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Surgery > Abdomen and Trunk > Flashcards

Abdomen and Trunk Flashcards

1
Q

Difference between direct and indirect inguinal hernia?

A
  • indirect: remnants of patent processus vaginalis, arise lateral to inferior epigastric vessels, through deep ring
  • direct: result of weak posterior wall of inguinal canal, arise medial to vessels, not within spermatic cord
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2
Q

Contents of spermatic cord

A

3 arteries: to vas deferens, testicular, cremasteric
3 nerves: ilioinguinal nerve (L1), to cremaster (genitofemoral), autonomic (T10)
3 others: vas deferens, pampiniform plexus, lymphatics to para-aortic nodes

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3
Q

What would you tell patients about their recovery from inguinal hernia repair?

A
  • mobilisation early
  • keep wound clean, can bathe immediately
  • 6 weeks off work if heavy lifting
  • avoid prolonged coughing and constipation
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4
Q

Complications of inguinal hernia repair

A
  • urinary retention
  • bruising
  • pain (often severe, chronic in 5%)
  • haematoma
  • infection
  • ischaemic orchitis (pampiniform plexus thrombosis)
  • recurrence
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5
Q

Differential of lump in the groin

A 
L - lymph node/lipoma
S - sapheno-varix/skin lesion
H - hernia
A - aneurysmal dilatation of femoral artery
P - psoas abcess/bursa
E - ectopic/undescended testis
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6
Q

What level does serum bilirubin need to rise to before jaundice can be detected on clinical exam?

A

Normal is < 17 mmol/L

Has to be 3x as much >50 mmol/L to discolour sclera.

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7
Q

How should obstructive jaundice be investigated?

A
  • urine for bilirubin
  • blood: FBC (anaemia, infection) U+Es (hepatorenal syn) LFTs, clotting
  • radiological: USS (common bile duct dilation >8mm, stones, pancreatic mass) CT, ERCP, MRCP
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8
Q

Causes of post-op jaundice

A
  • pre-hepatic: haemolysis post transfusion
  • hepatic: anaesthetics, sepsis, intra- or post-op hypotension
  • post-hepatic: biliary injury
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9
Q

Indications for forming a stoma

A
  • feeding
  • lavage
  • decompression
  • diversion: protect distal anastomosis, urinary post-cystectomy
  • exteriorisation
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10
Q

How would you prepare a patient for a stoma pre-op?

A
  • psychosocial and physical prep
  • explain indications and complications
  • CNS in stoma care
  • mark site with patient standing: within rectus muscle, away from scars, creases, bony point, waistline, easily accessible
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11
Q

Complications of stoma formation

A 
Specific
- ischamia/gangrene
- haemorrage
- retraction
- prolapse/intussuscption
- parastomal hernia
- stenosis
- skin excoriation
General
- stoma diarrhoea + hypokalaemia
- nutritional disorders
- renal and gall-stones following ileostomy
- pscyhosexual
- residual disease e.g. crohns
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12
Q

Difference between ileostomy and colostomy

A

Ileostomy: RIF, spouted, watery content
Colostomy: LIF, flush with skin, formed stool

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13
Q

How would you rehabilitate a patient following stoma placement?

A
  • normal diet
  • change bag once or twice-a-day
  • ileostomies need base plate changed every 5 days
  • psychological and psychosexual support
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14
Q

Hepatomegaly causes

A
  • physiological: reidel’s lobe, hyperexpanded chest
  • infections: viral (hepatitis, EBV, CMV), bacterial (TB, abcesss), protozoal (malaria, schistosomaisis)
  • alcoholic liver disease: fatty, cirrhosis
  • metabolic: Wilson’s, haemochromatosis, infiltration (amyloid)
  • malignant: primary/secondary, lymphoma, leukaemia
  • CCF: RHF, TR, Budd-Chiari
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15
Q

Significance of arterial bruit or venous hum over liver?

A

Arterial bruit = alcoholic hepatitis or carcinoma

Venous hum = portal hypertension

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16
Q

What is portal hypertension?

A
  • portal vein pressure > 10 mmHg
  • portal flow greatly reduced or reduced
  • pre-hep, hep and post hep causes
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17
Q

What is an incisional hernia?

A

Extrusion of peritoneum and abdo contents through a weak scar or accidental wound on abdo wall. Represents a partial wound dehiscence where the skin remains intact.

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18
Q

Complications of incisional hernia

A
  • intestinal obstruction
  • incarceration (irreducible)
  • strangulation (compromised blood supply)
  • skin excoriation
  • persistent pain
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19
Q

Predisposing factors to incisional hernias

A
  • pre-op: age, immunocompromised, obesity, malignancy, distension from obstruction or ascites
  • operative: poor technical closure, drains placed through wound
  • post-op: wound infection, haematoma, early mobilisation, atelectasis and chest infection
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20
Q

Incisional hernia treatment options

A
  • non-surgical: truss/corset, weight-loss, other risk factor management
  • surgical: optimise risk factors first, dissect sac, close defect +/- mesh
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21
Q

Pathogenesis of umbilical herniae?

