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gen surg Flashcards

1
Q

gen surg includes these specific areas

A 
Alimentary tract. 
Abdomen and its contents. 
Breast, skin, and soft tissue. 
Head and neck. 
Vascular system,
Comprehensive management of trauma.
Complete care of critically ill patients with underlying surgical conditions
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2
Q

definition of gen surg

A

A central core of knowledge embracing anatomy, physiology, metabolism, immunology, nutrition, pathology, wound healing, shock and resuscitation, intensive care, and neoplasia.

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3
Q

Definition of Hernia

how do you determine what type of hernia it is

A

Protrusion, bulge or projection of an organ or part of an organ through the body wall that usually contains it

WHERE THE DEFECT IS DETERMINES THE TYPE OF HERNIA

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4
Q

Inguinal Hernia are most commonly in the groin

A

Most common type of groin hernia is inguinal (96%)

femoral hernia (4%)

pantaloon hernia

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5
Q

are most direct or indirect ?

A

Approximately two thirds are indirect

most others are direct

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6
Q

what is a indirect hernia

A

lateral to the inferior epigastric artery

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7
Q

risk factors for inguinal hernia

A 
Increased intra-abdominal pressure
Abdominal wall injury
Strain from heavy lifting
Loss of skin turgor with advancing age weakens fascia
History of hernia or prior hernia repair
Male
chronic cough 
constiption
Caucasian

(obesity is NOT)

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8
Q

DIRECT
ACQUIRED HERNIA
HERNIA
travels where

A

direct hernias are less common and travel medial to the inferior epigastric artery within hesselbach’s triangle

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9
Q

which inguinal hernia is least likely to incarcerate

A

direct

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10
Q

which hernia occurs because of weakness in the floor of the inguinal canal

A

direct

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11
Q

which hernia goes through the deep inguinal ring

A

indirect

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12
Q

what is hesselbachs triangle

A

Triangle formed by inguinal ligament inferiorly (poupart’s ligament)

inferior epigastric vessels laterally

and rectus abdominus medially

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13
Q

groin hernias have been associated with what other disease process

A

connective tissue abnormalities like AA

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14
Q

how much more likely are we to see a hernia in men ?

how would a hernia present in women

A

Men 8 times more likely to develop hernia and 20 times more likely to need a repair

vague pelvic discomfort in women

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15
Q

what does a shutter mechanism have to do with a a hernia

A

shutter mechanism

is believed to close internal or deep ring to a slit and may not work properly in patients that have a patent processus vaginalis (communication between the peritoneum and scrotum); then things such as increase in intraabdominal wall pressure can force contents through the widened internal ring resulting in a hernia

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16
Q

what is a very important question to ask pts with a suspect hernia

A

Symptoms of bowel obstruction

Nausea, Vomiting, abdominal distention, abdominal pain

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17
Q

radiation of painful hernia may look like what?

what factors would be relieving and what factors would be aggrevating?

A

Discomfort may radiate to scrotum

Worse with extended activity or standing, improves with rest

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18
Q

what other important questions would you want to as with regards to ROS and social history

A

CONSTIPATION, CHRONIC COUGH, URINARY STRAIN
ASCITES, DM
SMOKER?
OPERATIVE RISKS

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19
Q

PE for a hernia should include what

A 
LOCATION
SKIN CHANGES
TENDER TO PALPATION
REDUCIBLE
EXTERNAL RING SIZE
PALPABLE TESTICLES
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20
Q

