Angela's Anatomy/Surgical complications Flashcards by Jennifer Vaz

What are the most common infections following splenectomy?

Pneumococcus, meningiococcus
*Strep pneumo is the most common of the 2
Also haemophilus influenza (HiB)
Encapsulated organisms

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What is LEAST important in management of pancreatic leak?
A) ngt decompression
B) surgery to repair leak
C) somatostatin
D) tpn

surgery to repair the leak

3x ULN amylase to define via drain

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In electrosurgery, which type of voltage causes the least amount of tissue injury?

Lowest voltage. Therefore CUT is less injuring because it has less voltage.

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A patient with a chronically obstructed ureter has <5% function at the time of en bloc resection of recurrent cancer. Do you tie off her ureter at the pelvic brim or do a nephrectomy?

Tie off ureter - less morbid

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Malignant hyperthermia - how does Dantrolene sodium work?

Binds to RYR1, inhibits sarcoplasmic reticulum calcium release

*requires sufficient Mg++ to work

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What is the treatment for malignant hyperthermia?

Duplicate

Dantrolene sodium 2.5 mg/kg, discontinuation of the trigger

internet: dantrolene acts intracellularly in skeletal muscle to lessen the excitation-contraction coupling interaction between actin and myosin within the individual sarcomere.

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Which is least likely to trigger malignant hyperthermia?
Halothane, sevoflurane, desflurane, propofol

Propofol

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What are symptoms of malignant hyperthermia?

Duplicate

hypercapnia/carbia (most reliable first sign)
tachycardia
masseter muscle rigidity
eventual EKG changes
rhabdomyolysis

First sign is unexplained ETCO2 increase, tachypnea

Due to calcium overload within the skeletal muscle cell that leads to sustained muscular contraction and breakdown -> anaerobic metabolism

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What electrolyte abnormality is common with malignant hyperthermia?

hyperkalemia

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What is the best repair for a 1cm laparoscopic trocar injury to the colon that has not been prepped?

primary closure

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What do you do if you make a clean transection of the ureter at the level of the uterine artery?

A) ureteroneocystotomy
B) ureteroureterostomy
C) transureteroureterostomy
D) urinary diversion
E) cutaneous ureterostomy

ureteroneocystotomy

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What do you do if you clamp the ureter, immediately recognize the mistake, and release the clamp?

stent

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What is the next best step to treating a patient with a ureteral leak at the level of a urinary conduit?

IR drainage of a large urinoma/abscess and either delayed removal of stents or reinsertion if already pulled - typically antegrade via PCN by IR

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What detrusor issue happens immediately postop in rad hyst?

detrusor hypertonia

UTD:
injury to the sensory and motor nerve supply to detrusor muscle of the bladder during the resection of anterior, lateral, and posterior parametrium and vaginal cuff Denervation results in detrusor hypertonicity.
Urodynamic studies: usually a phase during which the bladder has increased resting tone and small volume, with intermittent uncontrolled contractions. This is usually followed by a period of decreased bladder tone, increased residual volume, and absence of bladder wall contractions. Fortunately, constant drainage over several weeks or months often allows the bladder to resume more normal function.

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To what depth should VIN be ablated in non-hair baring areas?

1 mm non hair areas

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To what depth should VIN be ablated in hair bearing areas?

3 mm in hair areas

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Which is the greatest risk factor predisposing to leak during low anterior colorectal anastomosis?

distance from the anal verge “Low rectal anastomosis”, less 7 cm from anal verge

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What is most likely to decrease post op wound drainage after groin node dissection?

sparing the saphenous

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In inguinal lymphadenectomy do drains increase or decrease complications?

increase

B&H 2021 p1028

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MOA lovenox (enoxaparin)?

Duplicate

binds to and accelerates antithrombin III causing Xa inhibition

Enoxaparin binds to and potentiates antithrombin (a circulating anticoagulant) to form a complex that irreversibly inactivates clotting factor Xa. It has less activity against factor IIa (thrombin) compared to unfractionated heparin (UFH) due to its low molecular weight

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What is the advantage of LMWH compared to heparin?

fewer bleeding complications, greater ease of use

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What do you when you see HIT with heparin, how does it present?

Thrombosis !!! increasing clot despite heparin and low PLTs
usually 5-14 days after heparin was given though it may be earlier if they are being re-challenged

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How do you treat HIT?

