COMBANK Surg COMAT Flashcards
surg tx for intestinal malrotation
Ladd’s procedure
What is done in Ladd’s procedure?
disrupts the bands of Ladd (which are a fibrous extension of the peritoneum that anchor the cecum to the abd wall) allowing the surgeon to mobilize R colon and cecum to reduce intestinal malrotation
Nissen fundoplication
- uses the fundus of the stomach to posteriorly plicate, or encircle, the distal end of the esophagus 360 degrees creating a narrowed lower esophageal sphincter, especially during peristalsis of the stomach.
- Narrowing of the esophageal hiatus is also done with suture thereby reducing the risk of a sliding hernia
- tx for refractory GERD and/or hiatal hernia
Whipple’s procedure
- pancreaticoduodenectomy
- two stages of surgery which involve an antrectomy, cholecystectomy, choledochectomy, and duodenectomy as well as the removal of the head of the pancreas as well as regional lymph nodes
- jejunum is attached to the pancreas for digestive enzymes, the distal stomach for passage of food, and to the hepatic duct for bile passage
Ramstedt pyloromyotomy
- longitudinal incision along the pylorus of an infant with hypertrophic pyloric stenosis
Sigmoidopexy
correction of sigmoid volvulus (malrotation) by open, laparoscopic, or a tube passed through the rectum and followed by fixation of the sigmoid colon to the abdominal wall to prevent recurrence.
test of choice when SBO is suspected
abdominal series
- includes: an upright chest radiograph to look for pneumoperitoneum, an upright abdomen to see air-fluid levels, and a supine abdomen which best shows bowel dilation
Classic findings of a SBO on radiography
ladder-like dilated loops of bowel with air fluid levels
most common cause of SBO in US
Postoperative adhesions
all causes of SBO
postop adhesions hernias fecaliths neoplasm volvulus gallstone ileus intussusceptions SMA syndrome abscess diverticulitis annular pancreas bowel wall hematoma
most common cause of SBO in children and in non-industrialized nations
hernias
surgical indications in SBO
complete SBO, strangulated bowel, or bowel perforation
why are lactated ringers good in trauma/shock setting
lactate is converted to bicarbonate in the body and can buffer the hypovolemia-induced metabolic acidosis
- note: nml saline is also an equivalently good answer
when is hypertonic saline indicated
only in those with severe hyponatremia (< 115 mEq/L) with neurologic manifestations such as a coma or seizure
- ex 3% NS
what IV fluid can’t be given as a bolus
anything with dextrose b/c can cause hyperglycemia
Progression of persistently hypotensive trauma pt
- Lactated Ringers bolus
- up to 2-3 L of crystalloid infusion
- then colloid
- can consider giving blood transfusion of packed RBCs at time of 2nd fluid bolus
What are Crystalloids?
fluids that have an electrolyte composition similar to plasma such as Ringer’s lactate or normal saline
What are colloids?
blood products, albumin, as well as synthetic colloids such as hetastarch and hespan
Why do colloids work when crystalloids dont?
