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Surgery > General > Flashcards

General Flashcards

1
Q

How does an indirect inguinal hernia arise?

A

Failure of embryonic closure of deep inguinal ring, with hernial sac being the patent processus vaginalis

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2
Q

How does a direct inguinal hernia arise?

A

Through a weak spot in the posterior wall of inguinal canal (transversalis fascia)

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3
Q

Describe the relationship of indirect vs direct inguinal hernias to the inferior epigastric artery

A

Direct - medial to inferior epigastric

Indirect - lateral to inferior epigastric

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4
Q

What is Hesselbach’s triangle?

A

Where direct inguinal hernias occur

medial border: lateral border of rectus abdominis
Superolateral: inferior epigastric vessels
Inferior border: inguinal ligament

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5
Q

How can one clinically distinguish between indirect and direct inguinal hernias?

A

Reduce hernia by gently pushing upwards and laterally

Place index and middle fingers on deep inguinal ring surface and ask patient to cough

If direct: hernia appears medial to examiner’s two fingers

If indirect: no lump

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6
Q

What are the contents of the inguinal canal in males vs females?

A

Males - spermatic cord + ilioinguinal nerve

Females - round ligament of the uterus + ilioinguinal nerve

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7
Q

What are the contents of the spermatic cord?

A

3 arteries: cremasteric, testicular, vas deferens
3 nerves: cremasteric, genital branch of the genitofemoral nerve, autonomics
3 other things: lymphatics, ductus deferens, pampiniform plexus

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8
Q

What are the boundaries of the inguinal canal?

A

2 MALT: 2M 2A 2L 2T

Superior: 2 Muscles -internal oblique muscle, TA muscle

Anterior wall: 2 Aponeuroses

  • Aponeurosis of EO
  • Aponeurosis of IO

Lower wall: 2 Ligaments

  • Inguinal ligament
  • Lacunar ligament

Posterior wall: 2Ts

  • Transversalis fascia laterally
  • Conjoint tendon medially
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9
Q

What is the difference between the midinguinal point and the midpoint of the inguinal ligament?

A

Midinguinal point: midway between the ASIS and the pubic symphysis

Midpoint of the inguinal ligament: midway between the ASIS and the pubic tubercle

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10
Q

What is a Hartmann’s procedure and when is it indicated?

A

Surgical resection of the rectosigmoid colon, brining colon surface to create a colostomy, and closure of rectal stump. Colostomy can be reversed at a later time.

Indicated in sigmoid CRC or diverticulitis

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11
Q

List two differences in appearance between ileostomies and colostomies.

A

Ileostomy found in R lower quadrant, colostomy found in L lower quadrant

Ileostomy has full thickness eversion of the bowel (minimise excoriation) while colostomy made flush with skin (effluent is usually solid and thus is non-irritative)

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12
Q

When is a permanent end ileostomy indicated?

A

Permanent - after proctocolectomy for inflammatory bowel disease or familial polyposis

But development of newer sphincter-saving procedures means that it is no longer used as oftenetc.)

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13
Q

When is a temporary end ileostomy indicated?

A

In conjunction with subtotal abdominal colectomy for toxic colitis, L sided large bowel obstruction or ischaemic bowel

i.e. when anastomosis between ileum and colon/rectum risky due to ischaemia or severe sepsis etc.

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14
Q

When is a loop ileostomy indicated? (2)

A
  1. To protect a distal anastomosis i.e. in an ileal pouch-anal anastomosis or low colorectal anastomosis
  2. To divert stool from distal anorectum e.g. severe perineal trauma, perianal faecal incontinence
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15
Q

How does a loop ileostomy work?

A

Afferent (functioning) limb produces stool output

Efferent limb (defunctioned, smaller) allows passage of flatus and mucous discharge

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16
Q

When is a permanent end sigmoid colostomy indicated? (2)

A

In rectal resection

Alleviation of severe incontinence

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17
Q

List 7 stoma complications

A
  1. Obstruction
  2. Ischaemia
  3. Bleeding and ulceration
  4. Appliance leakage
  5. Stenosis, retraction, prolapse
  6. Peristomal excoriation (common around ileostomies due to irritant nature of small bowel fluid in skin)
  7. Dehydration due to excessive fluid loss
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18
Q

List 5 causes of small bowel obstruction. Which two are the most common?

A 
Adhesions 
Hernias
Neoplasms
Strictures: Crohn's disease, ischaemia
Gallstone ileus

Adhesions and hernias are most common

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19
Q

What are the clinical features of small bowel obstruction?