Duplicate

argatroban (Parenteral direct thrombin inhibitor) is probably best option

Argatroban: direct thrombin inhibitor, a class of anticoagulant drugs

Others:
Bivalirudin (Parenteral DTI) - if liver failure
Danaparoid (Parenteral inhibitor of thrombin and factor Xa (indirect, heparinoid)
Fondaparinux (parental Xa inhibitor)
Apixaban, Edoxaban, Rivaroxaban (PO Xa inhibitor)
Dabigatran (ODTI)
Warfarin (CANNOT BE USED INITIALLY)

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What is the blood supply to the long gracilis flap?

medial femoral circumflex artery

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what is the blood supply to the short gracilis flap?

terminal branches of obturator artery

Which 3 vessels are present in the superficial inguinal triangle?

1.superficial external pudenal 2.superficial inferior epigastric 3.superficial circumflex iliacs ? Seem to be vessels that are in the superficial area of hesselbach / inguinal triangle? Remember borders of Hesselbach / inguinal triangle are (rectus muscle - medial; inferior epigastric - superior; inguinal ligament inferior)

What are the borders of the femoral triangle?

1.sartorious 2.adductor longus 3.inguinal ligament

Most likely artery to be transected in rectal resection for ovarian cancer?

superior rectal

Rectal artery flow (Origins of rectal arteries)

1. Inferior Rectal a from internal pudenal 2. Middle rectal a from internal iliac 3. superior rectal from IMA

What muscle divides the subclavian artery and vein?

anterior scalene

What is the origin of the middle rectal artery?

The anterior branch of the internal iliac

What are the 4 major branches of the SMA?

1.inferior pancreaticoduodenal 2.middle colic 3.right colic 4. ileocolic

Where does the SMA arise from the aorta? (What spinal level)

Which half of the colon does the SMA supply?

right side: cecum, ascending, transverse colon

Which portions of the small bowel does the SMA supply?

ileum, jejunum, distal duodenum

At the time of reoperation, you notice the jejunum is necrotic. What artery was likely compromised?

SMA or jejunal

What are the arcades that anastomose the SMA and IMA along the bowel called?

Marginal artery of Drummond

Occasionally there is an anastomotic vessel between SMA and IMA, what is it called?

Arc of Riolan

Where does the inferior pancreaticoduodenal artery arise? what does it supply?

SMA, supplies pancreas and duodenum :)

What is the origin of the middle colic artery? what does it supply?

SMA, supplies transverse colon

Which portion of the colon does the IMA supply?

descending, sigmoid, rectum

What are the major branches of the IMA?

1.Left colic 2.Sigmoid 3.Superior rectal

What is the most likely collateral to the IMA? options: external iliac, splenic, internal iliac, pancreaticoduodeanl

internal iliac

Where does the IMA branch off the aorta?

**L3** (L4?)

Which artery supplies descending colon from splenic flexure to sigmoid colon? where does it originate?

left colic, originates IMA

What major artery supplies the rectum?

Superior rectal artery (originates from IMA)

What are the branches of the anterior division of the internal iliac artery?

Umbilical Superior vesicular Obturator Vaginal Uterine Middle rectal Internal pudendal Inferior gluteal (Everything serves midline structures except inferior gluteal and obturator)

What is the origin of the internal pudendal artery?

Anterior division of internal iliac

What is the origin of the uterine artery?

Anterior division of the internal iliac

What is the origin of the superior vesicle artery

Anterior division of the internal iliac

What is the origin of the obturator artery

Anterior division of the internal iliac

What is the origin of the inferior gluteal artery

Anterior division of the internal iliac (TRICKY: Inferior rectal a is from pudenal a)

What is the origin of the middle rectal artery

Anterior division of the internal iliac

What are the branches of the posterior division of the internal iliac artery?

Ileolumbar Lateral sacral Superior gluteal (I Like Spaghetti (PG rated)) (I Like Sex (R rated))

What is the origin of the ileolumbar artery

Posterior division of the internal iliac

What is the origin of the lateral sacral artery

Posterior division of the internal iliac

What is the origin of the superior gluteal artery

Posterior division of the internal iliac

What artery supplies the omentum?

The gastro-epiploic arteries

Where does the L gastro-epiploic artery originate from?

the splenic artery *the R originates from the gastro-duodenal artery which is a branch of the common hepatic artery

Where does the external jugular vein drain into?

