Flashcards in PACES Surgery Deck (191)
This is the pathological localised permanent dilatation of an artery to more than 1.5 times its original diameter involving all 3 layers of its parent wall.PSEUDOANEURYSM DOESN'T INVOLVE ALL THREE LAYERS OF THE ARTERIAL WALL.
Causes of bowel obstruction
Small bowel obstruction is more common than large bowel. The most common causes of small bowel obstruction are - adhesions- hernias- cancersThe most common causes for large bowel obstruction are:- cancers- diverticular disease- volvulusThe causes of bowel obstruction can be divided into mechanical and non-mechanical causes.Mechanical causes can be classified according to their relation to the bowel wall:- luminal: gallstones, meconium, impacted faces, ...- extramural: adhesions, cancers, hernia, volvulus- in the wall: congenital stenosis, strictures, IBD, diverticulitis, cancer...Non-mechanical causes, known as paralytic ileus, are due to - postop abdo surgery, - mesenteric ischemic- metabolic causes (hypokalemia, uremia, hypoglycemia and hypothyroidism)
Causes of clubbing
The most common cause of digital clubbing is idiopathic. However, there are many causes of clubbing and they can be classified into:- GI causes: IBD, PBC, coeliac- Resp causes: Lung Ca, bronchiecstasis (suppurating lung disease), CF, Mesothelioma, fibrosing alveolitis - cardiac causes: congenital cyanotic heart disease, endocarditis- other causes: familial, idiopathic, graves' diseaseShamroth's test
Ix for acute abdomen
!!! simple bedside tests:- ECG (to rule out ischemic/MI)- urinalysis (hematuria in renal calculi, UTI, or pregnancy test)- BM: blood sugar levels, if suspected DM presenting as abdo pain!!! Blood tests:--- Simple tests- FBC (raised WCC in infection or anemia if GI bleed)- U&E: look for dehydration, renal failure, raised urea in case of acute GI bleed, electrolyte imbalance secondary to massive fluid shifts in pancreatitis or cases of bowel obstruction- LFT: for acute cholecystitis, or obstructive jaundice- Amylase: compulsory in acute abdomen. Raised in acute pancreatitis to at least greater than 3 times the upper limit of normal - G&S: if expecting an operation or if there is blood loss- Cross-match: if expect pt will need operation and will require blood transfusion (eg upper GI bleed taken to theatre)- ABG: if pt particularly sick, will help to gauge how sick he is. Lactate and pH are helpful indicators of level of shock and can help unmask conditions like mesenteric ischemia.--- specialist tests (for pancreatitis for example: do BM, Ca levels, liver transaminases and CRP to score severity).!!! Imaging--- plain films- erect CXR: if suspecting perforated intra-abdominal viscous...then looking for air under diaphragm. Film taken while patient sitting upright for at least 20 min prior to film taken, because air will need time to rise and demonstrate a pneumoperitomeum. Sign only present in 80% of cases- AXR: if bowel obstruction thought- Contrast films: gastrograffin enema if bowel obstruction or IVU for ureteric colic.--- Ultrasound- USS liver: to scan biliary tree for evidence of gallstones or to measure size of common bile duct in suspected obstructive jaundice--- CT scans:- CT KUB: first line Ix for renal calculi- CT abdo/pelvis: depends on the case but useful in pts not responding to ttt and in whom urgent Sx exploration is not mandated.
