Abdo- surgery Flashcards
3 main causes of hepatomegaly
3 Cs Cirrhosis (fatty liver) Cancer Congestion (R heart failure)
3 main causes of splenomegaly
3 Ms Malaria Myelofibrosis Chronic myeloid leukaemia
Indications for splenectomy
Rupture: post trauma, iatrogenic, EBV Haem: sickle cell, ITP, lymphoma, leukaemia,
Work up for a splenectomy patient - 3 things?
Vaccination against encapsulated bacteria (pneumococcal, Meningitis, Hib, influenza) Prophylactic penicillin V Medic alert bracelet
Early complications of stoma
Haemorrhage Skin inflammation High output Necrosis
Late complications of stoma
Parastomal hernia Prolapse Obstruction Stenosis
5 indications for liver transplant
Acute liver failure
Liver cancer (Hepatocellular carcinoma)
Cirrhosis
PBC (Primary Biliary Cholangitis)
PSC (Primary Sclerosing Cholangitis)
Name of the kidney transplant scar
Rutherford Morrison
Complications of immunosuppression used in renal transplant patients
Gum hypertrophy - ciclosporin Fine tremor - tacrolimus Skin cancer
Management of hernias
Conservative: Wt loss, treat cough, belts, watchful waiting Surgical: open mesh/suture repair
WTF is hepatorenal syndrome
Portal HTN causing renal failure Portal hypertension —> increased shear stress in splanchnics –> vasodilators released –> reduced renal perfusion –> RAAS system activation –> this isn’t enough to overcome the splanchnic vasodilation + persistent underiflling of these vessels –> renal failure
Umbilical bruising in pancreatitis
Cullens sign - Suggests:
Pancreatitis
Ectopic Pregnancy
Trauma to abdomen
Aortic Rupture
Flank bruising in pancreatitis
Grey Turners sign:
Suggests bleeding into the retroperitoneum: ie around the kidneys and pancreas.
Causes of retroperitoneal haemorrhage
Pancreatitis
Ectopic pregnancy
Aortic rupture
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Grey Turners Sign or Cullens Sign
Grey Turners (LaTeral)
Cullens sign (Central, on umbilicus)
Causes of dysphagia (At least 3)
Motility: Achalasia,
Oesophageal spasm,
Bulbar/suprabulbar palsy
-From CVA or MND.
Myasthenia Gravis
Structural:
Plummer Vinson
Oesophagitis
Malignancy, Oesophageal cancer
Rolling hiatus hernia,
lung ca,
Retrosternal goitre
mediastinal LNs (extramural)
Management of BPH
Conservative:
- Reduce EtOH + caffeine
- Bladder training
Medical:
- Alpha blockers, (For urinary retention, Eg Tamsulosin)
- 5a-reductase inhibitors (Eg Finasteride)
Surgical:
- TURP (transurethral resection of the prostate)
- Laser prostatectomy
Management of prostate cancer
Conservative:
Watchful waiting.
Prostate biopsy: for grading (Gleason classification, grade 1-5)
Pelcvic CT: for staging
Medical:
Symptomatic:
TURP (Transurethral Resection of the Prostate)
Analgesia (WHO pain ladder)
Radiotherapy, for bone pain
LHRH analogs (Eg Goserelin)
Antiandrogens (Eg Flutamide)
Radical:
Radical prostatectomy
Brachytherapy (Basically a radioactive catheter)
Ix in man with lower urinary tract symptoms
Examination:
DRE
Bedside:
Urine dip
Urine Microscopy Culture and Sensitivity
Bloods:
U+Es,
PSA
Imaging:
Transrectal USS +/- biopsy
Specialist:
Urodynamics
Other:
Voiding diary
Consider:
- If ?ca –> MRI prostate + Bone scan
Define a hernia
Protrusion of a viscus through the walls of its containing cavity into an abnormal position
Aetiology of an inguinal hernia
Congenital: patent processus vaginalis –> indirect hernia
Acquired: anything which increases Intra Abdomenal Pressure:
- Cough
- Obesity
- Constipation
- Heavy lifting
- Ascites
Direct inguinal hernia - describe its main features
- Emerge through Hesselbach’s triangle
- More commoner elderly
- Rarely strangulate
Hesselbach’s triangle: borders? significance?
