Common Abdominal and Chest Surgeries Flashcards
1
Q
The major difference between open surgery and laparoscopic surgery is ?
A
size of the incision
2
Q
a single incision, multiple inches long, is made to access the abdomen
A
Open surgery or laparotomy
3
Q
- 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.
A
Laparoscopic surgery
4
Q
recovery time difference between Laparotomy vs Laparoscopy
A
- 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
5
Q
patient factors that determine Laparotomy vs Laparoscopy
A
- Overall Health
- BMI
- Prior surgeries
6
Q
scoring used for appendicitis
A
Alvarado score
score of 7-10
7
Q
Mc of appendicitis
A
Fecalith/appendiceal obstruction
Can be cancer; ?MC tumor of the appendix
8
Q
w/u for appendicitis
A
- Labs - leukocytosis
- US - inital imaging for kids; if body habitus permits
- +/- CT - PO contrast if perforation
9
Q
abx therapy for appendectomy
A
- rocephin + flagyl
- FQ/cefdinir + flagyl, augmentin
10
Q
30% will have recurrent appendicitis when?
A
1y
11
Q
T/F: it is ok to have pt with full bladder during laparoscopic appendectomy
A
F: have them void prior
12
Q
Pneumoperitoneum is achieved using either what two methods?
A
- Veress needle
- open Hassan technique
13
Q
Appendectomy - The laparoscope is inserted into the abdomen and two additional ports are placed under direct visualization where?
A
- One port LLQ
- One port in lower midline/suprapubic - Care must be taken not to put the port in the bladder.
14
Q
pt positioning for laparoscopic appendectomy
A
- Trendelenburg with left side of table down - uses gravity to help pull small bowel away from cecum
15
Q
laparoscopic appendectomy procedure
A
- 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.
16
Q
postop care for laproscopic appendectomy
A
- 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
17
Q
indications for cholecystectomy
A
- 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
18
Q
CI for cholecystectomy
A
- Diffuse peritonitis
- Hemodynamic compromise
- Uncontrolled bleeding disorders
19
Q
w/u for cholecystectomy
A
RUQ U/S, +/-abdominal CT scan, Labs, +/-MRCP, +/-ERCP
20
Q
indications for an open chole
A
- inability to safely/effectively perform a lap chole
- CA
- hemodynamic compromise
21
Q
complications from chole?
tx?
A
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
22
Q
postop care for uncomplicated lap chole
A
- Can D/C home same day
- pain meds
- F/U in office in 5-7 days.
23
Q
postop care If Open or complicated Lap Chole:
A
- Admit for 1-3 days
- Pain meds.
- Typically no abx needed - unless surgery contaminated.
- Monitor for complications
24
Q
anatomic structures involved in R colectomy
A
Cecum, Ascending Colon, Hepatic Flexure, first portion Transverse Colon
25
anatomic structures involved in L colectomy
Second portion of Transverse Colon, Splenic Flexure, Descending Colon, Sigmoid Colon
26
indications for colon surgery
1. Tumors / Masses (Benign - Polyps, Malignant)
1. Ulcerative Colitis
1. Diverticulitis / Perforation
1. Ischemic Colitis - Vasculopath; Intestinal volvulus /obstruction
27
w/u for colon surgery
1. PE-?palpable mass
1. Labs - tumor markers (CEA/CA 19-9)
1. Colonoscopy
1. CT abdomen and pelvis w/ IV and oral contrast
28
The indications for laparoscopic colectomy can be sub-grouped into colectomy for ____ vs _____
benign disease vs neoplasia
29
benign dz for lap colectomy
1. IBD
1. Diverticular disease
1. Rectal prolapse
1. Colonic dysmotility
30
neoplastic conditions for lap colectomy
1. Polyps not amenable to resection via colonoscopy
1. Colorectal cancers
1. Hereditary colon cancer syndromes - Familial adenomatous polyposis; Hereditary nonpolyposis colorectal cancer
31
Compared with open colectomy, laparoscopic surgery has been shown to be associated with decreased ____
1. post op pain analgesia requirement
1. faster return of bowel function
1. earlier resumption of PO intake
1. shorter hospital stay and better cosmesis.
