guided study pre msa

Question 1

what is the diapghram responsible for?

Answer 1

inspiration at rest

Question 2

describe the embrylogy of the diapghram

Answer 2

• develops in the neck mainly from the septum transversum close to the thoracic inlet
• nerve supply C3,4,5 (phrenic nerve)
• as the lungs expand during development the diapghram is forced inferiorly through the thoracic cage dragging the nerve supply with it.

Question 3

what are the 4 sources of origin of the diapghram?

Answer 3

1- septum transversum
2- 2 pleuro-peritoneal folds of membrane that fuse with the septum transversum
3- the oesophagus and its mesentery in the midline dorsally
4- the ingrowth from the body wall.

Question 4

what are the attachments of the diapghram?

Answer 4

• xiphoid process
• the costal margin
• ribs 11 and 12
• posteriorly the lateral and medial arcuate ligament

they all converge onto the central tendon.

Question 5

where does the right and left crura arise up to?

where does the median arcuate ligament lie?

Answer 5

left = L1 Aand L2
right = L1, L2 and L3

T12

Question 6

what is the inferior surface of the diapghram lined with?

Answer 6

inferior = peritoneum (apart from the ‘bare area’ that is posterior to the liver)

Question 7

how is the subphrenic intraperitoneal space made?

Answer 7

on the superior surface of the liver the peritoem reflects onto the diapghram to create the subphrenic intraperitoneal space where fluids can collect in the abdomen

Question 8

what are the 3 opening of the diapghram and what passes through each space?

Answer 8

T8= right phrenic nerve and inferior vena cava

T10 = oesophagus, anterior and posterior vagal trunks, left gastric vein and oesophageal branch of the left gastric artery

T12= thoracic duct, axygos and hemiazygous, descending thoracic aorta

Question 9

what is a hiatus hernia?

Answer 9

a condition where a small part of the stomach herniates through the diaphram into the thorax

Question 10

what is the differance between a sliding and a rolling hernia?

Answer 10

sliding = the cardia (the normally intra-abdominal part of the gastro-oesophageal junction has managed to get above the diapghragmatic oesophageal hiatus) is now above the constrictors allowing acid to be secreted into the lower esophagus.

rolling = part of the fundus of the stomach has herniated through the diapghram but the gastro oesophageal junction is still intact (this is not the case for sliding)

Question 11

what is the different symtpoms for rolling and sliding hernia?

Answer 11

sliding:
- severe heart burn
- dysphagia made worse by eating food or by lying down.
- others may be asymptomatic.

rolling:
- dysphagia from compression of the oesophagus
- early satiety
- inability to hold solid foods down

Question 12

describe what a congenital diapghragmatic hernia is?

Answer 12

• condition in new born babies where there is incomplete development of the diaghram
• a large amount of the midgut structure can pass into the thorax, imparing lung function or in some cases lung development.
• babies present with cyanosis and respiratory distres.

Question 13

how can you differentiate the pain from a bleeding duodenal ulcer and MI?

Answer 13

both will cause a sympathetic response to compensate for the inadequate perfusion of tissues = tachycardia
- MI is considerably more painful
- duodenal ulcer may have blood in stool.

The brain cannot localise visceral pain and it thinks it is coming from all over the skin.

C4 dermatome is on the shoulder (phrenic nerve is C3,4,5)

Question 14

why is the pain from a sliding hernia worse after eating food?

Answer 14

food and fluid in the stomach will stimulate the release of gastric acid which will irritate the lower eosophagus

Question 15

Answer 15

Midline Incision

Question 16

Answer 16

Subcostal incision

Question 17

Answer 17

Lanz approach to the appendix

Question 18

Answer 18

Gridiron approach to the appendix

Question 19

Answer 19

Pfannenstiel incision

Question 20

Answer 20

Laparoscopic incision

Question 21

Answer 21

Nephrectomy scar

Question 22

midline incision:
uses?
advantages?
disadvantages?

Answer 22

uses:
- almost all abdominal operations where full access if required

advantages:
- its made of only fibrous tissue = almost a bloodless approach
- very quick access
- minimal restriction ot view

disadvantages:
- large unsightly scar
- higher risk of wound break down
- painful post op

Question 23

paramedian incision:
uses?
advantages?
disadvantages?

Answer 23

uses:
- most operations that require good access to a specific half of the abdomen

advantages:
- provides better access to lateral structures than the midline approach

disadvantages:
- requires more time
- interrupts vessels and nerves passing from lateral to medial

Question 24

transverse incision:
use?
advantages?
disadvantages?

Answer 24

use:
- surgery on the ascending or descending colon, duodenum, pancreas

advantages:
- less painful
- better cosmetic result
- no dernervation
- reduced chance of herniation

disadvantages:
- less exposure
- sloower access

Question 25

subcostal incision:
uses?
advantages?
disadvanatges?

Answer 25

uses:
- biliary surgery on the right
- access to the spleen on the left

advanatages:
- good access to inferior surface of the liver
- less painful than a midline incision

disadvanatges:
- less exposure
- - must be closed in layers

Question 26

Gridiron/Lanz approach to the appendix:
uses?
advantages?
disadvantages?

Answer 26

uses:
appendectomy

advanatges:
- layered closure of muscles provides excellent stregth to the wound
- good access to appendix and caecum

Disadvantages:
- limited and specific access

Question 27

Pfannenstiel Incision:
uses?
advantages?
disadvantages?

Answer 27

uses:
- access to pelvic viscera
- caesarean

advantages:
- good access to pelvic cavity
- minimal scarring
- unlikely to interput nervous supply

disadvantages:
- poor access to abdominal viscera
- danger of damage to the bladder which sits just behind the abdominal wall