Final Exam Flashcards
GI anatomy
Major structures:
Mouth
Pharynx
Esophagus
Responsible for ingesting food
Stomach
Secreting, mixing food, digestion
Small intestine (duodénum, jejunum, ilium)
Absorption of nutrients
Large intestine (cecum, ascending colon, transverse colon, descending colon, sigmoid colon)
Adsorption of water (electrolytes)
Rectum and anus
Elimination
Define endoscopy
Visual exam of the bronchus/bronchi
Anatomy/physiology
Paphysiology/Indication Endoscopy
Epiglottis, true vocal cords, trachea, carina, right and left main stem of the bronchi
Performed to diagnose hemoptysis, infection, carcinoma. It is also performed to treat foreign bodies.
peristalsis
tylectomy
parenchyma
A progressive (involuntary), wave-like movement in a tubular structure Excision of palpable breast lesion Essential or functional parts of an organ
Types of Hernias
Inguinal
Direct (usually acquired)-Within Hesselbach’s Triangle
Indirect (usually congenital)-Outside of Hesselbach’s Triangle
Femoral
Umbilical
Epigastric AKA ventral or incisional
Hiatal (diaphragm)
Reducible
Non-reducible AKA incarcerated
Strangulated
Pantaloon hernia
Contents will go back in
Contents will not go back in, “stuck” inside hernia sac
Loop of bowel stuck in sac, blood supply compromised–On call case; plan for bowel resection
When both direct and indirect hernias are present (not Common)
Hesselbach’s Triangle
Rectus abdominus muscle medially (RAMM)
Inguinal ligament inferiorly (ILI)
Deep epigastric vessels laterally (DEVL)
Volvulus
Intussusception
A twisting of the intestine
A telescoping of the intestine
Define Thyroidectomy
Excision of both lobes of the thyroid gland and all thyroid tissue
Anatomy/physiology
Pathop[hysiology/Indication Thyroidectomy
Excision of both lobes of the thyroid gland and all thyroid tissue
Thyroid gland (and parts)
2 lobes and isthmus
Parathyroid glands, Recurrent laryngeal nerve (RLN; see procedure step 4), Trachea, Thyroid and cricoid cartilages
Endocrine gland
Metabolism; growth and development in fetuses and infants
Produce hormones T4; T5
Malignant tumors of the thyroid gland
Procedure steps for thyroidectomy
I/H/D/R
Identify thyroid gland and dissect it, ligating appropriate blood vessels
Identify RLN and preserve it; preserve parathyroid glands if possible
Remove thyroid gland
I/H/drain PRN/C/D
Define Laparoscopic cholecystectomy
Excision of gallbladder with the use of minimally invasive technique
Anatomy/physiology
Pathop[hysiology/Indication Laparoscopic cholecystectomy
Gallbladder; cystic duct; cystic artery, Liver; hepatic duct & artery, Common bile duct; duodenum
Storage/concentration of bile to emulsify ingested fat
Cholecystitis; cholelithiasis
Define TEP herniorrhaphy
Totally extra-peritoneal patch
Repair of a tear in the transversalis fascia through a minimally invasive approach
Anatomy/physiology
Pathop[hysiology/Indication TEP herniorrhaphy
Transversalis fascia, Inguinal canal; inguinal ligament; Cooper ligament, Internal and external rings, Hesselbach triangle(RAMM, ILI, DEVL) ilioinguinal nerve, Spermatic cord (Vas deferens, Testicular vessels, Cremaster muscle)
Inguinal hernia; direct or indirect
Procedure for TEP herniorrhaphy
I/H/dissect with balloon
Insufflate, place other ports
Continue dissection to identify and reduce hernia
Place mesh and secure (with staples/tacks)
I/H/remove ports/C/D
Define Laparoscopic Roux-en Y gastric bypass
Creation of a small gastric pouch connected to a segment of jejunum with connection of the duodenal limb to the lower jejunum using MIS techniques.