BULGE MOVING LATERAL TO MEDIAL IS

A

INDIRECT

need to perform exam with and with valsalva

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21
Q

what us the ring occlusion test

A

+ if no bulging of hernia and indicates a direct

  • if bulging =indirect
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22
Q

what are the risk factors for inca

A

Advancing age
Femoral hernia
Recurrent hernia

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23
Q

PE for inguinal hernia will look like

A

PAIN WITH PALPATION

FEVER

ERYTHEMA OR CHANGES IN SKIN COLOR OVERLYING

BULGE

NAUSEA/VOMITING
ABDOMINAL PAIN OR

BLOATING

TREATMENT IS URGENT

SURGICAL REPAIR FOR STRANGULATED OR

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24
Q

if hernia is symptomatic if

A

PAIN WITH EXERTION

DAILY ACTIVITIES
COMPROMISED
CHRONIC INCARCERATION

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25
asymptomatic hernia mnmgt
WATCHFUL WAITING TRUSS STRICT PRECAUTIONS FOR MEDICAL ATTENTION IF SX OF INCARCERATION DEVELOP
26
lap repairs of hernia are associated with
with less post p pain and quicker recovery but open minimizes the risk of bowel injury and can be used for larger hernias
27
what is a femoral hernia and what must you distinguish it from
Femoral canal is below the inguinal ligament Small bulge in the upper medial thigh MUST BE DISTINQUISHED FROM INGUINAL HERNIA
28
when do we normally see umbilical hernia
MORE COMMON IN WOMAN MULTIPLE PREGNANCIES OBESITY PRIOR SURGERY NEAR UMBILICUS RISK OF INCARCERATION IF NOT REPAIRED
29
SPIGELIAN HERNIA
through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally
30
what would be concerning for post op hernia
Pain worsening Systemic changes Incision with overlying skin changes, discharge or pain with palpation Bulge at incision site concerning for recurrence Always want to ask about eating, bowel movements, passing gas
31
review of gallbladder functions how much bile can it hold?
Bile ducts, gallbladder and sphincter of Oddi (pancreas) act together to modify, store and regulate the flow of bile – gallbladder contracts releasing bile and Sphincter of Oddi relaxes Gallbladder stores hepatic bile during the fasting state Gallbladder releases bile into duodenum in response to a meal During storage state, absorbs water and electrolytes to dilute the hepatic bile 30-60cc of bile
32
prevalence of cholelithiasis and the proportion that become symptomatic
10-15% of general population but approx 15-20% of those patients become symptomatic
33
RF for gall stones
``` North American Indians Rapid Weight Loss or Gain TPN Cirrhosis Anemia Hyperlipidemia Relative with gallstones Pregnancy (estrogen exposure) Obesity Female 40’s ```
34
MC Type of stone
Cholesterol – most common
35
what does black and brown pigment mean in terms of gallstones
Black – hemolytic blood dyscrasias | Brown - Bacterial or parasitic infection of biliary tree
36
when would you surgically treat an asymptotic gallstone
Patients with an increased risk of GB cancer Pts with congenital hemolytic disorders Pts undergoing bariatric surgery
37
complications of galls stones
Acute cholecystitis Choledocolithiasis Acute Cholangitis Gallstone pancreatitis Rare: gallbladder ca, gallstone ileus, Mirizzi syndrome
38
Acute cholecystitis | sxs
Pain lasting > 8hrs Positive Murphy’s sign Thickened gallbladder wall
39
Choledocolithiasis sxs
+/- jaundice CBD dilated LFTs elevated
40
Acute Cholangitis
Chariot’s triad (fever, RUQ pain, jaundice) Reynold’s pentad (Chariot’s triad plus altered mental status and shock) CBD stones
41
Gallstone pancreatitis sxs
Epigastric tender to deep palpation CBD dilation Elevated white count and serum amylase
42
Abdominal U/S pros and cons gall stone imaging-
Initial imaging | Not great study for choledocholithiasis
43
MRCP pros and cons gall stone imaging-
MRI study for billiard ducts and pancreatic ducts Cannot be used for extraction of CBD stones of visualized
44
ERCP pros and cons gall stone imaging-
Flexible endoscope | Can be performed for duct clearance
45
HIDA scan pros and cons for gall stone imaging
Also known as cholescintigraphy and hepatobiliary scintigraphy Good study for cholecystitis but also for cystic duct leaks or gallbaldder dyskinesia
