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Surgery Shelf > DeVirgilio > Flashcards

DeVirgilio Flashcards

1
Q

Richter’s hernia?

A

Only partial circumference is trapped in the sac

Patient will not have symptoms of SBO. Still a strangulation risk!!

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2
Q

Sliding hernia

A

indirect hernia with part of a retroperitoneal organ herniates with the bowel. Failure to recognize may lead to injury of the organ. Always open hernia sacs anteriorly!

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3
Q

Diagnosis? Imaging?

A

Clinical, finding of reducible mass. Ultrasound may be used in obese or to find Spigelian hernias (between abd walls). CT and MRI are equivalent and may be used if necessary or to diagnose if no clinical signs.

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4
Q

Lichtenstein repair?

A

Reduction of direct inguinal hernia with reinforcement of the floor of the inguinal canal with mesh.

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5
Q

Management of incarcerated hernias?

A

Attempt to reduce. If it is reducible repair can be done semi-electively. If irreducible, urgent surgical intervention is required.

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6
Q

Unique aspects of hernia repair in infants/children?

A

Vast majority are indirect
Not usually long standing = internal ring and inguinal floor do not need reinforcement
5-10% of infants will have bilateral hernias

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7
Q

Management of umbilical hernia in infants?

A

Very common in newborns and spontaneously resolve by age 2. Surgery if: persist past age 4, 2+ cm in diameter, strangulation, progressive enlargement after age 1

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8
Q

Meralgia paresthetica?

A

Burning pain associated with lateral femoral nerve injury

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9
Q

Reduction of strangulated hernia?

A

Only in OR after confirmation it is still living tissue. Otherwise reduction will introduce dead or gangrenous bowel into the peritoneum, resulting in sepsis and peritonitis

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10
Q

Loss of cremasteric reflex, sensation in anterior scrotum/labia majora?

A

Damage to genital branch of genitofemoral nerve

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11
Q

Result of transection of the testicular artery?

A

Rarely causes testicular ischemia due to blood supply from cremasteric artery and artery of the vas deferens. Testicular artery may be transected to mobilize undescended testicles.

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12
Q

Ddx of inguinal masses? Most common mass?

A

MINT: Malformations, Infections, Neoplasms, Trauma.

Most common: enlarged lymph nodes (Cloquet’s nodes)

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13
Q

Signs of strangulated hernia?

A

SIRS symptoms, vomiting, abd pain hypoactive/highpitched bowel sounds.

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14
Q

What’s the significance of an SBO in a patient without any abdominal surgical scars?

A

Suggest the patient has had no surgeries and removes adhesions (the most common benign cause of SBO) from ddx. Most adhesive SBOs will resolve with conservative tx, but most non-adhesive SBOs will not and may need emergent surgical intervention, as well as more thorough w/u to determine cause (malignancy, hernia, IBD)

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15
Q

Howship-Romberg sign?

A

Pain in medial aspect of thigh with abduction, internal rotation, or extension of the leg. Suggests obturator hernia is compressing obturator nerve.

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16
Q

4 cardinal signs of strangulated bowel?

A

Fever, tachycardia, leukocytosis, localized abdominal tenderness

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17
Q

Significance of severe abdominal pain and localized tenderness in pt with SBO?

A

Suggestive of a strangulated SBO. Emergent surgery required, 50% of SBO deaths are 2/2 strangulation. Continuous (not colicky) abd pain, SIRS signs, peritoneal signs, acidosis, absent bowel sounds, localized abd tenderness/painful mass, or blood in stool.

18
Q

Pathophys of SBO?

A

Gas and fluid accumulate proximal to obstruction, bowel dilates, motility increases to push material distal (hyperactive BS and colicky pain), further increase in bowel distention decreases motility and bowel sounds.

19
Q

Most common causes of SBO?

A 
Crohns's dz
Gallstone ileus
Hernia 
Intra-abdominal adhesions (single most common cause in industrialized countries)
Intussusception
Neoplasm
Volvulus
Appendicitis and diverticulitis (2/2 infection and inflammation)
20
Q

How does dehydration develop in SBO?

A

Increased hydrostatic pressure with the distended lumen causes fluid to accumulate in the bowel wall. This affects starling forces of capillary fluid exchange and leads to a net filtration of fluid, electrolytes, and proteins from the blood stream (third spacing).

