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General Surgery > Abdominal surgery > Flashcards

Abdominal surgery Flashcards

1
Q

Lateral abdo wall layers + their continuous spermatic + scrotal structure

A

Skin – epidermis, dermis, SC fat
Camper’s fascia – Dartos muscle
Scarpa’s fascia – Colle’s superficial perineal fascia
External oblique – inguinal ligament – external spermatic fascia
Internal oblique – cremasteric fascia
Transversus abdominis – posterior inguinal wall
Transversalis fascia – internal spermatic fascia
Preperitoneal fat
Peritoneum – tunica vaginalis

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2
Q

Midline abdo wall layers

A 
Skin 
Superficial fascia 
Rectus abdominis muscle 
Arteries 
Transversalis fascia 
Peritoneum
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3
Q

Arterial blood supply to liver, spleen + gallbladder?

A 
Liver = left + right hepatic 
Spleen = splenic
Gallbladder = cystic (branch of right hepatic)
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4
Q

Arterial blood supply to stomach + duodenum?

A

Lesser curvature = right + left gastric
Greater curvature = right gastroepiploic (branch of gastroduodenal), left gastroepiploic (branch of splenic)
Fundus = short gastric (branch of splenic)
Duodenum = gastroduodenal + pancreaticoduodenal

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5
Q

Arterial supply to pancreas, small + large intestine?

A

Pancreas = pancreatic branch of splenic + pancreaticoduodenal
Small intestine = superior mesenteric branches (jejunal, ileal, ileocolic)
Large = super mesenteric branches (right + middle colic) + inferior mesenteric branches (left colic, sigmoid + superior rectal)

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6
Q

What tests should be done in an acute abdomen to reach a diagnosis?

A 
ALP, ALT, AST, bilirubin 
Lipase/ amylase
Urinalysis 
bhCG 
Troponin 
Lactate
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7
Q

What tests should be done in an acute abdomen to prepare pt for OR?

A

CBC, electrolytes, creatinine, glucose
INR/ PTT
CXR if cardiac/ pulmonary disease
ECG if cardiac hx or >70

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8
Q

Surgical options for bariatric sugery

A

Combination of malabsorptive + restrictive:
Laparoscopic Roux-en-Y gastric bypass (most common, most effective, most complications)
Restrictive laparoscopic sleeve gastrectomy (only for severe obesity)
Laparoscopic adjustable gastric banding (modest weight loss)
Malabsorptive only: biliopancreatic diversion with duodenal switch

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9
Q

Complications of bariatric surgery

A 
Obstruction at enteroenterostomy 
Staple line dehiscence 
Dumping syndrome 
Cholelithiasis due to rapid weight loss 
Band abscess
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10
Q

Complications of gastric surgery

A 
Aklaline reflux gastritis 
Afferent loop syndrome 
Dumping syndrome 
Blind-loop syndrome 
Postvagotomy diarrhea
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11
Q

What is afferent loop syndrome?

A

Accumulation of bile + pancreatic secretions cause obstruction + distention
Causes postprandial distention, RUQ pain, bilious vomiting
Manage with surgery

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12
Q

What is dumping syndrome?

A

Rapid emptying of hyperosmotic chime leads to jejunal distension, stimulating release of vasoactive hormones. Also caused by hypoglycaemia following post-prandial insulin peak
Causes post-prandial epigastric crmaping, bloating, emesis, vasomotor symptoms (palpitations, tachy)
Management: frequent small meals, low in carbs

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13
Q

What is blind loop symdrome?

A

Bacterial overgrowth in afferent limb
Causes anemia, diarrhea, abdo pain, hypocalcaemia
Treat with abx + surgery

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14
Q

What is postvagotomy diarrhea?

A

Bile salts in colon inhibit water resorption

Tx with cholestyramine or surgery

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15
Q

What is the difference between a virgin + non-virgin abdo in the context of small bowel obstruction?

A 
Virgin = surgery ASAP
Non-virgin = adhesions likely, resolves with NGT decompression
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16
Q

Top 3 causes of small bowel obstruction

A

Adhesions
Hernias
Cancer

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17
Q

What does an acute abdomen + metabolic acidosis suggest?

A

Bowel ischemia

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18
Q

Carcinoid syndrome symptoms

A 
Flushing 
Diarrhea
Right sided HF 
Hypotension 
Bronchoconstriction
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19
Q

What are the malignant tumours of the small intestine?

A

Adenocarcinoma
Carcinoid
Lymphoma
Mets

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20
Q

Where are lymphomas in small intestine typically found?

A

Distal ileum

Proximal jejunum in pts with celiac disease

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21
Q

What is short gut syndrome?

A

Reduced surface area of small bowel causing insufficient absorption
Caused by resections following acute mesenteric ischemia, Crohns or malignancies

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22
Q

Management of short gut syndrome

A

TPN, PPI, antimotility agent, octreotide to reduce GI secretions
Surgery to increase length or transplant

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23
Q

What is the rule of 5s for indirect inguinal hernias?

A

5% lifetime incidence in males
5x more common than direct
5-10x more common in males
Occurs by 5th decade

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24
Q

What are the borders of Hesselbach’s triangle?

A 
Lateral = inferior epigastric artery 
Inferior = inguinal ligament 
Medial = lateral margin of rectus sheath
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25
Q

What is a Richter’s hernia?

