Surgery Flashcards
(194 cards)
AXR indications
- Clinical suspicion of obstruction (if perforation -> CXR)
- Acute exacerbation of inflammatory bowel disease
- Sharp/poisonous foreign body
In specific circumstances: • Palpable mass • Constipation • Acute and chronic pancreatitis • Smooth and small foreign body, e.g., coin, battery • Blunt or stab abdominal injury
How to differentiate between sigmoid and caecal volvulus?
Sigmoid volvulus - coffee bean shape
arises in the pelvis (left lower quadrant)
extends towards the RUQ
ahaustral in appearance
sigmoid volvulus causes obstruction of the proximal large bowel, therefore the ascending, transverse and descending colon may be dilated
few air-fluid levels may be seen
Caecal volvulus - embryonic shape arises in the right lower quadrant extends towards the epigastrium or LUQ colonic haustral pattern is maintained distal colon is usually collapsed and the small bowel is distended one air-fluid level may be seen
Ischaemic colitis
Definition: Ischemic colitis refers to inflammation of the colon secondary to vascular insufficiency and ischemia
Epi: disease of the elderly (age >60 years) where atherosclerotic disease or low flow states
PC: abdominal pain and bloody stools
Location of ischemia relates to anatomy of vessels SMA (Caecum to splenic flexture) IMA (beyond splenic flexure).
Path: Diminished or absent blood flow leads to bowel wall ischemia and secondary inflammation. Bacterial contamination may produce superimposed pseudomembranous inflammation. If necrosis develops then ulcerations or perforation can occur. Following the acute event, fibrosis may lead to stricture of the bowel lumen.
Ix, AXR can be normal or can show ‘thumbprinting’ due to mucosal edema/hemorrhage, dilatation
CT is investigation of choice and commonly shows bowel wall thickening, fat strands, vascular occlusion.
Mx: anticoagulation or thrombolysis, either systemically or locally
Layers of the scrotum and contents
Contents of the spermatic cord
Rule of Threes: Three layers (external spermatic from EO, cremasteric from IO and internal spermatic from transveralis fascia) Three arteries (Artery to vas, cremasteric artery, testicular artery) Three veins (Pampniform plexus, cremastric vein and vein of the vas) TWO nerves: Genital branch of genital femoral nerve, Sympathetic & Parasympthaetic nerve from T10-T11 Three extra things: obliterated processus vaginalis, Vas deferens, Lymphatics
Layers: Some Damned Englishmen called it The Testes
SCS, Dartos fascia, External spermatic fascia, Cremasteric fascia, Internal Spermatic Fascia, Tunica vaginalis, Tunica albuginea
Lanz incision
Horizontal incision of appendicitis, closer to the ASIS than Gridiron
Provides better cosmetic result but increases risk of inguinal hernia due to dividing nerves that can cause denervation of the muscles of the inguinal canal
Gridiron
One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line
Aka Mcburney’s incision as it is over mcburney’s point
Pfannestiel
Transverse incision 5cm above pubic symphsis 10-12 cm across midline Mostly used by gynae for cs and ovariation operations or urologists for access to bladder and prostate Offers excellent cosmetic results
Kocher
3cm below and parallel to the subcostal margin from midline to border of the rectus abdominis
R-sided kocher for open chole
L-sided for splenectomy
Can’t be extended medially, if extended too far laterally intercostal nerves can be dmaged
Rooftop incision
Double kocker linked into the middle
Access to liver and spleen and bilateral adrenalectomy, radical pancreatic and gastric surgery, whipples
Liver transplant /resection
Battle’s
Vertical incision medial to the lateral border of the abdominal rectus
Has high risk of incisional hernia and damaged nerves in rectus sheath- on longer recommended
Rutherford Morris
Extended gridiron (One third along the way of the line between the ASIS and umbilicus, transverse incision perpendicular to this line) that allow views of caecum and right colon
Acute diverticulitis classification
Hinchey’s classification:
Stage I: small or confined pericolic or mesenteric abscess.
Stage II: large paracolic abscess often extending into pelvis.
Stage III: perforated diverticulitis where a peri-diverticular abscess has perforated resulting in purulent peritonitis.
Stage IV: perforated diverticulitis where there is free perforation and is associated with faecal peritonitis.
Pre-op what drugs should you stop?
Stop:
1. Metformin if pt at risk of AKI OR pt is missing >1 meal. Stop it from when the pre-op fast begins. If pt has metform > OD, then replace with variable rate insulin infusion.
2. COCP
3. ACEi - stop for 24hrs, risk of hypotension
4. Spiro - don’t take morning of operation due to risk of hyperkalaemia
5. MAOi e.g. pethidine hydrochloride
6. Lithium - for 24hrs if its a major op
7- Warfarin - stop 5 days unless on metallic valve in which case admit and manage on heparin infusion pump
HIV - get specialist advice
Pre-op - what drugs shouldn’t you stop?