colloids have greater ability to stay intravascularly than do crystalloid solutions
most common cause of spontaneous bloody nipple discharge
solitary intraductal papilloma in one of the large subareolar ducts under the nipple
Richter’s hernia
when only the antimesenteric wall of a hollow abdominal organ becomes incarcerated in an inguinal hernia
— can see bowel ischemia without bowel obstruction (dangerous and difficult to dx)
Amyand hernia
- aka appendiceal hernia
- inguinal hernia containing the vermiform appendix
- can have s/sx of appendicitis
sliding inguinal hernia
hernia containing a hollow retroperitoneal organ, most commonly the bladder or colon
Littre’s hernia
hernia that contains a Meckel’s diverticulum
pantaloon hernia
inguinal hernia that contains elements of both a direct and an indirect inguinal hernia
acute hemorrhagic gastropathy
development of hemorrhagic gastric lesions shortly after exposure to toxic substances that contribute to ischemia or erosions in the stomach:
– NSAIDs, alcohol, cocaine, iron pills, and chemotherapy
- note: bleeding may be delayed up to one week
Mallory-Weiss syndrome
characterized by upper gastrointestinal bleed secondary to shear stress causing mucosal tears in GE junction…. due to an increase in abdominal pressure including vomiting and hiatal hernia
hemochromatosis complications
- mainly result from cirrhosis including portal HTN, esophageal varices
infectious causes of esophagitis
ommonly seen in immunocompromised hosts (HIV patients) include candida, cytomegalovirus, and herpes simplex virus
hallmark of esophageal candidiasis
odynophagia (painful swallowing) with or without oral thrush
treatment of active peptic ulcers associated with NSAID use
proton pump inhibitor (PPI) therapy and cessation of nonsteroidal anti-inflammatory drugs (NSAID)
Atypical ductal hyperplasia (ADH)
characterized by a proliferation of uniform epithelial cells with monomorphic round nuclei filling part, but not all, of the involved duct
Atypical ductal hyperplasia (ADH) tx
- usually dx by core needle biopsy
- tx with excisional biopsy of the lesion and continued mammographic screening
Achalasia
failure of the lower esophageal sphincter to relax and aperistalsis
causes of fever postoperatively
5 W’s: wind-atelectasis, water-urinary tract infection, wound-wound infection, walking-deep venous thrombosis (DVT), and wonder drugs-drug fever
note: medications can be anytime. Other causes have specific timeline
most common cause of fever postop 24-48h
atelectasis
— get CXR
most common cause of fever postop day 3
UTI
most common cause of fever postop day 5
wound infection
really anytime but usually after day 5
most common cause of fever postop day 7-10
DVT/PE
can be as early as day 5
Malignant hyperthermia syndrome (MH)
inherited, pharmacogenetic disorder of skeletal muscle that results in a hypermetabolic state post anesthesia administration
what agents trigger malignant hyperthermia?
all potent inhalation agents and succinylcholine
pathophys of malignant hyperthermia
- AD
- most frequently associated with a mutation in the ryanodine receptor gene (RYR1). RYR1 mutations result in increased sensitivity of skeletal muscle calcium channels to agonists, leading to uncontrolled calcium release into the muscle sarcoplasm. Intracellular hypercalcemia in skeletal muscle activates metabolic pathways leading to ATP depletion, acidosis, membrane destruction and cell death
tx of malignant hyperthermia
discontinuing medication, cooling, hyperventilation, and dantrolene administration
— often given procainamide too to avoid v-fib
common etiology in elderly patient of weakness, weight loss, and microcytic anemia with a positive stool guaiac test
colorectal cancer
— must consider before other dx
best test to screen for and diagnose colorectal cancer
colonoscopy
– can do tissue biopsy
charcot’s triad
RUQ pain
jaundice
fever
= cholangitis
Reynolds pentad
charcot’s triad (RUQ pain, jaundice, fever)
hypotension
AMS
tx of Chron’s disease
- For acute/remission: 5-ASA meds (Ex/ sulfasalazine, mesalamine)
+/- abx (cipro, metro) - For acute: corticosteroids
- For remission/refractory: immunomodulators (6-MP, AZAthioprine, infliximab)
most common cause of GERD
decreased lower esophageal sphincter tone
test of choice in evaluation of GERD
only needed if refractory or with dysphagia:
upper endoscopy with biopsy
deficiency of ___ in hemophilia A
factor VIII
lab value identifying Hemophilia A
prolonged PTT
normal PT
normal bleeding time
normal platelet count
Tx for hemophilia A
cryoprecipitate
— rich in factor VIII and fibrinogen
tx of Hempohilia B
factor IX products
key identifier between partial and full thickness wounds
pain
painless = full thickness
superficial partial burn characteristics
- involves upper dermal layers