A

Defect through linea alba often due to obesity stretching.

  • true umbilical herniae occur through umbilical scar, usually congenital
  • paraumbilical herniae occur around scar
  • neck of sac often tight, higher risk of strangulation
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22
Q

Umbilical herniae in children

A

Minor defects common in neonates, often repair spontaneously.
Only repair if symptomatic

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23
Q

Causes of acquired umbilical herniae in adults

A
  • pregnancy
  • ascites
  • ovarian cysts
  • fibroids
  • bowel distension
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24
Q

How would an umbilical hernia be repaired?

A
  • optimise concurrent medical problems
  • Mayo’s ‘vest-over-pants’ op
  • dissect sac, reduce contents, excise sac, sublay extraperitoneal mesh below rectus, suture upper edge of rectus over lower edge with interrupted mattress non-absorbable sutures
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25
Q

Splenomegaly causes

A
  • Infective: EBV, CMV, HIV, I.E. malaria
  • Haematological: haemolytic anaemia, myeloproliferative disorders, sickle-cell, leukaemia (CML), lymphoma
  • Portal hypertension: cirrhosis, vein thrombosis
  • Systemic diseases: amyloidosism, sarcoidosis, RA (Felty’s)
26
Q

Causes of massive splenomegaly

A
  • myelofibrosis
  • CML
  • malaria
27
Q

Indications for splenectomy

A 
Trauma
Hypersplenism:
- autoimmune thrombocytopaenia/haemolytic anaemia
- hereditary spherocytosis
- thrombotic thromovytopaenia
- sickle-cell/thalassaemia
- myelofibrosis, CML, Hodgkin's
28
Q

Functions of the spleen

A
  • produces IgM
  • filters micro-organisms esp encapsulated
  • sequesters and removes old RBCs and platelets
  • recycles iron
  • pools platelets (30%)
29
Q

Immunisations before splenectomy

A
  • pneumococcal
  • HIB
  • meningococcal
  • annual flu
  • consider lifelong penicillin
  • warn about risk of malaria
30
Q

Blood film appearences post splenectomy

A
  • increased platelet count and size
  • increased neutrophils
  • nucleated red cells with Howell-Jolly bodies and target cells
  • increased leukocytosis to infection
31
Q

Definition of severe exacerbation of IBD?

A

Truelove and Witts’ classification

  • GI: bloody stool >6x day
  • Systemic: tachy >90, pyrexia >37.8
  • Lab findings: Hb 30
32
Q

Indications for surgery in IBD

A
  • Acute severe UC: toxic megacolon (>6cm), perforation, severe GI bleeding
  • Chronic UC: medical Mx failure, malignant transformation, maturation failure in children
  • Crohn’s: abscess, fistulae, stenosis causing obstruction, control acute/chronic bleeding
33
Q

Hepatobiliary complications of IBD

A
  • Liver: fatty change, hepatitis, cirrhosis, amyloidosis

- Biliary system: gallstones, PSC, cholangiocarcinoma

34
Q

Surgical options for UC

A
  • subtotal colectomy with ileostomy +/- mucous fistula formation: op of choice for acute severe colitis, leaves distal sigmoid and rectum.
  • panproctocolectomy: all colon + rectum + anus. Permanent thus only as patient choice or if no other option.
  • restorative proctocolectomy: avoids permanent stoma: formation of ileal pouch anastomosed to anus, often covered by diverting loop ileostomy
35
Q

Surgical options for Crohn’s

A
  • preserve as much small bowel as possible
  • limited ileocaecectomy for distal ileal disease
  • colonic defuctioning loop ileostomy may be needed for failure medical therapy
  • occasionally subtotal colectomy with permanent end ileostomy
  • pouch surgery generally contraindicated in Crohn’s
36
Q

What is a hydrocoele?

A

Excess accumulation of fluid in the processus vaginalis

37
Q

Anatomical classification of hydrocoeles

A
  • Vaginal: fluid in tunica vaginalis which surround testes but does not extend up cord
  • Cord: fluid around spermatic cord, difficult to distinguish from inguinal hernia
  • Congenital: sac communicates directly with peritoneum thus filled with peritoneum fluid
  • Infantile: only obliterated at deep ring thus fluid around cord and testes but does not communicate
38
Q

Hydrocoele treatment

A
  • exclude malignancy
  • watch and wait
  • aspiration relieves symptoms but often reaccumulates
  • Lord’s plication
  • Jaboulay’s operation
39
Q

What is a secondary hydrocoele?

