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FRCS A > Emergency Surgery > Flashcards

Emergency Surgery Flashcards

1
Q

Scoring system for Perf Peptic Ulcer

A

Manheim Peritonitis index
Body score and PULP (peptic Ulceration Perforation) score

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2
Q

Lap vs Open PU

A

Tan et al - Meta analysis of 5RCTs 2016

Less post op pain, shorter NG time, Less SSI

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3
Q

Treatment of Giant Ulcer

A

Patch still an option is healthy tissue around edge - leak rate high

If stable - consider resection - partial distal gastrectomy/duodenectomy with Billroth 1/2

Closure around a T tube to convert to fistula is an option if unwell

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4
Q

Evidence for early vs delayed Cholecsytectomy

A

Cochrane 2013 not much difference.

Nice guidelines lap Chloe within 1 week of diagnosis. SWORD database

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5
Q

Management of CBD stones

A

ERCP
Lap CBD exploration
Open CBD exploration

Lap CBD exploration safe with similar results to ERCP

Open CBD exploration superior to ERCP in achieving duct clearance

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6
Q

Incidence of bile duct injury

A

Incidence in Lap Chole is aroumnd 1in 500 (dholes study)

Usually assocaiated with R hepatic artery damage

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7
Q

Management of CBD injury

A

Early recogn either intra or post. If not a HPB surgeon do not attempt repair

If transection or excision do not attempt repair - highly likely to fail
T tube into bile duct is recognised intra-op

Partial injury can be repaired primarily (T-tube or not) if surgeon experienced

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8
Q

Classification of bile duct injury

A

Bismuth
1- Low common hepatic - stump >2cm
2- Proximal CHD -stump <2cm
3- Hilar no residual CHD
4: Destruction of HD confluence
5 Involvement of aberrant R sectoral duct only

Strasburg
A - Leakage from cystic duct/subvesical duct
B Occlusion of par of Hillary tree (usually RHD)
C- Type B involves transection without ligation
D- latreal injury to binary tree
E- Bismuth (E1-5)

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9
Q

Boarders of the femoral canal

A

Anterior - Inguinal ligament
Medial - Lacumar ligament
posterior - Pectineal ligament, pectinous muscle and superior rami of pubic bone
Lateral - Femoral vein

Conents - Lymphatic vessels, Deep LN (Cloquets), loose connective tissue, empty space

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10
Q

Diagnostic Criteria for Acute Panc

A

Revised Atlanta Criteria 2012 - at least 2 of the 3

1- Abdo pain cosistent with pancreatic
2- Serum amylase 3x upper limit of normal
3-Findings consistent with Panc on imaging

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11
Q

Scoring systems for Panc

A

Acute Physiology and Chronic Health Evaluation 2 (APACHE2)
Ranson Score - alcohol related Panc
SIRS
Bedside Index for the severity in Acute Panc
Harmless Acute Panc Score

Cap good indicator of severity (CRP <110 signifies low risk of necrosis)

The scores help triage patients to appropriate levels of care

Mortality for predicted severe panic is significantly higher (10%) than those with mild (<1%)

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12
Q

Causes of Pancreatitis

A

Gallstones 50%
Alcohol 25%
ERCP 3%

Less common hypercalcaemia, hypertriglyceridaemia, mediations, trauma, malignancy, infection

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13
Q

Feeding in acute Panc

A

Cochraine review 2010 - Early feeding leads to lower rates of infection, organ failure and death (Entral vs TPN)

Mild should resume asap when symptoms allow

Consider NG/NJ feeding (non-superior) if not making calorific requirement 3-5days

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14
Q

ERCP in pancraetiis

A

Only for severe

IAP/APA 2013 and WSES 2019 guidline) urgent ERCP within 24hrs and sphincterotomy for patients with acute pancreatic and co-existent acute cholangitis

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15
Q

Grading of acute Panc compciations

A

Balthazar CT severity index 1994
Based on level of Panc inflammation, necrosis and extra-pancreatic complication - Mild, Mod or severe

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16
Q

Pancreatic Pseudocysts

A

Approx 25% of people develop fluid collections.- encapsulate or resolve - 4-6weeks

Symptomatic pseudocysts - manage conservatively for 12weeks - 50% resolve
If not can drain percutaneous trans gastric - fluid dominant (risk of fistula)
Endoscopically + stent and washout
Surgically

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17
Q

Pancreatic Necrosis

A

If sterile -conservative
Approx 1/3 of collections get infected.

POINTER trial (Dutch) - Step-up approach of percutaneous drainage then video assisted debridement if not settling s laparotomy - Reduced death and major complications

Tension (Dutch) 2018 Endoscopic treatment not superior but reduced risk of fsiulta and length of stay

18
Q

Sigmoid volvulus

A

AXR only 30% sensitivity for sigmoid Volvulus so CT recommended on 1st occurrence (rules out malignancy

High recurrent rate - 90%

19
Q

Classification of limb ischaemia

A

Rutherford classification
1) Viable
2) Threaten a)marginally
b)immediately
3)Irreversible

19
Q

Lower limb fasciotomy

A

Consider if ischaemic time >6hrs
Lateral incision accesses the lateral and anterior compartments
Medial incision - superficial and deep compartments

20
Q

Thrombolysis

A

Surgery 3-5x more common
Can be used as a bridge to revascularisation in acute on chronic
Review on 42 studies shows lower rate of mortality and better rates of limb salvage