A

Only part of bowel circumference is strangulated so may not be obstructed + may self-reduce

26
Q

Difference between strangulated + incarcerated hernia

A

Incarcerated = irreducible

Strangulated – vascular supply is compromised

27
Q

Complications of hernia post-op

A 
Recurrence 
Scrotal hematoma 
Nerve entrapment 
Stenosis of femoral vein 
Ischemic colitis
28
Q

Findings in Crohns

A

Cobblestone appearance
Skip lesions
Creeping fat

29
Q

Findings in UC

A

Crypt abscesses + branching + atrophy

30
Q

Top 3 causes of large bowel obstruction

A

Cancer
Diverticulitis
Volvulus

31
Q

What signs in LBO indicate impending perforation?

A

Cecum >12cm

Tenderness over cecum

32
Q

Open vs closed loop large bowel obstruction features

A 
Open = incompetent ileocaecal valve = similar to SBO S+S 
Closed = proximal + distal occlusion, massive colonic distension causing bowel wall ischemia + necrosis
33
Q

What is Ogilvie’s syndrome?

A

Acute pseudo-obstruction of bowel

34
Q

Differences between paralytic ileus + bowel obstruction

A

Ileus = minimal pain, absent bowel sounds, air throughout small bowel + colon

35
Q

Tubular vs villous colon polyps

A

Tubuar – small, pedunculated, even distribution throughout colon
Villous = large, sessile, high risk of turning malignant, left sided mostly

36
Q

What criteria is used to assess whether HNPCC should be screened for?

A

Bethesda criteria

37
Q

What is LAR vs APR (reference to colon cancer?)

A 
APR = removes distal sigmoid colon, rectum + anus, permanent end colostomy 
LAR = removes distal sigmoid + rectum with anastomosis from colon to anus
38
Q

What is angiodysplasia?

A

Vascular malformation, frequently in right colon

Venous dilatation + tortuosity

39
Q

When do you see the ace of spades or bird beak sign?

A

Barium enema of sigmoid volvulus

40
Q

What is toxic megacolon?

A

Inflammation in smooth muscle layer of bowel causing paralysis
Caused by infection on IBD

41
Q

Reasons fistulas stay open

A 
FB
Radiation 
Infection 
Epithelialisation 
Neoplasm
Distal obstruction 
Others = increased flow, steroids
42
Q

What is a mucous fistula?

A

Connection of distal limb of colon to abdo wall

43
Q

What is a ileal conduit?

A

Connection of bowel to ureter proximally + abdo wall distally to drain urine

44
Q

Differences between ileostomy + colostomy

A 
Ileostomy = RLQ, liquid, has a spout 
Colostomy = stool, on LLQ
45
Q

Complications of stomas

A 
Obstruction 
Abscess + fistula 
Skin irritation 
Prolapse or retraction 
Diarrhea
46
Q

Definition of anal fissure

A

Tear of anal canal below dentate line

47
Q

What is Goodsall’s rule?

A

Fistulas originating from anterior to transverse line will have straight course + exit anteriorly
Fistulas originating posterior to transverse line will begin in midline + have curved tract

48
Q

What is Zollinger-Ellison syndrome?

A

Gastric acid hypersecretion – caused by gastrinoma

Pt has diarrhea + abdo pain, peptic disease reflux

49
Q

What is Whipple’s triad?

A

Symptomatic fasting hypoglycaemia
Serum glucose <50
Relief of symptoms when glucose is given
Sign of insulinoma

50
Q

Describe the localisation of pain in the abdomen

A

Most pain is perceived in the midline due to bilaterally symmetric innervation
Kidney, ureter or ovary is likely to cause lateral pain

51
Q

Where does biliary + renal colic radiate to?

A 
Biliary = right shoulder/ scapular 
Renal = groin
52
Q

Where does AAA, perforated ulcer + pancreatitis radiate to?

A 
AAA = back or flank 
Ulcer = RLQ (right paracolic gutter)
Pancreatitis = to back
53
Q

Causes of diffuse abdo pain

A 
Peritonitis 
Early appendicitis 
Mesenteric ischemia 
Gastroenteritis 
Constipation 
Bowel obstruction 
Pancreatitis 
IBD 
IBS 
AAA
Sickle cell crisis 
Perforated ectopic 
PID 
Acute urinary retention 
Carcinoid syndrome 
DKA
Addisonian crisis 
Hypercalcaemia 
Lead poisoning 
Tertiary syphilis
54
Q

What do waves of colicky pain suggest?

A

Bowel obstruction

55
Q

What does pain out of proportion to clinical findings suggest?

A

Ischemic bowel

56
Q

DDx abdo mass in RUQ

A

Cholecystitis, cholangiocarcinoma, peri-ampullary malignancy, cholelithiasis
Klatskin tumor (biliary tract)
Hepatomegaly, hepatitis, abscess, tumour

57
Q

DDx abdo mass in midline

A 
Pancreatic adenocarcinoma, pseudocyst 
AAA 
Gastric tumour, MALT lymphoma 
Pregnancy, fibroids, uterine cancer, pyometra
Bladder distension, bladder cancer
58
Q

DDx for abdo mass in RLQ

A

Stool, tumour, mesenteric adenitis, abscess, intusseception, Crohns inflammation
Ectopic, cyst, ovarian tumour
Tubo-ovarian abscess, hydrosalpinx

59
Q

DDx for abdo mass in LUQ

A

Splenomegaly, tumour, abscess, splenic haemorrhage

Gastric tumour

60
Q

DDx for abdo mass in LLQ

A

Stool, tumour, abscess

Ovarian pathology

61
Q

Indications for urgent surgery in an acute abdomen

A

Ischemia
Hemorrhage
Obstruction
Perforation

62
Q

What is occult vs obscure bleeding?

A 
Occult = bleeding from rectum not obvious to naked eye 
Obscure = bleeding with no identifiable source eg after endoscopy

General Surgery (2 decks)

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