General Surgery Flashcards
(123 cards)
1
Q
Major Layers of the Abdominal Wall
A
Superficial Fascia
Deep Fascia
Peritoneum
2
Q
Layers of the Superficial Fascia
A
Camper’s
Scarpa’s
3
Q
Layers of the Deep Fascia
A
External Oblique Internal Oblique Transversus Abdominus Transversalis fascia
4
Q
Right Upper Quadrant
A
Liver
GB
Duodenum
5
Q
Left Upper Quadrant
A
Spleen
Stomach
6
Q
Right Lower Quadrant
A
Appendix
Ascending Colon
SI
GU
7
Q
Left Lower Quadrant
A
LI
SI
GU
8
Q
Abdominal Arteries
A
Superior Epigastric Inferior Epigastric Superficial Circumflex iliac Superficial epigastric External pudendal
9
Q
Superior Epigastric A.
A
Arises from internal thoracic
Anastomoses with inferior epigastric
10
Q
Inferior epigastric A.
A
Arises from external iliac
Anastomoses with superior epigastic
11
Q
Supreficial Circumflex iliac A.
A
Arises from femoral
Anastomoses with deep circumflex iliac
12
Q
Superficial epigastric A.
A
Arises from femoral
Runs toward umbilicus
13
Q
External pudendal A.
A
Arises from femoral
Runs toward pubis
14
Q
Abdominal incision characteristics
A
Exposure Flexibility Closure Speed Cosmesis
15
Q
Flexibility in an incision
A
Ability to extend incision
16
Q
Closure in terms of abdominal incisions
A
Re-establish strength
Prevent hernia
17
Q
Cosmesis in terms of incisions
A
Langer’s lines
Skin tension
18
Q
Abdominal incision - opening
A
Only required exposure
Divide muscle in fiber direction (except rectus)
Avoid nerves
Retract toward NV supply
19
Q
Abdominal incision - Closing
A
Midline - Fascia to fascia Transverse - Close fascial layers - Big bites - Approximate, don't strangulate - appropriate suture
20
Q
Common Abdominal Incision - General
A
Transverse Vertical Subcostal McBurney / Rocky-Davis Pfannenstiel Paramedian
21
Q
Transverse Incision
A
More physiologic Along Langer's lines In direction of muscle tension Less dehiscence / herniation Less flexible Transection of vascular structures
22
Q
Vertical Incision
A
Midline (trauma, exlap) Good exposure Extendable No vascular structures Scarring More tension on repair
23
Q
Subcostal Incision
A
Good for upper abdominal organs
24
Q
McBurney / Rocky-Davis Incision
A
Appendectomy
25
Pfannenstiel Incision
GYN procedures
26
Paramedian Incision
Time consuming
Denervation risk
Weak closure
27
Laparoscopy - In general
Access via ports in the abdomen with video assistance
| Dx and therapeutic
28
Laparoscopy - Types
Hasson
| Closed Via Visiport
29
Laparoscopy - Advantages
```
Less post-op pain
Fewer wound complications
Often outpatient or 1 night stay
Quicker return to ADLs
Decreased ileus
```
30
Laparoscopy - Disadvantages
Hand-eye coordination
Camera Driver
Limited movement
31
Laparoscopy - Contraindications
```
Potential for adhesions
PG
Severe cardiopulmonary dz
Inability to tolerate general anesthesia
Uncorrectable coagulopathy
```
32
Laparoscopy - Complications
Trocar site bleeding
Injuries upon entry
CO2 embolus
Hernia
33
Appendectomy - S/s
```
Periumbilical pain
N/V
Anorexia
RLQ pain
Positive Rosving's
Positive McBurney's Point
Mild leukocytosis
```
34
Appendectomy - Clinical dx
Hx
| PE
35
Appendectomy - Incision
Laproscopic > Open
36
Appendectomy - Procedure
Appendix held up to retraction
Appendix transsected with a GIA stapler
Drain if perforated
37
Appendectomy - Closure
Buried SQ stitch to close skin
| May need to close fascia to pt is thin
38
Appendectomy - No perforation
Outpatient
39
Appendectomy - Perforation
Requires at least 1-2 days of IV abx
| Then 7-10 days of oral abx
40
Cholecystectomy - S/s
```
Pain
- RUQ
- Epigastric
- Back Pain
Increase after eating
- N/V/D
- Reflux
Positive Murphy's sign
```
41
Cholecystectomy - dx
US - RUQ
HIDA Scan
Hx
PE
42
Cholecystectomy - Incision
Laparoscopic > Open
43
Cholecystectomy - Number of ports & reasons for variation
3-4 ports
Cholecystitis vs. cholelithiasis
Pt anatomy & Size
44
Cholecystectomy - Procedure
GB neck is dissected to clearly visualized the cystic duct and cystic A.
