General Surgery Flashcards by Miranda King

Changing point of the external iliac to femoral

Once it passes the inguinal ligament becomes the common femoral

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Vessels to avoid in laparoscopy

Inferior epigastric vessels - paired structures

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Contents of the Inguinal Canal (Males)

Rule of 3
Arteries - vas, testicular, cremasteric
Nerves - genito-femoral, ilio-inguinal
Fascial Layers - external, cremasteric, internal
Other Things - pampiniform plexus, vas, lymphatics

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What is contained in the femoral sheath?

Artery and vein

Nerve travels outside of the femoral sheath

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What structures does the inguinal ligament run between?

Pubic tubercle and ASIS

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Borders of the femoral canal

Problem with the femoral canal

Femoral vein
Lacunar ligament 
Inguinal canal 
Pectineus 
These borders are rigid, there is little room for expansion, high risk of strangulation in femoral hernias

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Incarcerated VS Strangulated Hernia

I = hernia is stuck, usually contained within it's sac 
S = disruption to the blood supply: first venous drainage disrupted then arterial supply > ischaemic

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Types of Hernia Fixation (2)

Herniorronaphy = fix the hernia and fix the wall 
Herniotomy = fix the hernia, do nothing to the wall

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Differential of Groin Lump in IVDU (not hernia)

1st. Groin Abscess

2nd. Pseudoaneurysm - will have a thrill and bruit

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Clinical Test for Direct vs Indirect Hernia

Result

= control hernia at the deep ring, ask patient to cough
Re-Appears = direct
Doesn’t Re-Appear = indirect

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Immediate Hernia Surgery Complications

Bleeding
Anaesthetic Reaction
Bowel Perforation

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Early Hernia Surgery Complications

Infection 
Loss of Testicle (ischaemia)
Haematoma
Systemic Sepsis 
Procedure Failure

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Late Hernia Surgery Complications

Chronic Pain
Recurrence
PE

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Pathophysiology of Femoral Hernias

Most often in elderly ladies who were previously overweight and now are not
The femoral space is now empty and so a small section of bowel slips down

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Presentation of Femoral Hernias

Colicky Midgut Pain

Normal AXR

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Scrotal Lump VS Hernia

Can get above a scrotal lump

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Differentiating Duodenal and Gastric Ulcer

Duodenal ulcer pain relieved by eating

Gastric ulcer pain made worse by eating

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Choice of Ix in Appendicitis (Pregnancy)

MRI

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Sensitivity of Mammogram and Age

Increases with age

Need to be >40 for mammogram to be helpful/effective

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When to use MRI to investigate breast pathology

High risk young patietns

Previous surgery

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Paralytic ileus =

= temporary impairment of peristalsis causing obstruction

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Most common causes of small bowel obstruction

Adhesions

Incarcerated hernia

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Most common causes of large bowel obstruction

Malignant tumours

Volvulus

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Presentation of large bowel obstruction

Constipation occurs early

Vomiting occurs late

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AXR Findings in Bowel Obstruction

Small bowel >3cm Colon >6cm Caecum >9cm

Gallbladder wall thickening =

= inflammation | Can differentiate between biliary colic and acute cholecystitis

Rosving's Sign

Press in LIF feel pain in RIF with appendicitis

Charcot's Triad

Fever RUQ pain Jaundice

Complications of ERCP (3)

Pancreatitis Duodenal Rupture Haemorrhage

Where does haemorrhage come from in ERCP?

Gastroduodenal artery

Risk in popliteal artery aneurysm

Thromboembolism

Infectious causes of aneurysm (2)

Luetic aneurysm - syphilis | Mycotic aneurysm - TB

Mirizzi's Syndrome =

= gallstone becomes impacted in cystic duct causing extrinsic compression of common hepatic duct

Procedure to allow drainage of Gallbladder

Cholecystostomy | = stoma into gallbladder allows drainage

Stoma Types | Stoma Techniques

- Colostomy, ileostomy, urostomy | - End or loop

Complications of Stoma (5)

``` Leakage Retraction Prolapse Hernia Mucocutaneous Separation ```

Artery between SMA and IMA

Marginal artery of Drummond | Means that splenic flexure is at risk of ischaemic colitis

Mesenteric adenitis

= inflamed lymph nodes in abdomen in association with viral illness Seen in kids

Tests for peritonism (3)

Jump - mainly kids Cough Percussion of abdomen

Definition of varicose veins

Dilated Tortuous Elongated superficial veins

What is CEA? | What is it raised in?

= carcinoembryonic antigen | - Can be raised in bowel cancer and smokers

Drug which can trigger/worsen IBD flares

NSAIDs

Pressure dependent organs (3)

Brain Kidneys Heart

Mild Flare of UC

<4 bowel movements a day | No systemic features

Moderate Flare of UC

4-6 bowel movements a day | No systemic features

Severe Flare of UC