A

Vaginal hydrocoele can be due to local pathology:

  • testicular tumours
  • torsion
  • orchitis
  • trauma
  • following inguinal hernia repair
40
Q

Epididymal cyst treatment

A
  • leave alone if not troublesome, esp in young men
  • very large or painful cysts can be removed
  • occasionally total epididymal excision indicated to prevent frequent recurrence of painful cysts
41
Q

Aetiology of varicoceles

A
  • dilated tortuous ‘varicose’ veins in pampiniform plexus
  • occur in 15% young men around puberty
  • if suddenly appear in older men, exclude underlying retroperitoneal disease including left renal carcinoma
42
Q

Why are 98% of varicoceles left-sided?

A

Left testicular vein:
- is more vertical where it connects to the renal vein
- is longer than the right
- frequently lacks terminal valve
Also, the left renal vein can be compressed by colon

43
Q

Varicocele treatment

A

Transfemoral radiological embolisation of testicular vein
Surgical ligation of veins
- Palomo op: high retroperitoneal approach
- Inguinal approach
- Laproscopic

44
Q

Causes of a right iliac fossa mass

A
  • from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
  • from bowel: caecal Ca, Crohn’s mass, TB mass, appendicular mass/abscess
  • from gyane organs: ovarian tumour, fibroid uterus
  • from male repro organs: undescended testis, ectopic testis
    from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
  • from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
45
Q

Investigations for a RIF mass

A
  • USS
  • CT
  • IV contrast CT
46
Q

Causes of a left iliac fossa mass

A
  • from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
  • from bowel: diverticular mass, colon Ca, faecal mass
  • from gyane organs: ovarian tumour, fibroid uterus
  • from male repro organs: undescended testis, ectopic testis
    from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
  • from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
47
Q

Major indications/causes for kidney transplant

A

End stage renal failure due to:

  • DM
  • Hypertensive renal disease
  • Glomerulonephritis
  • PCKD
48
Q

How is ‘matching’ of transplanted kidneys performed?

A
  • ABO

- HLA: DR > B > A

49
Q

Stages of transplant rejection

A
  • Hyperacute: within hrs from preformed antibodies
  • Accelerated acute: 1-4 days from secondary immune response (T mem cell activation)
  • Acute: 5 days-2 weeks from cell-mediated immunity
  • Chronic: humoral mechanisms most important
50
Q

Signs of renal transplant rejection?

A
  • graft tenderness
  • reduced urine output
  • rising creatinine
51
Q

Causes of ascites?

A
  • CLD
  • RHF
  • Intra-abdominal malignancy
  • Hypoalbuminaemia
  • Nephrotic syndrome
  • TB
  • Chylous ascites
52
Q

Differential of epigastric mass

A
  • from skin and soft tissues: sebaceous cyst, sarcoma, lipoma, hernia
  • from GI tract: stomach Ca, hepatomegaly, pancreatic Ca, pancreatic pseudocyst
  • from vascular system: AAA, retroperitoneal lymphadenopathy
53
Q

Causes of dysphagia

A

Mechanical
- Lumen: FB, oesophageal web
- Wall: Ca, oesophagitis, Barrett’s, stricture
- Outside wall: retrosternal goitre, lung Ca, pharyngeal pouch
Coordination abnormalities
- Motility disorder: spasm, achalasia
- Neuromuscular disease: MG, bulbar palsy (MND), CVA

54
Q

Enlarged kidney differential

A 
Congenital
- cystic disease
- horseshoe kidney
- hypertrophic single kidney
Acquired
- Renal: cysts, tumours, hydronephrosis, pyonephrosis, perinephric abcess, renal vein thrombosis
- Systemic: DM, amyloidosis, SLE
55
Q

Beck’s triad

A

For renal cell Ca

  • haematuria
  • loin mass
  • loin pain
56
Q

Classification of breast disease

A

Malignant
- Ductal Ca (70%)
- Lobular Ca (20%)
- Other: mucinous, tubular, medullary (10%)
Benign
- Congenital: extra nipples, hypoplasia
- Aberrations of normal dev and involution (ANDI): fibroadenomas, cysts, sclerotic/fibrotic lesions
- Non-ANDI: infective, lipomas, fat necrosis

57
Q

Indications for mastectomy

A
  • patient preference
  • clinical evidence of multifocal/multicentric disease
  • large lump in small breast tissue
  • nipple involvement
58
Q

Preparing a patient for breast surgery

A 
Physical
- mark site
- explain procedure + post op drain
- expect numb skin in axilla and upper arm (T1) as intercostal nerve is divided
- anaesthetic work-up including CX (pul mets)
Psychological
- breast care nurse
- fully explanation of reasons for op
- reconstruction options discussion
59
Q

When should post-mastectomy drain be removed?

A

Often two placed (axilla and at breast)

  • 3-5 days, until drainage <50 ml in 1 day
  • patients can be sent home with drains and district nurse support
60
Q

Types of breast reconstruction

A

Timing
- immediate
- delayed
Technique
- Tissue expansion (implants): subcutaneous or submuscular
- Autologous tissue: transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, superficial IEP, latissimus dorsi flap.

Surgery (4 decks)

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