A

If proximal: nausea and vomiting (early presentation)

If distal: 2-3 day history of crampy abdominal pain prior to vomiting and distension and constipation

Bowel sounds initially hyperactive and high-pitched - in delayed presentation, may be decreased secondary to ileus

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20
Q

How should suspected SBO be investigated? (4)

A
  1. Bloodwork - FBE (increased WCC may indicate perforation), lactate (sign of ischaemia), UECs for metabolic disturbance
  2. Abdo x-rays: supine and erect
    - erect will show if there is any perforation (free gas under diaphragm)
    - supine will show dilated small bowel proximal obstruction with air-fluid levels
  3. Contrast radiography with gastrografin - determines extent of obstruction and also has mild therapeutic effect
  4. CT if clinical and radio graphic findings inconclusive
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21
Q

How should SBO be managed? (2)

A
  1. Conservative - NBM, NGT tube insertion, IV fluid and electrolyte replacement, analgesia?
  2. Surgery in patients who show signs of peritonism or who are less well
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22
Q

What are the 3 main causes of large bowel obstruction?

A

Carcinoma of colon/rectum - 50% of cases
Sigmoid volvulus
Diverticular disease

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23
Q

In which population does a sigmoi volvulus most commonly occur?

A

Condition of the elderly and frail who have a long history of constipation and laxatives

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24
Q

What are the clinical feature of large bowel obstruction?

A

Abdo pain
Distension due to retention of faeces and flatus
Constpiation
Peritonism if perforation has occurred
Vomiting = late symptoms (consider competency of ileocaecal valve)

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25
Q

How is large bowel obstruction investigated?

A

Plain abo x-ray - if free intraperitoneal gas, surgery. if distended colon - do gastrografin enema.

Gastrografin enema will show whether mechanical obstruction or pseudo-obtruction.

26
Q

What surgery is indicated in a sigmoid CRC?

A

Hartmann’s procedure; reversal can be done 3-6 months

27
Q

What surgery is indicated for in cancer of the caecum or ascending colon?

A

R hemicolectomy

28
Q

What surgery is indicated in a transverse-descending colon cancer?

A

‘Extended right’ - subtotal colectomy +/- (?temporary end ileostomy)

29
Q

In which instances does pseudo-obstruction occur?

A

Assoc. with complex metabolic disturbances (uraemia) - causing form of ileus in large intestine

30
Q

How is pseudo-obstruction managed? (4)

A

Reverse metabolic issues
Aperients
Neostigmine
Colonoscopic decompresion +/- stoma

31
Q

What are the causes of pancreatitis?

A 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP and emboli
Drugs - thiazide diuretics
32
Q

What are the clinical features of acute pancreatitis?

A

Severe epigastric pain radiating to the back, and sitting forward

Vomiting/nausea and varying signs of shock

May be signs of peritonism

In severe cases: flank ecchymosis - grey turner’s sign; peri umbilical ecchymosis - Cullen’s sign

33
Q

What investigations would you conduct in suspected acute pancreatitis?

A
  1. Bloodwork: FBE, UEC, LFTs, calcium, glucose, LIPASE
  2. US if gallstones are suspected cause
  3. CXR to exclude other causes (perforation etc.)
34
Q

How is acute pancreatitis managed?

A
  1. NBM/IV fluid replacement
  2. Analgesia
  3. NGT in severe vomiting
  4. Antibiotics for specific infections
  5. Surgical interventions if complications present or in gallstone pancreatitis
35
Q

What are the clinical features of acute cholecystitis?

A
  1. Severe RUQ or epigastric pain, continuous, often radiating to tip of scapula
  2. Vomiting
  3. Fever
  4. Positive Murphy’s sign - pain and arrest of inspiration upon deep palpation of RUQ while nil pain when done in LUQ
36
Q

How is suspected acute cholecystitis investigated?

A

FBE (WCC should be increased), LFTs, lipase (to exclude pancreatitis)

US: thickened gallbladder with gallstones

AXR only shows 10% of gallbladder

37
Q

How is acute cholecystitis managed?

A
  1. Analgesia
  2. IV fluids
  3. Early lap chole is treatment of choice however sometimes can be delayed 6-8 weeks once pain has subsided
38
Q

What is biliary colic? How does it differ to acute cholecystitis?

A

Pain that occurs when gallstone transiently obstructs cystic duct, increases in intensity following ingestion of fat. Similar pain profile to acute cholecystitis BUT doesn’t have constitutional symptoms (fever etc.)

39
Q

What is choledocholithiasis?

A

Gallstones in common bile duct

40
Q

What are the different types of pancreatic cancer? Which is the most common?

A
  1. Adenocarcinoma - most common - arising from ductular lining, usually occurs in the head of the pancreas
  2. Ampullary cancer - adenocarcinomas that originate in the region of the ampulla of Vater - not common, but have a lower malignant propensity
  3. Cystic tumours
41
Q

What is Courvoisier’s law?

A

Painless obstructive jaundice + distended/palpable gallbladder that is not tender = not likely to be due to gallstones

42
Q

What is Trosseau’s sign of malignancy?

A

Thrombophlebitis migrans - malignancy associated hypercoagulability, sometimes seen in pancreatic cancer

43
Q

What is a Whipple’s procedure?