- often causes fluid filled blisters several hours later
- underlying tissue is moist, pink, painful
- blanches upon palpation
deep partial burn characteristics
- extend into reticular dermis
- blisters, painful, blanch (or not blanch)
- pink and white mottled appearance of underlying wound (compromised blood flow)
epidermal burn characteristics
- erythematous (dilation of underlying dermal vasculature)
- painful
- no blisters
fourth degree burn characteristics
- deep
- potentially life-threatening
- extend into underlying tissues (fascia, muscle, bone)
full thickness burn characteristics
- range in color (white -> black)
- leathery with eschar
- do not blanche
- insensate
vitamin deficiency in Crohn’s
zinc
vit B12
s/sx of zinc depletion
dermatitis (acrodermatitis enteropathica, alopecia, eczema)
hypogonadism
growth retardation
taste abnormalities
acute hemolytic transfusion reaction (AHTR) pathophys
rapid destruction of donor RBCs by preformed antibodies
cause of acute hemolytic transfusion reaction (AHTR)
ABO incompatibility
acute hemolytic transfusion reaction (AHTR) s/sx
fever, chills shock hemolysis DIC (oozing blood, hemoglobinuria) renal failure (acute tubular necrosis)
focal nodular hyperplasia on CT scan
hypervascular mass containing arteriovenous connections
in liver
(usually asymptomatic)
hepatic adenoma on CT scan
NO AV connections
appearance of gastric ulcers
discrete mucosal lesions with a punched-out smooth ulcer base, often filled with whitish fibrinoid exudate
appearance of duodenal ulcers
- sharply demarcated edges
- exposed underlying submucosa
- clean and smooth ulcer base (but acute ulcers and those with recent hemorrhage can demonstrate eschar or adherent exudate)
ulcers and food
- shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer.
- Food or antacids relieve the pain of duodenal ulcers but provide minimal relief of gastric ulcer pain.
Dieulafoy’s lesion
single large tortuous arteriole in the submucosa which does not undergo normal branching or a branch with caliber of 1–5 mm (more than 10 times the normal diameter of mucosal capillaries)
- causes erosion and bleeds
when should you not use permanent prosthetics
- ex mesh
in setting of fecal contamination
Oral tongue cancer
- Squamous cell carcinoma is the most common
- most commonly presents as an ulcerated exophytic lesion on the posterior and lateral aspect.
difference between pilonidal disease and hidradenitis suppurativa (aka acne inversa)
- chronicity of HS/AI compared to pilonidal disease with a strong history of chronic disease and recurrence of disease.
- HS/AI is seen in family history and can be seen in axillae, groin, breast, thigh of family members
- Both can involve gluteal cleft, are painful with abscess and sinus tracts, and are follicular occlusion
tx of gastric adenocarcinoma
depends on location and spread of tumor:
- antrum -> subtotal gastrectomy
- middle or upper -> total gastrectomy
Clean contaminated wounds
sterile wounds that require opening of a non-sterile hollow viscus organ without significant spillage of infectious contents
Contaminated wounds
accidental wounds that involve violation of sterile fields or gross spillage of infectious content into a previously sterile field.
Gross contaminated wounds
traumatic wounds that have a significant delay in attaining treatment, oftentimes including areas of necrosis or frank purulence.
tx of Tension pneumothorax
should initially be needle decompressed followed by tube thoracostomy
how to estimate burn size
In adults (rule of 9s):
- the anterior and posterior trunk each account for 18% ,
- each lower extremity is 18%,
- each upper extremity is 9%,
- and the head is 9%.
Superficial or first-degree burns should not be included when calculating the percent TBSA
Schatzki ring
- aka esophageal ring
- a mucosal thickening causing stricture usually at the squamocolumnar junction of the lower esophagus
- tx = dilation
tx fro Zenker’s diverticulum
cricopharyngeal myotomy (b/c is outpouching of the cricopharyngeal m.)
Billroth’s operation
partial gastrectomy where the pylorus is removed and the proximal stomach anastomosed to the duodenum
Heller myotomy
esophagomyotomy
- cutting the esophageal sphincter muscle, performed laparoscopically
Blind loop syndrome
can result after a chronic obstruction to a portion of the intestines causing bacterial overgrowth due to stasis within the obstructed limb
- note: bacteria bind vit B12 and can cause megaloblastic anemia and peripheral neuropathy. (can also see vit A def)
electrolyte effect of succinylcholine
can cause hyperkalemia in predisposed pt (burn and spinal cord injury)
Spigelian hernias
arise from a defect in Spigel’s fascia, the aponeurotic layer between the rectus abdominis and external oblique muscle along the linea semilunaris.
