Gen Surg Flashcards
what is the lymphatic drainage of the rectal canal above the pectinate line ?
Internal iliac lymph nodes
what is the generic name for Herceptin ?
Trastuzumab
what is the lymphatic drainage from the posterior surface of the liver ?
phrenic and posterior mediastinal nodes, which join the right lymphatic and thoracic ducts.
Fat wrapping of the terminal ileum is seen in what condition ?
Chrohns
how is the surgical management of inguinal hernia’s in kids different to adults ?
Adults tend to have open repair with a mesh
Kids tend to have open herniotomty because their hernias are almost always indirect
what are the two tributaries of the azygous vein ?
Hemiazygos vein, accessory hemiazygos vein
Hirschprungs is initially managed with washouts . At what age do kids have definiive management and what is the treatment ?
between 9 and 12 months of age, definitive surgery (usually resection and primary anastomosis) is performed.
where are AAAs most likley to bleed into ?
80% rupture posteriorly into the retroperitoneal space
What arterial structure in the mediastinum aids venous flow of the azygous vein ?
Thoracic aorta
what levels do the hemi-azygous and accessary hemi azgous join the azygous veins ?
hemiazygos vein - T8
accessory hemiazygos vein - T7
What is the lymphatic drainge of the ovaries ?
Para aortic lymph nodes
What is the fascia that separates the rectum from the sacrum ?
Waldeyers fascia
which IBD condition presents with Granuloma’s (non caseating epithelioid cell aggregates with Langhans’ giant cells)
Chrohns
what types of epithelium is found above and below the pectinate line ?
Above - columnar epithelium
Below - non keratinised stratified squamous
what is the risk of you pull the RIGHT adrenal gland suddenly in theatre ?
it may be avulsed off the IVC.
what vessels make up the hepatic portal vein
- superior mesenteric vein
- Inferior mesenteric vein
- splenic vein
what is the function of the azygous vein ?
Drains viscera within the mediastinum
what is the NHS colorectal screening process ?
FIT testing every 2 years in people aged 56 to 74.
Positive results are referred to colonoscopy
what is the lymphatic drainage of the rectal canal below the pectinate line ?
Superficial inguinal lymph nodes
The portal triad is enclosed in what structure ?
Hepatoduodenal ligament
When is a herniotomy indicated ?
Inguinal hernias in children are almost always of an indirect type and therefore are usually dealt with by herniotomy,
Where does the superior mesenteric vein drain into ?
Hepatic portal vein
Ileo-ileal intussusception are far less common than the ileo-colic variant. How does the management differ ?
- Ileo-colic is managed with air insufflation
- ileo-ileo is managed with laprotomy
What is the largest lymphatic vessel in the body ?
Thoracic duct
Decribe the mid inguinal point ?
Mid inguinal point is the point halfway along a line between the ASIS and the pubic symphysis
List two drugs that promote gastric emptying
- Erythromycin
- Metoclopromide
Hydroceles in children occur due to a patent procesus vaginalis. Where does the fluid accumulate ?
Between the visceral and parental layers of the tunica vaginalis
what is the treatment for inguinal hernias in children ?
herniotomy without implantation of mesh
what are the indications for AAA surgery
- Symptomatic aneurysms (80% annual mortality if untreated)
- Increasing size above 5.5cm if asymptomatic
- Rupture (100% mortality without surgery)
What is the difference in management between first time inguinal hernia in adults versus recurrent hernias
first time hernia is managed with open inguinal hernia repair; recurrent is laproscopic
Intra and extrahepatic billiary strictures are characteristic of primary sclerosing cholangitis. What condition is PSC classicaly linked to ?
Ulcerative colitis
What structure attaches to the dudodenojejunal felxure and provides support ?
ligament of Treitz
what is the main arterial supply to the pelvic viscera ?
Internal illiac artery
describe the peritoneal reflection
Where the peritoneum ends and it meets the retroperitoneum
what is first line treatment for necrtosing entercolitis in the abscene of a perforation ?
total gut rest and TPN [babies with perforations will require laparotomy]
The uterine vein drains into what vessel ?
Internal illiac vein
Describe how the rectum is associated with peritoneum
In the superior third of the rectum, the anterior surface and lateral sides are covered by peritoneum. The middle third only has an anterior peritoneal covering, and the lower 1/3 has no peritoneum associated with it.
