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Flashcards in Surgery Residents Deck (62):

name of the classification system for perihilar cholangiocarcinoma



classification of gastric ulcers

1: antrum, near lesser curvature.
2: combined gastric and duodenal
3: prepyloric
4: proximal stomach, near cardia


antecolic vs. retrocolic approach for Roux-en-Y gastric bypass

retrocolic creates more potential internal hernia sites (i.e. Petersen defect), more bowel obstructions. antecolic requires longer length of the roux limb and puts more strain on the limb.


rouviere's sulcus (incisura hepatica dextra, Gans incisura)

naturally occurring cleft in the R lobe of the liver. useful landmark for beginning dissection of Calot's triangle.


Petersen defect

opening between the mesentery of the alimentary loop and the transverse mesocolon. a potential internal hernia site for a retrocolic roux limb in lap RNYGB.


Rigler's triad for gallstone ileus

SBO + gallstone outside the gallbladder + pneumobilia


name of the classification system for bile duct injury



what is the most common bile duct injury?

transection of the CBD


what is the recurrence rate for PSC after liver transplant?

up to 10%


when patient has total colectomy for ulcerative colitis, which of the associated symptoms is cured?

erythema nodosum


McBurney's point

1/3 distance from ASIS to umbilicus


Rovsing sign

positive if palpation of LLQ increases pain in RLQ


RNYGB vs. sleeve gastrectomy

RNYGB: both restriction and malabsorption, greater weight loss. SG:


why does patient has multiple bowel movements after total colectomy?

no colon for water absorption so increased water in stool


what is acceptable blood glucose levels for wound healing?



how does hyperglycemia contribute to poor wound healing?

increased amount of blood sugar leads to stiff and rigid cell walls > impaired blood flow through small vessels located at wound surface > impedes flow and permeability of RBCs (required for development of dermal tissue). impair Hb release of O2 > starves affected area of oxygen and nutrients that promote wound healing.


how long do you have to be off Plavix (clopidogrel) and why?

aspirin and/or plavix should be stopped 7-10 days before surgery. platelets blocked by clopidogrel are affected for the remainder of their lifespan (7-10 days).


what is the mechanism of action of Plavix?

irreversibly blocks P2Y12 component of ADP receptors on platelet surface > prevents activation of GPIIb/IIIa receptor complex > reducing platelet aggregation


cantlie's line

a plane without any surface markings running from the gallbladder to the L side of the lVC divide the liver into R and L lobes; also known as portal fissure or the line of the main scissura


what are the watershed areas?

regions of the body that receive dual blood supply from the most distal branches of two large arteries. splenic flexure receives blood from SMA and IMA. sigmoid colon and rectum receive blood from iliac and pudendal circulations.


what is the significance of watershed area?

during times of blockage, these regions spared from ischemia because of dual blood supply. during systemic hypoperfusion, these regions particularly vulnerable to ischemia because they are supplied by the most distal branches of their arteries and thus least likely to receive sufficient blood.


what is the normal size of the cecum?

3-6-9 rule: <3cm dilation for small bowel, <6cm dilation for colon, <9cm dilation for cecum and sigmoid


why do patients on neostigmine have to be on tele? what is treatment?

causes bradycardia. stop neostigmine drip and give atropine.


types of endoleak

type 1: leak after graft ends (inadequate seal); 1a= proximal, 1b=distal, 1c=iliac occluder.
type 2: sac filling via branch vessel; MC after AAA repair; 2a=single vessel; 2b=2+ vessels.
type 3: leak through defect in graft fabric (mechanical failure of graft); 3a=junctional separation of modular components;3b=fractures/holes involving endograft.
type 4: generally porous graft (intentional design graft).
type 5: endotension.


what study should be ordered for patient after Graham patch repair prior to initiating diet?