32
complications from colectomy
1. Anastomotic leak
1. Intra-abdominal abscess
1. Bleeding
1. Bowel obstruction
33
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
34
indications for colostomy
1. Gangrenous/perforated bowel
1. Colorectal cancer
1. IBD
1. Trauma - GSW/penetrating wounds
1. Fecal diversion - Common in Quad/Para pts who have decubitus ulcers; Prevents fecal contamination/infection
35
postop care for colostomy
1. admit (6-12d for open; 4-6d for lap)
2. NPO x 24h, then clear liquids x 24h, then regular diet
3. abx if needed
4. pain management
5. ambulation (up with assistance POD 2, walking with assistance POD 3)
6. spirometer use
7. f/u 10 days PO (5-7 d after DC)
36
RF for hernias
* Straining
* Fascial weakness or defect - Previous incision or injury
* Obesity
* MC males
37
diagnostics for hernia
1. PE: Pain with movement; Bulge or mass that worsens with straining; palpable mass
1. CT
38
difference between Direct vs Indirect vs Femoral hernia
1. Indirect - passes thru inguinal canal and into scrotum
1. Direct - originates in Hesselbach’s triangle - bulge above inguinal ligament
1. Femoral - bulge below inguinal ligament in area of the femoral canal
39
1. transverse inguinal cnal
2. enter inguinal canal at deep inguinal ring
3. lateral to inferior epigastic vessels
4. can pass into scrotum or labia majora
5. Male > female
6. congenital, injury
which type of hernia
indirect
40
2. buldge through weakened fascia of abd wall
3. directly behind superficial inguinal ring
4. medial to inferior epigastric vessels
5. rarely enter scrotum
6. common in elderly men with weak abd muscles
which type of hernia
direct
41
nerve supplies that could be affected by hernia?
1. Ilioinguinal
1. Genito-femoral
1. Genital
1. Femoral
1. Lateral cutaneous - branch of femoral
42
mgmt for Inguinal & Femoral hernias
1. Surgery is indicated for all inguinal and femoral hernias; urgent If strangulated/incarcerated
1. observe if men w/o sx
1. All women should have surgery
- higher risk for complications and strangulation/incarceration
- Femoral hernias MC in elderly women
43
complications from herniorrhaphy
1. Hematoma/Seroma - most common
1. Chronic pain
- Post-hernia repair neuralgia (m/c with open)
- Pain lasts > 3 months postop
1. Infection
1. Hernia recurrence
1. Mesh erosion/infection
44
Indications for lumpectomy
1. Lump - Fibroadenoma
1. Ductal Carcinoma in situ
1. Invasive breast cancer
45
Indications for Mastectomy
1. Prior radiation to breast/chest wall
1. Radiation therapy is contraindicated 2/2 pregnancy
1. Inflammatory breast cancer
1. Diffuse suspicious or malignant appearing microcalcifications
1. Widespread disease in multiple quadrants
1. Positive pathologic margin after repeat excision
46
w/u for beast surgeries
1. Palpable mass on PE
1. Mammogram
1. U/S
1. Biopsy
1. Tumor markers - CA 15-3, CEA, CA 27/29
47
Reconstruction s/p Mastectomy (2)
1. implants
2. flaps
48
postop care for breast surgeries
1. Admitted - Monitored for a day or two; Pain control; Wound/Drain care
1. F/U within week for drain removal
49
complications from breast surgeries
1. Infection
1. DVT
1. Hematoma/Seroma
1. Delayed healing
1. Abnormal scar formation
1. Winged scapula - from exposing long thoracic nerve during axillary lymphadenectomy
50
copmlications with flap/implant breast surgeries
1. Flap ischemia
1. Fat necrosis
1. Capsular contracture
1. Implant failure
51
indications for lung surgeries
1. empyema - MCC PNA
2. CA - Small Cell vs Non Small Cell
3. bullous lung - Air space within the lung measuring >1cm in diameter
4. lung reduction surgery - COPD/emphysema
52
w/u for lung surgery
1. CXR/CT chest
1. Labs - Inflammatory markers
1. Tumor markers - CEA, SCC, NSE
1. Blood gas
1. SpO2 levels
53
postop care for lung surgeries
1. Admitted to ICU - Close cardiopulmonary monitoring ; Likely to remain intubated, wean as able
1. Chest tube
1. Pain control
1. Wound Care
54
complications from lung surgeries
1. Pneumothorax - Chest tubes left in place post operatively
1. Infection
1. Bleeding
1. Atrial Fibrillation
1. Dyspnea
55
indications for CABG
1. Congenital defect repair
1. 3 vessel blockage or left main stem artery stenosis - MC LAD or proximal left circumflex
