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Surgery 2 Flashcards

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1
Q

What is a direct inguinal hernia?

A

passes through Hesselbach’s triangle in the abdominal wall

passes through superficial inguinal ring

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2
Q

What are the borders of Hesselbach’s triangle

A

inguinal ligament at base
lateral border of the rectus sheath
inferior epigastric vessels laterally

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3
Q

What is an indirect inguinal hernia

A

passes through patent process vaginalis through deep inguinal ring

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4
Q

Where is the deep inguinal ring found?

A

midpoint of the inguinal ligament

= between ASIS and pubic tubercle

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5
Q

What is found at the midinguinal point?

A

femoral artery

= between ASIS and pubic symphysis

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6
Q

What is the relation of the inguinal hernias to the inferior epigastric vessels

A 
direct = medial to the inferior epigastric vessels
indirect = lateral to the inferior epigastric vessels
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7
Q

What are the risk factors for inguinal hernias

A 
heavy weight lifting
chronic cough
obesity
chronic constipation
male
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8
Q

what are the signs of an inguinal hernia

A

lump media and superior to the pubic tubercle
positive cough impulse
reducible?
if enters scrotum - can you get above it?

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9
Q

What is the treatment for an inguinal hernia

A

reduction - open or laparoscopic mesh

laparoscopic preferred for bilateral or recurrent inguinal hernias

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10
Q

What are the complications of an inguinal hernia repair

A

early: bruising, wound infection
late: chronic pain, recurrence
damage to vas deferens or testicular vessels

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11
Q

Define hernia

A

the protrusion of part or whole of an organ or tissue through the wall of the cavity that normally contains it.

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12
Q

What are the symptoms and signs of an irreducible or incarcerated hernia

A

painful, tender, and erythematous lump

features of bowel obstruction

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13
Q

What is an irreducible or incarcerated hernia?

A

bowel unable to return to original cavity

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14
Q

What is an strangulated hernia

A

compression of bowel has cut off blood supply to bowel, so ischaemia occurs

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15
Q

How can direct and indirect inguinal hernias be differentiated on examination?

A 
reduce hernia
occlude deep femoral ring at mid point of inguinal ligament
cough impusle
if hernia does not protrude = indirect
if hernia still protrudes = direct
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16
Q

What is the differential diagnosis for an inguinal hernia

A 
Femoral hernia
Saphena varix
Inguinal lymphadenopathy
Lipoma
Groin abscess
Internal iliac aneurysm
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17
Q

What are the differential diagnoses for a mass in the scrotum

A

varicocoele
hydrocoele
inguinal hernia
testicular mass

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18
Q

When is an USS recommended when diagnosing an inguinal hernia

A

if there is diagnostic uncertainty

or to exclude other pathology.

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19
Q

What is the annual risk of strangulation of an inguinal hernia?

A

3%

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20
Q

What is a femoral hernia

A

protrusion of bowel through the femoral ring into the femoral canal

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21
Q

What are boundaries of the femoral ring

A

anterior = inguinal ligament
posterior = pectineal ligament
lateral - femoral vein
medial = lacunar ligament

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22
Q

What are risk factors for a femoral hernia

A

female
multiple pregnancies
obesity
chronic constipation or coughing

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23
Q

What are the signs of a femoral hernia

A

lump in groin
inferior and lateral to the pubic tubercle
below inguinal ligament
medial to femoral pulse