Question about discussing the management
Start with stating Hx, examination, Ix, differential diagnosis and ttt options.Ttt options can be either:- conservative: includes anything non-surgical. May be in the forms of IV fluids, NG tube for drainage of stomach contents and urinary catheterisation. Includes as well MDT approach (OT, PT, clinical nurse specialists) in chronic debilitating conditions such as OA or cancers- medical: any drugs (eg analgesia, antibiotics...). May also take form of more invasive but non-surgical ttt options, such as injection sclerotherapy in varicose veins or injecting Hemorrhoids. Some surgeons argue that endoscopic ttt options fall under this category.- surgical: any surgical procedure performed
Discussing surgical complications
2 main categories1- complications from anaesthetics: 1.1 damage to local structures (mouth, pharynx, teeth) 1.2 allergic reactions to agents (minor vs major) 1.3 slow recovery (due to poor cardiac, hepatic renal function...) 1.4 malignant hyperpyrexia (caused by anesthetic gas or suxamethonium) 1.5 awareness (pt paralysed but without effective anaesthetic)2. Complications due to surgery 2.1 related to any surgical operation: pain, infection, bleeding, DVt/PE 2.2 specific to the surgical procedure 2.2.1 immediate 2.2.2 early 2.2.3 late
Postop complications of total thyroidectomy
1. Cpx from anaesthetics2. Cpx from surgery 2.1- general to any surgical operation 2.2- specific to thyroidectomy A- immediate (3 weeks): hypothyroidism, keloid scar formation, recurrence.FYI: primary hge or laryngeal edema compromising the airway is a surgical emergency. Surgical clips should be removed to facilitate evacuation and help relieve the immediate airway compromise (buys time before definitive surgical evacuation). Surgical clip removers always by the bedside of post-thyroidectomy pts.
Testicular pain age groups
- prepubertal: mumps orchitis, idiopathic scrotal oedema, testicular torsion- adolescent (10-21): testicular torsion (most likely), epididymo-orchitis, torsion of the Hydatid of Morgagni (7-14)- adult (>21): epididymo-orchitis (most likely), testicular torsion- all age groups: trauma
Focused Hx for Testicular pain
- patient age- testicular pain: bilateral (mumps orchitis), unilateral (testicular torsion or epididymo-orchitis), acute onset (torsion) vs gradual onset / hours (epididymo-orchitis), sharp pain (torsion) vs dull heavy (epididymo-orchitis), pain relieved by standing up or wearing scrotal support (epididymo-orchitis), radiation to thigh groin or abdomen (t10 dermatome) implies testicle, if to penile shaft or perineum implies idiopathic scrotal edema.- Urinary symptoms: dysuria, urinary frequency and urethral discharge commonly seen in epididymis-orchitis. Nothing in torsion.- sexual HX; relevant for epididymo-orchitis- swelling: + erythema = scrotal edema or mumps orchitis / just after trauma = hemToma / swelling can occur with torsion.- previous HX: torsion (usually intermittent torsion previously) - fever/vomiting: with epididymo-orchitis, torsion or mumps. Vomit from pain in torsion.
How to describe a scar
1- Identify scar: name with eponymous name or anatomically ((eg 2cm scar in R groin). Comment on whether scar recent (raised and pink/red) or old (flat and same colour as surrounding skin)2- check for incisional hernia: ask pt to cough or raise head off the bed3- suggest possible operations
Possible operations for Midline laparotomy scarWhat about Upper midline scar and lower midline scar
Exploratory laparotomyHemicolectomy Hartmann'sAAA repairUpper midline scar: splenectomy (massive)Lower midline scar: para-umbilical hernia repair, colectomy
Possible operations for Kocher's or right subcostal scar
Open cholecystectomyPartial liver resectionAny biliary surgery
Reversed Kocher's (left subcostal)
Possible operations for Double Kocher's or rooftop scar (=R and L subcostal)
Ivor Lewis (Oesophagectomy)Complex pancreatic/gastric surgery
Possible operations for Mercedes scar or extended rooftop
Complex upper GI surgery (eg McKeown Oesophagectomy, gastrectomy, liver transplant
Possible operations for left nephrectomy scar or loin incision
NephrectomySpecialist renal surgery
Possible operations for Gridiron or McBurney's scar
Possible operations for Pfannestiel scar
- pelvic surgery: bladder resection, prostatectomy, bilateral hernia repairs- gynae: C-section, cystectomy, hysterectomy
Possible operations for Rutherford Morrison or hockey stick scar
(When seeing a renal transplant scar, what else would u like to examine/look for?