- usually present without a bulge
test to dx achalasia
esophageal motility study (manometry) (showing aperistalsis, increased resting pressure of LES, failure of relaxation of LES in response to swallowing)
- Note: if unsure, then get barium esophagram
surgery for achalasia
Heller myotomy with partial fundoplication
- Note: pneumatic dilation is also first line tx
abs for colorectal surgery
general:
- second gen cephalosporins (cefotetan and cefoxitin) if single drug
- – (b/c need to cover g- and anaerobes)
- ampicillin/sulbactam
- cefazolin + metro
- clindamycin + fluorquinolone or aztreonam
if bowel perf: broader spectrum abx
paraphimosis
retracted foreskin develops a fixed constriction proximal to the glans
Phimosis
inability to retract the foreskin proximally to the glans penis
Balanoposthitis
inflammation secondary to an infection of the glans penis and the surrounding foreskin
manifestations of Peutz-Jeghers syndrome
pigmented mucocutaneous macules (often around mouth) and
multiple hamartomatous gastrointestinal polyps
—> at risk for intussusception
common GI complication in Peutz-Jeghers syndrome
nearly half will have an intussusception due to hamartomatous polyps of GI tract
orchiopexy
permanent fixation of testicle to scrotum
- do this bilaterally after a testicular torsion within 6hrs of event
tx of LCIS
tamoxifen therapy if ER+
LCIS is not cancerous or pre-malignant so no surgery needed. Just indicates increased risk of breast CA in general
when to drain a post-op seroma
should not be performed unless the seroma is symptomatic or lasts for longer than 6-8 weeks due to the risk of mesh infection
when are glycogen stores depleted
after 24-48h of starvation
what to do with large polyp found on colonoscopy
remove by saliine injection & cautery snare if possible. If not (ex/ >2-3cm) then surg consult.
bezoar
- mass trapped in the gastrointestinal system
- most often in stomach
abx for MRSA resistant infections
Linezolid
activity against MRSA, streptococci, almost all g+, some anaerobic… and as effective as Vanco
treatment of appendiceal carcinoid
- greater than 1.5 cm is a right hemicolectomy
- less than 1.5 cm then an appendectomy
- Octreotide for carcinoid syndrome
sx of compartment syndrome
5 P’s: pain, paresthesias, pallor, paralysis, and pulselessness.
What to remove when surgery for appendiceal cystic lesion.
- can either be a cystadenoma or a cystadenocarcinoma.
- – Cystadenomas can be treated with an appendectomy alone, but are often difficult to diagnose grossly.
- – A right hemicolectomy is indicated if suspicious for cystadenocarcinoma.
- These cysts should not be biopsied to avoid rupture which can cause pseudomyxoma peritonei.
layer of the intestinal wall is most important in maintaining tensile strength
The submucosal layer
- has a high content of collagen fibers and is where the tensile strength of the bowel lies
- Tensile strength is mainly determined by collagen cross linking.
Inflammatory breast cancer vs infectious mastitis
Failure of oral antibiotics and lack of an abscess help distinguish inflammatory cancer from mastitis.
Immediate treatment of central retinal artery occlusion
ocular massage
– Repeated pressure for 10-15 seconds on the orbit improves retinal blood flow and may allow the embolus to move downstream to restore blood flow to some of the retina
window for tPA
4-6hrs from sx onset
treatment for toxic megacolon
subtotal abdominal colectomy with end ileostomy.
abx C diff is resistant to
clindamycin
cephalosporins
fluoroquinolones
Things that cause a right shift of the hemoglobin-oxygen dissociation curve
(decrease in affinity of Hb for O2)
acidosis, high altitude, increase in pCO2, increase in temperature, and increase in metabolic needs.
apple core abd XR
colon carcinoma
Kidney/coffee bean sign abd XR
sigmoid volvulus
or closed loop SBO
Rigler sign
presence of both inner and outer walls of the bowel on abd XR
= pneumoperitoneum
Billroth II procedure
gastrojejunostomy
- for PUD or gastric adenocarcinoma
Billroth I procedure
gastroduodenostomy
- for PUD or gastric adenocarcinoma