UGI to check for leaks before any feeding


young person with perforated gastric ulcer

smoking, high NSAID use, possible h. pylori


why no FloraQ (probiotics) with bowel perforation?

contraindicated because think worse peritonitis and colonization


what is sympathetic dysuria?

no UTI and dysuria due to abdominal inflammation like appendicitis


what is concerning when patient has left subclavian stenosis?

left subclavian steal syndrome


how do you manage patient with left subclavian stenosis?

if asymptomatic, then no indication for surgery and therefore no imaging is needed.


what is vital AF?

broken down = predigested = elemental


what are elemental tube feeds?

NPO patients lose gut enzymes. elemental formulas have higher osmolarity so tend to cause diarrhea.



maintenance formula feed



lower glycemic index + fiber


what is the monospot test?

heterophile antibody. false (+) rate 10-15%


what is the monospot test?

heterophile antibody. false (+) rate 10-15%


increased risk of thoracic aortic aneurysm

temporal arteritis, Marfan's syndrome


increased risk of thoracic aortic aneurysm

temporal arteritis, Marfan's syndrome, family history


what is the difference in using Bactrim vs clindamycin for MRSA?

clindamycin is bacteriostatic but Bactrim is bactericidal


risk factors for atrial fibrillation after CABG

1) age >70 2) h/o atrial fibrillation 3) electrolyte abnormalities


if you see an active bleed on EGD and this bleed is treated/stopped during the EGD, what is the chance of recurrence?

...based on level of bleed


if you see an active bleed on EGD and this bleed is treated/stopped during the EGD, what is the chance of recurrence?

...based on level of bleed


what is the most common site of GI bleed?

duodenal? lesser curvature?


when should you not trust an ABI?

ABIs can be very inaccurate in diabetic patients secondary to incompressibility of vessels; often have to go off Doppler waveforms in these patients.


if a person with penetrating trauma to the leg has a normal ABI, do you need a CT?

no, because the normal ABI says they have arterial flow to the extremity


what does ABI tell you?

ABI <0.9 = start to get claudication (typically occurs at same distance each time).
ABI <0.5 = start to get rest pain (usually across the distal arch and foot).
ABI < 0.4 = ulcers (usually starts in toes).
ABI < 0.3 = gangrene.


what is the minimum number of LNs that need to be resected in order to be adequate in assessment of colon cancer?

at least 12 LNs


what is the first sign of active bleeding?

widening pulse pressure


what is the importance of knowing if a patient has surgicel when they also have a JP drain?

the surgicel turns the drainage black and thick, almost like bile. to differentiate if there is presence of bile, can shake the reservoir. bile will form bubbles similar to oil and water.


how many units of blood do you wait to start massive transfusion protocol?

4-6 units


how much fluid is produced in the stomach?



consumptive coagulopathy + giant hemangioma + thrombocytopenia



what are the 3 steps of graft taking?

1) imbibition 2) inosculation 3) angiogenesis


what causes skin graft failure?

hematoma (MCC), infection, fluid beneath the graft, excessive pressure on a fresh graft


if doing culture for ventilator-associated pneumonia, does it matter how many colonies grow?

no, it doesn't matter. just being colonized is an indication for treatment.


if doing culture for ventilator-associated pneumonia, does it matter how many colonies grow?

no, it doesn't matter. just being colonized is an indication for treatment.


what is Kehr sign?

occurrence of acute pain in the tip of the shoulder due to presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classic symptom of ruptured spleen.


have performed trach and now patient is coughing up blood. what would be the most concerning (life-threatening) and would require return to OR?

erosion of the esophagus causing bleeding of the inominate artery. would inflate the trach cuff to tamponade bleeding until able to get to OR.


critical view of safety in cholecystectomy

to minimize bile duct injury, use critical view of safety. involves dissection of infundibulum of GB and continuation of dissection by taking down cystic plate and separating lower 1/3 of GB from its attachments to liver.


layers of the abdominal wall

skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose tissue, peritoneum


stages of empyema

exudative (1st wk), fibroproliferative (2nd wk), organized (3rd-4th wk)


stages of empyema

exudative (1st wk), fibro-proliferative (2nd wk), organized (3rd-4th wk)