Common Abdominal and Chest Surgeries Flashcards
The major difference between open surgery and laparoscopic surgery is ?
size of the incision
a single incision, multiple inches long, is made to access the abdomen
Open surgery or laparotomy
- minimally invasive surgery that uses several incisions of one-quarter or less.
- uses laparoscope for very small incisions.
- uses more advanced techniques as compared to open surgery.
Laparoscopic surgery
recovery time difference between Laparotomy vs Laparoscopy
- Laparotomy - longer recovery time; requires admission
- Laparoscopic - less blood loss, less trauma, faster recovery, reduced hospitalization; Many can go home that day or after 23 hr OBSl; Can be more $$$ due to equipment
patient factors that determine Laparotomy vs Laparoscopy
- Overall Health
- BMI
- Prior surgeries
scoring used for appendicitis
Alvarado score
score of 7-10
Mc of appendicitis
Fecalith/appendiceal obstruction
Can be cancer; ?MC tumor of the appendix
w/u for appendicitis
- Labs - leukocytosis
- US - inital imaging for kids; if body habitus permits
- +/- CT - PO contrast if perforation
abx therapy for appendectomy
- rocephin + flagyl
- FQ/cefdinir + flagyl, augmentin
30% will have recurrent appendicitis when?
1y
T/F: it is ok to have pt with full bladder during laparoscopic appendectomy
F: have them void prior
Pneumoperitoneum is achieved using either what two methods?
- Veress needle
- open Hassan technique
Appendectomy - The laparoscope is inserted into the abdomen and two additional ports are placed under direct visualization where?
- One port LLQ
- One port in lower midline/suprapubic - Care must be taken not to put the port in the bladder.
pt positioning for laparoscopic appendectomy
- Trendelenburg with left side of table down - uses gravity to help pull small bowel away from cecum
laparoscopic appendectomy procedure
- The abdomen is then inspected and the cecum identified
- cecum is grasped and the appendix identified
- The mesoappendix is grasped and divided using an endoscopic stapler
- endoscopic stapler used to remove appendix from cecum at the base.
- The abdomen is irrigated and inspected for signs of bleeding.
- ports are removed under direct visualization, the fascia and skin are closed, and dressings applied.
postop care for laproscopic appendectomy
- D/C home same day if nonperforated/uncomplicated
- Admit for perforation or open technique
- Complicated appendectomy - Ceftriaxone + Metronidazole x 5-7 days
- uncomplicated: just need preop abx
indications for cholecystectomy
- Symptomatic Cholelithiasis - May also require intraoperative cholangiogram
- Asx Cholelithiasis - if at incr risk of GB carcinoma or gallstone complications
- Acalculous Cholecystitis
- Gallbladder polyps >0.5cm
- Porcelain Gallbladder
CI for cholecystectomy
- Diffuse peritonitis
- Hemodynamic compromise
- Uncontrolled bleeding disorders
w/u for cholecystectomy
RUQ U/S, +/-abdominal CT scan, Labs, +/-MRCP, +/-ERCP
indications for an open chole
- inability to safely/effectively perform a lap chole
- CA
- hemodynamic compromise
complications from chole?
tx?
CBD injury/CBD leaks/Obstruction
- Suspect with fever, abdominal pain
- 2 - 10 days postop
- Confirm with U/S or CT
- Possible peritonitis/infection - Treat with U/S guided percutaneous drainage with ERCP to stent or repair OR re-operation
- other: Bowel injury, Liver injury, Intra-abdominal abscess, Bleeding; dyspepsia, diarrhea
postop care for uncomplicated lap chole
- Can D/C home same day
- pain meds
- F/U in office in 5-7 days.
postop care If Open or complicated Lap Chole:
- Admit for 1-3 days
- Pain meds.
- Typically no abx needed - unless surgery contaminated.
- Monitor for complications
anatomic structures involved in R colectomy
Cecum, Ascending Colon, Hepatic Flexure, first portion Transverse Colon
anatomic structures involved in L colectomy
Second portion of Transverse Colon, Splenic Flexure, Descending Colon, Sigmoid Colon
indications for colon surgery
- Tumors / Masses (Benign - Polyps, Malignant)
- Ulcerative Colitis
- Diverticulitis / Perforation
- Ischemic Colitis - Vasculopath; Intestinal volvulus /obstruction
w/u for colon surgery
- PE-?palpable mass
- Labs - tumor markers (CEA/CA 19-9)
- Colonoscopy
- CT abdomen and pelvis w/ IV and oral contrast
The indications for laparoscopic colectomy can be sub-grouped into colectomy for ____ vs _____
benign disease vs neoplasia
benign dz for lap colectomy
- IBD
- Diverticular disease
- Rectal prolapse
- Colonic dysmotility
neoplastic conditions for lap colectomy
- Polyps not amenable to resection via colonoscopy
- Colorectal cancers
- Hereditary colon cancer syndromes - Familial adenomatous polyposis; Hereditary nonpolyposis colorectal cancer
Compared with open colectomy, laparoscopic surgery has been shown to be associated with decreased ____
- post op pain analgesia requirement
- faster return of bowel function
- earlier resumption of PO intake
- shorter hospital stay and better cosmesis.