Anti-parkinsonian Anti-epileptics Thyroid or Antithyroid Drugs of dependence Antipsychotics Anxiolytics Bronchodilators Glaucoma Meds Immunosuppressants
What would need a midline laparotomy?
Emergency: Perforation (bowel) Trauma AAA rupture Hartmann’s
Elective:
Colectomy
AAA
Vascular bypass
Layers of the abdominal wall when you make a midline incision
Skin Camper’s fascia Scarper’s Fascia Linea Alba (Midline) Transveralis fascia Pre-peritoneal fat Peritoneum
Abdominal muscles
Anterior SCS External oblique, Internal oblique, Transversus abdominis, Transveralis fascia , Preperitoneal fat, Peritoneum.
Whats the significance of the arcuate line?
Arcuate line - marks when the IO and TA pass anteriorly to the rectus muscles. (Really important learn this)
The arcuate line or semicircular line of Douglas is located at roughly one-third of the distance from the pubic crest to the umbilicus. It is the demarcation where the internal oblique and transversus abdominis aponeuroses of the rectus sheath start to pass anteriorly to the rectus abdominis muscle, leaving only the transversalis fascia posteriorly.
Post op complications
Immediate: Anaesthetic complications, bleeding (primary or reactionary), damage to near by structures
Early complications: Bleeding (secondary often due to inflammation), infection & abscess, dehiscence*, pain, VTE, atelectasis**, CAP (can be secondary to atelectais), Post op urinary retention and hypovolaemic shock; Paralytic Ileus (pts vomit, monitor electrolytes), abx associated colitis.
Specific: anastamotic leak, eneterocutenaous fistulae
Late: failure/recurrence, scarring (hypertrophic or keloid)
- rupture along the surgical suture- if superficial rupture just wash and wound care, if full thickness > resus and return to theatre RTT)
- *(people in bed, pain, etc - chest physio)
Hernia
Protrusion of a viscous (or part of a viscus) through a defect in its wall into an abnormal position.
TCC vs SCC of the bladder
PAINLESS HAEMATURIA
Other: voiding irritability: dysuria, frequency, urgency; Recurrent UTIs and retention and obstructive renal failure
Most common bladder cancer is transitional cell carcinoma (SCC is developing countries due to schistosomiasis, schistoma cause chronic bladder inflammation),
Things to ask in the history:
- Exposure to dye or rubber industries due to beta-napthlamine
- Other causes is staghorn calculi, or long term catheter or any bladder inflammation
Patients present with Painless frank haematuria or with multiple UTIs
Ix to order:
Urine dip (sterile pyuria), cytology, FBC (anaemia), U&Es,
IV Urography would show filling defects
Cystoscopy + Biopsy for diagnosis
Bimanual EUA to help assess spread (rubberythickness = T2, mobile mass T3, fixed mass T4)
MRI/CT for staging
TCC management
Depends on the staging: Tis = carcinoma in situ Ta = confined to epithelium T1 = Tumour in lamina propria Felt at EUA: T2 = Superficial muscle involved T3= Deep muscle involves T4 = Invasion of prostate, uterus or vagina
SUPERFICIAL (Tis, Ta and T1 = 80% of patients)
- Transurethral Resection of Bladder Tumour (TURBT) can be done via resection or diathermy
- Intravesciular Chemo: Mitomycin C
- Intravesicular immunotherapy: BCG
INVASIVE (T2, T3):
1. Radical cystectomy, LN dissection + ileal conduit is gold standard
± Radiotherapy
± Adjuvant chemo -MVAC (Methotrexate, vinblastine, doxorubicin and cisplatin)
2nd line Immunotherapy e.g. nivolumab
T4 PALLIATIVE:
C- Long term catheter
M- pallaitve chemo MVAC and radiotherapy
+ EXTENSIVE FOLLOW UP as 70% Of bladder tumours recur
Low risk @ 9 month then yearly
High risk every 3 months for 2 years then every 6 months
What is a radical cystecomy and what happens after a radical cystectomy? + incl complications
Cystectomy - removal of bladder
Radical cystectomy M: prostate and seminal vesicles. F: removal of the uterus, ovaries and part of the vagina
After:
Upper tract diversion (end urostomy) or neo bladder (60cm small bowel joined to ureter and urethras, still have external sphincter, continent, need to be able to self catheterise, initially when they have it they can only hold 200ml but as time goes on you can hold 600ml)
Complications:
Early - urinary leak from stents, infection, DVT
Late - infection, uteroileal strictures and reflux of infected urine can both lead to hydronephrosis / renal function decline, poor bladder emptying can lead to urinary calculi, metabolic acidosis (worse with more proximal bowel conduits) due to the absorption of ammonia from urine (NH4 > NH3 + H+) in the intestinal luminal cells, causing excess hydrogen ions and metabolic acidosis
Common sites of impaction of renal calculi
- Ureteropelvic junction (pelvis meets ureters)
- Where the iliac artery crosses the ureter
- Vas deferens/broad ligament
- Ureterovesical junction (Ureter meets the bladder wall)
- Ureteric office