I would like to look for associated scars:eg - AV fistula at wrist, - median sternotomy scar, - CAPD (Tenckhoff) scar on abdominal wall or - infraclavicular scars from previous dialysis access (Vas Cath insertions)
Gridiron scar vs Lanz scar
Gridiron scar perpendicular to McBurney's line at McBurney's pointLanz is a transverse muscle splitting incision better for cosmetic result (incision follows Langers's lines)
What structures would you go through in 1- an Appendicectomy scar?2- a midline laparotomy scar?
Appendicectomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa's fascia, Linea alba3- muscle layers: external oblique, internal oblique than transfers us abdominis4- transversalis fascia5- extra peritoneal fat then parietal peritoneumMidline laparotomy scar: From superficial to deep:1- skin, subcutaneous tissue2- scarpa's fascia, Linea alba3- transversalis fascia4- extra peritoneal fat then parietal peritoneum
What's a peritoneum?
It's a serous membrane that forms the lining of the abdominal cavity. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum supports the abdo organs and serves as a conduit for their blood vessels, lymph vessels and nerves.
Pros and cons of midline laparotomy scar
Pros: - good access- can be easily extended- speed of closure and opening- relatively avascular (Linea alba)Cons:- incision more painful than transverse incision- scar crosses Langer's lines (poor cosmetic appearance)- Narrow Linea alba below umbilicus (therefore can damage bladder)
What features determine the placement of laparoscopic ports?
In general, ports should be placed away from areas of high risk, such as:- previous scars, adhesions and known organomegaly- the vessels of the anterior abdominal wall should be avoided , particularly the inferior epigastric arteryThe minimum number of ports should be used (typically 3)The positioning of these ports should then allow for the target organ to be at an apex of an imaginary diamond formed by the various ports as well as the target organ itself.The 10 mm port is the camera and is useful for the removal of organs such as the gallbladder in a cholecystectomy. All other ports are typically 5mm in size.
Pros and cons of laparoscopic surgery
Pros:- shorter hospital stay and rehabilitation- less post-op pain- better cosmetic result- less wound complications- decreased handling of organs (eg bowel)- less trauma to tissues- later reduced incidence of postop adhesionsCons:- lack of tactile feedback to the operating surgeon- longer operation times- more technical expertise required, prolonged training- expensive equipment- difficulty in controlling massive bleed- increased risk of iatrogenic injury to surrounding organs- not always feasible due to CI (eg adhesions)
Nine regions of abdomen
From R to L:- Upper: R hypochondrial, Epigastric, L hypochondrial- Middle: R lumbar, umbilical, L lumbar- lower: R iliac fossa, suprapubic, L iliac fossa
Underlying organs behind the 9 abdominal regions
- R hypochondrial: liver, gallbladder, R kidney, hepatic flexure of colon- R lumbar: ascending colon, small bowel, R urinary tract- R iliac: caecum, appendix, terminal ileum, R ovary and R Fallopian tube- Epigastric: Liver (left lobe), pylorus, duodenum, transverse colon, head and body of the pancreas- Umbilical: Duodenum, small bowel, abdominal aorta- Suprapubic: Bladder, uterus- L hypochondrial: spleen, stomach, splenic flexure of colon, tail of the pancreas, L kidney- L lumbar: descending colon, small bowel- L iliac: sigmoid colon, L ovary and L Fallopian tube
Umbilical vs paraumbilical hernias
Central umbilical hernia-Clinical featuresOccurs following failed fusion of the anterior abdominal wall after birth.Often evident a few days after delivery.The hernias are usually small.The underlying defect is usually smaller than the visible hernia.A cough reflex is present. - Management:Most settle spontaneously and parents can be reassured.Surgeons are usually unhappy to operate before one year old.Strangulation never occurs in central hernias.Paraumbilical hernia- Clinical featuresOccur as a central swelling usually above or below the umbilicus.These hernias may become very large.More common in adults (especially women), than children.May be associated with obesity and weak abdominal muscles.The sac may contain both bowel and omentum.This is a true defect in the linea alba close to the umbilicus. - ManagementThese hernias will not resolve without surgical intervention.The patient should be advised to lose weight.Surgical repair is recommended because of strangulation risk.