Blue Boxes Flashcards
Describe the potential space in which prostheses are placed to repair inguinal hernias
Space of Bogros = anterolateral portion of potential space between the transversalis fascia and the parietal peritoneum
When and why is a protuberant abdomen normal?
Infants and young children; abdomen is full of air, abdominal cavity is enlarging, and abdominal muscles are still gaining strength
6 F’s of abdominal protrusion
Food Fluid Fat Feces Flatus Fetus
Eversion of the umbilicus may be a sign of increased abdominal pressure d/t what 2 causes?
Ascites
Large mass
What type of hernia protrudes through the linea alba?
Epigastric hernia
Hernia along the semilunar lines, usually associated with obesity
Spigelian hernia
The common nerve supply of the skin and muscles of the abdominal wall explains why ________ occurs when palpating the abdomen with cold hands, or when palpating an acute abdomen (e.g., appendicitis)
Guarding
Superficial abdominal reflex
Contraction of the abdominal muscles elicited by quickly stroking horizontally lateral to medial toward umbilicus
What 3 nerves supply multi-segmental innervation of abdominal muscles?
Inferior thoracic spinal nn (T7-12)
Iliohypogastric n
Ilioinguinal n
Surgeons avoid transecting muscles in order to avoid irreversible necrosis of muscle fibers. What is the exception to this in the abdominal wall?
Rectus abdominis - can be transected bc its muscle fibers run short distances between tendinous intersections, and the segmental nn supplying it enter the lateral part of the rectus sheath where they can be located and preserved
What type of incision is preferred for exploratory operations because they offer good exposure of and access to the viscera and can be extended as necessary with minimal complicaation?
Longitudinal incisions
What type of incisions can be made rapidly without cutting muscle, major vessels, or nerves?
Median/midline incisions - can be made along any part of length of linea alba from xiphoid to pubic symphysis
Note that bc of relatively poor blood supply, linea alba may undergo necrosis and degeneration after incision if its edges are not aligned properly during closure
Can a transverse incicion be made through the tendinous intersections of the rectus abdominis?
No, bc cutaneous nn and branches of superior epigastric vessels pierce these regions
What type of incision is used to access the gallblader and biliary ducts on the right side and the spleen on the left?
Subcostal incisions
What 2 types of incisions are considered “high-risk”?
Pararectus - along lateral border of rectus sheath (may cut nerve supply to rectus abdominis)
Inguinal incisions - may injure ilioinguinal n
An incisional hernia is a protrusion of _____ or organ through surgical incision
Omentum
When flow in the SVC or IVC is obstructed, anastomoses form between tributaries of these systemic veins, such as the ____ v., providing collateral pathway for blood back to the heart
Thoracoepigastric vv
______ = undescended testis, or non-retractable testis
Cryptorchidism
Undescended testes are typically found somewhere along the normal path of prenatal descent, commonly in what location?
Inguinal canal
What type of hernia leaves the peritoneal cavity medial to that of a direct inguinal hernia, repair of which puts the iliohypogastric nerve at risk
External supravesical hernia
The umbilical vein (which later forms the round ligament of the liver) is patent for some time after birth. What procedure might it be used for?
Umbilical vein catheterization for exchange transfusion during early infancy, for ex. in infants with erythroblastosis fetalis
Metastatic uterine cancer cells (especially from tubmors adjacent to the proimal attachment of the round ligament) can spread from the uterus to what location?
Labium majus, and from there to superficial inguinal nodes
Which is more common, direct or indirect inguinal hernias?
Indirect
The peritoneal part of the hernial sac of an indirect inguinal hernia is formed by what embryonic remnant in males?
Processus vaginalis of testes
[if the entire stalk of the processus vaginalis persists, the hernia extends into the scrotum superior to the testis, forming complete indirect inguinal hernia]
Describe the cremasteric muscle reflex. What nerve is responsible?
Elicited by lightly stroking the skin on the medial aspect of the superior part of the thigh
Ilioinguinal n. stimulation causes rapid elevation of the testis on the same side
Indirect inguinal hernias are more common in men, but when the processus vaginalis persists in females, it forms a small peritoneal pouch called what? What is the significance?
