Abdominal Procedures Flashcards
What are the layer you go through when opening up the abdomen?
Skin Subcutaneous fat Campers fascia Scarpas fascia Abdominal wall fascia Pre-Peritoneal fat Peritoneum
Why do we need to think about what incision we use?
Exposure
Location of pathology
Prior surgery
Extensile exposure
Exposure
essential to good surgery
Prior surgery
danger of adhesive diseases, possible bowl injury Devascularizing skin (paramedian/midline)
Extensile exposure
Midline can continue to a midline sternotomy
Kocher can be extended to a small clam shell
Laparoscopy
Abdominal access via small incisions
intraperitoneal insufflation w/CO2
Preformance of surgery utilizing camera and special laparoscopic instruments
Advantages of a Laparoscopy
Minimal access (less scarring)
decreased pain
shorter hospitalization
better anatomical visualization
Disadvantages of a Laparoscopy
Carries same risk as open surgery w/ addition of GAS EMBOLISM AND PNEUMOTHORAX
May require conversion to open surgery
Poor visualization
No tactile sense
Contraindications of a laparoscopy
Inability ti withstand general anesthesia
Hypovolemic shock
Heart failure, severe COPD (cannot tolerate pneumperitoneum)
Intractable bleeding disorders
End stage liver disease
What is the most common GI operation preformed in the US?
cholecystectomy
Cholelithiasis
present in 12% of americans
5 “fs”
most are asymptomatic
70-80 percent of gallstones are cholesterol stones
alone assymptomatic not an indication for surgery
Biliary Colic
Symptomatic gallstones Impaction of the gallstone at GB neck intermittent RUQ pain-post-prandially \+/- NV Indication for elective cholecystectomy
Cholecystisis
Gall stone obstruction at cystic duct leading to wall distention and inflammation
Persistent RUQ pain, N/V, loss of appetite
Gallstone on US, murphy’s sign, wall thickening, pericholecystic fluid +/- fever/WBC/elevated LFTs
Indication for a cholecystectomy during same hospitalization
Ascending Cholangitis
Obstruction w/ bacterial stasis and inflammation
Charcots triad- fever jaundice, RUQ pain
Reynolds Pentad- same as triad, with shock and mental status change
GENUINE MEDICAL/SURGICAL EMERGENCY
Emergent fluids, foley catherter, abx, ICU admission
Endoscopic decompression
Should this fail, surgical extraction of stone, t-tube draining of biliary system
Acute Appendicitis
N/V/anorexia pain starting centrally, moving RLQ Localizes at McBurney point Fever mildly increased WBCs CBC, UA, Pelvic/Rectal exams CT often preformed, rarely necessary Patient to OR for appendectomy- usually preformed laporoscopically
Perforated Appendicitis
Waxing/Waning course w/ sudden recovery
Re-emergence of symptoms, fever
CT for diagnosis, percutaneous drainage
At 6 weeks, +/- interval appendectomy preformed
Open Surgery
McBurney/Lanz/Rocky Davis incision Identify cecum Deliver appendix into the wound Control mesoappendix, divide appendix, control base- purse string suture Higher rate of local wound infection!!!
Laparoscopic Surgery
3 parts (5mm at umbilicus, 5mm at suprapubic, 5mm at LLQ
Identify appendix, separate from cecum
Laparoscopic stapler to divide mesoappendix and appendix
Higher rate of pelvic abscess
Diverticulitus
LLQ pain
Out pouching of weakened colon at site of vascular perforation
Typically left (sigmoid) colon
Usually seen in older adults, but now also seen in younger ages
When these become obstructed, bacterial growth occurs
Present with abdominal pain, bright red blood per rectum, fever, elevated WBC
May form contained abscess amendable to CT drainage which may or may not be followed by operation
May require urgent operation (sigmoid-colectomy-hartmann’s procedure)
Inflammatory Bowel Disease
Crohns and Ulcerative Colitis
Crohn’s
May affect mouth to anus; BUT Spares the rectum
Presents with diarrhea, usually not bloody
Transmural inflammatory disease with cobble stoning ulcers
Diagnosis of Crohn’s
Colonoscopy w/biopsy
Management of Crohns
Medical!
Anti-inflammatory meds, steroids for acute exacerbations
Surgical management reserved for bowel obstruction unresponsive to medical management or perforation
Ulcerative Colitis
Chronic inflammation that involves the rectum
Persistent diarrhea/red blood in rectum
Friable mucosal disease with pseudopolyps