Anatomy/physiology
Pathop[hysiology/Indication Laparoscopic Roux-en Y gastric bypass
Stomach, Duodenum, Ligament of Treitz, Jejunum, Omentum, and Mesentery
Digestion ; absorption of nutrients
Procedure for Laparoscopic Roux-en Y gastric bypass
Establish laparoscopic access
Create gastric pouch with staplers
Identify ligament of Treitz by retracting away theOmentum and transverse colon
Transect jejunum with stapler
Create gastrojejunostomy (pass jejunum up to stomach and staple or sew)
Perform duodenojejunostomy (biliary limb)Check for leaks; close mesenteric defect;
I/H/C/D
Define Colon resection (open approach)
Excision or resection of the colon
Anatomy/physiology
Pathop[hysiology/Indication Colon resection (open approach)
Colon (Cecum, Ascending, Transverse, Descending, Sigmoid colon, Rectum), Mesentery, Liver, Spleen, and Ureters
Absorption of water; defecation
Colon cancer
Procedure steps for Colon resection (open approach)
I/H/D/R
Mobilize colon, isolate from mesentery (blood supply)
Clamps placed on colon, transect colon (stapler x 2 fires)
Perform anastomosis (1 GIA; 1 TA)
Remove contaminated items to prepare for clean closing
Close mesentery; I/H/C/D
Anatomy for Inguinal Hernia:
Transversalis fascia
Inguinal canal
Cremaster muscle
Spermatic cord
In females; the round ligament is in place of the spermatic cord
Inguinal ligament
Cooper ligament
Ilioinguinal nerve
Internal inguinal ring
External inguinal ringList the 6 main structures of the female reproductive system.
Vulva Vagina Cervix Uterus Tubes Ovaries
List the 4 supporting ligaments of the uterus:
Round, broad, cardinal, uterosacral ligaments
List the 3 parts of cervix:
List 4 parts of the uterus:
List the three layers of the uterine body
Internal os; external os; endocervical canal
Fundus, cornua, body (corpus), cervix
Endometrium, myometrium, perimetrium
Adnexa menstrual; Dyspareunia PID (CIS) Dysplasia Intraepithelial Neoplasia Pruritus Ectopic pregnancy
accessory structures: Tubes and Ovaries Pertaining to to the menses or menstruation Difficult or painful sexual intercourse Pelvic inflammatory disease Carcinoma in situ Condition; ill, bad, or poor; growth Pertaining to; within; epithelium Condition; new; growth Severe itching A fertilized egg attached outside the uterus
Physiology of the: Vulva Vagina Cervix Uterus Tubes Ovaries
Vulva–Facilitate sexual intercourse
Vagina –Intercourse; menstrual discharge, and delivery of infant
Cervix–Holds developing fetus inside uterus
Uterus–Support developing embryo/fetus
Tubes–Fertilization, peristalsis of zygote (fertilized ovum) to uterus
Ovaries–Store, mature, and release ovum “egg”
Define Laparoscopic hysterectomy (robotic)
Excision of uterus through the vagina, with MIS techniques for dissection from pelvic cavity
Anatomy/physiology
Pathophysiology/Indication Laparoscopic hysterectomy (robotic)
Vagina
Cervix
Internal os; External os; Endocervical canal
Uterus
Ligaments: round, broad, cardinal, uterosacral
Uterine tubes
Ovaries
Bladder
Ureters
Physiology: Reproduction; conception/growth of infant
Absence of genital prolapse
(ligaments too tight to pull uterus into vagina easily)
Presence of intra-abdominal scarring
Such as post c-section (bladder adhesions) or PID scars
Large fibroids or adnexal massesCancer; endometrial or cervical
Procedure steps for Laparoscopic hysterectomy (robotic)
Insert a vaginal manipulator into the cervix and a vaginal balloon occluder into the vagina
Establish laparoscopic access
laparoscopic access
Dock the robots and position the instruments in the robotic arms and through the ports
Manipulate the uterus as the surgeon directed
Transect the round ligament using bipolar cautery
Identify the ureters
Hydrodissect broad ligament; free bladder from uterus
Transect the uterosacral and cardinal ligaments and blood vessels
Open vaginal vault (FYI: colpotomy; will lose pneumoperitoneum)
Move to vaginal approach, transect remaining attachments (including vessels), remove uterus; close vault
Restore pneumoperitoneum to
Irrigate surgical site with normal saline
Achieve hemostasis
Close incision and apply dressings (Dermabond, Steri-strips, Obi/peri pad)
Define Cesarean section
Delivery of a fetus (or fetuses) through abdominal and uterine incisions
Anatomy/physiology
Pathophysiology/Indication Cesarean section
Uterus
Tubes & ovaries
Bladder
Cervix
Uterine vessels (huge)
Placenta; umbilical cord
Physiology: reproduction
Elective
Malpresentation (malposition)
Fetus is not in correct position for delivery
Cephalopelvic disproportion (CPD)
fetus’ head is too big to pass through mother’s pelvic outlet
multiple fetuses (quadruplets; quintuplets; etc.)
