Abdominal Procedures

Question 1

What are the layer you go through when opening up the abdomen?

Answer 1

Skin
Subcutaneous fat
Campers fascia
Scarpas fascia
Abdominal wall fascia
Pre-Peritoneal fat
Peritoneum

Question 2

Why do we need to think about what incision we use?

Answer 2

Exposure
Location of pathology
Prior surgery
Extensile exposure

Question 3

Exposure

Answer 3

essential to good surgery

Question 4

Prior surgery

Answer 4

danger of adhesive diseases, possible bowl injury
Devascularizing skin (paramedian/midline)

Question 5

Extensile exposure

Answer 5

Midline can continue to a midline sternotomy

Kocher can be extended to a small clam shell

Question 6

Laparoscopy

Answer 6

Abdominal access via small incisions
intraperitoneal insufflation w/CO2
Preformance of surgery utilizing camera and special laparoscopic instruments

Question 7

Advantages of a Laparoscopy

Answer 7

Minimal access (less scarring)
decreased pain
shorter hospitalization
better anatomical visualization

Question 8

Disadvantages of a Laparoscopy

Answer 8

Carries same risk as open surgery w/ addition of GAS EMBOLISM AND PNEUMOTHORAX
May require conversion to open surgery
Poor visualization
No tactile sense

Question 9

Contraindications of a laparoscopy

Answer 9

Inability ti withstand general anesthesia
Hypovolemic shock
Heart failure, severe COPD (cannot tolerate pneumperitoneum)
Intractable bleeding disorders
End stage liver disease

Question 10

What is the most common GI operation preformed in the US?

Answer 10

cholecystectomy

Question 11

Cholelithiasis

Answer 11

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

Question 12

Biliary Colic

Answer 12

Symptomatic gallstones
Impaction of the gallstone at GB neck
intermittent RUQ pain-post-prandially
\+/- NV
Indication for elective cholecystectomy

Question 13

Cholecystisis

Answer 13

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

Question 14

Ascending Cholangitis

Answer 14

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

Question 15

Acute Appendicitis

Answer 15

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

Question 16

Perforated Appendicitis

Answer 16

Waxing/Waning course w/ sudden recovery
Re-emergence of symptoms, fever
CT for diagnosis, percutaneous drainage
At 6 weeks, +/- interval appendectomy preformed

Question 17

Open Surgery

Answer 17

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!!!

Question 18

Laparoscopic Surgery

Answer 18

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

Question 19

Diverticulitus

Answer 19

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)

Question 20

Inflammatory Bowel Disease

Answer 20

Crohns and Ulcerative Colitis

Question 21

Crohn’s

Answer 21

May affect mouth to anus; BUT Spares the rectum
Presents with diarrhea, usually not bloody
Transmural inflammatory disease with cobble stoning ulcers

Question 22

Diagnosis of Crohn’s

Answer 22

Colonoscopy w/biopsy

Question 23

Management of Crohns

Answer 23

Medical!
Anti-inflammatory meds, steroids for acute exacerbations
Surgical management reserved for bowel obstruction unresponsive to medical management or perforation

Question 24

Ulcerative Colitis

Answer 24

Chronic inflammation that involves the rectum
Persistent diarrhea/red blood in rectum
Friable mucosal disease with pseudopolyps

Question 25

Diagnosis of UC

Answer 25

Colonoscopy w/biopsy; incresed risk of cancer

Question 26

Management of UC

Answer 26

SURGICAL

total proctocolectomy w/end ileostomy or ileal J pouch

Question 27

Post Op concerns for ileostomy

Answer 27

fluid losses, in ability to absorb B12, Vit A, D, E or K

Question 28

Post Op concerns for colostomy

Answer 28

loss of colons capacity to reabsorb

with both skin irritation, prolapse, parastomal hernia

Question 29

Closing the abdomen, considerations

Answer 29

counts correct (lap pads, instruments, malleable)
visual inspection
tactile 4 quadrant search
ensure good paralysis
inform anesthetic team
ICU/Resp therapy/transport
Facial closure (running suture/interrupted suture)
Retention structures (internal/external)
Skin Closure (none, staples, suture)
Other (secure drains, ostomy appliance, abdominal binder)

Question 30

RUQ pain =

Answer 30

Cholecustitis/Cholecystectomy

Question 31

RLQ pain =

Answer 31

Appendicitis/Appendectomy

Question 32

RLQ pain and obstruction =

Answer 32

IBD – Crohn’s Disease

Question 33

LLQ pain =

Answer 33

Diverticulitis/Colon Resection