Canal of Nuck
Canal may extend into labia majus, can enlarge and form cysts in inguinal canal which produce a bulge in the anterior part of labium majus and have the potential to develop into an indirect inguinal hernia
What surgical correction is made to prevent reccurence or occurence of torsion of spermatic cord on contralateral side?
Both testes are surgically fixed to the scrotal septum
How would you go about anesthetizing the scrotum?
Since the anterolateral surface is supplied by the lumbar plexus (primarily L1 via ilioinguinal n) and the postero-inferior surface is supplied by the sacral plexus (primarily S3 via pudendal n), a spinal anesthetic agent must be injected more superiorly to anesthitize the anterolateral surface than is necessary to anesthetize its posteroinferior surface
Retention cyst in the epididymis containing milky fluid
Spermatocele
What embryological remnants may be seen around the testes when the tunica vaginalis is opened (if pathological changes have occurred)
Appendix of testes (vesicular remnant of paramesonephric duct)
Appendices of epididymis (remnants of mesonerphric ducts)
Why do varicoceles predominantly occur on the left side?
Likely bc acute angle at which right vein enters IVC = more favorable to flow than nearly 90 degree angle at which left testicular v. enters left renal v.
Metastasis of testicular cancer
Initially to retroperitoneal lumbar LNs which lie just inferior to renal veins; subsequently to mediastinal and supraclavicular LNs
[may also occur hematologically to lungs, liver, brain, and bone]
Metastasis of cancer of the scrotum
Superficial inguinal LNs, which lie in subQ tissue just inferior to inguinal ligament and along terminal part of great saphenous v
What is the purpose of hysterosalpingography?
Tests the patency of uterine tubes - air or dye is injected into uterine cavity from which it normally flows through uterine tubes into peritoneal cavity
Infection and inflammation of the peritoneum due to contamination during surgery or ruptured organ
Peritonitis
Cause exudation of serum, fibrin, cells, and pus into peritoneal cavity + pain in overlying skin and increase in tone of anterolateral abdominal mm.
May cause severe abdominal pain, tenderness, nausea, vomiting, fever, and/or constipation
Perforation of an ulcer through the stomach or duodenum, spilling acid content into the peritoneal cavity may cause what 2 conditions?
General peritonitis
Ascites
Paradoxical abdominothoracic rhythm may indicate what 2 conditions?
[rhythmic movements of anterolateral abdominal wall - abdomen drawn in as chest expands]
May indicate peritonitis or pneumonitis
What causes adhesions to form in the abdomen?
Damage to the peritoneum causes inflammation and fibrin deposit on peritoneal surfaces making them sticky, a they heal fibrin is replaced by fibrous tissue causing adherence of surfaces
Treatment of general peritonitis
Removal of ascitic fluid via paracentesis and large doses of abx
Needle inserted through anterolateral abdominal wall into peritoneal cavity through the linea alba, superior to urinary bladder in a location that avoids the inferior epigastric a.
What tx involving the peritoneum may be used to treat renal failure in which waste products such as urea have accumulated in the blood and tissues?
Peritoneal dialysis - soluble substances and excess water are removed from the system by transfer across the peritoneum, using dilute sterile solution introduced to peritoneal cavity on one side then drained from the other
Functions of greater omentum
Prevents visceral peritoneum from adhering to parietal peritoneum
Forms adhesions adjacent to inflamed organ, sometimes walling it off and protecting other viscera from it
Cushions abdominal organs against injury
Insulation against loss of body heat
Perforation of duodenal ulcer, rupture of gallbladder, or perforation of appendix may lead to formation of _____ = circumscribed collection of purulent exudate in subphrenic recess
Abscess
____ ____ provide pathways for flow of ascitic fluid and spread of intraperitoneal infections in that purulent material can be transported along into the pelvis when pt is upright
Paracolic gutters
How should a patient with peritonitis be positioned?
Seated at 45 degree angle - to facilitate flow of exudate into pelvic cavity where absorption of toxins is slow
What causes fluid to accumulate in omental bursa?
Perforation of posterior stomach wall
Inflamed or injured pancreas —> pancreatic pseudocyst
How would you go about treating a strangulated loop of small intestine that has passed through the omental foramen into the omental bursa?
