Surgical Abdomen

Question 1

Ascending Colon Issue (Op + Stoma)

Answer 1

Right Hemicolectomy
No Stoma
Ileo-colic Anastomosis
Right and Mid Colic Arteries Ligated

Question 2

Ascending + Transverse Colon Issue

(Op + Stoma)

Answer 2

Extended Right Hemicolectomy
No Stoma
Ileo-colic Anastomosis
Right, Mid and Left Colic arteries ligated

Question 3

Descending Colon Issue

Op + Stoma

Answer 3

Left Hemicolectomy
No Stoma
Colo-colic Anastomosis
L.Colic ligated

Question 4

Sigmoid Issue

Op + Stoma

Answer 4

Proctosigmoidectoy
Emergency= Hartmann's
End Colostomy
No Anastomosis
Sigmoidal Artery Ligated

Question 5

Anal/Rectal Tumour Crossing the Anal Verge

Op + Stoma

Answer 5

Abdominoperineal Resection
End Colostomy
No Anastomosis
Sigmoidal and superior rectal arteries ligated

Question 6

Upper Rectal Tumour

Op + Stoma

Answer 6

Anterior Resection (w/total mesorectal excision)
Loop Ileostomy
Colorectal anastomosis

Question 7

Lower Rectal Tumour

Op + Stoma

Answer 7

Anterior Resection (w/low total mesorectal excision)
Loop Ileostomy
Colorectal anastomosis

Question 8

Sigmoidal Tumour

Op + Stoma

Answer 8

High Anterior Resection
Loop Ileostomy
Colorectal anastomosis

Question 9

Extensive Disease sparing the anus

Op + Stoma

Answer 9

Subtotal Colectomy
End Ileostomy
No Anastomosis
Open Anus

Question 10

Extensive Disease Involving the Anus

Op + Stoma

Answer 10

Pan-proctocolectomy
End Ileostomy
No Anastomosis
Closed Anus

Question 11

What is a Hernia?

Answer 11

Protrusion of a viscous through a defect in the wall of the cavity containing it

Question 12

Borders of the inguinal caanal

Answer 12

Deep --> Superficial Ring
Anterior: Aponeuroses of Internal Oblique and External Oblique 
Roof: Transversus Abdominus
Posterior: Transversalis Fascia
Floor: Inguinal Ligment

Question 13

Hesselbach’s Triangle (direct inguinal hernia)

Answer 13

Medial: Rectus Abdominus
Inferior: Inguinal Ligament
Superior: Epigastric Vessel’s

Question 14

Direct Hernias

Answer 14

Medial to Epigastric vessels

Question 15

Indirect Hernias location

Answer 15

Lateral to the Epigastric vessels

Question 16

How to distinguish Inguinal Hernias

Answer 16

Block deep ring and ask patient to cough
If hernia appears: Direct
If it disappears: Indirect
Indirect hernias also extend into the scrotum

Question 17

Management of Inguinal Hernias

Answer 17

Cons: Weight Loss
Medical: Pain
Surgical:
- Open: Mesh- Lichtenstein or Suture: Shouldice
- Lap: TAPP or TEP
- Herniotomy (removal of hernial sac), -rrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal) or -plasty (herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh)

Question 18

Borders of the Femoral Canal

Answer 18

Lateral: Femoral Vein
Medial: Lacunar Ligament
Anterior: Inguinal Ligament
Posterior: Pectineus

Question 19

Inguinal vs Femoral hernia

Answer 19

Femoral: Inferolateral
Inguinal: Superomedial

Question 20

Other Hernias

Answer 20

Incisional: in the midline
Umbilical: Hemispherical Umbilicus
Para-umbilical: Cresent Umbilicus
Epigastric: Lipomas or port-site incisional hernia
Pantaloon: Most common (both direct and indirect)

Question 21

Associations with a sigmoid volvulus

Answer 21

older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia

Question 22

Associations with caecal volvulus

Answer 22

all ages
adhesions
pregnancy

Question 23

Mucous Fistula vs. Stoma

Answer 23

mucous fistula is to allow decompression of DISTAL end of bowl after an end colostomy normally

Question 24

Types of anal fistulae and Mx

Answer 24

1. Superficial/submucosal Fistula → Fistula laid open using a drainage seton
2. Intersphincteric → Cutting Seton to progressively tighten
3. Transphincteric → Fibrin glue to plug
4. Extrasphincteric
5. Suprasphincteric

Question 25

GoodSall's Law

Answer 25

Anterior Fistuale will have a direct radial tract | Posterior Fistulae will have a curvilinear course

Question 26

Haemarrhoids

Answer 26

1st degree: never prolapse 2nd: prolapse on defecation but spontaneously reduce 3rd: prolapse on defecation but require digital reduction 4th: remain permanently prolapsed

Question 27

What are causes of hernial incarcerations

Answer 27

Long irreducible hernia will have epithelisation and adhesions

Question 28

Causes of mechanical Large bowel obstruction?

Answer 28

``` EXTRINSIC Tumours Adhesions Hernia Volvulus Intussusception Inflammatory masses (Abdominal Lymphoma) Congenital bands ``` ``` INTRINSIC Crohn’s Carcinoma TB Congenital atresia ``` ``` LUMINAL Gallstones Foreign Bodies Polypoid tumours Bezoars Parasites ```

Question 29

Causes of small bowel obstruction? (ABC)

Answer 29

adhesions, bulge (hernia), cancer

Question 30

Differentials for a groin mass?

Answer 30

``` Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!) ```

Question 31

What ix can you do prior to reversal of a loop ileostomy to ensure there is no anastamotic leak?

Answer 31

Gastrografin enema

Question 32

What type of op can be used for some T1 colorectal cancers?

Answer 32

en-bloc endoscopic mucosal resection or endoscopic submucosal dissection

Question 33

Indications for laparoscopic hernia repair?

Answer 33

Bilateral hernias Recurrent hernia Chronic pain

Question 34

Main 3 branches of abdominal aorta - where do they come off and what do they supply?

Answer 34

Coeliac trunk: T12 --> splits into left gastric, common hepatic and splenic artery - liver - spleen - stomach - abdominal oesophagus - superior duodenum - superior pancreas Superior mesenteric artery: L1 - distal duodenum - jejunum/ileum - ascending colon - part of transverse colon Inferior mesenteric artery: L3 - large intestine from splenic flexure to upper rectum