping syndrome?

Rapid emptying of hyperosmotic chime leads to jejunal distension, stimulating release of vasoactive hormones. Also caused by hypoglycaemia following post-prandial insulin peak
Causes post-prandial epigastric crmaping, bloating, emesis, vasomotor symptoms (palpitations, tachy)
Management: frequent small meals, low in carbs

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What is blind loop symdrome?

Bacterial overgrowth in afferent limb
Causes anemia, diarrhea, abdo pain, hypocalcaemia
Treat with abx + surgery

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What is postvagotomy diarrhea?

Bile salts in colon inhibit water resorption

Tx with cholestyramine or surgery

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What is the difference between a virgin + non-virgin abdo in the context of small bowel obstruction?

Virgin = surgery ASAP
Non-virgin = adhesions likely, resolves with NGT decompression

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Top 3 causes of small bowel obstruction

Adhesions
Hernias
Cancer

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What does an acute abdomen + metabolic acidosis suggest?

Bowel ischemia

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Carcinoid syndrome symptoms

Flushing 
Diarrhea
Right sided HF 
Hypotension 
Bronchoconstriction

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What are the malignant tumours of the small intestine?

Adenocarcinoma
Carcinoid
Lymphoma
Mets

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Where are lymphomas in small intestine typically found?

Distal ileum

Proximal jejunum in pts with celiac disease

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What is short gut syndrome?

Reduced surface area of small bowel causing insufficient absorption
Caused by resections following acute mesenteric ischemia, Crohns or malignancies

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Management of short gut syndrome

TPN, PPI, antimotility agent, octreotide to reduce GI secretions
Surgery to increase length or transplant

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What is the rule of 5s for indirect inguinal hernias?

5% lifetime incidence in males
5x more common than direct
5-10x more common in males
Occurs by 5th decade

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What are the borders of Hesselbach’s triangle?

Lateral = inferior epigastric artery 
Inferior = inguinal ligament 
Medial = lateral margin of rectus sheath

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What is a Richter’s hernia?

Only part of bowel circumference is strangulated so may not be obstructed + may self-reduce

Difference between strangulated + incarcerated hernia

Incarcerated = irreducible | Strangulated – vascular supply is compromised

Complications of hernia post-op

``` Recurrence Scrotal hematoma Nerve entrapment Stenosis of femoral vein Ischemic colitis ```

Findings in Crohns

Cobblestone appearance Skip lesions Creeping fat

Findings in UC

Crypt abscesses + branching + atrophy

Top 3 causes of large bowel obstruction

Cancer Diverticulitis Volvulus

What signs in LBO indicate impending perforation?

Cecum >12cm | Tenderness over cecum

Open vs closed loop large bowel obstruction features

``` Open = incompetent ileocaecal valve = similar to SBO S+S Closed = proximal + distal occlusion, massive colonic distension causing bowel wall ischemia + necrosis ```

What is Ogilvie’s syndrome?

Acute pseudo-obstruction of bowel

Differences between paralytic ileus + bowel obstruction

Ileus = minimal pain, absent bowel sounds, air throughout small bowel + colon

Tubular vs villous colon polyps

Tubuar – small, pedunculated, even distribution throughout colon Villous = large, sessile, high risk of turning malignant, left sided mostly

What criteria is used to assess whether HNPCC should be screened for?

Bethesda criteria

What is LAR vs APR (reference to colon cancer?)

``` APR = removes distal sigmoid colon, rectum + anus, permanent end colostomy LAR = removes distal sigmoid + rectum with anastomosis from colon to anus ```

What is angiodysplasia?

Vascular malformation, frequently in right colon | Venous dilatation + tortuosity

When do you see the ace of spades or bird beak sign?

Barium enema of sigmoid volvulus

What is toxic megacolon?

Inflammation in smooth muscle layer of bowel causing paralysis Caused by infection on IBD

Reasons fistulas stay open

``` FB Radiation Infection Epithelialisation Neoplasm Distal obstruction Others = increased flow, steroids ```

What is a mucous fistula?

Connection of distal limb of colon to abdo wall

What is a ileal conduit?

Connection of bowel to ureter proximally + abdo wall distally to drain urine

Differences between ileostomy + colostomy

``` Ileostomy = RLQ, liquid, has a spout Colostomy = stool, on LLQ ```

Complications of stomas

``` Obstruction Abscess + fistula Skin irritation Prolapse or retraction Diarrhea ```

Definition of anal fissure

Tear of anal canal below dentate line

What is Goodsall’s rule?

Fistulas originating from anterior to transverse line will have straight course + exit anteriorly Fistulas originating posterior to transverse line will begin in midline + have curved tract

What is Zollinger-Ellison syndrome?

Gastric acid hypersecretion – caused by gastrinoma | Pt has diarrhea + abdo pain, peptic disease reflux

What is Whipple’s triad?

Symptomatic fasting hypoglycaemia Serum glucose <50 Relief of symptoms when glucose is given Sign of insulinoma

Describe the localisation of pain in the abdomen

Most pain is perceived in the midline due to bilaterally symmetric innervation Kidney, ureter or ovary is likely to cause lateral pain

Where does biliary + renal colic radiate to?

``` Biliary = right shoulder/ scapular Renal = groin ```

Where does AAA, perforated ulcer + pancreatitis radiate to?

``` AAA = back or flank Ulcer = RLQ (right paracolic gutter) Pancreatitis = to back ```

Causes of diffuse abdo pain

``` Peritonitis Early appendicitis Mesenteric ischemia Gastroenteritis Constipation Bowel obstruction Pancreatitis IBD IBS AAA Sickle cell crisis Perforated ectopic PID Acute urinary retention Carcinoid syndrome DKA Addisonian crisis Hypercalcaemia Lead poisoning Tertiary syphilis ```

What do waves of colicky pain suggest?

Bowel obstruction

What does pain out of proportion to clinical findings suggest?

Ischemic bowel

DDx abdo mass in RUQ

Cholecystitis, cholangiocarcinoma, peri-ampullary malignancy, cholelithiasis Klatskin tumor (biliary tract) Hepatomegaly, hepatitis, abscess, tumour

DDx abdo mass in midline

``` Pancreatic adenocarcinoma, pseudocyst AAA Gastric tumour, MALT lymphoma Pregnancy, fibroids, uterine cancer, pyometra Bladder distension, bladder cancer ```

DDx for abdo mass in RLQ

Stool, tumour, mesenteric adenitis, abscess, intusseception, Crohns inflammation Ectopic, cyst, ovarian tumour Tubo-ovarian abscess, hydrosalpinx

DDx for abdo mass in LUQ

Splenomegaly, tumour, abscess, splenic haemorrhage | Gastric tumour

DDx for abdo mass in LLQ

Stool, tumour, abscess | Ovarian pathology

Indications for urgent surgery in an acute abdomen

Ischemia Hemorrhage Obstruction Perforation

What is occult vs obscure bleeding?

``` Occult = bleeding from rectum not obvious to naked eye Obscure = bleeding with no identifiable source eg after endoscopy ```

Abdominal surgery Flashcards

(62 cards)