General Surgery

Question 1

What is the optimal repair of a large duodenal ulcer perforation?

Answer 1

Jejunal patch (Thal patch), pyloric exclusion, and gastrojejunostomy.

Question 2

How do symptoms of appendicitis differ from gastroenteritis?

Answer 2

Appendicitis: Anorexia –> abd pain –> n/v

Gastroenteritis: n/v –> abd pain

Question 3

What is the Iliopsoas test?

Answer 3

pain with extension of right thigh when lying on side = retrocecal appendix

Question 4

Obturator test

Answer 4

pain with internal rotation of the thigh = pelvic appendix

Question 5

What are 2 ways to treat a

perforated appendix?

Answer 5

Immediate appendectomy - some evidence says increased risk of bowel obstruction, wound infection, and reoperation

or

Treat with abx and delayed appendectomy
Abx either ampicillin, gentamicin and clindamycin or metronidazole

Question 6

The 2 most common bacteria associated w/ a perforated appendix?

Answer 6

E. Coli and Bacteroides

Question 7

What criteria for operative SBO have a higher conversion rate of laparoscopic to open?

When are high-grade SBO’s are normally operated on?

Answer 7

Dilated small bowel > 4cm

If no relief after 2-3 days but post-operative SBO’s are different, prefer to wait 2-3 weeks.

Question 8

What kind of closures are used for infected fields?

Answer 8

Staged.

Not formal closures

Question 9

If in cholecystectomy the cystic duct and artery cannot be identified then …?
(3 options)

Answer 9

1. Try maneuvers to improved visibility, ie: lateral retraction of infindibulum
2. Intraoperative cholangiogram by injecting into infidibulum
3. Convert to open

NOT ercp or cbde

Question 10

Endoscopy stuff:
Pt position and when to rotate scope?
Type of scope?
What positions are ampulla of vater, CBD and pancreatic duct?

Answer 10

Patient starts in left lateral decubitis and then once scope reaches the duodenum the patient is rotated to prone.

A side viewing scope is used.

Ampulla of vater is a small longitudinal nubbin at the 12 to 1 o’clock position

CBD is at the 11 o’clock position

Pancreatic duct is found at 1 o’clock

Question 11

ERCP’s most common complication is?

Answer 11

Pancreatitis. Usually from the contrast injection causing overfilling of ductules.

Question 12

What is the optimal repair of a small duodenal ulcer perforation?

Answer 12

Small - primary repair and patch

Question 13

What is treatment for 2nd portion duodenum strictures if short? If long?

Answer 13

Short are treated with stricturoplasty

Long are treated with gastrojejunostomy and selective vagotomy

Question 14

What procedures are performed for strictures of small bowel if . . . 
5-7cm segment
10-15 segment
> 15cm segment
Multiple segments

Answer 14

Excluding proximal duodenum? - these are bypassed with a gastrojejunostomy? Confusing. ***

5-7cm segment - Heinecke-Mikulicz stricturoplasty -

10-15 segment - Finney stricturoplasty -

> 15cm segment - Michelassi stricturoplasty -

Multiple segments - resection

Question 15

How to manage large bowel strictures?

Answer 15

Resection because 7% of large bowel strictures are malignant

Question 16

After splenectomy symptomatic pancreatic leaks are treated with?

Answer 16

Drainage and abx

Question 17

What vaccines are given after splenectomy?

Answer 17

Pneumococcal 23 valent - booster dose 4-6 years later and again at 65 if > 5 yrs since last dose

Haemophilus infl vac - no need for repeat vaccination

Meningiococcal vac - booster dose every 5 years

Question 18

Splenic artery aneurysms should be repaired via ______ in

pregnancy, liver transplant pts, and elderly?

Answer 18

catheter embolization due to increased risk of rupture

Question 19

MC spleen anatomic variation is?

Answer 19

Short splenic trunk that splits into 6-12 branches entering the spleen, “distributed variant”.

Question 20

Splenorenal ligament contains?

Answer 20

The splenic vessels and the tail of the pancreas

Question 21

Describe the types of hernias

Bochdalek

Morgagni

Amyand

Littre

Richter

Indirect

Direct

Femoral

Answer 21

Bochdalek - posterior-lateral diaphragmatic hernia, more common

Morgagni - anterior-medial diaphragmatic hernia, less common

Amyand - assoc. with appendix

Littre - assoc. with a meckel’s diverticulum

Richter - only antimesenteric part of bowel wall

Indirect - patent processus vaginalis - lateral to epigastric vessels

Direct - weak conjoined tendon - medial to epigastric vessels

Femoral - defect in iliopubic tract - forms the anterior and medial border of the femoral canal - inferior to inguinal ligament.

Question 22

Lichtenstein tension-free hernia repair key points to reduce recurrence and prevent pain?

Answer 22

• use large mesh, 7x15, extend 3-4cm above hesselbach’s triangle, 2cm medial to the pubic tubercle, 5-6cm lateral to the inguinal ring
• cross tails of the mesh behind the spermatic cord lateral to the internal ring
• keep the mesh in a tented or loose fashion
• secure mesh medially to conjoined tendon with 2 interrupted sutures, laterally to inguinal ligament with 1 continuous suture to prevent folding/displacement
• ID nerves throughout operation
• Ilioinguinal nerve (sensation to skin at penis base and upper scrotum) is over the spermatocord
• Iliohypogastric nerve is between the internal and external oblique muscles, visible when spreading these to make room for the mesh
• lateral branch supplies skin over glute
• anterior branch supplies skin above the pubis
• innervates internal and transverse abdominus muscles
• Genital branch of the genitofemoral nerve is under the cord structures. Protected from mesh contact by the cremasteric fascia (important to keep the cremasteric muscle intact if possible).
• genitofemoral nerve is responsible for both the sensory (femoral branch) and motor portions (genital branch) of the cremasteric reflex, which describes contraction of the cremasteric muscle when the skin of the superior medial part of the thigh is touched

Question 23

What causes ischemic orchitis?