The duodenum is divided into how many parts ?
Four parts
What is the treatment for Fitz-Hugh Curtis syndrome ?
Usually medically managed- doxycycline or azithromycin
*pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions.
what level does the azygous vein start and finish ?
T4 - T12
HIV patient commonly get what type of liver disease ?
sclerosis cholangitis
what drugs classically cause acute pancreatitis ?
- Diuretics
- Azathioprine
- NSAIDs
The gastroduodenal artery divides into what structures ?
**gastro-epiploic and pancreaticoduodenal arteries **at the superior aspect of the pancreas.
what are the structures that can be found in gallstones ?
Bil salts
Bile pigments [bilirubin]
cholesterol
calcium
Trigylceride
Spot diagnosis
Abdo pain, peri hepatic inflammation/adhesions in a young woman
Fitz-Hugh Curtis syndrome
With regards to the arterial blood supply to the duodenum - what is the relavance of the major duodenal papilla ?
major duodenal papilla – the opening at which bile and pancreatic secretions to enter from the ampulla of Vater (hepatopancreatic ampulla).
This transition is important – **it marks the change from the embryological foregut to midgut. **
Proximal to the major duodenal papilla – supplied by the gastroduodenal artery (branch of the common hepatic artery from the coeliac trunk).
Distal to the major duodenal papilla – supplied by the inferior pancreaticoduodenal artery (branch of superior mesenteric artery).
Vitamin K is a cofactor for making what clotting factors ?
2, 7, 9 and 10
List the muscles that make up Levator ani
pubococcygeus, puborectalis and iliococcygeus.
anal cancers are mostly what cell type ?
squamous cell carcinoma
what structures are clamped during a pringle mannouvre ?
**Portal triad **
1. Proper hepatic artery
2. portal vein
3. common bile duct
parasympathetic nerve fibers to the uterus are from where ?
pelvic splanchnic nerves (S2-S4).
which levator ani muscle is responsible for minataining fecal incontinence ?
Puborectalis
what part of the rectum drains into rthe portal system ?
seperior rectal vein –> inferior mesenteric vein –> Portal vein
what is Trosier sign ?
Enlargement of large lymph node in the left supraclavicular area that drains the lymph from the gut - sign of bowel malignancy
what is the relevance of the mid inguinal point ?
Tells you where the femoral artery starts
what structure is found at the junction of the rectum and the anal canal ?
anorectal ring
The liver is covered by a fibrous layer, known as Glisson’s capsule. What is the nerve supply to the capsule ?
lower intercostal nerves
what is the lymphatic drainage for the anterior surface of the liver ?
drain into hepatic lymph nodes. These lie along the hepatic vessels and ducts in the lesser omentum, and empty in the coeliac lymph nodes which in turn, drain into the cisterna chyli.
what is a Dieulafoy Lesion ?
AV malformation in the stomach that increases risk of spontaneous GI bleeding.
what nerves supply sympathetic innervation to the uterus ?
Sympathetic nerve fibres of the uterus arise from the uterovaginal plexus.
The inferior mesenteric vein drains the hindgut. what vessel does the inferior mesenteric vein drain into ?
Splenic vein
In a patient with gallstone illeus, you perform a Laparotomy and removal of gallstone from small bowel. Where is the enterotomy made ?
Proximal to the site of the obstruction
which part of the duodenum is most commnoly affected by duodenal ulceration ?
D1
non caseating granulomas are characteristic of what condition ?
sarcoid
ovarian arteries are tributaries from vessel ?
Abdominal aorta at level L2/L3
The caudate lobe is located between what two structures ?
The IVC and a fossa produced by the ligamentum venosum
what is the defect that leads to formation of anuerysms ?
Loss of elastin from tunica medial layer
What is first line treatment for Anal fissures
GTN ointment + diltalezem cream
_____ separates the anal canal into upper and lower segments
pectinate/dentate line
what is the anatomical location of the cysterna chylli
Posterior to the abdominal aorta and anterior to L1/L2
what are the border of callots triangle ?
Medial – common hepatic duct.
Inferior – cystic duct.
Superior – inferior surface of the liver.