Borders:
- Inferior epigastric vessels
- Inguinal ligament
- Rectus abdominis: lateral border
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Direct inguinal hernia location!
Borders of the inguinal canal
MALT
Roof: Transversus abdominis MUSCLE and Internal oblique MUSCLE
Anterior: Aponeurosis of External oblique
Floor: Inguinal Ligament
Posterior: Transversalis fascia (+ Conjoint Tendon)
Contents of the inguinal canal
Male:
- Spermatic cord
- Ilioingiunal nerve
Female:
- lioinguinal nerve,
- Round ligament,
- gen branch of the genitofemoral nerve
Anatomical location of inguinal vs femoral hernia
Inguinal hernia: above inguinal ligament
Femoral hernia: below inguinal ligament
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In, Above
Location of the deep inguinal ring
mid point of the inguinal ligament
O/E, how can u differentiate between direct + indirect inguinal hernia
Place fingers over the deep ring (mid pt of the inguinal ligament)
If hernia is ‘controlled’ = indirect hernia
If not = Direct
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Indirect goes through Deep ring.
Direct Doesn’t go Through Deep Ring
(Deep ring is a Detour. Not done by Direct inguinal hernia)
Direct doesn’t do the Deep ring.
Where is the femoral canal
Medial to the femoral vein, behind the inguinal ligament
Where is the femoral pulse
Mid inguinal point (btw ASIS + pubic symphysis)
4 distinguishing features O/E of an inguinal hernia
cough impulse reducible above the pubic tubercle bowel sounds heard
SURGICAL management of inguinal hernias
Open or lap (lap if recurrent/bilateral) Open = LICHTENSTEIN TENSION FREE MESH Lap = TEP (enters the peritoneal cavity) vs TAPP
Complications of hernia repair (specific)
Early: Haematoma/seroma (10%) Infection (1%) Urinary retention Late: Chronic groin pain (5%) Ischemic orchitis (thrombosis in pampiniform plexus)
What complication must you mention to a patient undergoing inguinal hernia repair
Risk of testicular damage Ischemic orchitis from thrombosis in pampniform plexus (this is in the spermatic cord)
Femoral hernia - risk of strangulation? Mx?
50% risk of strangulation in 1 month! Lockwood(elective) or McEvedy (urgent = high approach to allow visualtion and resection of non-viable bowel)
Hydrocele - definition?causes? Ix?
Accumulation of fluid within the tunica vaginalis Causes: primary (patent proc vaginalis) secondary = tumour, epididymo-orchitis, trauma Ix: MUST do an USS to exclude malignancy
which side is varicocele more common? why?
LEFT is more common Left testicular vein is more vertical than right Left testicular vein is LONGER - more likely compressed by colon - sudden onset –> think L renal cell carcinoma!!!