What is treatment?

Answer 23

Venous congestion of pampiniform plexus or disruption of testicular artery.
Tx is NSAIDs and pain relief. Can last up to 12 weeks.

Question 24

For indirect inguinal hernia repair - the hernia sack is found where anatomically?

Answer 24

Found deep to the cremaster muscle and anterior & superior to the spermatic cord structures.

Question 25

During laparoscopic inguinal hernia repair, where should you avoid stapling? What should you do if an enterotomy is made?

Answer 25

The femoral, lateral femoral cutaneous and genitofemoral nerves are found inferior to the iliopubic tract Can repair, then close and observe on IV abx. If no signs of sepsis then may do delayed mesh placement on POD 3 to 7.

Question 26

Describe the anatomy of a: Petit hernia Grynfelt hernia

Answer 26

Inferior lumbar - External oblique muscle, latissimus dorsi muscle, and iliac crest Superior lumbar - 12th rub, paraspinal muscle, internal oblique, external oblique

Question 27

``` Describe: Rives-Stoppa-Wantz repair Intraperitoneal mesh Preperitoneal mesh Chevrel Onlay ```

Answer 27

Rives-Stoppa-Wantz repair- mesh goes between the rectus muscle and the posterior rectus sheath. Retrorectus position. Intraperitoneal mesh - sub-lay of mesh Preperitoneal mesh - similar sub-lay but mesh is separated from the bowel by peritoneum Chevrel Onlay - mesh over the fascial repair

Question 28

Femoral hernia occur mostly in women because? Describe the anatomy. What test incites pain? Who requires repair? What should be done to reduce the herniated bowel?

Answer 28

Wider bone structure of the female pelvis. Through femoral canal - inguinal ligament anteriorly, pectineal ligament posteriorly, lacunar ligament medially, and the femoral vein laterally. Pain with external rotation of thigh All require repair Inguinal ligament is often divided to fully reduce the herniated bowel.

Question 29

What type of hernia repairs are better tolerated from an anterior approach?

Answer 29

epigastric hernia (unlike other types of ventral hernias)

Question 30

Describe component separation

Answer 30

- elevate skin and subcutaneous tissue from underlying rectus and external oblique muscles, goes from costal margin to pubis and to the anterior axillary line and iliac crest - incision in the external oblique aponeurosis 2cm lateral to the border of the rectus and external oblique muscles - external oblique dissected from underlying internal oblique, don't disrupt neurovascular supply in between internal oblique and the trasnversus abdominis - IF flap is not sufficient then rectus muscle can be dissected free of its posterior sheath 20cm total release is possible Image result for component separation steps

Question 31

For component separation repairs, use of a ______ mesh can prevent recurrence. If using an intraperitoneal mesh then make it a ______ mesh. If a crohn's dz then use a _____ mesh Avoid _____ repairs due to higher recurrence rates.

Answer 31

prosthetic composite mesh retrorectus Avoid inlay repairs due to higher recurrence rates.

Question 32

What should you do If short bowel syndrome is a concern during operation?

Answer 32

Then place a gastrostomy tube to allow for continuous feeds if needed later.

Question 33

What kind of tissue does the ileum contain?

Answer 33

The most prominent amount of lymphoid tissue; therefore, it is the likely location of a small bowel lymphoma.

Question 34

Recurrence rate for appendicitis?

Answer 34

7%. Interval appendectomies are not done to prevent recurrence, they are more to rule out malignancy.

Question 35

Lap Appendectomy trocar placement in pregnant patients in 1st trimester? 2nd trimester? 3rd trimester?

Answer 35

1st trimester - normal - Umbilicus, suprapubic, LLQ 2nd trimester - Umbilicus, RLQ, LLQ 3rd trimester - umbilicus, RUQ, RLQ

Question 36

Lap cholecystectomy trocar placement in pregnant patients in 1st trimester? 2nd trimester? 3rd trimester?

Answer 36

1st trimester - umbilicus, subxiphoid, 2 below right costal margin 2nd trimester - umbilcal trocar moved higher? 3rd trimester - ???

Question 37

MCC of small bowel bleeding is? How is it diagnosed? Treatment? Associated w/ what disease?

Answer 37

Angiodysplasia. Usually diagnosed via enteroscopy, but sometimes pill endoscopy is used, not angiography. Treated with endoscopic directed SB resection. Increased association with Osler Weber Rendu, vWF deficiency, and renal failure.

Question 38

What duration qualifies at prolonged air leak? | What is indicated for treatment at this point?

Answer 38

> 4 days VATS and pleurodesis is indicated.

Question 39

Light's Criteria for Exudative Effusions

Answer 39

Pleural:serum fluid protein ratio > 0.5 Pleural:serum fluid lactate dehydrogenase (LDH) ratio > 0.6 Pleural fluid LDH > 2/3 upper limit of normal

Question 40

What are Glomus tumors? How are they found? What signs are used to diagnose them? Treatment?

Answer 40

- Glomus tumors = AV shunts that respond to temperature changes - MRI can localize the glomus tumor. - Love sign (extreme pain on direct focal pressure) is positive. - Hildreth sign is also positive, which is ablation of pain with proximal tourniquet inflation. - Treat by Complete excision - results in rapid resolution of symptoms.