At what size would AAAs need further investigating with CT
most vascular surgeons will subject patients with an **aneurysm size of 5cm or greater **to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy and planning treatment
the transpyloric plane is located at L1 - What important strcutures are located here ?
when would you perform a total gastrectomy for gastric cancer ?
When the tumour is <5cm from the GOJ.
what is the difference between venous drainge of the right adrenal and the left adrenal ?
Right adrenal - Via one central vein directly into the IVC
Left adrenal - Via one central vein into the left renal vein
3/4 parts of the duodenum are retroperitoneal - what part is covered by peritonuem ?
D1
what type of gall stones are classicially seen in patients with haemolytic anaemia ?
Pigmented stones
Bile pigment is made from Billurin and Bilverdin.
what is the venous drainge of the inferior rectum ?
Internal pudendal vein
what is the indication for an Ivor Lewis procedure ?
Lower and middle third oesophageal lesion
The inferior epigastric artery is a branch of what vessel ?
External illiac artery
Building on the pneumonic I8 10E A12 for the structures that pass through the diaphragm - list the other structures that accompany these major viscera through the diaphragm
The aorta - thoracic duct as it traverses the aortic hiatus.
The vagal trunks - oesophagus which passes through the muscular part of the diaphragm on the right.
The right phrenic nerve accompanies the IVC as it passes through the caval opening.
During the thoracotomy portion of an Ivor Lewis oesopogectomy - what structure may need to be mobilsed to access the oesophagus ?
Azygous vein
how are phyllodes tumours or large fibroadenoma’s managed ?
Excision biopsy
what is the anatomical course of the pudendal nerve ?
Leaves the pelvia via the greater sciatic foramen and then re-enters via the lesser sciatic foramen
what is the function of Denonvilliers fascia ?
Separates the prostate from the rectum
Pancreatitis is due to premature and exaggerated activation of the digestive enzymes within the pancreas.
Enzymes are released from the pancreas into the systemic circulation, causing autodigestion of fats (resulting in a ‘fat necrosis’) and blood vessels (sometimes leading to haemorrhage in the retroperitoneal space).
What is the main enzyme responsible for autodigestion ?
Trypsinogen
The inferior rectal artery supplies the rectal canal below the pectinate line.
what artery is this a branch of ?
Internal pudendal artery
what is the gold standard method to obtain histology specimens in suspected breast ca ?
Core biopsy
An Ivor Lewis oesophogectomy is made of two different procedures. what are these ?
Laporotomy to mobilise the stomach and thoracotomy for Oesophageal resection and oesophagogastric anastomosis
what nerve is commonly damaged during inguinal hernia surgery
Illioinguinal nerve [L1]
what structure separates the superior caudate lobe and the inferior quadrate lobe ?
porta hepatis
AFP is raised in what type of cancer ?
Hepatocellular carncinoma
How would you treat gastric cancer disease greater than 5-10cm from the OG junction
sub total gastrectomy
Your main concern is if the tumour is close enough to the GOJ that will allow it to spread to the oesophagus. If there is no concern of this i.e greater than 5cm away from the GOJ - then perform a subtotal gastrectomy
what is dumping syndrome ?
- Dumping syndrome occurs when food, especially sugar, **moves too quickly from the stomach to the duodenum. **
- This condition is also called rapid gastric emptying
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus ?
Azygous vein
How would bleeding due to a dielulafoy lesion present differently to bleeding from gastric cancer or ulcer ?
Bleeding from Dieulafoy lesions tend not to have any prodromal symptoms
what are the contents of callots triangle ?
Right hepatic artery
Cystic artery
Lymph node of Lund
Lymphatics
the azgous vein drains into what strcture ?
SVC
list the branches of the Anterior trunk of the internal illiac artery
obturator artery
Umbilical artery –> superior vesical artery
inferior vescical artery
vaginal
uterine
Middle rectal artery
Internal pudendal artery
Superior and inferior gluteal artery
Spot diagnosis
Epigastric pain imporved by eating ?
Duodenal ulcer
As a rule - all fistulae will resolve spontaneously except in what scenario ?
If there is a distal obstruction
What important structures like medial to the azygous vein ?
the thoracic duct
aorta
oesophagus
trachea
right vagus nerve
what is the lymphatic drainge of the vagina ?