Placenta previa
A portion of the placenta is seated over the cervix
Toxemia
pre-eclampsia – hypertension, edema, proteinuria
Eclampsia – all signs listed above plus seizures
Active Herpes or presence of genital warts
Some patients with diabetes
Some previous C-sections
Urgent
Dystocia; AKA failure to progress
Cervical dystocia: fails to soften to dilate and efface
Uterine dysfunction: won’t contract effectually even with oxytocin
Emergent
Fetal distress
Diagnosed by fetal heart rate/tone and blood chemistry (pH)
Abruptio placenta (AKA: placental abruption)
Placenta detaches before delivery; varying degrees from minor detachment to major detachment
Prolapsed cord
Umbilical cord drops out ahead of baby
Procedure steps for Cesarean section
Using a #10 blade on a #3 knife handle a Pfannenstiel incision is made
Achieve hemostasis PRN using ESU
The incision is carried deeper with ESU and tissue forceps
Fascia is identified and incised
Goalet or Army-Navy retractors is used to retract the abdominal wall
Superior edge of fascia is grasped (Kochers x 2), fascia is bluntly dissected from underlying rectus muscle
ESU used on perforating vessels, transect septum, repeat on inferior edge of fascia
Rectus abdominis muscles are separated at midline by blunt dissection
Peritoneum is identified, grasped (hemostat x 2), and lifted
Incise peritoneum and extend with Metzenbaum scissors
Place self-retaining retractor for abdominal wall
After open peritoneum:
Separate bladder flap and retract it inferiorly
Palpate the uterus to determine the fetal placement and position
Incise uterus with knife, extend with bandage scissors
The obstetrician places their hand into the uterus and manipulates the fetus
Remove retractors, deliver baby’s head
Clamp and cut cord the umbilical cord using Metzenbaum scissors or Lister bandage scissors, pass baby off to neonatal team
Clamp uterine walls (Ring forceps or Penningtons)
Deliver placenta, inspected it, and removed from the back table
Close uterus in layers using absorbable sutures
FYI: First closing count
Suture to reattach bladder flap
Irrigate the surgical site
Achieve hemostasis
Close the abdominal wall, followed by the skin
Stiches or skin staplers may be used to lose the skin
Dressings (ABD pad, 4x4 gauze or long tegaderm) and perineal pad is applied.