complications from colectomy
- Anastomotic leak
- Intra-abdominal abscess
- Bleeding
- Bowel obstruction
piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon.
colostomy
indications for colostomy
- Gangrenous/perforated bowel
- Colorectal cancer
- IBD
- Trauma - GSW/penetrating wounds
- Fecal diversion - Common in Quad/Para pts who have decubitus ulcers; Prevents fecal contamination/infection
postop care for colostomy
- admit (6-12d for open; 4-6d for lap)
- NPO x 24h, then clear liquids x 24h, then regular diet
- abx if needed
- pain management
- ambulation (up with assistance POD 2, walking with assistance POD 3)
- spirometer use
- f/u 10 days PO (5-7 d after DC)
RF for hernias
- Straining
- Fascial weakness or defect - Previous incision or injury
- Obesity
- MC males
diagnostics for hernia
- PE: Pain with movement; Bulge or mass that worsens with straining; palpable mass
- CT
difference between Direct vs Indirect vs Femoral hernia
- Indirect - passes thru inguinal canal and into scrotum
- Direct - originates in Hesselbach’s triangle - bulge above inguinal ligament
- Femoral - bulge below inguinal ligament in area of the femoral canal
- transverse inguinal cnal
- enter inguinal canal at deep inguinal ring
- lateral to inferior epigastic vessels
- can pass into scrotum or labia majora
- Male > female
- congenital, injury
which type of hernia
indirect
- buldge through weakened fascia of abd wall
- directly behind superficial inguinal ring
- medial to inferior epigastric vessels
- rarely enter scrotum
- common in elderly men with weak abd muscles
which type of hernia
direct
nerve supplies that could be affected by hernia?
- Ilioinguinal
- Genito-femoral
- Genital
- Femoral
- Lateral cutaneous - branch of femoral
mgmt for Inguinal & Femoral hernias
- Surgery is indicated for all inguinal and femoral hernias; urgent If strangulated/incarcerated
- observe if men w/o sx
- All women should have surgery
- higher risk for complications and strangulation/incarceration
- Femoral hernias MC in elderly women
complications from herniorrhaphy
- Hematoma/Seroma - most common
- Chronic pain
- Post-hernia repair neuralgia (m/c with open)
- Pain lasts > 3 months postop - Infection
- Hernia recurrence
- Mesh erosion/infection
Indications for lumpectomy
- Lump - Fibroadenoma
- Ductal Carcinoma in situ
- Invasive breast cancer
Indications for Mastectomy
- Prior radiation to breast/chest wall
- Radiation therapy is contraindicated 2/2 pregnancy
- Inflammatory breast cancer
- Diffuse suspicious or malignant appearing microcalcifications
- Widespread disease in multiple quadrants
- Positive pathologic margin after repeat excision
w/u for beast surgeries
- Palpable mass on PE
- Mammogram
- U/S
- Biopsy
- Tumor markers - CA 15-3, CEA, CA 27/29
Reconstruction s/p Mastectomy (2)
- implants
- flaps
postop care for breast surgeries
- Admitted - Monitored for a day or two; Pain control; Wound/Drain care
- F/U within week for drain removal
complications from breast surgeries
- Infection
- DVT
- Hematoma/Seroma
- Delayed healing
- Abnormal scar formation
- Winged scapula - from exposing long thoracic nerve during axillary lymphadenectomy
copmlications with flap/implant breast surgeries
- Flap ischemia
- Fat necrosis
- Capsular contracture
- Implant failure
indications for lung surgeries
- empyema - MCC PNA
- CA - Small Cell vs Non Small Cell
- bullous lung - Air space within the lung measuring >1cm in diameter
- lung reduction surgery - COPD/emphysema
w/u for lung surgery
- CXR/CT chest
- Labs - Inflammatory markers
- Tumor markers - CEA, SCC, NSE
- Blood gas
- SpO2 levels
postop care for lung surgeries
- Admitted to ICU - Close cardiopulmonary monitoring ; Likely to remain intubated, wean as able
- Chest tube
- Pain control
- Wound Care
complications from lung surgeries
- Pneumothorax - Chest tubes left in place post operatively
- Infection
- Bleeding
- Atrial Fibrillation
- Dyspnea
indications for CABG
- Congenital defect repair
- 3 vessel blockage or left main stem artery stenosis - MC LAD or proximal left circumflex
- Heart Valve dysfunction
- infection - constrictive pericarditis
- Pericardial Tamponade/Ventricular rupture
w/u for CABG
- ECHO
- Stress test - Chemical vs Bruce Protocol
- EKG
- Labs
postop care for CABG
- Admitted - ICU; Intubated; Close cardiopulmonary monitoring
- Chest tube
- Pain control
- Wound care
postop complications from CABG
- Death
- Bleeding
- Infection
- Atrial Fibrillation
- Bradycardia
- DVT
- Pleural Effusion/ PNA
indications for Peripheral Venous Lines
- Short-term access for medication administration, hydration, or blood product transfusions.