A

Pancreaticoduodenectomy

For cure of ampullary or head of pancreas cancers

Head of pancreas + adjacent duodenum + lower bile duct + 1/2 of stomach removed - Continuity re-established via reanastomosis of pancreas, bile duct and stomach

44
Q

What are the clinical features of acute appendicitis?

A

Perimublicial gnawing pain migrating to RIF within a few hours

Decreased food intake, N & V in preceding period

Diarrhoea, fever may be present

Signs of peritonitis - Rovsing’s sign, rebound tenderness

45
Q

What is Rovsing’s sign?

A

Palpation in LLQ elicits pain in RLQ - sign of peritonitis (can be seen in acute appendicitis)

46
Q

Where is McBurney’s point?

A

1/3 down from ASIS - umbilicus

47
Q

What investigations should be conducted in suspected acute appendicitis?

A

Usually a clinical diagnosis

  1. Bloodwork: FBE (increased WCC), CRP (increased),beta-HCG (to exclude pregnancy)
  2. Can do urinalysis to exclude UTI
  3. US - may show thick-walled appendix with dilated lumen/mass/abscess but adds little to clinical diagnosis. Can also rule out gynaecological pathology.
48
Q

Describe the reasoning for the pattern of pain seen in acute appendicitis.

A

Periumbilical pain occurs first because pain initially mediated through visceral pain fibres as mid-gut fibres

As appendicitis becomes transmural - it involves serosa and parietal peritoneum - pain is mediated through somatic pain fibres and becomes localised to RIF

49
Q

Where do peptic ulcers most commonly arise?

A

Duodenum

50
Q

What are the clinical features of peptic ulcers?

A

Dull/burning epigastric pain, worse several hours after a meal but relieved by eating (coating stomach against acid). Pain can wake patient up at night

N&V during acute exacerbation.. Haematemesis (coffee ground) and melaenia if bleeding ulcer.

51
Q

How is suspected peptic ulcer investigated? (2)

A
  1. Endoscopy +/- biopsy (particularly if stomach - ?malignancy)
  2. C14 breath test - to detect for H. pylori (convert urea to carbon dioxide)
52
Q

How are peptic ulcers treated? (4)

A
  1. Antacids - pain relief
  2. H2 blockers or PPI
  3. H. pylori eradication - ‘triple therapy’ - PPI + amoxicillin + clarithromycin
  4. If bleeding, can control source via injection therapy (adrenaline) or banding or thermal therapy
53
Q

What is the MoA of H2 blockers vs PPIs?

A

H2 blockers (e.g. ranitidine) - blocks gastric acid secretion

PPIs (e.g. omeprazole) - inhibits gastric acid production - generally better

54
Q

What is Barrett’s oesophagus?

A

characterized by the replacement of the normal stratified squamous epithelium lining of the esophagus by simple columnar epithelium with goblet cells - thought to be due to chronic reflux disease - increased risk of adenocarcinoma

55
Q

What is the management of GORD? (3)

A
  1. Lifestyle - avoid foods that trigger episodes, stop smoking and alochol
  2. Prolonged PPI +/- H2 blocker therapy
  3. In GORD refractory to medical therapy - Nisse fundoplication (the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia)
56
Q

List 5 clinical features of caecal and R sided carcinoma

A
  1. Iron deficiency anaemia from occult faecal blood loss
  2. Distal ileal obstruction
  3. Palpable R iliac fossa mass
  4. Lethargy/fever of unknown origin
  5. Acute appendicitis
57
Q

List 4 clinical features of a L sided carcinoma

A
  1. Alteration of bowel habit: constipation, alternating with diarrhoea
  2. Lower abdominal colic, distension and desire to defaecate
  3. Rectal bleeding, blood mixed in with stool
  4. Palpable L sided mass
58
Q

Define tenesmus

A

Continuous urge to defaecate - feature of rectal carcinoma

59
Q

What is the imaging modality of choice in suspected diverticular disease?

A

CT

60
Q

How is mild diverticulitis managed? (4)

A

Can be done as an outpatient

  1. Begin low-residue diet
  2. Amoxicillin + clavulanate
  3. If no improvement in 48 to 72 hours - CT
  4. If first episode of diverticulitis - confirm with colonoscopy 6 weeks later
61
Q

What antibiotics are used in the treatment of severe or complicated diverticulitis?

A

those with significant systemic features (high fever, marked rebound tenderness) or with mild disease that fails to respond to outpatient management.

Amoxycillin + gentamicin + metronidazole

62
Q

When is surgical intervention indicated for in diverticulitis? (acute vs elective)

A

Acute: peritonitis associated with perforation; abscess that is not amenable to percutaneous drainage; bowel obstruction.

Elective surgery is indicated if a fistula has formed between a diverticulum and an adjacent organ. It should also be considered (but is not mandatory) if a patient has more than two episodes of severe diverticulitis (ie requiring hospitalisation).

Surgery (6 decks)

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