gen surg Flashcards
adhesions
scar tissue that binds surfaces together
fistula
abnormal connection between 2 epithelial surfaces
tenesmus
sensation of needed to topen bowels without being able to produce stools
hemocolectomy
removing portion ofLI
hartmanns procedure
proctosigmoidectomy=removal rectosigmoid colon with closure anorectal stump and formation colostomy
anterior resection
removal of rectum
whipple procedure
removal of head of pancreas, duodenum, GB and bile duct
what is kocher incision used in
open cholecytectomy
what is chevron/rooftop incision used in
liver transplant, whipple, pancreatic, upper GI
what is mercedes benz incision used in
liver transplant
what is midline incision used in
general laparotomy
what is hockey stick incision used in
renal transplant
incisions that can be used for open appendicectomy
battle incision=paramedian
cridiron/mcburnery=oblique
lanz=transverse
what is rutherford morrison incision for
open appendicectomy
colectomy
incisions for CS
pfannestiel=curved above pubic symphysis
joel-cohen=straight, higher. RECOMMENDED
laparoscopic incisions
5-10mm incisions for ports
monopolar diathermy
grounding plate/pad
when is bipolar diathermy used
microsurgery
if have pacemaker
WHO Surgical checklist
do before anaesthesia, incision, leave theatre
identity, allergies, oepration, bleeding risk, intro to team, anticipated critical events, counts
consent form types
- for yourself
- parent for child
- won’t have impaired consciousness
- lacks capacity
what can cause generalised abdo pain
peritonitis
ruptured AAA
intestinal obstruction
ischaemic colitis
causes RUQ pain
biliary colic
acute cholecystitis
acute cholangitis
causes epigastric pain
acute gastritis
peptic ulcer disease
pancreatitis
ruptured AAA
causes central abdo pain
ruptured AAA
intestinal obstruction
ischaemic colitis
early appendicitis
causes R iliac fossa pain
appendicitis
ectopic pregnancy
ruptured ovarian cyst
ovarian torsion
meckels diverticulitis
causes L iliac fossa pain
appendicitis
ectopic pregnancy
ruptured ovarian cyst
ovarian torsion
meckels diverticulitis
causes suprapubic pain
UTI
urinaru retention
PID
prostatitis
causes loin to groin pain
renal colic
ruptured AAA
pyelonephritis
causes testicular pain
torsion
epididymo-orchitis
sx peritonitis
guarding
rigidity
rebound tenderness
cough test
percussion tenderness
causes peritonitis
localised=organ inflammation, e.g. appendiciits
generalised=perforation
what is spontaneous bacterial peritonitis
infection of ascites
ix before theatre
FBC (Hb, WCC)
U+Es
LFTs
CRP
amylase
INR
Ca
hCG
ABG
lactate
group and save
+/- cultures, XR, USS, CT
sx appendicitis
central abdo pain ->RIF
tender McBurnerys pont
anorexia
N+V
fever
Rovsings sign
guarding
rebound tenderness
percussion tenderness
McBurneys point
1/3 way from ASIS to umbilicus
Rovsings sign
positive in appendicitis
palpation LIF = pain in RIF
ix appendicitis
bloods
USS
mx appendicitis
appendicectomy
complicatios appendicectomy
bleeding
infection
damage to bowel/bladder
VTE
causes bowel obstruction
main= adhesions (SBO), hernias (SBO), malignancy (LBO)
other=volvulus (LBO), diverticular disease, strictures, intussusception
main causes small bowel obstruction
adhesions
hernias
main cause large bowel obstruction
malignancy
what is closed loop obstruction
2 points obstruction
adhesions, hernias, volvulus
or with a competent ileocaecal valve
will continue to expand leading to ischaemia and perforation
features bowel obstruction
vomiting- green bilious
abdo distension
abdo pain
constipation and no flatulence
‘tinkling’ bowel sounds in early obstruction
XR features bowel obstruction
distended loops bowel
mx bowel obstructio
if stable=conservative
definitive=surgery - laparoscopy or laparotomy
what is ileus
peristalsis temporarily stops
causes ileus
injury to bowel
post op
infection
electrolytes - low K/Na
features ileus
green bilious vom
abdo distension and pain
absolute constipation
abent bowel sounds
mx ileus
nil by mouth
NG tube
IV fluids
mobilise
what happens in volvulus
bowel twists around itself and mesentery leading to closed loop obstruction
where does volvulus occut
sigmoid - more common