Contraindications - recent internal bleeding, pregnancy, stroke, TIA, craniotomy in last 2 months, Intracerebral tumour, aneurysm, AVM, severe bleeding tendency, vascular/abdo surgery in last 2 weeks, puncture of non-compressible artery, previous GI bleed or trauma in last 10 days

21
Q

Perianal abscess packing/seeton

A

PPAC and PPAC2 trials showed no need for long term packing

Approx 1/3 of fistulas found at initial EUAs would close spontaneously so no seton required as converts a potential fistula to an actual

Approx 1/3 will develop a fistula long term

22
Q

Pathophysiology of perianal abscess

A

Cryptoglandular theory
infection starts in obstructed perianal glands
Abscess may drain via crypts of Margani or externally leading to fistula

Common organism include E. coli, Bacteroides, Enterococci

23
Q

Swallowed FB

A

Series AXR - every 2-3days - is remains in stomach >48hrs then needs OGD to remove
IF stuck in oesophagus need emergency OGD 2-6hrs

24
Q

narrow points of GI tract

A

Upper OG sphincter, aortic arch, Left main stem bronchus, Lower OG sphincter, pylorus, IVC

Once past oesophagus most past within 48hrs

Objects >2.5cm not pass pylori or ICVand 5-6cm not pass through duodenal angulation

25
Q

Damage control Laparotomy

A

Aim to stop bleeding and limit containingation
Avoid triad of coagulopatcy, hypothermia and acidosis

26
Q

Pringle maneouver

A

Traction on stomach to bring down, finger through foramen of Winslow and create window through pars flaccid with thumb - compress Portal vein and hepatic artery. - release every 15-20mins

27
Q

IVC injury

A

Exposure using right medial visceral rotation - Cattel Branch manoeuvre

Kockerise duodenum, mobilise Right colon and small bowel mesentery.

Gain proximal and distal control

28
Q

Liver injury grading

A

American Association for the surgery of trauma Liver injury scale
1) Haematoma is sub capsular and <10% surface area or laceration is capsular tear <1cm depth
2) haematoma 10-50% or intraparenchymal <10cm diameter or laceration 1-3cm depth <10cm length
3) haemtoma>50% surface area, >10cm diameter intraparenchymal, laceration >3cm
4) Laceration with parenchymal disruption 25-75% hepatic lobe or involves 1-3 couinaud segments
5)Laceration with parenchymal disruption >75% of lobe or involving ?3 segments (within 1 lobe. Vascular juxtahepatic venous injury (retrohepatic vena or major veins
6) vascular hepatic avulsion

29
Q

Blunt trauma injuries

A

Spleen 40-55%
Liver35-45%
small bowel 5-10%
15% incidence of retroperitoneal haematoma

30
Q

Crohns disease o diagnostic Lap

A

ECCO-ESCP guidelines 2017 - Not in favour of resecting and not removing healthy appendix as risk of fistulation

31
Q

CT in pregnancy

A

Ionising radiation so avoid if possible
Doubles risk of childhood cancer (baseline 1in500)
dose is 10-30milligrays for Ct A/P- stillbirths at >50
Delaying is greater risk - 66% increased risk of perforation at 24hrs delay, foetal loss 20-35% (risk of perforation is double in third trimester

32
Q

Lap Surgery in Pregnancy

A

Possible increased risk of foetal loss
Tilt patient to left 30 Degree to move uterus of IVC
first port midline cm above the gravid uterus - open Hasson) insertion

33
Q

Hinchey Classification

A

1) Localised abscess (parabolica)
2)Pelvic abscess
3)Purulent peritonitis
4) Faecal peritonitis

34
Q

IR drain for diverticular abscess

A

Consider if >4cm
If not feasible and not responding to IV abx then consider Lap washout

35
Q

Evidence for Lap washout in perf sigmoid diverticultitis (Hinchey 3

A

LOLA arm of Ladies was stopped early due to safety concerns
SCANDIV trial showed higher reoperation rates in Lap peritoneal lavage group - stoma rates lower in lavage group and no difference in major complciationbv.
DILALA trial initially showed equivalent re-operation rates at 30days and similar complications at 30 and 90days, shorter operative and hospital stays - 2yr data on mortality for grade 3 showed no difference

36
Q

Surgical approach for Hinchey 3

A

Traditional approach would be Hartmans but significant morbidity and mortality with 30-60% never reversed
Can consider primary resection and anastomosis with/without ileostomy after colonic lavage.

37
Q

ABC for uncomplicated Diverticulitis

A

Swedish AVOD RCT 2012 and Dutch DIABLO RCT 2017 showed omitting ABC did not prolong recovery or prevent complications or reoccurance

If admitted would start

38
Q

Well leg compartment syndrome

A

Fascial compartment pressure exceeds perfusion pressure causing tissue ischaemia and necrosis. This occurs in the abscess of trauma and may occur without pre-existing vascular disease

39
Q

Riglers triad

A

1) Pneumobilia
2 Small bowel obstruction
3) Ectopic calcified gallstone (usually RIF)

40
Q

Chest drain >1.5L

A

Massive haemothorax is defined as >1500ml or >1/3 of blood volume in chest cavity

Indication for surgical intervention

Likely sources are:
-Intercostal vessels
-Pulmonary parenchyma
-Major thoracic vessels or mediastinal injury

41
Q

Complications of subclavian artery injury

A

Early - persistent haemorrhage or recurrent bleeding, haemothorax, brachial plexus injury, thrombosis or embolus, SSI or mediastinitis

Late - Pseudoaneurysm formation, arterial stenosis (chronic limb ischaemia), chronic pain/functional impairment, post traumatic AV fistula

FRCS A (9 decks)

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