Clips are placed & these are ligated
GB separated from the liver via electrocautery
Drain may be placed if bleeding or excessive bile spilage occurs
45
Cholecystectomy - clousure
Buried SQ stitch to close skin
| May need to close fascia if pt is thin
46
Triangle of Calot
Common hepatic duct (medially)
Cystic Duct (inferiorly)
Inferior edge of the liver (superiorly)
The cystic A. normally passes through the triangle as well as the Node of Calot
47
Inguinal Hernia Repair - S/s
Inguinal pain
Bulge
Incarceration / strangulation
48
Inguinal Hernia Repair - Direct
Through the posterior inguinal wall
No association with processus vaginalis
Hesselbach's triangles
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Hesselbach's Triangle
Rectus Sheath
Inferior epigastric vessels
Inguinal ligament
50
Inguinal Hernia Repair - Indirect
Through deep inguinal ring & Canal
Protrusion of peritoneum along the spermatic cord
Congenital when processus vaginal remains patent
51
Inguinal Hernia Repair - Procedure
Outpatient
Mesh repair most common
Lichenstein
Mesh plug
52
Inguinal Hernia Repair - Lichtenstein
Msh sewn in place over the internal oblique but below the external oblique
Slit cut for spermatic cord
53
Inguinal Hernia Repair - Mesh-plug
Plug placed into defect (tip first)
54
Inguinal Hernia Repair - Post-op pain
6-13% have chronic pain
55
Nissen Fundoplication - S/s
Reflux Hernia
Hiatal Hernia
Paraesophageal hernia
56
Nissen Fundoplication - dx
Endoscopy
Barium esophagram
24h pH study
Esophageal manometry
57
Nissen Fundoplication - Procedure
Laparoscopic > Open
Hernia reduced
Diaphragm repaired
Cauterization of short gastrics
58
Nissen Procedure
Fundus wrapped behind the stomach
Upper portion of greater curvature brought up to meet the fundus
Sutures placed
59
Nissen Fundoplication - Post-op
1 night stay
| Diet restrictions - 2 weeks
60
Small bowel resection - S/s
```
Abdominal pain
Leukocytosis
SBO
Mass
Free air
Air-fluid levels
Bleeding of unknown origin
Transition point
```
61
Small bowel resection - Cause
Ischemia
| Adhesions
62
Small bowel resection - dx
XR
SBFT
CT (PO / IV)
Clinical presentation
63
Small bowel resection - Procedure
Exploratory laparotomy
Vertical midline incision
GIA stapler used to transect bowel on both sides of the diseased bowel
Ends reattached with stapler
64
Small bowel resection - Closure
0 or 2-0 monofilament used to close fascia
Stapler to close skin
65
Small bowel resection - Post-op
5-7 day hospital stay
66
Colonoscopy - In general
```
Most accurate dx tool for colonic pathology
Primary modality for evaluation of
- Lower GI bleeding of unknown etiology
- Inflammatory bowel dz
- Stricture
- Post-tumor removal
- Pseudo-obstruction
- Polyps
- Unequivocal barium enema findings
Allows visualization of the entire colon, rectum and last few cm of the terminal ileum
```
67
Colonoscopy - Therapeutic options
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Polyp removal
Colonic decompression
Structure dilation
Hemorrhage control
Foreign body removal
```
68
Colonoscopy - Preparation
Bowel Prep
| Mild sedation
69
Colectomy - Causes (in general)
Diverticulitis / Diverticulosis
Carcinoma
Volvulus
UC
70
Colectomy - Diverticulitis / Diverticulosis
2 or more bouts that require hospitalization
| May require temporary diverting colostomy
71
Colectomy - Carcinoma
Type depending on location of tumor
72
Colectomy - Closure
GIA stapler used on both sides of the affected tissue
Healthy bowel is reattached
Colostomy / ileostomy if needed
73
Colectomy - Post-op
5-7 days
74
LBO is almost always
A tumor
75
When performing a colectomy for colon ca it is important to recall that operative resection is dictated by
Lymphatic drainage patterns that parallel the blood supply
76
Diagnostic laparoscopy - In general
In the top 5 of all general sx performed
77
Diagnostic laparoscopy - Indications
Abdominal pain of unkonwn origin
| Everything has been r/o
78
Diagnostic laparoscopy - Procedure
Look for adhesions and take them down
Run the bowel
Most often outpatient
79
Breast bx - Indications
Lumpectomy if tumor <4cm
80
Breast bx - Axillary staging
Noninvasive (DCIS) dz does not require axillary staging
81
Breast bx - Contraindications
Dermal lymphatic involvement
Diffuse or multiple tumors
Unwillingness or inability to undergo radiation therapy
Expectation of an unacceptable cosmetic result
82
Breast bx - Procedure
Outpatient
83
Breast bx - Additional interventions
Mastectomy is an option / necessity
| Chemo & radiation may be necessary
84
Lesion / Mass excision - Indications
Used to remove a variety of lesions
- Sebaceous cyst
- Mole
- Melanoma / other skin ca
- Lipoma, etc
85
Lesion / Mass excision - In office vs. sx suite
Office & OR
| Depending on size and location as well as need for pain control or anesthesia
86
Lesion / Mass excision - Incision
Linear - lipoma
Ellipse
