Abdominal Surgery and Hernia

Question 1

what is a clean wound?

Answer 1

uninfected operative wound in which no viscus is entered, no purulence is found, and the wound is closed primarily

Question 2

what is a clean contaminated wound?

Answer 2

operative wound in which a viscus is entered under controlled conditions and without unusual contamination

Question 3

what is a contaminated wound?

Answer 3

wounds where purulence was encountered, wound from operations with major breaks in sterile technique, or wounds from operations with gross viscus spillage

Question 4

what is a dirty wound?

Answer 4

old traumatic wounds with retained devitalized tissue, foreign bodies, or fecal contamination or wounds that involve existing clinical infection or perforated viscus

Question 5

what is the most common cause of emergent surgery in the US?

Answer 5

appendicitis

(most common in 20s-30s)

Question 6

what are the symptoms and signs of appendicitis?

Answer 6

Over a 24 hour period

right LQ abd pain

anorexia

nausea and sometimes vomiting

low grade fever up to 101

leukocytosis with a left shift (12-13k)

Question 7

how long before surgery should prohylactic abx be given?

Answer 7

60 minutes

may need more time with Vancomycin because it needs to be infused slowly

Question 8

What is the definitive method of diagnosing appendicitis?

Answer 8

imaging

• abdomen and pelvis CT with IV and PO contrast
• U/S - good for kids and patients who can’t tolerate CT
• MRI

Question 9

what is the most common cause of acute appendicitis?

Answer 9

Meckel’s diverticulum - congenital abnormality

Question 10

do we recommend surgery for patients with asymptomatic gallstones?

Answer 10

No - just supportive care and patient education

Question 11

what is acute cholecystitis?

Answer 11

syndrome of RUQ pain, fever and leukocystosis associated with gallbladder inflammation

USUALLY caused by stones, but can occur without stones

Question 12

what labs should you order with choleystitis?

Answer 12

CBC - shows leukocytosis with bands

CMP = LFTs will be normal unless there is obstruction

lipase - negative to R/O pancreatitis

Question 13

how do you confirm a dianosis of acute cholecystitis?

Answer 13

1. gallbladder wall thickening or edema or pericholecystic flud on u/s
2. with positive Murphy’s sign
3. or positive HIDA scan (hepatobiliary scan)
4. MRCP (MRI of hepactic biliary ducts) can be done as well

Question 14

what is the definition of chronic cholecystitis?

Answer 14

chronic inflammation of the gallbladder secondary to stones or repeated attacks of cholecystitis, resulting in fibrosis and thickening of the gallbladder wall

Question 15

what is the significance of gallbladder polyps?

Answer 15

when present with stones they are a risk factor for gallbladder cancer

depending upon size, they are considered malignant

>2cm - considered malignant

1-2 cm - high malignant potential

<5mm - benign

Question 16

what is biliary dyskenisa? when should you suspect it?

Answer 16

a gallbladder motility disorder - think of it when therew are complaints typical of biliary symptoms without gallstones or other findings consistent with choleycystitis

Question 17

what is the definition of a hernia?

Answer 17

a condition where an organ or tissue protrudes through the wall of the compartment that normally contains it.

Question 18

what is the epidemiology of umbilical hernias?

Answer 18

can be congenital/acquired

in adults, more common in females (pregnancy or obesity)

Question 19

what is a femoral hernia?

Answer 19

hernia in the femoral canal, below the inguinal ligament and medial to the femoral vein

Question 20

what is the epidemiology of femoral hernias?

Answer 20

women > men

often has peritoneal sac

frequently presents with incarceration (stuck)

sometimes mistaken with cloquet’s node - node adjacent to femoral canal

Question 21

How do you diagnose a hernia using imaging?

Answer 21

u/s or CT for femoral

CT more useful for ventral, incisional or traumatic hernias or unusual hernias

Question 22

what is the ddx for hernia?

Answer 22

lipoma

lymphadenopathy

testicular tumor

hydrocele - incomplete obliteration of the PV

femoral aneurysm

Answer 23

Question 24

what is diastasis recti?

Answer 24

separation of the rectus abdominus muscles due to excessive intra-abdominal pressure

Question 25

what is the most common hiatal hernia?

Answer 25

Type I - sliding where the GE junction is above the right crus of the diaphragm