Gen Surg Flashcards
<p>Sengstaken- Blakemore tube (or Minnesota tube)</p>
<p>Rx for variceal bleed when sclerotherapy or banding failed</p>
<p>Inflate the gastric part then oesophageal part of the balloon</p>
<p>Deflate after 12 hours or oesophageal necrosis</p>
<p>DUKE classifiacation mortality</p>
<p>5 year survival</p>
<p>A- 95%</p>
<p>B- 75%</p>
<p>C- 50%</p>
<p>D- 25% (if resectable) 6% if not</p>
<p>Indication for conservative mx of splenic trauma</p>
<p>Small subcapsular haematoma</p>
<p>Minimal intra abdo blood</p>
<p>No hilar injuries</p>
<p>Refeeding syndrome mx</p>
<p>Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days</p>
<p>+ oral thiamine 200-300mg/day</p>
<p>+ vitamin B co strong 1 tds</p>
<p>Pseudo-obstruction def</p>
<p>progressive and painless dilation of the colon.</p>
<p>Dx of pseudo-obstruction</p>
<p>Excluding obstruction with X ray and contrast enema</p>
<p>Mx of pseudo obstruction</p>
<p>Electrolyte level correction</p>
<p>If not effective: try decompressing colonoscopy/neostigmine</p>
<p></p>
<p>Ogilvies syndrome</p>
<p>aka psuedo-obstruction</p>
<p>Difference between pseudo-obstruction and ilieus</p>
<p>Ilieus affects both large and small bowel vs just large bowel</p>
<p>Indication for Abdominoperineal vs low anterior resection</p>
<p>if <5cm from anal verge, abdominoperineal</p>
<p>Hinchey grading of diverticular perforation</p>
<p>I- localised (paracolic) abscess (1a phlegmen 1b pericolic or mesneteric abscess</p>
<p>II- pelvic abscess</p>
<p>III- Pus in abdo (purulent peritonitis)</p>
<p>IV- Faeculent peritonitis</p>
<p>Hinchey III mx</p>
<p>Sometimes may be managed laproscopically through inserting a drain</p>
<p>It may be appropriate to perfrom resection later as an elective procedure and avoid stoma formation</p>
<p>Hinchey IV mx</p>
<p>Hartman's procedure: resected section + proximal bowel to skin as an end stoma</p>
<p>Pancreatic necrosis mx</p>
<p>If infection suspected: FNA and culture to confirm</p>
<p>If infection confirmed: nectosectomy/radiological drainage</p>
<p>Acute pancreatitis mx</p>
<p>Keep enteral feeding</p>
<p>Consider abx</p>
<p>Early cholecystectomy if gallstones</p>
<p>Why does pancreatitis lead to low calcium</p>
<p>Pancreatic enzymes enter circulation, leading to fat necrosis and saponification (free fatty acids released bind to calcium result in hypocalcaemia)</p>
<p>Calcium and pancreatitis</p>
<p>Hypo - complication</p>
<p>Hyper: cause</p>
<p>Cholangiocarcinoma mx</p>
<p>resection</p>
<p>Mx of bile duct injury following cholecystectomy</p>
<p>Reconstruction</p>
<p>If the operating surgeon does not regularly practise this type of surgery then the area should be drained and the patient transferred to an HPB uni</p>
<p>Anastomic leak presentation</p>
<p>New AF<br></br>
| Raised inflam markers 5 days post op</p>
<p>Anastomic leak ix</p>
<p>CT abdo</p>
<p>Anastomic leak mx</p>
<p>If pt septic and leak, op to undo anastomosis and bring bowel ends to skin</p>
<p>Anastomatic leak diagnosis</p>
<p>Gastrigraffin enema (not barrium as causes peritonitis)</p>
<p>Inguinal hernia treatments</p>
<p>1st time: open inguinal herniotomy + mesh posterior to cord</p>
<p>Recurrent/bilateral: laproscopic herniotomy + mesh posterior to deep ring</p>
Herniotomy vs herniorraphy vs hernioplasty
Herniotomoy- only in children
Herniorraphy- herniotomoy + posterior wall repair
Hernioplasty- herniorraphy + mesh
Indication for laproscopy+conservation mx of splenic trauma
Modertate amount of intra abdo blood
Moderate haemodynamic compromise
Tears or lacerations affecting <50%
Indications for splenectomy for splenic trauma
Hilar injuries
Major haemorrhage
Duodonal ulcers
Anterior - perforates
Posterior - bleeds
Why posterior duodenal ulcers bleed
erode into gastroduodonal artery
Source of bleeding in ulcer on posterior wall body of stomach
Splenic artery
Management of complete abdo wound dehiscence
Analgesia
IV fluids + abx
Cover with saline impregnated gauze (on the ward)
Arrangements made for a return to theatre
When does abdominal wound dehiscence occur
6 days post op
Blatchford score components
Urea
Hb
BP
HR
Rockall score interpretation
Predicts mortality and risk of rebleeding
<3 = <4% risk
Rockall score component
ABCDE
A: Age
B: Blood pressure drop (Shock)
C: Co-morbidity
D: Diagnosis
E: Evidence of bleeding
Blatchford score interpretation
0< =high risk
predicts need for admission and endoscopy
Lichtenstein hernia repair
Open anterior approach
Mesh placement deep to the cord