None of the boundaries of the foramen can be incised bc each contains blood vessles, so the swollen intestine must be decompressed with a needle prior to returning it to the greater sac of the peritoneal cavity through the foramen
What artery must be ligated and severed during a cholecystectomy? What if it is severed prior to ligation?
Cystic a.
Surgeon must control hemorrhage by compressing hepatic a. as it traverses the hepatoduodenal ligament; the index finger is placed in omental foramen and thumb on its anterior wall. Alternate compression and release of pressure allows surgeon to identify bleeding artery and clamp it
Most common type of esophageal discomfort or substernal pain
Pyrosis - d/t GERD (Heartburn)
Pyrosis may be associated with what type of hernia
Hiatal
Esophageal varices commonly develop in persons who have developed which of the following
A. Hiatal hernia B. Pylorospasm C. Pyloric stenosis D. Pancreatitis E. Liver cirrhosis
E. Liver cirrhosis
With sliding hiatal hernias, some regurgitation of stomach contents may occur because the clamping action of what muscle on the inferior end of the esophagus is weak?
The right crus of the diaphragm
____ = characterized by failure of smooth muscle fibers encircling the pyloric canal to relax normally, resulting in overfilled stomach which can lead to discomfort and vomiting
Pylorospasm
What nodes can and cannot be removed in gastric cancer?
Can be removed: nodes along splenic vessels, nodes along gastroomental vessels
Cannot be removed (or very difficult to remove): aortic and celiac nodes and those around head of pancreas
Partial gastrectomy of pyloric antrum = greater omentum is incised parallel and inferior to right gastroomental a., requiring ligation of all its branches. Why does the omentum not degenerate following this procedure?
Anastomoses of other arteries such as the omental branches of the L gastroomental a.
Removal of what pyloric lymph nodes is commonly done in cases of pyloric carcinoma?
Pyloric LNs
Right gastroomental LNs
As cancer advances, celiac LNs may also be removed - to which all gastric nodes drain
Difference b/w gastric ulcers and peptic ulcers
Gastric = open lesions of stomach mucosa
Peptic = lesions of mucosa of pyloric canal or duodenum
Removal of what nerve is performed in some people with chronic or recurring ulcers to reduce the production of acid?
Vagus n. (Selective gastric vagotomy or selective proximal vagotomy - preserves vagus innervation to pylorus, liver, biliary ducts, intestines, and celiac plexus)
A posterior gastric ulcer may erode through stomach wall into pancreas, resulting in referred pain to the _____; in such cases, the erosion of the ___ artery results in severe hemorrhage in peritoneal cavity
Back; splenic
Where is visceral referred pain from a gastric ulcer perceived?
Epigastric region bc stomach is supplied by pain afferents that reach T7 and 8 spinal sensory ganglia and spinal cord segments through greater splanchnic n. The brain interprets the pain as though the irritation occured in the skin of the epigastric region, which is also supplied by the same sensory ganglia and spinal cord segments
Rebound tenderness
Extreme localized pain felt when digital pressure is applied to the anterolateral abdominal wall over the site of inflammation then removed suddenly
Where do most duodenal ulcers occur?
Posterior wall of superior part of duodenum within 3 cm of pylorus
What structures are most likely to adhere to the duodenum in the event of peritonitis d/t ruptured duodenal ulcer?
Liver
Gallbladder
Pancreas
May also get erosion of gastroduodenal a
T/F: during the early fetal period, the entire duodenum has a mesentery
True - it later fuses with posterior abdominal wall d/t pressure from transverse colon
What vessels must you watch out for while repairing a paraduodenal hernia?
Inferior mesenteric a. and v.
Ascending branches of left colic a.
Embryonic midgut rotation occurs around the axis of what structure?
SMA
Occlusion of the ______ by emboli results in ischemia and possible necrosis of the involved segment, and possibly _____, which is an obstruction of the intestine accompanied by severe colicky pain and abdominal distension, vomiting, fever, and dehydration
Vasa recta; ileus
Most common method of diagnosing an ileus
Superior mesenteric arteriogram