- Removal of other lesions
- 4:1 or 3:1 ratio to ensure proper closure of skin (don't be afraid to make a big incision)
87
Lesion / Mass excision - Anesthesia
Once size of excision is determined, local anesthesia is administered
88
Lesion / Mass excision - Procedure
Full-thickness skin and SQ tissue are excicsed in the case of a potentially malignant lesion
89
Lesion / Mass excision - Closure
Closure of deeper tissue with absorbable suture
Skin closure with 4-0 monofilament for SQ stitch or 3-0 for running or interrupted sutures
Skin glue / steri-strips for buried closures
90
Sleeve gastrectomy - in general
Weight loss sx
| Laparoscopic
91
Sleeve gastrectomy - procedure
About 85% of the stomach is removed creating a tube or sleeve
Includes the portion which produces ghrelin
No cutting or rerouting of intestine
92
Ghrelin
Hunger stimulating hormone
93
Sleeve gastrectomy - post-op
50-60% of excess weight in the first 8 months
94
Roux-en-Y Gastric Bypass - In general
Weight loss procedure (can be done for other things / reflux after other failed sx)
95
Roux-en-Y Gastric Bypass - Procedure
Stoma is created using the upper portion of the stomach, stapling off the rest
Ileum is divided as well
Distal segment of the ileum is attached to the stoma, bypassing the absorption, resulting in weight loss
96
Roux-en-Y Gastric Bypass - Post-op
Rapid weight loss
| 60-70% of excess weight
97
Thyroidectomy - Surgeon
Usually ENT
98
Thyroidectomy - Indications
Tx
- Thyroid ca
- Thyroid nodules
- Hyperthyroidism
99
Thyroidectomy - Procedure
All of just a portion of the thyroid can be removed
100
Thyroidectomy - Post-op
Total - requires thyroid meds
| Subtotal - may or may not require thyroid meds
101
Vascular sx - Overall
Tx via angiography, stenting, sclerotherapy & endovenous laser tx are rapidly replace major sx
Reduced stays, lower costs, lower morbidity & mortality
Sx still common for carotid stenosis, open AAA repair, ischemic limbs that are responsive to stenting artherectomy
102
Maintenance Fluids - ml/h
4 x 1st-10kg
2 x 2nd-10kg
1 x remaining kg
103
Maintenance Fluids - daily amount / 24h
100 ml x 1st-10kg
50 ml x 2nd-10kg
20 ml x remaining kg
104
Carcinoma of the sigmoid colon causes high-graded obstruction. What is the classic finding on radiologic study?
Apple core leision
105
S/S of damage to the Mandibular branch of the facial nerve
Inability to raise the corner of the mouth
106
S/S of damage to the glossopharyngeal N.
Horner syndrome
| Decreased gag reflex
107
S/S of damage to the recurrent laryngeal N.
Hoarseness
108
S/S of damage to the superior laryngeal N.
Voice fatiguability
109
S/S of damage to the Hypoglossal N.
Deviation of the tongue to the side of injury
110
What is the most common emergent sx procedure?
Appendectomy
111
What determines whether or not a penetrating neck injury must be further investigated, ie taken to the OR?
Any kind of penetrating neck injury
112
What anatomic landmark is located at the duodenal-jejunal junction?
Ligament of Treitz
113
```
Which of the following is indicative of appendicitis?
A. T103.5, WBC 19.2
B. T100.3, WBC 13.6
C. T97.4, WBC 18.1
D. 98.9, WBC 8.7
```
B
114
What percentage fo breast ca develop in the upper outer quadrant?
50%
115
Signs of necrotizing soft tissue infection
Rapid progression of soft-tissue infection
Marked hemodynamic response to infection
Apparent cellulitis with ecchymosis, bullae, dermal gangrene and crepitus
116
What is the most important step in dx and tx necrotizing soft tissue infection?
Cut it out
117
How could placement of a trocar through the epigastric vessel be avoided?
Illuminate the abdomen
118
What organ is at greatest risk for injury during a laparoscopic nissen fundoplication?
Spleen
119
Using an isotope injected in the tumor region can help identify the first LN drainage the area. This can be used to eval for metastatic dz. This node is called what?
Sentinel node
120
Four basic parts of sx
Rounds
OR
Clinic
Call
121
Rounds
May be expected to round each morning. You will need to pre-round & be done by the time the surgeon is ready to round.
Vitals, labs, I&Os, direct exam
Post-op pts - pain, N/V, flatus, BM, activity
Know diet, abx, culture, IV fluids
Present SOAP format, 1-2 min.
122
OR
TEAMWORK
Look for opportunities to learn from the whole team, IV, foley, intubations, etc
ASK - if you want to learn
Be attentive during the case. Take your cues from the team, know when to speak and when to be be quiet & observe. Ask your questions later.
Introduce yourself to the OR staff
Get you gown & glove for the tech
Bring a lock for your locker!
123
Clinic
W/o clinic you don't have pts to operated on (Necessary evil)
Gives you a chance to follow pts through the entire process
Start by following the surgeon or the PA. You will be expected to do complete H&P's and present your findings after a few days