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24
Q

Why are femoral hernias prone to strangulation

A

tight ligament borders of the femoral ring

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25
What are the differential diagnoses in femoral hernia
``` Low presentation of inguinal hernia Femoral canal lipoma Femoral lymph node Saphena varix Femoral artery aneurysm ```
26
What is the gold standard investigation for femoral hernia
USS
27
Why are all femoral hernias meant to be surgically managed
due to high risk of strangulation
28
What is the surgical management of a femoral hernia
reduction of the hernia | surgical narrowing of the femoral ring with the use of interrupted sutures
29
What is the risk of strangulation of femoral hernia at 3m and 21m after initial diagnosis
``` 3m = 22% 21m = 45% ```
30
Describe a hiatus hernia
protrusion of the stomach into the thorax through the oesophageal hiatus
31
What is the difference between a rolling and sliding hiatus hernia
sliding = movement of oesophagus and gastroeosophageal junction upwards rolling = GOJ in same place. fundus moves up to lie next to GOJ
32
Do you get symptoms of reflux in sliding or rolling hiatus hernia
sliding - GOJ compromised
33
what are teh symptoms of hiatus hernia
``` GORD vomiting weight loss hiccuping swallowing difficulties ```
34
What are the complications of hiatus hernia
incarceration strangulation volvulus
35
What is the conservative management of hiatus hernia
PPI diet modification weight loss stop alcohol and smoking
36
What is the surgical management of hiatus hernia
curoplasty = reduction into abdomen fundoplication = fundus wrapped arounf LOS and stretched to stregthen LOS
37
When would you consider surgical management of hiatus hernia
if conservative failed if high risk of strangulation if nutritional failure
38
What are the signs and symptoms of gastric volvulus
Severe epigastric pain Retching without vomiting Inability to pass an NG tube
39
What increases the risk of an incisional hernia
``` obesity midline incisions age pregnancy cough diabetes steroids smoking ```
40
What is the definition of a peptic ulcer
break in the mucosal surface of the stomach or duodenum that extends to the muscularis mucosae
41
What is the most common location for a peptic ulcer
first part of the duodenum | lesser curvature of the stomach
42
What are the causes of PUD
``` Helicobacter pylori infecion NSAIDs alcohol smoking ZE syndrome steroids ```
43
What class of bacteria is H pylori
gram negative bacillus spiral shaped urease producing
44
What enable H pylori to survive in the stomach
urease: urea to ammonium. creates neutral environment for the bacteria to survive in
45
Why does H pylori infection leads to PUD
causes inflammation of the mucosa stimulates G cells to secrete gastrin, leading to increased acid production atrophy imbalance between acid and protective mucus
46
Why do NSAIDs cause PUD
inhibition of prostaglandin synthesis causes reduction in mucus priduction imbalance between acid and protective mucus
47
What are the symptoms of PUD
``` epigastric pain - worse on eating (gastric) or 2-4h after (duodenal) nausea anorexia weight loss tiredness malaena ```
48
What are the red flag symptoms for gastric cancer which require urgent OGD
new onset dysphagia >55 with weight loss + abdo pain, reflux or dyspepsia
49
What investigations should be carried out in suspected PUD
FOB FBC, U+E, Urease breath test - must stop PPI at least 2 weeks prior
50
What is the management of PUD
lifestyle interventions PPI for 4-8weeks if proven H pylori - triple therapy OGD to check resolution
51
What are some lifestyle interventions for PUD
``` stop smoking less alchohol small meals not eating for 3 hours before bed Lose weight Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty or spicy foods. ```
52
What is triple therapy for H pylori
PPI eg lansoprazole amoxicillin clarithromycin 7 days if penicillin allergic = clarithromycin + metronidazole
53
What are the complications of PUD
``` haemorrhage perforation gastric outlet obstruction malignancy - H pylori increases risk anaemia ```
54
What artery is most likely to cause haemorrhage in PUD
gastroduodenal
55
What is an AAA
dilation of the abs=dominal aorta >3cm (normal - 1.5cm)
56
What is the pathophysiology of AAA
