Acute Care Surgery

Question 1

Mnuemonic for remembering most common causes of groin masses:

Answer 1

MINT: malformations, nfections, neoplasms, or trauma

Question 2

Groin mass that is tender, mobile, and <1 cm

diagnosis?

Answer 2

‘shotty’ lymph nodes, reactive with follicular hyperplasia (2/2 minor infections, scrapes, or cuts)

Question 3

a patient who has ‘shotty’ reactive lymph nodes in their groin area s/p a small cut to the skin above it. What type of mass is it?

Answer 3

Groin mass that is tender, mobile, firm, and <1 cm

Question 4

Groin mass that is tender, large (>1 cm), and limited to the inguinal region

possible diagnosis?

Answer 4

syphilis, chancroid, or lymphogranuloma venerum

Question 5

what types of groin mass do you expect to see with syphilis, chancroid, or lymphogranuloma venerum?

Answer 5

tender, large (>1 cm) and limited to the inguinal region

Question 6

Groin mass that is non-tender and associated with diffuse lymphadenopathy?

diagnosis?

Answer 6

systemic process of some kind (infectious, malignant, or autoimmune) (not very specific)

Question 7

non-tender groin mass that is limited to the inguinal region.

possible diagnosis?

Answer 7

metastatic cancer from local source such as melanoma, anal, genital OR from lymphoma / lipoma

Question 8

what cancer originating in the groin region does NOT metastasize to the inguinal region? (i.e. cause a non-tender mass that is limited to the inguinal region)

where does this cancer mets to?

Answer 8

testicular cancer.

this metastasizes to the retroperitoneum

Question 9

pathophysiology (explain why these occur):

1. direct inguinal hernia
2. indirect inguinal hernia
3. femoral hernia

Answer 9

1. acquired weakness in abdominal floor or chronic strining
2. congenital
3. multiple pregnancies dilated femoral veins and widens the femoral canal

Question 10

Hernia sac lining for the following hernias:

1. direct inguinal hernia
2. indirect inguinal hernia
3. femoral hernia

Answer 10

1. peritoneum
2. patent processus vaginalis
3. peritoneum

Question 11

1. most likely hernia to strangulate?
2. most common hernia in Men? women? children?
3. what populaton are femoral hernias most common in?

Answer 11

1. femoral hernia
2. all = indirecti inguinal hernia
3. females

Question 12

Which hernia ONLY goes through the superficial ring?

Answer 12

Direct inguinal hernia

Question 13

What ring(s) in the inguinal canal does

1. the direct hernia pass through?
2. the indirect hernia pass through?

Answer 13

1. direct only goes through superficial ring
2. indirect goes through both the deep AND superficial ring
   * *Reminder: External ring = superficial ring, and internal ring = deep ring.*

Question 14

Pt with femoral hernia has absentbowel sounds and localized pain over the region.

diagnosis?

Answer 14

ischemic bowel (if just SBO would see hyperactive BS 2/2 to hyperperistalsis to try to push past the obstruction)

Question 15

1. Direct inguinal hernia occurs _____ to the inferior epigastric arteries
2. Indirect inguinal hernia occurs ______ to the inferior epigastric arteries

Answer 15

1. direct = medial
2. indirect = lateral

Question 16

What is a richter’s hernia? why is it important to not miss?

Answer 16

circumference of bowel trapped in the hernia sac

important to catch because high likelihood of strangulation and causing ischemia

Question 17

when the entire cirumference of bowel is trapped within a hernia sac, this is called a ______ hernia

Answer 17

Richter’s Hernia

Question 18

1. What is a sliding hernia?
2. what population do they most occur in?
3. do they occur most often on the left or right side of the body?

Answer 18

1. an indirect hernia where a retroperitoneal organ (eg colon or bladder) herniates within a sac and makes up the posterior wall of the sac
2. males > females
3. Left > right

Question 19

when do you want to repair umbilical hernia in children?

Answer 19

you only want to repair if:

1. it persists for >4 yo
2. the defect is >2 cm
3. if there is progressive enlargement s/p age 2

Question 20

What nerves can be injured in a hernia repair and what would the subsequent deficit be? (x4 nerves)

Answer 20

1. genital branch of genitofemoral nerve = loss of cremaster reflex + loss of sensation to anterior scrotum / labia majora
2. ilioinguinal nerve: loss of sensation at base of penis, mons pubis, and inner thigh
3. iliohypogastric nerve = loss of sensation in suprapubic region
4. lateral femoral cutaneous nerve = loss of sensation in lateral side of thigh, down to knee (more common in laparoscopic repair)

Question 21

A patient had a laparoscopic repair of a right sided inguinal hernia. Now they have been having a burning sensation to their lateral right thigh, and on physical exam you notice loss of sensation to the lateral side of the thigh, down to the level of the knee.

1. what is this disease process called?
2. what was injured?

Answer 21

1. ‘meralgia paresthetica’ (the burning pain)
2. lateral femoral cutaneous nerve

Question 22

indirect hernias travel with the _________ so they need to be separted for fear of injuring the ________ or _______

Answer 22

spermatic cord

testicular vessels; vas deferens

Question 23

what is the leading cause of testicular ischemia?

Answer 23

attempting to excise an indirect hernia that was extended and adhered to the scrotum, should’ve been left in situ!

Question 24

is hernia recurrence s/p repair more common in laparoscopic or open?

Answer 24

laparoscopic

Question 25

cramping abdominal pain, nausea, bilious vomiting, abdominal distension, hypoactive BS 1. diagnosis? 2. what part of hx would make you more concerned that this is the diagnosis?

Answer 25

1. small bowel obstruction 2. prior abdominal surgery, indicating likely adhesions

Question 26

cramping abdominal pain, fevers, nausea, vomiting, diarrhea, and hyperactive BS diagnosis?

Answer 26

gastroenteritis

Question 27

diffuse abdominal pain, hypoactive BS, stool in rectum but pt notes intermittent diarrhea since her appendectomy 5 days ago

Answer 27

paralytic ileus (or post-op ileus)

Question 28

gradually increasing abdominal pain that is intermittent but with increasing intervals between pain, distension, feculent vomiting in 80 yo female diagnosis?

Answer 28

large bowel obstruction

Question 29

debilitated, hospitalized male who is passing flatus and has large amount of abdominal distension. diagnosis?

Answer 29

colonic pseudo-obstruction ## Footnote *Reminder: this is normally idiopathic*

Question 30

A patient comes in with LUQ abdominal pain; she has not had an appetite or felt like eating. She notes bloody diarrhea for the past x1 day. Physical exam shows chandalier sign to the LUQ. diagnosis?

Answer 30

mesenteric ischemia

Question 31

1. what surgeries in the US are most likely to cause adhesions that in turn may cause a SBO? 2. most common cause of SBOs worldwide

Answer 31

1. Appendectomy, colorectal resection, gyn procedure 2. hernias