1. Heart Valve dysfunction
2. infection - constrictive pericarditis
3. Pericardial Tamponade/Ventricular rupture
56
w/u for CABG
1. ECHO
1. Stress test - Chemical vs Bruce Protocol
1. EKG
1. Labs
57
postop care for CABG
1. Admitted - ICU; Intubated; Close cardiopulmonary monitoring
1. Chest tube
1. Pain control
1. Wound care
58
postop complications from CABG
1. Death
1. Bleeding
1. Infection
1. Atrial Fibrillation
1. Bradycardia
1. DVT
1. Pleural Effusion/ PNA
59
indications for Peripheral Venous Lines
1. Short-term access for medication administration, hydration, or blood product transfusions.
1. Suitable for patients who require frequent blood draws or intermittent intravenous therapy.
60
contraindications for peripheral venous lines
1. Severe peripheral vascular disease or damage
1. Thrombosis in vein intended for cannulation.
1. Cellulitis or infection at the intended insertion site.
1. Inadequate peripheral venous access due to collapsed or sclerosed veins
61
procedure for peripheral venous line
1. Introduction: Clean the site, insert a catheter into a peripheral vein using aseptic technique, and secure it in place. Confirm placement and initiate therapy.
1. Discontinuation: Remove the dressing, gently withdraw the catheter, apply pressure to the site, and assess for any complications.
62
complications from peripheral venous lines
1. Phlebitis (inflammation of the vein).
1. Infiltration/extravasation (leakage of fluid into surrounding tissues).
1. Thrombophlebitis (blood clot formation within the vein).
1. Infection at the insertion site.
63
indications for central venous line
1. Long-term venous access for chemotherapy, prolonged antibiotic therapy, parenteral nutrition, hemodynamic monitoring, etc.
1. Administration of irritant medications that may cause peripheral vein damage.
64
contraindications for central venous lines
1. Coagulopathy or bleeding disorders.
1. Infection at the insertion site.
1. Presence of severe hypotension or shock.
1. Severe thrombocytopenia.
65
3 sites for central venous line
1. internal jugular
1. femoral
1. subclavian
66
which sites are the most direct paths to the right atrium via the superior vena cava
1. right internal jugular
1. subclavian valves
67
central venous line site if pt is high risk for bleeding
femoral vein
68
complications of central venous lines
1. Infection: Central line-associated bloodstream infections (CLABSIs)
1. Thrombosis
1. Pneumothorax
1. Hemorrhage
2. Catheter Malposition
3. Air Embolism: can lead to stroke or MI
4. Nerve Injury
5. Skin Irritation and Breakdown: from prolonged use
69
equipment for central lines
1. Sterile Gloves
1. Sterile Gowns and Drapes
2. US machine
3. Flushing solutions - Heparin; NaCl
1. 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.
70
indications for cut-down venous access
1. Emergencies
1. Inability to access veins using traditional methods: scarring, obesity, or dehydration.
1. Peds
71
contraindications for cut-down venous access
1. Infection at the site of incision
1. Thrombosis or vascular compromise in the area of the planned incision
1. Patient refusal or inability to tolerate the procedure under local anesthesia or sedation
72
MC vein for cut-down venous access
saphenous vein
73
what are Intraosseous Lines
involves inserting a needle directly into the bone marrow cavity to access the systemic circulation.
74
indications for intraosseous lines
1. Emergencies when vascular access cannot be achieved
1. Cardiac arrest or shock.
1. Pediatric patients with difficult peripheral venous access.
75
complications for intraosseous lines
1. Infection at the insertion site.
1. Extravasation of fluids or medications.
1. Dislodgement of the needle.
1. Bone fractures in fragile bones.
76
common sites for intraosseous lines
1. Proximal tibia (MC in adults and children)
1. Distal femur (less commonly used)
77
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.
78
indications for vNOTES
1. Ovarian cysts
1. Fibroids
1. Tubal sterilization
1. Abnormal uterine bleeding
1. Adenomyosis
79
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
80
benefits of vNOTES
1. Shorter hospital stay (often less than 24 hours)
1. Less postoperative pain
1. Less pain medication
1. No visible scarring