caecal
RF sigmoid volvulus
older patient
due to chronic constipation/laxatives/high fibre
who is caecal volvulus more common in
younger patient
RF volvulus
neuropsych
in nursing home
adhesions in pregnancy
chronic constipation
high fibre
features volvulus
green bilious vom
abdo distension and pain
absolute constipation
diagnosis volvulus
AXR=coffee bean sign in sigmoid
contrast CT
mx volvulus
endoscopic decompression
surgery: hartmanns for sigmoid, ileocaecal resection
sx abdo hernia
soft lump
protrude on cough
aching/pulling
complications hernias
incarceration ->obstruction or strangulation
richters hernia
partial herniation ->strangulation ->ischaemia bowel wall
maydls hernia
2 different loops of bowel
mx abdo hernias
conservative
tension free repair - mesh
tension repair
indirect inguinal hernias
through inguinal canal
pressure on deep inguinal ring stops herniation
direct inguinal hernias
through abdo wall at hesselbachs triangle
which hernias are at high risk complications
femoral
hesselbachs triangle
rectus abdominus medially
inferior epigastric vessels sup/laterally
inguinal ligament inferiorly
femoral canal
femoral vein laterlaly
lacunar ligament medially
inguinal ligament anteriorly
pectineal ligament posteriorly
femoral triangle
sartorius laterally
adductor longus medially
inguinal ligament superiorly
what does femoral triangle contain
femoral nerve, arterl and vein and femoral canal (lymphatics)
incisional hernias
from previous surgery - hard to repair
mx umbilical hernias
resolve spontaneouslt
who gets umbilical hernias
neonates
older adults
spigelian hernia
between rectus abdominus andspigelian fascia
features spigelian hernia
narrow base
pain +/- lump
diastasis recti
widening linea alba
midline bulge
causes diastasis recti
pregnant
congenital
obturator hernias
through obturator foramen
RF obturator hernias
pregnancy
howship romberg sign
pain from inner thigh -> knee when hip internally rotated due to compression on pbturator nerve from obturator hernia
sign for obturator hernias
howship romberg sign
hiatus hernia
stomach through diaphragm
types hiatus hernia
1=sliding
2=rolling
3=sliding and rolling
4=large and other organs
sx hiatus hernia
dyspepsia
halitosis
reflux
mx hiatus hernia
conservative
surgery
haemorrhoids
enlarged anal vascular cushions
RF haemorrhoids
pregnant
obese
cough
constipation
degrees of haemorrhoids
- no prolapse
- prolapse when strain
- prolapse when strain that needs to be pushed back
- permanent prolapse
sx haemorrhoids
bright red blood
pain
ix haemorrhoids
protoscopy
mx haemorrhoids
topical
laxatives
rubber band ligation
artery ligation
cause thrombosed haemorrhoids
due to strangulation
features thrombosed haemorrhoids
purple
painful
mx thrombosed haemorrhoids
may need surgery
diverticulosis
diverticula (pouch in bowel wall) present
RF diverticula
age
low fibre
obesity
nsaids
diverituclar disease
diverticula cause sx e.g. pain, constipation, bleeding
diverticulitis
inflammation diverticula
sx diverticulitis
LIF pain
N+V
fever
rectal bleeding
mx diverticulitis
uncomlicated=oral co-amox, only clear liquids 2-3d
complicated = IV fluids and abx
what does coeliac artery supply
foregut: liver, pancreas, spleen, stomach, proximal duodenum, billiary system
what does superior mesenteric artery supply
midgut: distal duodenum to first 1/2 transverse colon
what does inferior mesenteric artery supply
hindgut: 2nd half transverse colon to rectum
cause chronic mesenteric ischaemia
narrow vessels due to atherosclerosis
sx chronic mesenteric ischaemia
colicky abdo pain after eating
wt loss
abdo bruit
mx chronic mesenteric ischaemia
reduce RF
revascularisation - stent
cause acute mesenteric ischaemia
thrombus
RF acute mesenteric ischaemia
AF
features acute mesenteric ischaemia
non sepcific abdo pain -> shock, sepsis, necrosis, perforation
ix acute mesenteric ischaemia
contrast CT
met acidosis
high lactate
mx acute mesenteric ischaemia
surgery to remove necrotic bowel and thrombus
RF bowel cancer
fhx
familial adenomatous polyposis
HNPCC/lynch syndrome
IBD
age
diet
obese
smoking
alcohol
features bowel cancer
change bowel habit
wt loss
bleeding
abdo pain