Shouldice hernia repair
Anterior approach
No mesh
Anterior wall repair with sutures
(used for small hernias)
TEP hernia repair
Laparoscopic hernial repair (hernia pulled into the peritoneum laparoscopically)
Mesh place deep to the deep ring
Abdominoperineal resection (APR)
Resection of rectum and anus and formation of an end colostomy
For tumours within 5cm of the anal verge
Lower anterior resection (LAR)
Resection of rectum and anastomisis to anus
Better quality of life than APR
For tumours more than 5 cm away from anal verge
In what scenario, can a fistula be treated conservatively for spontaneous healing
Absence of IBD
No distal obstruction (assessed by gastrograffin enema)
Mx of infected perianal fistula caused by crohns
Drain the acute sepsis
Maintain the drainage using setons
Timing to surgery for large bowel obstruction
Sun should not rise and set on unrelieved large bowel obstruction
A caecal diameter >12cm and competent ileocaecal valve is a sign of impending perforation and needs prompt surgery
Goodsalls rule
Fistulas with their external openign within 3 cm of anal verge
If posterior, they open in 6 o clock, no matter where from
If anterior, open in wherever they originate
Use of fistulotomy
For low fistulas that do not involve the anal sphincter
Types of setons
Loose (goes through fistula)
Cutting (cuts through the sphincter)
Use of seton
To allow a passage for drainage of the infection and to induce fibrosis
The theory behind cutting seton
To slowly re-tighten to bring down a high fistula
The issue with cutting seton
12% long term incontinence rate
Stoma option for colectomy and colorectal anastomosis
You do a temporary loop ileostomy to allow defunctionign of the anastomosis as high leak rate in left-sided anastomosis
Anastomotic leak mx
CT to confirm
Abx + laparotomy to take down the anastomosis and exteriorize the bowel ends
Mx of cholangitis
IV abx
ERCP and stent
(happens in bile duct obstruction where there is no drainage of bile, leading to infection. Needs to be unobstructed or it will get worse and perforate)
Treatment of obstructive jaundice in presence of malignancy
ERCP and stent
If failed, percutaneous transhepatic cholangiogram and drain (propensity to displacement)
Mx of jaundice caused by gallstones
ERCP to remove intraductal stones followed by cholecystectomy
If doubt about the efficacy of the ERCP, an intra-operative cholangiogram can be done
If stones within the duct intraoperatively, bile duct exploration needed.
When bile duct formally opened, options are closing over a T tube or choledochoduodonostomy or choledochojejunostomy.
Pancreatic pseudocyst mx
Observe for up to 12 wks as 50% resolve
If not, endoscopic/surgical: cystogastrostomy or aspiration
Biliary colic vs acute cholecystitis vs cholangitis
Biliary colic- colicky abdo pain
Cholecystitis- RUQ pain + fever
Cholangitis- RUQ pain + Fever + jaundice
What to do if during cholecystectomy, Calot's triangle is not easy to identify (due to an empyema or inflammation)
Undertake an operative cholecystostomy to relieve the obstruction and a later date to try and do cholecystectomy
Time frame for doing a hot cholecystectomy
Within 72 hours
Why proximal enterotomy to the site of impaction is done in gallstone ileus
Bowel at the site of obstruction is inflamed and may not heal well
Mx of gallstone ileus
Proximal site enterotomy to remove the stone and leave gallbladder and fistula untouched (hostile anatomy)
Closure options after bile duct exploration
When bile duct formally opened, options are closing over a T tube or choledochoduodonostomy or choledochojejunostomy.
Timing for endoscopy in UGI bleed
All pts within 24hrs,
If haemodynamically unstable, immediately after resus
Mx of variceal bleed
Banding or sclerotherapy
If not, Minnesota tube
Reduce portal pressure by medical therapy (IV terlipressin in vaoesophageal varices reduces splanchnic blood flow + abx) +/- TIPPS
Use of PPIs in UGI bleed
72 hrs of IV omeprazole
Reduces the risk of rebleed in ulcers
Surgical option for bleeding duodenal ulcer
Laparatomy, duodenotomy and under running of the ulcer
Duodenotomy is done longitudinally and closed transversely to reduce risk of stenosis
Surgical options for bleeding gastric ulcers
Under running or partial or total gastrectomy
Chiladitis sign
Loop of bowel between liver and diaphragm giving the impression of perforation and air leak
Loop of bowel between liver and diaphragm giving the impression of perforation and air leak