Define Cystectomy with ileal conduit
Excision of bladder with diversion of urine into an isolated segment of bowel
Anatomy/physiology
Pathophysiology/Indication Cystectomy with ileal conduit
Bladder, ureters, urethra
Ileum and mesentery
Physiology: evacuation of urine
Bladder cancer
Procedure steps for Cystectomy with ileal conduit
I/H/D/R per Pfannenstiel incision; EUA
Isolate bladder from attachments and excise bladder
Identify, mobilize and transect ureters; (create mesenteric tunnel)
Resect segment of ileum keeping mesenteric blood supply intact
Re-anastomose original ileum; close mesentery
Sew ureters into the isolated segment of ileum
Bring ileal pouch to abdominal wall and create small ostomy
Place ureteral catheters as stents; I/H/drain/C/D
Define Nephrectomy
Excision of kidney
Anatomy/physiology
Pathophysiology/Indication Nephrectomy
Kidney; Gerota’s capsule/fascia Renal pelvis; ureter Renal artery and vein (renal pedicle) Vena cava and aorta Physiology of kidney: formation and excretion of urine Renal Cancer
Procedure steps for Nephrectomy
Mark the incision site with a skin marker
Using #15 blade on a #3 knife handle a flank incision is made
Achieve hemostasis using ESU
The incision is carried deeper through the fat, latissimus dorsi, external oblique, and internal oblique muscles
Retract the skin, subcutaneous layers, and rib
Incise the transverses abdomens fascia
Expose the Gerota’s capsule by dissecting paranephric fat
Isolate, clamp, cut, ligate ureter
Isolate, clamp, triply ligate, cut renal artery then renal vein
heavy silk ties - #1 or #2
Remove the kidney
Close the incision by layer
Gerota’s capsule
External oblique muscle
Skin
Place a drain
Apply dressings (4x4 gauze, Long tegaderm, ABD pad, and Surgical tape)
Define Laparoscopic prostatectomy (robotic)
Removal of the prostate gland through MIS approach with robotic assistance
Anatomy/physiology
Pathophysiology/Indication Laparoscopic prostatectomy (robotic)
Prostate gland and capsule Seminal vesicles, rectum Penis, urethra, bladder neck, bladder Physiology: Secretion of seminal fluid Prostate cancer
Procedure steps for Laparoscopic prostatectomy (robotic)
A 24 Fr Foley catheter is inserted into the patient
Establish laparoscopic access • Dock the robots and position the instruments in the robotic arms and through the ports
Replace the 30 degree camera with a 0 degree
Grasp and pull the bowel superiorly
Identify the rectum
Incise the peritoneum
Identify and divide the vas deferens and seminal vesicles and dissect gland
Preserve the neurovascular bundle
Replace the 0 degree camera with a 30 degree
Incise the transverse peritoneum
Divide the umbilical ligament
Incise bladder neck, transect urethra distal to prostate
A surgical entrapment bad is inserted through the sheath and the prostate is placed inside
The specimen is remove
Perform urethrovesical anastomosis and test it
The sheaths are removed and each incision site is checked for hemostasis
Desufflate
A new Foley is inserted
Each port site is closed and dressing is applied (derma bond, steri-trips).
ESWL TAH BSO RSO LSO LAVH VBAC
Extracorporeal shock wave lithotripsy
To crush stone using shockwaves outside the body
Total abdominal hysterectomy with bilateral salpingooophorectomy
Right salpingooophorectomy
Left salpingooophorectomy
Laparoscopic-assisted vaginal hysterectomy
Vaginal birth after cesarean
Pfannenstiel steps
Incision made with 10 blade on #3 handle, hemostasis, deepen with ESU and tissue forceps
Fascia is identified, incised, and incision extended
Small retractor placed in lateral corners to view
Superior edge of fascia is grasped (Kochers x 2), fascia is bluntly dissected from underlying rectus muscle
ESU used on perforating vessels, transect septum, repeat on inferior edge of fascia
Rectus abdominis muscles are separated at midline by blunt dissection
Peritoneum is identified, grasped (hemostat x 2), and lifted
Incise peritoneum and extend with Metzenbaum scissors
(FYI: caution don’t damage bladder inferiorly)
Place self-retaining retractor for abdominal wall
Anatomy and Physiology of GU
Kidneys: filter waste from the body by excretion of urine
Adrenal glands: part of the endocrine system
Ureters: Peristalsis to carry urine to bladder
Urinary bladder: Reservoir for urine
bladder trigone:
Ureteral orifices (openings) and the urethral orifice
Urethra: Exit of urine from body
list 5 anatomic features of the kidney
Perirenal fat – serves to protect kidneys
Fascia renalis (Gerota’s capsule)– keeps kidneys in position
Hilum – concave area where vessels enter/exit
Renal artery and vein – blood supply to kidneys
Together with nerves + lymph vessels are called the pedicle
Renal pelvis and calyces – funnel for urine
UPJ UVJ UA UTI PSA BUN KUB IVU RU
- ureteropelvic junction
- ureterovesical junction
Urinalysis
urinary tract infection
prostate specific antigen
blood urea nitrogen
x-ray of kidneys, ureters, bladder
intravenous urogram
retrograde urogram
Male Reproductive System Anatomy/physiology
Prostate gland: Production of alkaline fluid for sperm viability
Testes: Produce sperm and secrete hormones (reproductive & endocrine)
Epididymis (head, body, tail): Seminal fluid secretion
Vas deferens: Sperm transport to seminal vesicle
Penis: Urination and reproduction
Three vascular bodies of the penis
corpora cavernosum (2) Spongiosum
Sterile water is used for?