The subclavian vein

Where does the inferior mesenteric vein drain into?

The splenic vein

Where does the superior mesenteric vein drain into?

Comes together with the splenic vein to make the portal vein

What intra-operative injury causes wrist drop? a. cutaneous b. ulnar c. radial

c. radial

What nerve runs over the ileopsoas muscle? What motor deficit would the patient have?

Femoral nerve Decreased extension of the knee (could also have decreased hip flexion but this was not an answer choice)

During a pelvic lymph node dissection, what nerve was injured if the patient experiences numbness of the anterior and medial thigh? What nerve roots form this nerve?

Genitofemoral nerve L1-2

Which injury results in difficulty walking and tingling anterior thigh?

Femoral nerve (lateral cutaneous femoral) <— don’t think this is correct bc femoral supplies anterior thigh sensory

What are the nerve roots that form the lateral cutaneous femoral nerve?

L2-3 Notes say L2-4, but this is incorrect - this is femoral

Injury to which nerve causes numbness of the symphysis pubis and groin? What are the nerve roots of this nerve?

Ilioinguinal T12-L1

What is the innervation pattern of the femoral nerve? i.e. sensory/motor paterns

L2-4 sensory - anterior femoral cutaneous - medial femoral cutaneous motor - iliopsoas (hip flexor) - quadriceps (knee extension) *femoral nerve emerges lateral to the iliopsoas in the pelvis before exiting under the inguinal ligament into the femoral triangle

What is the course of the pudendal vessels and nerve?

Internal Pudendal Artery: originates from anterior division of internal iliac artery; exits the greater sciatic foramen (between the piriformis and coccygeus mm) and enters back in through the lesser sciatic foramen into the pudendal canal of Alcock (with nerve) which terminates 2-3cm proximal to ischial tuberosity - branches: inferior rectal, perineal (gives off the transverse perineal), continues on as clitoral artery (gives off the deep clitoral)

What are the branches of the pudendal nerve?

Inferior rectal (inferior anal) supplies the anus and perianal skin Perineal--supplies small muscles of the superficial and deep spaces (motor) and labia minora and majora (sensory) Dorsal clitoras--sensory

Necrotic transverse colon. Must have ligated the?

Middle Colic..comes from SMA

How to perform urinary conduit after radiation?

select unradiated bowel or use transverse colon

What is the next best step to treating a patient who has an obstruction after radiation?

simple intestinal bypass with non radiated bowel

Prevention of parastomal hernia?

bring colostomy through the rectus muscle *to repair the hernia - place colstomy through mesh or put colostomy retroperitoneal

What artery supplies sartorius muscle?

lateral femoral circumflex artery

Perineal artery (from internal iliac anterior branch) is the main supply to what?

vulva *Pernieal artery is the terminal branch of pudenal artery from anterior division of hypogastric

Where does external jugular vein empty?

subclavian vein

Contraindication for TRAM FLAP?

maylard incision TRAM (transverse rectus abdominus muscle) flap procedure harvests abdominal tissue. This is the most common method of breast reconstruction using the patient's own tissue. It uses the lower abdominal skin, fat and rectus abdominal muscle.

What is the best way to treat a patient with a SBO in the area of distal ileum and cecum?

if there is necrosis or perforation, it needs resection. If the cecum has been radiated, the resection includes cecum and portion of ascending colon to get above radiation field. bowel continuity is re-established by a stapled functional end to end entero=ascending colostomy. right hemicolectomy is an option but preservation of colon is important bc taking out small bowel too if 12 inches from the cecum is involved then place the proximal ileum into transverse colon

transection of the ureter at cardinal ligament?

ureteronecoystotomy

transection of ureter above bifurcation of iliac?

ureteroureterostomy CI: local sepsis, prior XRT, prior ureteral dissection

encapsulated bugs?

S.pneumonia Meningococcal H.influzena

Vaccines for splenectomy? Duplicate

1. 20 valent pneumococcal conjugated vaccine alone (or 15 valent + 13 valent) followed by 23 valent >8 weeks later 2.H influenza type B vaccine 3.quadrivalent meningococcal conjugat ACWY series 4.monovalent meningococcal B vaccine series revaccinate every 5 years Vaccinate 14 days before surgery or 14 days after. from up to date

Angela's Anatomy/Surgical complications Flashcards

(84 cards)