Key Qs in the examination of a scrotal lump
- Get above it? (no = inguinal hernia) 2. Feels separate from testis? (yes = varicocele, epididymal cyst. no = tumour, hydrocele) 3. Transilluminable? (hydrocele, epididymal cyst)
Oesophageal cancer: types
Squamous cell or Adenocarcinoma Lower 1/3: ADENOcarcinoma (GORD) Upper 2/3: SqCC (smoking, EtOH)
Sx of oesophageal cancer***
Dysphagia (liquids –> solids) Weight loss Retrosternal chest pain
Ix for ?oesophageal cancer
FBC (anaemia) Ferritin 2 week wait for OGD + biopsy Staging: CT Thoracoscopy + laparoscopy (mets)
Mx
only 1/3 are suitable for oesophagectomy - 2 stage (ivor lewis): abdo + R thoracotomy - 3 stage (mackeown): abdo + R thoracotomy + L neck incision - transhiatal USUALLY palliative: laser coagulation, analgesia, stenting, chemoradiotherapy
Oesophageal cancer: staging
T1: submucosa T2: muscular T3: adventitia T4: adjacent structures (eg R laryngeal nerve, lymphatics) N1: LNs M1: distant mets
Vomiting, retrosternal chest pain, subcut emphysema
Oesophageal rupture
Complications of splenectomy
Haemorrhage Pancreatic fistula Infection w encapsulated organisms Thrombocytosis
Mx of sigmoid volvulus
Rigid sigmoidoscopy + rectal tube insertion
Mx of caecal volvulus
SURGICAL - usually, R hemicolectomy
Main parts of presenting a Stoma examination
LTTBS Location Type Tissue Bag Systemic
Indications for an end ileostomy
End ileostomy = may be permanent (panproctocolectomy) or temporary (subtotal w future IPAA)
Pt has an end ileostomy - why would a patient have a subtotal colectomy and not a panproctocolectomy
Future potential of an ileal pouch anal anastamosis
Indications for loop ileostomy?
CRC –> excision of ca + anastomosis formed –> Loop ileo diverts from healing anastomosis Crohns –> loop ileostomy provides temporary diversion from disease
End ileostomy - what must you check and why?
Is there an anus? No anus –> panproctocolectomy therefore permanent ileostomy
2 diseases which are indications for formation of end colostomy? which procedures?
CRC + diverticulitis Either following: AP resection (no anus) or Hartmann’s
Complications of a stoma
Early: (- Bleeding - Infection - Pain) - High output –> K - Ischemia + necrosis - Perforation Late: Parastomal hernia Prolapse Retraction Stenosis Psych Dermatitis
AP resection vs anterior resection of a rectal tumour
anterior resection = can be performed if cancer is >4cm from anal verge
Why is there no way an end colostomy would be formed after an anterior resection
Anterior resection = removal of upper rectum + sigmoid. lower rectum and desc colon are anastomosed. The anastomosis would need to be rested via a loop ileostomy
Diverticular disease vs diverticulosis vs diverticulitis
Diverticulosis = presence of diverticula Diverticular disease = recurrent abdo pain Diverticulitis = acute inflammation
Mx of diverticular disease
Conservative: high fibre diet Medical: Abx Surgical: Hartmanns + loop ileostomy
Midline laparotomy - what layers are cut through?
Skin Campers fascia Scarpa’s fascia Linea alba Transversalis fascia Pre-Peritoneal fat Peritoneum
Midline laparotomy - uses?
Emergency: Hartmann’s procedure, perforated DU (GI) Ruptured AAA, trauma Elective: AAA Vascular bypass…
+ves and -ves of midline laparotomy
+ves: No arteries Minimal nerve + muscle injury -ve: bare pain
Name of a R sided oblique subcostal scar
Kocher’s
Indications for Kocher’s scar
R sided = open cholecystectomy L sided = splenectomy
Indications for a rooftop scar
Liver + biliary tree - Whipple’s procedure - Liver transplant - Liver resection
Name of a horizontal, suprapubic scar? Uses?
Pfannensteil Gynae surgery Lower urinary tract
Layers of abdo wall in a McBurneys/Lanz incision
Skin Campers fascia Scrapas fascia External oblique Internal Oblique Transversus Transversalis fascia Pre-peritoneal fat Peritoneum
2 types of appendicectomy scar - names? Which one is favoured?
Oblique = McBurneys Transverse = Lanz Lanz favoured = hidden in skin crease
Half a Pfannensteil scar (i.e. v groiny + transverse) - what is the use?
Emergency femoral hernia repair
Scar following a R hemicolectomy?
Transverse muscle splitting
Subtotal colectomy - what is excised? - Indication? - stomas formed?
Whole colon except the distal sigmoid + rectum Acute + severe UC Initially, end ileo formed. This is followed by IPAA or completion proctectomy
Indication for R hemicolectomy? L hemicolectomy?