loss of elastic proteins and extracellular matrix in intima and media of the AA due to proteolytic activity and lymphocytic infiltration
57
What are the risk factors for AAA
``` male age HTN hyperlipidaemia smoking FH ```
58
What are the signs and symptoms of AAA
none! back/.abdo/loin pain distal emboli pulsating mass above umbilicus
59
What is the ddx of AAA
``` renal colic IBD/IBS diverticulitis appendicitis GI haemorrhage ```
60
Describe the screening programme for AAA
abdominal USS for men aged 65 small 3-4.4cm USS every year medium 4.5-5.4cm USS every 3m large >5.5cm offer surgery
61
Define small medium and large AAA
small 3-4.4cm medium 4.5-5.4cm large >5.5cm
62
What investigations are done in suspected AAA
USS abdomen | CT with contrast if >5.5cm for operative planning
63
What is the conservative management of AAA
stop smoking weight loss control BP statin and aspirin
64
When should the DVLA be informed of an AAA
when it is greater than 6cm | need to stop driving due to risk of rupture
65
What benefits does stopping smoking have in AAA
slows rate of progression | decreases risk of rupture
66
When is surgery offered in AAA
if >5.5cm if expanding at >1cm/year if symptomatic
67
What are the surgical options in AAA
endovascular repair | open repair
68
What are the risks and benefits of endovascular aneurysm repair (EVAR) of AAA
risks: endoleak, increased risk of reintervention and rupture. will need regular CT angiograms to monitor benefits: reduced 30 day mortality, reduced hospital stay same long term outcomes as open
69
What is an endovascular leak
a leak around a graft used in endovascular repair
70
State the types of endovascular leak
``` 1 = leak around edge of graft 2 = filling by branch vessel 3 = leak through defect in graft 4 = leak through porous material of graft 5 = no obvious site of leakage, but the aneurysm is expanding ```
71
What increases the risk of AAA rupture
smoking female HTN FH
72
What are the symptoms and signs of AAA rupture
``` back/abdo pain (most are retroperitoneal) vomiting syncope low BP raised HR pulsatile abdo mass abdominal tenderness ```
73
how should an AAA rupture be managed
``` high flow oxygen 2x large bore cannulae bloods - FBC, amylase, cross match ECG o-ve blood keep BP below 100 CONTACT VASCULAR TEAM ```
74
Why does the blood pressure need to be maintained below 100mmHg in AAA rupture
prevents excessive blood loss | reduces risk of rupturing contained leak
75
When should warfarin be stopped pre-operatively?
5 days before op
76
When should clopidogrel be stopped pre-operatively?
5 days before op
77
Why are pre-medications given in surgery
decrease gastric volume decrease post op N+V decrease anxiety
78
Define the ASA grades
``` 1 = normal healthy 2 = mild systemic disease 3 = severe systemic disease 4 = severe systemic disease that is a constant threat to life 5 = moribund who is not expected to survive without op ```
79
What are the criteria for discharge form the recovery room to the ward
patient fully conscious, able to maintain a clear airway respiration and oxygenation satisfactory CVS stable - BP, pulse, perfusion pain and emesis controlled - analgesia and anti=emetics prescribed temperature within acceptable limitis o2 and IV fluid therapy prescribed if appropraite
80
What are patient factors that increase the risk of PONV
female motion sickness prev PONV non-smoker
81
What are surgical factors that increase the risk of PONV
laparascopic abdominal or pelvic middle ear o intracranial long operation
82
What are anaesthetic factors that increase the risk of PONV
``` NO opiods long anaethesia spinal intra op dehydration overuse of bag+mask ```
83
What are the main classes of antiemetics
antihistamines dopamine antagonists 5HT3 antagonist
84
What causes nausea
visceral stimulation in response to distention/irritation detected by mechano/chemoreceptors chemoreceptor tigger zone in response to drugs, hormones or toxin in blood higher neurological inputs in response to psychological stress, CNVIII and CN IX gag reflex
85
What neurotransmitters do the mechano/chemoreceptors in the viscera use? Where do these act
5-HT3 and dopamine vagus nerve simulates vomiting centre in medulla oblongata
86
Where is the chemoreceptor trigger zone
in teh fourth ventricle floor outside blood brain barrier