Lymphatic drainage is divided into three sections:
Superior – drains to external iliac nodes
Middle – drains to internal iliac nodes
Inferior – drains to superficial inguinal lymph nodes.
what is morrisons pouch ?
A potential space between the visceral surface of the liver and the right kidney.
Pathological abdominal fluid such as blood or ascites is most likely to collect in this region in a bedridden patient.
The vaginal and uterine arteries are tributaries of what artery ?
Internal illiac artery
what drug is gievn to mangage high output fistula’s (e.g. high jejunal or duodenal) ?
octreotide to reduce volume and protect skin.
what is the gold standard investigation for Hirschprungs disease ?
full thickness suction rectal biopsy
what medication should be given to people with high output stomas of the small bowel ?
Octeotride to dry up the fistula
Dont forget to give TPN
_____ is the only curative option in colon cancer
Resection surgery
at what level does the hemi azygous vein join the azygous vein ?
T8
Explain the pathophysiology of dumping syndrome
- rapid movement of fluid into the intestine following a sudden addition of a large amount of food from the stomach
- Spikes in insulin due to large volumes of food
First time hernias may be treated by performing an open inguinal hernia repair - what is this procedure called ?
An open Lichtenstein repair using mesh
what vertebral level does azygous vein cover ?
T4 - T12
what is the anatomical relevance of the major duodenal papilla and where in the duodenum is it located ?
- D2
- Marks the transition from foregut to midgut
The lesser omentumn attaches the liver to what structures
- The lesser curvature of the stomach
- First part of the duodenum
spot diagnosis:
Nipple discharge (clear or blood stained) with no palpable mass
Intraductal papilloma
what nerve is found on the anterior surface of the psoas major ?
Genitofemoral nerve L1/L2
what surgical incision is this ? and what procedure is it used for ?
**kocher incisoin **
open cholecytectomy
what is this incision called and what surgery is it used in ?
**Lanz incision **
Incision in right iliac fossa - Appendicectomy
what incision is this and whay procedure is it used in ?
Gridiron
used in appendicectomy
where is a gable incision ?
what is this incision called ? and what is it used for ?
Pfannenstiel’s
To access pelvid organs
when is a rutherford morrison incision used ?
Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
Describe the common surgical incisoins you know
what structures are at risk during radical masatectomy or axillary node clearance ?
axillary vein, the thoracodorsal pedicle, and the long thoracic nerve
what is the function of the thoracodorsal pedicle ?
supplies the latissimus dorsi
The intercostobrachial nerve is commonly damaged during mastectomies and axillary node surgery. What is the function of this nerve ?
**Pure sensory **
Provides sensory innervation to the upper medial arm, lateral chest, and axilla
what is kher’s sign ?
left shoulder pain caused by the irritation of the inferior surface of the diaphragm due to bleeding from a splenic rupture.
describe the splenic injury scale
what grade of splenic injuries can be managed conservatively ?
Grade 1-3
people without a spleen should be on long term abx prophylaxis. What is the antibiotic of choice ?
Pen V
spot diagnosis
Young child presenting with abdo pain after recent tonsilitis or upper respiratory tract infectoin
Mesenteric adenitis
protein digestion begins in the stomach. What enzyme does this ?
Pepsin
what is the main site of dietary iron absorption ?
Duodenum and jejunum
what are the 2 main things absorbed by the ileum ?
B12 and bile acids
describe the grades of liver lacerations
what part of the liver is in direct contact with the diaphragm ?
The bare area of the liver
what is the function of the coronary ligaments ?
attaches the superior surface of the liver to the inferior surface of the **diaphragm **and demarcates the bare area of the liver.
what are the triangular ligaments ?
formed by the union of the anterior and posterior layers of the coronary ligament at the apex of the liver and attaches the liver to the diaphragm.
Other than the portal vein, proper hepatic artery and bile duct, what else is found in the portal triad ?
lymphatic vessels and vagus nerve
what are the antibiotics of choice for treating MRSA ?
First line - Vancomycin
Teicoplanin
Linezolid
what are the normal daily IV fluids + electrolyte recommendations
where is Hartmanns pouch ?
In the gall bladder
what is Alcocks canal and where is it located ?
Alcocks canal is also known as pudendal canal
The pudendal canal is located along the lateral wall of the ischioanal fossa at the inferior margin of the obturator internus muscle.
what are the features of venous stasis ulcers ?