R = tumour L = tumour
Indication for AP resection? Indication for anterior resection
AP resection = tumour<4cm from anal verge anterior resection = tumour >4cm from anal verge (the colorectal anstamosis is covered by loop ileo)
What is excised in panproctocolectomy? Give 2 indications
Whole colon + rectum + anus UC or FAP
Complications of UC
Toxic megacolon Haemorrhage CRC, cholangiocarcionma
complications of Crohns
Fistulae Abscess (^both perianal) Strictures Malabsorption
Indications for surgery in IBD?
Acutely: Toxic megacolon (UC) Perforation Severe bleed Chronic: Failed medical Mx Malignancy
Commonly affected area for Crohns
Terminal ileum
Definition of a severe IBD exacerbation
Symptoms: BM >6x/day Large PR bleed Systemic: HR>90, Pyrexial Bloods: Anemia, raised ESR
Extra intestinal features of IBD
Episcleritis/anterior uveitis Erythema nodosum Arthritis Gallstones PSC (UC)
Contrast studies performed in UC?
Gastrograffin or barium enema
Surgical mx of pharyngeal pouch
Dohlman’s procedure Endoscopic stapling of pouch
Surgical mx of achalasia
Heller’s cardiomyotomy - incision through muscular propria at lower oesophageal sphincter
Surgical mx of umbilical hernia
Mayo repair
2 approaches to femoral hernia repair - in which context is one favoured over another?
Lockwood or mcevedy Lockwood = lower approach, elective McEvedy = high approach from inguinal region, emergency
2 approaches to inguinal hernia repair
TEP (totally extraperitoneal) TAPP (transabdo pre peritoneal)
Surgical mx of anal fissure
Lateral sphincterotomy = division of internal anal sphincter
Ddx of RIF mass
Caecal cancer Crohns disease Appendix abscess Hepatmegaly
Imaging for palpable RIF mass
Abdo USS Barium enema Colonoscopy CT
Pt with ?perforated bowel needs investigation. what kind of enema should be used?
Water soluble enema
In whom would barium enema be unsuitable
Requires ouptaitnet bowel prep + giving loads of fluid Frail pts (can’t make it to toilet) Severe arthritis HF + dialysis pts (can’t tolerate fluids) ?Colonic perforation
3 Ix for old man with dysphagia + FLAWs (apart from bloods)
OGD Barium swallow CXR - to look for dysphagia due to lung ca
Pancreatitis - amylase level is over???
1000
Pancreatic pseudocyst - how is it formed? what would the next step be?
Blockage of pancreatic ducts from pancreatitis Therefore ERCP - a blockage can then be stunted or Percutaneous drainage
Mx of sigmoid volvulus
Sigmoidoscopy + flatus tube insertion –> may require sigmoid colectomy
AXR - coffee been sign
Sigmoid volvlus
Caecal vs sigmoid volvulus on AXR?
Sigmoid volvulus: no haustra seen on bowel loop Large bowel dilatation Caecal volvulus: bowel loop has haustra Small bowel dilatation
Management of rectal cancer
Adjuvant radiotherapy Surgical excision: >4cm from anal verge –> anterior resection + defunctioning loop ileostomy <4cm from anal verge –> AP resection + end colostomy + total mesolectal excision
Mx of diverticular idsease
High fibre diet Mebeverin Elective resection for chronic pain
Mx of acute diverticulitis? Indications for surgery?
Admit if unwell/pain uncontrolled: - NBM (may need surgery) - Analgesia - IV fluids - Abx - Indications for surgery(Hartmann’s): perforation, massive bleed, stricture –> obstruction
mx of abscess from diverticulitis
abx + Ct/US guided drainage
Causes of small bowel obstruction?
Adhesions (Ia)
Hernias, obstructive (Ab)
Caecal Carcinoma (Ma)
Strictures, due to UC/ Crohns (Au)
Any cause of large bowel obstruction (Ab)
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IAMAA
Sigmoid Volvulus management?
- Supportive, analgesia and fluids
- Sigmoidoscopy and decompression with a flatus tube
- If recurring, consider sigmoid colectomy