87
What neurotransmitters does the CTZ use?
5-HT3 and dopamine
88
What neurotransmitters does the CTZ use? | Where do these act?
ACh, histamine at CTZ -> vomiting centre
89
How do antihistamines act as an antiemetic
block H1 receptor in vomiting centre
90
Give an example of an antihistamine used as an antiemetic
cyclizine
91
When is cyclizine best used as an anti-emetic
pregnancy | labyrinthine disorders
92
How do dopamine antagonists act as an antiemetic
inhibition at CTZ
93
Give an example of an dopamine antagonist used as an antiemetic
metaclopramide, | domperidone
94
When are dopamine antagonists best used as an anti-emetic
in decreased gut motility (they stimulate) | also for nausea caused by drugs, cytotoxins
95
How do 5HT3 antagonists act as an antiemetic
block 5HT3 receptors in gut and CTZ
96
Give an example of a 5HT3 antagonist used as an antiemetic
ondansetron
97
When are 5HT3 antagonists best used as an anti-emetic
PONV - opiod induced | chemo
98
Describe teh analgesic pain ladder
non-opiate weak opiate eg codeine, tramadol strong opiate eg morphine, diamorphine
99
What are the main side effects of an epidural
decrease BP loss of bladder control sickness headache
100
What layers does an epidural needle go through
superficial tissues supraspinous ligament interspinous ligament ligamentum flavum stops before dura and arachnoid
101
Name the 9 areas of the abdomen
``` right hypochondrium epigastrium left hypochondrium right flank periumbilical left flank right iliac fossa suprapubic left iliac fossa ```
102
What bacteria are most likely to cause a wound infection
staph aureus strep pyogenes enterococci
103
What is the antibiotic treatment for a wound infection
flucloxacillin teicoplanin IV if more severe
104
How is C diff treated
metronidazole/vancomycin
105
How much of a crystalloid fluid will remian in the intravacular space
25%
106
How much a 0.9% dextrose solution will remain in the extravascular space
1/12th
107
What is the difference between hypovolaemia and dehydration
hypovolaemia = loss of Na+ and water. haemodynamically unstable dehydraion = loss of water. hypernatraemic, hypertonic plasma
108
How should hypovolaemia be treated?
IV fluid bolus
109
How should dehydration be treated?
oral fluids | slow IV fluids
110
Whjat are an adult's daily fluid, glucose and electrolyte requirements
25ml/kg/hr water 50g/day glucose 1 mmol/kg/day Na+ and K+
111
What antibodies and antigens does A blood have
``` antigens = A antibodies = B ```
112
What antibodies and antigens does AB blood have
``` antigens = A B antibodies = none ```
113
What antibodies and antigens does B blood have
``` antigens = B antibodies = A ```
114
What antibodies and antigens does O blood have
``` antigens = none antibodies = A B ```
115
What does cross matching of blood involve
mixing a bit of the patient's blood with the donor's | takes about 40mins
116
What are the indications for O-ve blood
blood group unknown | o-ve pt
117
What gauge cannulae are used for blood transfusions
Green 18G | Grey 16G
118
What is the definition of a massive blood transfusion
replacement of >1x blood volume in 24h >50% volume in 4 hours blood volume = 75ml/kg >40ml/kg in children
119
What is FFP and what is it used for?
fresh frozen plasma used to correct clotting disorders eg warfarin, DIC, liver disease
120
What is cryoprecipitate and what is it used for?
made from FFP. contains fibrinogen, vWF, factors VIII and XIII and fibronectin used in hypofibrinogenaemia von Willebrand's disease.
121
What are some early complications of a blood transfusion
``` pyrexia anaphylaxis fluid overload transfusion related acute lung injury acute haemolytic reaction ```
122
What are some late complications of a blood transfusion
infection iron overload graft versus host disease post tranfusion purpura
123
What does a CVP monitor measure?
central venous pressur emonitor measures pressure in RA and IVC
124
Which veins can be used for central venous access
internal jugular femoral subclavian
125
What are the indications for a central line
drugs | CVP monitoring
126
What are teh complications of a central line bein ginserted
``` infection bleeding from punctured artery pneumothorax phrenic nerve palsy air embolism thrmobus formation ```
127
State three features of an obstructed airway