Located above the medial malleolus
Indolent appearance with basal granulation tissue
Variable degree of scarring
Non ischaemic edges
Haemosiderin deposition in the gaiter area (and also lipodermatosclerosis).
what artery is at risk during an axillary node clearance ?
Thoracoacromial artery
What is the treatment for Stanford A Aortic dissections ?
Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg
For type A dissections the standard of care is aortic root replacement [open surgery]
what are CURLINGS ulcers ?
Gastric or duodenal stress ulcers that are seen in burns patients. These ulcers are high risk of bleeding
what structures are posterior to the gall bladder ?
Covered by peritoneum
Transverse colon
1st part of the duodenum
what is the gold standard treatment for axillary vein thrombosis ?
Local catheter directed TPA
During a splenectomy, the GASTROSPLENIC ligament is divided. what structures are located in this ligament ?
short gastric vessels
what is the position of the appendix ? intra or retroperitoneal ?
Intraperitoneal
spot diagnosis: young girl, abdominal pain, scream attacks
Intussusception
whats is a sequestration crisis in sickle cell ?
caused by parvovirus
Patients normally have viral prodrome
this is a temporary cessation of red blood cell production.
Results in transient aplastic crisis.
Bloods will show Low Hb and LOW RETICULOCYTES
From what structure does the inguinal ligament arise ?
External oblique
what procedure is performed if a CBD stone cannot be removed following CBD exploration ?
choledochoduodenostomy
what is a Littre hernia ?
Any hernia containing Meckel diverticulum
what is Richters hernia ?
Passage of the antimesenteric border of bowel through a hernia
There is continuity of bowel so does not present with classic bowel obstruction symptoms
the inguinal ligament forms the inferior border of one structure and the superior border of another - what are these ?
Inferior border - Hesselbach triangle
Superior border - Femoral triangle
At what level do the left and right iliac vein combine ?
L5
Both the left and right vagus nerve pass through the diaphragm with the oesophagus. what are their positions relative to the
The left vagus passes anteriorly
The right vagus passes posteriorly.
the spleen is found under which ribs ?
9 - 11
what structure is located immediately below the rectus abdominis muscle ?
Transversalis fascia
At what levels do the abdominal aorta and IVC bifurcate ?
AA - L4
IVC - L5
90% of cases of pages disease of the breast are linked to what breast condition ?
DCIS
valvulae conniventes is classically found in what portion of bowel ?
jejunum
the water under the bridge pneumonic describes what anatomical relationship ?
the ureters run underneath the uterine artery. During a hysterectomy, where the uterus and uterine artery are removed, the ureter is in danger of being accidentally damaged
In both the males and females, the gonads develop from where ?
Mesonephric ridge
what is riglers sign ?
Rigler’s sign means pneumoperitoneum
double wall sign
what is a meckel diverticulum ?
Meckel’s diverticulum is a small pouch in the lower small intestine that’s present at birth in about 2% of the population.
Supplied by the illiocolic artery
what causes a meckel diverticulum ?
incomplete obliteration of the vitelline duct during embryonic development.
where is a collection post cholecystectomy most likely to accumulate ?
Morrisons pouch [hepatorenal recess]
What is the blood supply to the oesophagus ?
Upper third - inferior thyroid artery
Middle third - oesophageal arteries [direct branch off thoracic aorta]
Distal third - Left gastric artery
what line of pelvic XRs is used to diagnose prolapse of pelvic organs
pubococcygeal line
what structures are at risk if someone is stabbed at the border of the 9th costal cartilage ?
gall bladder and other L1 structures
spot diagnosis
DJ flexure in a kid displaced to the right
Midgut volvulus
what arteries branch off the splenic artery ?
- short gastric arteries
- left gastroepiploic artery
were do the inferior and superior epigastric artery originate ?
Inferior epigastric artery - external iliac
superior epigastric artery - internal thoracic artery
The cystic artery is a branch of what artery ?
Right hepatic artery
how do the layers of the abdominal wall contribute to the spermatic fascia
External oblique - external spermatic fascia
Internal oblique and transverus abdominis - cremasteric fascia
Transversalis fascia - Internal spermatic fascia
scampers fascia - dartos fascia