Saline is used for?
TURP use either
Cystoscopy and RU
Sterile water is hypotonic
Basic ureteroscopy
Saline is isotonic, but is electrolytic
3% Sorbitol or 1.5% GlycineOstomy
Pyelo
Otomy
to create an opening
renal pelvis
Cutting into
List the 5 stages of normal bone healing
Inflammation Cellular proliferation Callus formation Ossification Remodeling
Antibiotics
Hemostatics
Steroids
Prevent SSI or to treat existing infections
Reduce bone bleeding
Reduce post-op inflammation, swelling
basic bone physiology:
Support, movement
Mineral storage
Formation of blood cells (hematopoiesis)
Flexion
Extension
Internal rotation
External rotation
Act of bending or being bent, decreasing the angle at a joint
Moving parts of a limb into a straight position, increasing the angle at a joint
rotate a limb medially
rotate a limb laterally
Define Knee arthroscopy
Visual exam of the knee joint
Anatomy/Physiology
Pathophysiology/Indication Knee arthroscopy
Bones and bone features:
Femur
Femoral condyles
Tibia
Tibial plateau
Patella
Ligaments
Anterior cruciate ligament (ACL)
Posterior cruciate ligament (PCL)
Medial (tibial) collateral ligament (MCL)
Lateral (fibular) collateral ligament (LCL)
Soft tissues
Joint capsule
Synovium
Suprapatellar pouch
Patellar tendon
Articular cartilage
Menisci; medial (1) and lateral (2)
Support and movement
Torn meniscus
Loose bodies
Worn patella
Torn ACLPrecedure steps Knee arthroscopy
A tiny incision is made for inflow cannula is made using #11 blade; distend joint with fluid
Another incision is made for sheath; sharp trocar using #11 blade; change to blunt trocar then place arthroscope and camera
Determine the incision site by inserting a spinal needle Make another incision using #11 blade and insert probe for EUA
Treat PRN (provide an example)
Shave away meniscus, cartilage, or patella
Repair meniscus or remove loose body
Remove instruments, arthroscope and trocars
Irrigate, close, dress (FYI: inject for post-op pain control)
Define Shoulder arthroscopy
Visual exam of shoulder joint
Anatomy/Physiology
Pathophysiology/Indication Shoulder arthroscopy
Bones and bone features:
Clavicle
Acromion process
Scapula
Coracoid process
Glenoid fossa (cavity)
Glenoid labrum (ligament ring surrounding articular cartilage)
Humerus (Humeral head)
Joints
Glenohumeral and acromioclavicular
Muscles (rotator cuff)
Supraspinatus and Infraspinatus
Teres minor and Subscapularis
Movement
Torn glenoid labrum
Torn rotator cuff
Impingement syndromeProcedure steps Shoulder arthroscopy
Distend joint with fluid via syringe and spinal needle
Inject local
The spinal needle is removed and an incision is made over the joint capsule using #11 blade
Insert the sheath and sharp trocar into the incision
Change into a blunt obturator and insert scope/camera/with inflow cannula
Additional Incisions is made for the other port sites; insert instruments PRN;
The bicep tendon is identified and examined
The bicep tendon is used as a landmark throughout the procedure.