- Suitable for patients who require frequent blood draws or intermittent intravenous therapy.
contraindications for peripheral venous lines
- Severe peripheral vascular disease or damage
- Thrombosis in vein intended for cannulation.
- Cellulitis or infection at the intended insertion site.
- Inadequate peripheral venous access due to collapsed or sclerosed veins
procedure for peripheral venous line
- Introduction: Clean the site, insert a catheter into a peripheral vein using aseptic technique, and secure it in place. Confirm placement and initiate therapy.
- Discontinuation: Remove the dressing, gently withdraw the catheter, apply pressure to the site, and assess for any complications.
complications from peripheral venous lines
- Phlebitis (inflammation of the vein).
- Infiltration/extravasation (leakage of fluid into surrounding tissues).
- Thrombophlebitis (blood clot formation within the vein).
- Infection at the insertion site.
indications for central venous line
- Long-term venous access for chemotherapy, prolonged antibiotic therapy, parenteral nutrition, hemodynamic monitoring, etc.
- Administration of irritant medications that may cause peripheral vein damage.
contraindications for central venous lines
- Coagulopathy or bleeding disorders.
- Infection at the insertion site.
- Presence of severe hypotension or shock.
- Severe thrombocytopenia.
3 sites for central venous line
- internal jugular
- femoral
- subclavian
which sites are the most direct paths to the right atrium via the superior vena cava
- right internal jugular
- subclavian valves
central venous line site if pt is high risk for bleeding
femoral vein
complications of central venous lines
- Infection: Central line-associated bloodstream infections (CLABSIs)
- Thrombosis
- Pneumothorax
- Hemorrhage
- Catheter Malposition
- Air Embolism: can lead to stroke or MI
- Nerve Injury
- Skin Irritation and Breakdown: from prolonged use
equipment for central lines
- Sterile Gloves
- Sterile Gowns and Drapes
- US machine
- Flushing solutions - Heparin; NaCl
- Central Line Kit:
- Antiseptic solution (e.g., CHG) for skin preparation.
- Sterile drapes to cover the patient.
- Sterile gloves for the clinician.
- Central venous catheter.
- Syringes and needles for administering local anesthesia and medication.
- Scalpel for making a small incision.
- Sutures or adhesive strips for securing the catheter in place.
- Dressing to cover the insertion site.
indications for cut-down venous access
- Emergencies
- Inability to access veins using traditional methods: scarring, obesity, or dehydration.
- Peds
contraindications for cut-down venous access
- Infection at the site of incision
- Thrombosis or vascular compromise in the area of the planned incision
- Patient refusal or inability to tolerate the procedure under local anesthesia or sedation
MC vein for cut-down venous access
saphenous vein
what are Intraosseous Lines
involves inserting a needle directly into the bone marrow cavity to access the systemic circulation.
indications for intraosseous lines
- Emergencies when vascular access cannot be achieved
- Cardiac arrest or shock.
- Pediatric patients with difficult peripheral venous access.
complications for intraosseous lines
- Infection at the insertion site.
- Extravasation of fluids or medications.
- Dislodgement of the needle.
- Bone fractures in fragile bones.
common sites for intraosseous lines
- Proximal tibia (MC in adults and children)
- Distal femur (less commonly used)
what is vNOTES
- Vaginal Natural Orifice Transluminal Endoscopic Surgery
- Combines benefits of lap and vaginal approaches to gynecologic surgery
- Instruments are placed through the vagina into pelvic cavity, giving access to the uterus, fallopian tubes and ovaries without the need for abdominal skin incisions.
- allows complex surgery to be performed without visible incisions with faster recovery and return to normal activities.
indications for vNOTES
- Ovarian cysts
- Fibroids
- Tubal sterilization
- Abnormal uterine bleeding
- Adenomyosis
procedures for vNOTES
- Hysterectomy – the removal of the uterus
- Salpingectomy – the removal of one or both fallopian tubes
- Oophorectomy – the removal of one or both ovaries
- Removal of ovarian cysts
benefits of vNOTES
- Shorter hospital stay (often less than 24 hours)
- Less postoperative pain
- Less pain medication
- No visible scarring