``` >6 bowel movements a day Temperature >37.8 Heart Rate >90 Abdominal Distension CRP >30 Hb <10.5g/dL ```

Colon Cancer and UC

If UC >10 years need annual colonoscopy due to ++ cancer risk

Ileal Involvement in UC

Can affect the ileum if there is an incompetent ileo-caecal valve

Surgical Indications in UC

Acute Colitis Chronic Symptomatic Colitis Perforation Neoplasia

Surgical options in UC

1. Proctocolectomy with ilionanal pouch formation - most common 2. Pan proctocolectomy with end ileostomy - needs a stoma 3. Subtotal colectomy with ileostomy - emergency situations

Scoring System Used in Upper GI Bleeding

Rockall Scoring System

Urea in Upper GI Bleed

Disproportionately high compared to kidney function | = GI tract digests the blood producing urea

Dark PR Bleeding + Isolated High Urea

= urgent OGD

Stage of shock associated with confusion

Stage 4

GI bleeding is a risk factor for...

Decompensation of existing liver disease

RIF discriminator

Appetite - reliably reduced in appendicitis

Appendicitis Presentation but Older Age Group

Perforated Caecal Cancer

Reversing Warfarin | Time taken to work

Oral Vitamin K - takes 24 hours | IV 10mg Vitamin K - takes approx 4 hours

INR needed to operate

<1.5

Association of Ovarian Pain

Often mid-cycle, associated with ovulation

Where is McBurney's Point?

2/3rds between the ASIS and umbilicus

Ix of Choice for Ovarian Pathology

USS | Especially if suspected ovarian torsion

Scoring System Appendicitis

Alvarado's Score | Especially useful in children - try to avoid imaging children if possible

What is Hartmann's Procedure? Reversibility Uses

= resection of the rectosigmoid colon with closure of anorectal stump Results in formation of end colostomy = reversible Use to treat colon cancer or inflammation

Management of ER+VE Breast Cancers

Pre and perimenopausal - tamoxifen | Post menopausal - anastrozole

Iliac VS Femoral Claudication

Buttock pain = iliac | Calf pain = femoral

Finding in Takayasu's Arteritis

Pulseless peripheries

Calcium and Glasgow Score

Hypocalcaemia is part of the scoring system | Indicates increased severity

Indications for Endarterectomy

<14 days from event 70-99% stenosis of carotid Don't do endarterectomy in 100% stenosis: no risk of embolism

What is amaurosis fugax?

= clot in the ophthalmic artery | An indication for endarterectomy as O.A is a branch of the internal carotid

What is diaphragmatic splinting?

= diaphragm not moving down as much due to abdominal pain or increased abdominal pressure

When do you give antibiotics in pancreatitis?

Only give in necrotising pancreatitis

Formal boundary between upper and lower GI tracts

Duodenojejunal junction | Marked by the ligament of Treitz

Association with Lynch Syndrome

RIGHT sided colon cancers

Associated with achlasia

Squamous cell carcinoma of oesophagus

Nature of carotid occlusive disease

Mostly embolic

Indications for excision of fibroadenoma

>3cm

Medication used in PAD

Clopidogrel

Findings in amoebiasis (3)

Colonic ulceration Abdominal pain Bloody diarrhoea

Association of Primary Gastric Lymphoma

H. pylori

Anatomical source of rectal varices

Superior rectal veins

Signet ring sign

Gastric adenocarcinoma

Complications: 1. Crohn's 2. UC

``` Crohn's = fistulae, abscesses UC = bowel cancer, toxic megacolon ```

Non-Medical Method to Induce Remission in Crohn's

Exclusive enteral nutrition

Femoral hernia relative to the pubic tubercle

Below and lateral

Inguinal hernia relative to the pubic tubercle

Above and medial

Borders of Hesselbach's Triangle

``` Medial = rectus abdominus Lateral = epigastric vessels Inferior = inguinal ligament ```

Direct VS Indirect Hernia

Direct goes through the wall of the inguinal canal, will reappear on reduction and occlusion of the deep ring Indirect goes through the canal itself

INR needed to perform surgery

<1.5

General Surgery Flashcards

(89 cards)