46
Gallstones become symptomatic when ... | what does that look like
Gallstones become symptomatic when they obstruct gallbladder outlet or cystic duct Increase in pressure is what leads to pain Usually constant, not colicky RUQ but could be epigastrium, or even substernal Radiating to back (or shoulder blade) Associated with diaphoresis, nausea and/or vomiting
47
how long does biliary colic usually last
30 min – 1 hr, usually less than 6hrs 30% reoccurrence
48
sxs associated with Uncomplicated symptomatic cholelithiasis
Chest pain Epigastric pain or burning Nonspecific abdominal pain Gas, bloating, dypepsia, early satiety seen with normal PE and normal labs image with US and CT
49
Relevant comorbidities when working up a suspected coliolithiesis
Hepatitis? Pancreatitis? GERD/PUD OPERATIVE RISKS/SURGICAL CANDIDATE?
50
advantages of a lap cholecystectomy
Less post operative pain Better cosmetic Shorter hospital stay Less time off work
51
cons of a lap cholecystectomy
Increased risk of common bile duct injury | May require conversion to open
52
indications for a open cholecystectomy
Patients unable to tolerate pneumoperitoneum Refractory coagulopathy Suspect gallbladder cancer Additional abdominal pathology needing gb r removed as part of procedure Complications
53
complication of a cholecystectomy
Bleeding Bowel or bile duct injury Infection Diarrhea/loose stool Retained common bile duct stone Post cholecystectomy syndrome
54
what is expected following a cholecystectomy
Pain usually improving Lap v Open Numbness near incision sites, especially with open procedure Loose stool
55
what is concerning following a cholesytectomy
Pain that is worsening Fever/chills, tachycardia (systemic signs) Incision sites with erythema
56
what is the appendix made out of and what does it secrete
lymphoid tissue Secretes immunoglobulins as part of the colonic system Appendectomy does not alter immune function**
57
RF for appendicitis and special populations
10-30 year old Males Dependent on amount of lymphoid tissue in appendix special pops WOMEN OF REPRODUCTIVE AGE ELDERLY AND SICK
58
Obstruction of appendix lumen/orifice followed by inflammation
Fecalith Lymphoid hyperplasia Foreign body Tumor
59
GI symptoms associated wiht appendicitis
Constipation or diarrhea
60
PSOAS SIGN associated with what type
PAIN ON PASSIVE EXTENSION OF RIGHT THIGH Associated with retrocecal appendix
61
OBTURATOR TEST associated with what type
Flexing patients right hip and knee with internal rotation of right hip causes RLQ pain Associated with pelvic appendix
62
ROVSINGS SIGN
PAIN IN RLQ WITH PALP OF LLQ
63
DUNPHY’S SIGN
INCREASED PAIN WITH COUGHING
64
Pain elicited in abdomen when patient drops from standing on toes to heels
MARKLE SIGN
65
Rebound tenderness
BLUMBERG SIGN
66
alvarado score
Migratory RLQ pain (1 pt) Anorexia (1 pt) Nausea or vomiting (1 pt) Tenderness in RLQ (2 pts) Rebound tenderness in RLQ (1 pt) Fever >37.5°C (99.5°F) (1 pt) WBC > 10,000 (2 pts)
67
SCORING evaluation of alvarado
< 4 - Safe to observe | > 4 - Imaging and surgical evaluation
68
other than appendix obstruction
Localized ischemia, bacterial overgrowth and eventually necrosis
69
labs
WBC, serum CRP and pregnancy test
70
PSOAS SIGN
PAIN ON PASSIVE EXTENSION OF RIGHT THIGH | Associated with retrocecal appendix
71
ddx of appendicitis
``` Pelvic inflammatory disease (PID) or tubo-ovarian abscess Endometriosis Ovarian cyst or torsion Ureterolithiasis and renal colic Diverticulitis Crohn’s disease Colon cancer Cholecystitis Bacterial enteritis Mesenteric adenitis ```
72
advantages of a appendicial lap
Lower rate of infection Less pain Shorter duration of hospital stay Pts with uncertain dx, obese patients, or older patients
73
oepn lap
Lower rate of intra-abdominal abscesses Shorter operative time Open may convert to Lap
74
f/u for appendicitis
Pt returns to clinic approx 2 weeks post lap appy and reports that he is feeling much better
75
concerns for appendix post op
Pain that is worsening Severe constipation or not passing gas Fever/chills, tachycardia (systemic signs) Incision sites with erythema, drainage

Surgery (18 decks)

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