Treat PRN*
Bankart
(Done for recurrent anterior dislocations; repair torn labrum)
Reattach labrum to glenoid with bone anchors
Rotator cuff repair
Insert anchors; and secure sutures to repair tear
Acromioplasty
(done to correct impingement syndrome; often done in conjunction with other repairs)
Use burr to trim portion of acromion
Change ports w/switching stick PRN
I and remove any loose bodies/Additional local may be inject for post-op pain control/C/D
Define ORIF radius
Open Reduction and Internal Fixation of the radius
Procedure steps ORIF radius
I/H/D until the fracture is exposed/R; EXPOSE FRACTURE
Reduce fracture with self-retaining bone reduction forceps
Malleable plates are placed against the bone and contoured to the radius using a plate benders
The plate is placed on the bone and held in place with a self-retaining bone holding forceps
The first hole is made using a drill and drill guide.
Depth gauge is used to determine the size of the screw
The screw is selected and placed on the bone
Fixate fracture by applying plat and screw
The wound is thoroughly irrigated
The tourniquet is released
Hemostasis is achieved PRN using ESU
The incision is closed and dressings are applied
Procedure steps ORIF hip fracture
I/H/D until the fracture is exposed/R: expose fracture
Place guide pin into femoral head with guide angle
Determine the reaming and tapping depth and screw length
Assemble the appropriate triple reamer and place it on the power drill
The reamer is placed over the guide pin and drilled into the femoral head
Assemble the lag screw insertion together and place it over the guide pin to insert the lag screw
The wrench, guide shaft, and guide pin are removed
The plate is seated using an impactor and mallet
Fixate the plate against the femur using screws
The wound is thoroughly irrigated
Hemostasis is achieved PRN using ESU
The incision is closed and dressings are applied (xeroform, 4x4 gauze, and ABD pad)
Anatomy/Physiology
Pathophysiology/Indication Total knee arthroplasty
Femur
Intercondylar notch
Condyles
Intramedullary canal
Tibia
Tibial plateau
Osteoarthritis (degenerative joint disease)
Wear and tear over time; previous injury to joint; usually just one.
Rheumatoid arthritis
Auto-immune disease; body attacks its own synovial membranes; all synovial joints affected
Procedure steps Total knee arthroplasty
I/H/D/R; expose joint; reflect patella
Align the femur
Place a remear into the femoral canal
ream
Position and secure a femoral valgus angle guide
Trim the distal femur
Place a, A-P femoral sizer against the resected femur; size by trial
Align the tibia
Position and secure the tibial resection guide to the tibia
Resect and size tibia; place trial
Measure, trim, and size patella
Place trip and confirm its placement with an alignment rod
Test the trials ROM Once the surgeon is satisfied with the ROM remove the trials
Place implants and perform ROM
I/H/Drains PRN/C/D
Periosteum
Ligament
Tendon
Layer of connective tissue covering bone
Bands of dense connective tissue that hold bone to bone
Strands of fibrous tissue that form ends of muscles and connect muscle to bone
Cartilage
Cortical bone
Cancellous bone
Avascular, aneural connective tissue found at ends of bones
Hard, dense, bone that forms the outer shell of the bone marrow cavity
Soft spongy bone found inside cortical shell
Long bone
Short bone
Flat bone
The bones of limbs that have a shaft and 2 ends; examples: femur, tibia, fibula, humerus, radius, ulna, phalanges
Bones of the wrist and ankle that occur in clusters; examples: carpals, tarsals
Bones having a partially flat surface; examples: scapula, sternum, pelvic girdle
Irregular bone
Sesamoid bone
Diaphysis
Bones having varied shapes; examples: Skull bones, facial bones, vertebrae
Bones found within tendons; examples: patella (large), head of 1st metatarsal (2)
Shaft of a long bone
Epiphysis
Joint
Synarthrosis
Flared ends of long bone where growth takes place (epiphyseal plate)
a place where 2 bones come together
An immovable, fibrous joint; example: suture lines of cranial bones
Amphiarthrosis
Diarthrosis
Axial skeleton
Appendicular skeleton
A slightly movable, cartilaginous joint; examples: symphysis pubis; intervertebral; manubriosternal
A freely movable; synovial joint; examples: Knee, hip; shoulder; wrist; C1 and C2
The central portion of the skeleton made up of the skull; vertebral column; ribs
The portion of the skeleton made up of the shoulder; arms; hip; legs