iron deficiency anaemia
when to 2ww for bowel cancer
> 40 and abdo pain and wt loss
50 and rectal bleeding
60 and change in bowel habits or iron deficiency anaemia
ix bowel cancer
FIT (faecal immunochemical) - screening
colonoscopy and biopsy
staging = CT TAP
mx bowel cancer
staging TNM
surgical resection
chemo
radio
palliative
follow up after bowel cancer
serum carcinoembryonic antigen (marker(
CT
lower anterior resection syndrome
urgency and frequency bowels
incontinence
difficulty controlling flatulence
colostomy
LI
more solid stools
usually LIF
end colostomy
portion removed and proximal end brought to skin
loop colostomy
temporary - 6-8w
both ends brought to skin
ileostomy
SI
more liquid
RIF
gastrostomy
fitted using PEG
connection between stomach and abdo wall
urostomy
urinary system
RIF
stoma complications
psych
skin irritated
parastomal hernia
loss bowel length -> dehydration and malnutrition
constipation
stenosis
obstruction
retractio
prolapse
bleeding
granuloma
cholestasis
blockage to bile flow
cholelithiasis
gallstones
choledocholithiasis
gallstones in bile duct
biliary colic
RUQ pain caused by gallstones irritating bile ducts
triggered by fatty meals
lasts 30m-8h
N+V
cholecytitis
inflammation gallbladder
cholangitis
inflammation bile ducts
RF gallstones
fat
fair
F
40+
sx gallstones
biliary colic
acute cholecysitis
acute cholangitis
obstructive jaundice
pancreatitis
ix gallstones
LFTs: increased bilirubin, increased ALP, slightly increased ALT/AST
USS
MRCP
mx gallstones
ERCP
cholecystectomy
features post-cholecystectomy syndrome
due to changes in bile flow
diarrhoea
RUQ pain
nausea
intolerance fatty foods
flatulence
causes acute cholecystitis
usually gallstones
sx acute cholecystitis
RUQ pain
fever
N+V
increased HR and RR
murphys sign
ix acute cholecystitis
USS=thickened GB, stones/sludge in GB, fluids around GB
MRCP
mx acute cholecystitis
IV fluids
abx
tx gallstones
complications acute cholecystitis
sepsis
GB empyema
gangrenous GB
perforation
cause acute cholangitis
e.coli
klebsiella
enterococcus
features acute cholangitis
CHARCOTS TRIAD
RUQ pain
fever
jaundice (increased bilirubin)
mx acute cholangitis
IV fluidss and abx
abdo USS
MRCP
cholangiocarcinoma
bile duct cancer
mainly adenocarcinoma
RF cholangiocarcinoma
UC
primary sclerosing cholangitis
liver flukes (parasite)
sx cholangiocarcinoma
obstructive jaundice
wt loss
RUQ pain
palpable GB
hepatomegaly
ix cholangiocarcinoma
CT
biopsy
Ca19-9
mx cholangiocarcinoma
surgery (rarely curative)
chemo
radio
courvoisers law
palpable GB and jaundice unlikely to be gallstones
usualy cholangiocarcinoma or pancreatic cancer
trousseas sign of malignancy
migratory thrombophlebitis (vessel inflamation due to clot)
particularly in pancreatic adenocarcinoma
pancreatic cancer
usually head
usually adenocarcinoma
metastasises early to liver, peritoneum, lungs, bones
where does pancreatic cancer metastasise to
early to liver, peritoneum, lungs, bones
sx pancreatic cancer
painless obstructive jaundice
abdo/back pain
wt loss
change bowels
new DM
ix pancreatic cancer
CT
biopsy
Ca19-9
mx pancreatic cancer
surgery - whipple if just head
causes pancreatitis
main: gallstones, alcohol post-ERCP
other: trauma, steroids, mumps, AI, scorpion sting, hyperlipidaemia, drugs (furosemide, thiazide like diuretics, azathioprine)
score for pancreatitis
GLASCOW SCORE
PaO2 <8
age >55
neutrophils >15
Ca<2
urea >16
enzymes: LDH >600 or AST/ALT >200
albumin <32
sugar (glucose) >10
interpreting glascow score for pancreatitis
0/1=mild
2=mod
3=sev
mx acute pancreatitis
IV fluids
tx gallstones
abx
complications acute pancreatitis
necrosis
abscess
acute perippancreatic fluid collection
psuedocysts
chronic pancreatitis
cause chronic pancreaittis
alcohol
complications chronic pancreatitis
chronic epigastric pain
loss exocrine function
loss endocrine function (no insulin)
abscness
mx chronic pancreaitis
replace enzymes (creon)
insulin
surgery
what does patient require after liver transplant
lilfelong immunosuppression: steroids, azathioprine, tacrolimus
rejection sx after liver transplant
abnormal LFTs
fatigue
fever
jaundice
incision for liver transplant
rooftop or mercedes benz