unable to speak no chest wall movement respiratory distess
128
What can cause an obstructed aiway
external compression swelling of airway foreing body
129
What manoeuvres can be used to relieve an obstructed airway
jaw thrust | head tilt
130
State the colour cannulas in asceinding size
``` blue - 22G pink - 20G green - 18G grey - 16G orange - 14G ```
131
According to days post op, what is the most likely infection?
``` 1-2 = resp 2-5 = urinary 5-7 = surgical site/abscess ``` any! = IV lines
132
What can cause a post op fever
infection iatrogenic - dtugs, transfusion VTE pyrexia of unknown origin
133
What are important questions to ask a patient with post op pyrexia
``` cough, dyspnoea, chest pain, haemoptysis urinary freq, dysuria, urgency wound tenderness or discharge IV line tenderness or sicharge calf pain ```
134
What investifations should be done in a patient with post op fever
ECG, urine dipstick FBC, U+E, CRP, blood cultures, sputum culture, urine culture, swab culture CXR ?CT if risk anatamotic leak calculate Wells
135
What is the antibiotic treatment for a post op LRTI
co-amoxiclav 5d
136
What is the antibiotic treatment for a post op LUTI
trimethoprim 3d
137
What is the antibiotic treatment for a post op UUTI
co-amoxiclav 14d
138
What is the antibiotic treatment for a post op intraabdominal infection
cefuroxime + metronidazole IV
139
What is the antibiotic treatment for a post op infection of unkown origin
cefuroxime + metronidazole IV | + STAT does gentamicin
140
How do gallstones causes pancreatitis
blockage of common bile duct means pancreatic secretions cannot pass into duodenum thee secretions remain in the pancreas leading to inflammation and injury enzyme mediated inflammation
141
Which organs most commonly perforate
large bowel appendix duodenum
142
Define peritonitis
inflammation of the peritoneum
143
What investigation should be performed in suspected peritonitis what does this show? if -ve, what test shuld be done next?
erect CXR air under the diaphragm CT abdo pelvis
144
What are the signs of peritonitis
``` prostration shock lying still positive cough test - pain on coughing tenderness - rebound, on percussion abdominal rigidity guarding no bowel sounds ```
145
How is peritonitis treated?
laparotmoy to diagnose and repair perforation
146
What can cause peritonitis
``` PUD perforation of small bowel or large bowel crohn's appendicitis diverticular disease SBO/LBO ```
147
Why might you need to form a stoma
bowel rest | not enough blood supply to area of bowel needing to be anastamosed
148
Distinguish between an ileostomy and a colostomy
ileostomy: spout, RIF, liquid contents, smaller lumen, mucosal folds colostomy: flush to skin, LIF, solid contents, greater lumen diameter
149
What are the complications of TPN
thrombophlebitis refeeding syndrorme sepsis thromobus formation - PE/SVC obstruction
150
When can nasogastric nutrition be used
if the oral route is not viable
151
When can nasojejunal nutrition be used
when pt at risk of aspiration (pulmonary regurgitation)
152
When can a gastrostomy be used for nutrition
if there is oesophageal dysfunction
153
When can a jejunostomy be used for nutrition
if the stomach is inaccessible or there is outflow obstruction of the stomach
154
What is a diverticulum
outpocketing of teh colonic mucosa through the muscular wall of teh colon at sies of entry of perforating arteries
155
What causes diverticulum to form
increased intraluminal pressure leads to weakness of the bowel wall over time
156
Where is it most common for diverticula to form?
sigmoid
157
Define diverticulosis
presence of diverticula, no sx
158
define diverticular disease
presence of diverticular + sx
159
define diverticulitis
inflammation of a diverticulum
160
What are the risk factors for diverticular disease
``` low fibre diet obesity smoking FH smoking NSAIDs ```
161
What are the symptoms of diverticular disease
pain in LIF - relieved by defecation change in bowel habits Nausea flatulence
162
What are the symptoms and signs of diverticulitis
``` pain in LIF PR bleed N+V raised temp tenderness on palpation ? peritonitis ```
163
What investigation should be done in diverticular disease/diverticulitis
``` ECG FBC, U+E, LFT, ABG if perforation CT abdo plevis sigmoidoscopy AXR and erect CXR if perforation ```