21
Q

Electrolyte specific acid-base effect of repeated emesis?

A

Often hypokalemic, hypochloremic metabolic alkalosis

22
Q

Labs for work up of SBO?

A

CBC, BMP, Lactate.
CBC - hemoconcentration, leukocytosis if infective/ etiology or bowel perforation
BMP - Hydration status, hypokalemia, hypochloremia, BUN:Cr ratio
Lactate: elevation may indicate ischemic bowel

23
Q

Imaging for SBO?

A

Upright CXR: Rule out free air
Upright Abdominal XR: Look for air fluid levels
Supine abd XR: width of small bowel to estimate distention

24
Q

Difference between SBO and Large BO?

A

LBO causes gradually increasing abd pain, progressive distention and constipation, and occasionally feculent vomiting.

25
Q

Common causes of LBO and their signs on imaging?

A

Colon cancer - “apple core” lesion
Volvulus - “Bird-beak” tapering toward lower left quadrant
Diverticulitis - no imaging sign noted

26
Q

Difference between post-op ileus and SBO?

A

Very similar in appearance (abd pain, nausea, vomiting, distention). Ileus usually has hypoactive bowel sounds and constant dull pain. Else, if the patient had return of normal bowel function and then developed symptoms, suspect SBO

27
Q

Initial management of SBO?

A

Fluid resuscitation (NS) and electrolyte replenishment.
Early placement of NG tube for decompression.
Indwelling catheter to monitor urine output

28
Q

Operative vs non-operative tx of SBO?

A

If no peritonitis or evidence of ischemia: non-op management initially. Determine whether SBO is partial or complete (partial is less likely to strangulate). Inc abd pain, tenderness on exam, and/or inc lactate = prompt surgery.

29
Q

Use of IV fluorescein dye?

A

Test for tissue viability. Living tissue will take up the dye, which is then visible with UV (Wood’s) lamp

30
Q

History and PE for SBO?

A

Acute onset of colicky abd pain, N/V, obstipation
Hx of pelvic or abd operations
Examine for hernias

31
Q

Diagnosis of SBO?

A

Radiographic findings: dilated loops of small bowel, air-fluid levels, bowel stacking.
CT can distinguish between post-op ileus and SBO, and can reveal etiology of SBO

32
Q

Symptoms of Hyperparathyroid?

A 
Kindly stones
Bone aches or osteoporosis
Abdominal complaints
Psychiatric conditions
"Stones, bones, groans, and psychiatric overtones"
33
Q

Differential of HPT?

A

CHIMPANZEES

34
Q

Most common cause of HPT in outpatients? In in-patients?

A

Out-patient: Primary HPT

In-patient: Malignancy

35
Q

Pathophys of primary HPT?

A

Excess secretion of PTH increases bone breakdown and calcium absorption via Vit D activation in the kidneys, leading to increased calcium absorption in gut with hypercalcemia and osteopenia.

36
Q

How are the majority of HPT patients found?

A

Majority are asymptomatic and found incidentally on routine chemical panels

37
Q

How is primary HPT diagnosed? Other necessary test?

A

Labs. Elevated serum calcium with inappropriately normal or elevated PTH
Bone densitometry in asymptomatic patients

38
Q

How is secondary HPT diagnosed? Other necessary test?

A

Labs. Low serum calcium with increased PTH, most often seen with renal disease or Vit D deficiency.
Bone densitometry in asymptomatic patients

39
Q

Indications for parathyroidectomy in asymptomatic patients with primary HPT?

A

Serum calcium 1.0 mg/dL greater than the upper limit of normal.
Creatinine clearance reduced to less than 60mL/min
Bone mineral density with T-score less than -2.5 at any site (i.e., osteoporosis)
Age less than 50
Patient who does not desire or cannot undergo routine surveillance

40
Q

Indication for parathyroidectomy in secondary HPT?

A 
High PTH level despite medical management
Bone pain
Pruritus
Progressive renal disease
Osteopenic fractures
Calciphylaxis
41
Q

How is a PTH adenoma localized?

A

Sestamibi scan and ultrasound

42
Q

How many glands are usually involved in HPT?

A

Most commonly caused by a single parathyroid adenoma
Multiple gland disease is present in 10-15% of patients
PT glands can be variable in their location, anatomy must be carefully considered.

Surgery Shelf (9 decks)

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