164
What are the possible complications of diverticular disease
``` perforation fistulae hammorrhage strictures abscesses ```
165
What are the typical features of an abscess
swinging pyrexia | leucocytosis
166
How should diverticular disease be managed
increase fibre and oral fluids pain relief - paracetamol NOT NSAIDs or opioids weight loss stop smoking
167
How should a mild episode of diverticulitis be managed
oral fluids bowel rest analgesia antibiotics
168
How should a severe episode of diverticulitis be managed
``` admission analgesia NBM IV fluids IV abx ```
169
When is an episode of diverticulitis considered severe
``` pain not controlled with analgesics at home pt dehydrated PR bleed severe comorbidities presence of peritonitis >48hrs of symptoms ```
170
When is surgical treatment recommended in acute diverticulitis
perforation sepsis failure to improve with conservative management
171
What are the surgical optionsn in the management of acute diverticulits
resection - Hartmann's | laparascopic peritoneal lavage
172
When is elecrtive surgery for diverticular disease recommended
stenosis fistulae recurrent bleeding
173
What are the common side effects of mesalazine
indigestion, nausea, abdo pain Diarrhoea Headache, muscle aches and pains
174
Why might mesalazine be contraindicated
allergy! | severe hepatic or renal impairment
175
What should be monitored in mesalazine therapy?
U+E, eGFR before starting and at 3 months of treatment, and then annually during treatment.
176
What info should be given to a patient before starting mesalazine therapy
need to monitor your kidney function can cause blood disorders - report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment.
177
When is lanzoprazole contraindicated
pregnancy and breast feeding
178
How is lansoprazole meant to be taken?`
at least 30 minutes before a meal Do not take indigestion remedies during the two hours before or during the two hours after you take lansoprazole as they can interfere with the way lansoprazole is absorbed by your body.
179
What are the common side effects of lansoprazole
``` nausea, stomach ache Diarrhoea Constipation Headache Feeling dizzy or tired Dry mouth or throat, itchy skin rash ```
180
What are some important things to remember when prescribing lansoprazole
Can increase the risk of fractures due to osteoporosis ; may increase the risk of gastro-intestinal infections (including Clostridium difficile infection); may mask the symptoms of gastric cancer (in adults)
181
What are the potential causes of haematemesis
``` PUD oesophageal varices Mallory-Weiss oesophagitis gastritis ```
182
What are oesophageal varices
portosystemic anastamoses caused by portal HTN
183
What is a Mallory weiss tear
tear in oesophageal epithelium
184
What can cause oesophagitis
candida GORD bisphosphonates
185
What are the important aspects of a history following haematemesis
timing, frew, volume prev dyspeosia, dysphagiaa or odynophagia ? alchohol/smoking liver disease NSAIDs, steroids, anticoagulation, bisphosphonates
186
What might be found on examination in a case of haematemesis
epigastric pain/tenderness | liver stigmata - hepatosplenomegaly, nodular liver, spider naevi,
187
What investigations should be done in a case of haematemesis
FBC, U+E, LFTs, clotting, ABG, G+S, cross match erect CXR, CT abdomen with IV contrast OGD
188
What does the Glasgow Blatchford Bleeding score calculate
the risk of needing an intervention in haematemesis
189
What does somatostatin do in the management of oesophageal varices
decreases sphlanchic blood flow
190
Describe the pathophysiology of achalasia
Failure of oesophageal peristalsis and of relaxation of LOS due to degenerative loss of ganglia from Auerbach's plexus
191
What are the symptom of achalasia
dysphagia of sloids and liquids varibale sx reflux regurgitation
192
What investigations hsould be done in achalasia
manometry - assess LOS function | barium swallow - see bird's beak appearance
193
What is the treatment of achalasia
intra-sphincteric injection of botulinum toxin
194
What is Boerhaave syndrom
transmural perforation of the oesophagus | in Mallory-Weiss syndrome it is a nontransmural esophageal tear

Finals (32 decks)

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