General Surgery Flashcards
What features should be noted on INSPECTION of mass?
Site Shape Size Symmetry Skin changes (e.g. erythema, swelling) Scars present
What features should be noted on PALPATION of a mass?
Temperature Tenderness Translucency Colour Attachments Mobility Pulsations Fluctuation Irreducibility Regional lymph nodes Edges
Risk factors for GALLBLADDER DISEASE?
✔️ female ✔️ aged > 40 years ✔️ obesity ✔️ rapid weight loss / weight gain ✔️ prolonged starvation ✔️ pregnancy ✔️ nephrotic syndrome, hypothyroidism (promote hypercholesterolemia)
What are the components of CHARCOT’S TRIAD?
✔️ jaundice
✔️ RUQ pain
✔️ fever
What are the components of REYNOLD’S PENTAD?
✔️ jaundice ✔️ RUQ pain ✔️ fever ✔️ shock ✔️ altered mental status
Describe the procedure of LAPAROSCOPIC CHOLECYSTECTOMY.
- Performed under general anaesthetic.
- Abdomen is washed with antiseptic wash (e.g. chlorhexadine)
- Three small incisions are made in the abdomen (umbilicus and lower quadrants) to allow for insertion of a small camera and tools for the procedure.
- The abdomen is inflated with gas to allow visualisation of organs.
- The cystic artery and the cystic duct are identified and clamped. Intra-operative cholangiogram (X-Ray) allows for visualisation of these vessels.
- Once visualised, the vessels are ligated and the gallbladder is removed.
- A drain may be put in place to assist with drainage of residual fluid.
What are the risks associated with LAPAROSCOPIC CHOLECYSTECTOMY?
ANASTHETIC RISKS ✔️ damage to teeth and airways ✔️ cardiovascular and respiratory complications ✔️ anaphylaxis / allergy to medications ✔️ malignant hyperthermia
INTRA-OPERATIVE RISKS ✔️ bleeding (rare) ✔️ bile duct damage ✔️ damage to other surrounding organs (e.g. bowel) ✔️ infection ✔️ conversion to open
EARLY POST-OP RISKS ✔️ pain ✔️ nausea and vomiting ✔️ lung infection + collapse ✔️ DVT + PE ✔️ infection of surgical site ✔️ bile leak
LATE POST-OP RISKS ✔️ adhesions ✔️ bowel obstruction ✔️ hernia ✔️ bile duct fibrosis ✔️ bile reflex --> chronic liver disease
What are the three main causes of small bowel obstruction?
- adhesions (usually secondary to previous abdominal surgery)
- hernias (usually internal)
- carcinoma
Describe the clinical presentation of bowel obstruction.
What symptoms are suggestive of perforation / peritonitis?
CLINICAL FEATURES ✔️ acute onset, colicky abdominal pain ✔️ nausea + vomiting (feculant vomiting is a late-sign) ✔️ constipation ✔️ nil flatus ✔️ increasing abdominal distension
PERFORATION ✔️ severe abdominal pain ✔️ fever ✔️ tachycardia / tachyponea ✔️ bounding pulse / wide pulse pressure (suggestive of sepsis) ✔️ rigid abdomen + abdominal guarding ✔️ tinkling bowel sounds
Outline appropriante investigations for SMALL BOWEL OBSTRUCTION and the indication for each.
BEDSIDE Ix
✔️ ABG –> metabolic acidosis
✔️ ECG –> monitor electrolyte abnormalities leading to arrythmia
✔️ blood glucose level
LABORATORY Ix
✔️ FBC + WCC –> leucocytosis
✔️ UECs –> base line renal function (AKI is a complication)
✔️ LFTs –> in case of surgery
✔️ coags –> in case of surgery
✔️ group and hold + cross match (in case of surgery)
IMAGING
✔️ abdominal X ray
✔️ abdominal CT –> to look for complications such as perforation, bowel wall ischemia, bowel wall necrosis
✔️ gastrograffin challenge (via NGT or PO)
What are the findings of SBO on abdominal X ray?
- dilation of bowel loops > 3cm (proximal) with collapse of bowel distal to obstruction
- absence of haustra
- centrally located
- air fluid levels
- air beneath diaphragm suggestive of perforation
Explain the purpose / use of GASTROGRAFFIN in the diagnosis of SBO.
Gastrograffin is a water-soluble contrast agent that has both diagnostic and therapeutic use in the management of adhesional SBO, specifically.
GGF is given via NGT or orally. An abdominal X ray is taken at the time of administration. A repeat abdominal X ray is performed 6 to 24 hours after administration.
If GGF is seen in the cecum, it suggests a PARTIAL aSBO. This is highly likely to resolve spontaneously.
If GGF is NOT seen in the cecum, it suggests a COMPLETE / COMPLICATED aSBO. These findings are less supportive of spontaneous resolution; surgical intervention is more likely to be required.
N.B. It is extremely important that all patients with query SBO undergo abdominal CT prior to GGF. This is to check for complications (e.g. perforation, necrosis, ischemia, closed loop obstruction) and to identify an underlying cause for the obstruction other than adhesions (e.g. hernia, malignancy, volvulus).
Describe the MEDICAL MANAGEMENT of SBO.
✔️ primary survey (ABCDE) ✔️ commence IV fluids (0.9% NaCl) ✔️ appropriate analgesia ✔️ keep NBM ✔️ insert NGT (gastric decompression) ✔️ surgical referral ✔️ monitor for ongoing changes and signs of surgical intervention (i.e. perforation, bowel wall necrosis, bowel wall ischemia)
What are the indications for SURGICAL INTERVENTION of SBO and what does the procedure involve?
INDICATIONS: ✔️ bowel wall ischemia ✔️ bowel wall necrosis ✔️ perforation --> peritonism ✔️ closed loop obstruction
Surgical management of SBO involves resection of non-viable bowel and re-anastomosis. If re-anastomosis is not possible, a stoma may have to be formed.
Identify the MECHANICAL and FUNCTIONAL causes of large bowel obstruction.
MECHANICAL CAUSES
✔️ colorectal carcinoma (sigmoid colon)
✔️ sigmoid volvulus
✔️ diverticular disease
FUNCTIONAL CAUSES
✔️ toxic megacolon (secondary to ulcerative colitis of C. difficle infection)
✔️ hypokalaemia and other electrolyte disturbances
✔️ hypothyroidism
✔️ Parkinson’s disease
✔️ severe Type 2 DM (autonomic neuropathy)
✔️ spinal cord dysfunction
What are the findings of LBO on abdominal X ray?
- dilated bowel loops > 6cm proximal to obstruction + collapsed bowel loops distal to obstruction
- haustra
- peripherally located
- air fluid levels
- free air under diaphragm in the case of perforation
What is HARTMANN’S PROCEDURE and when is it indicated?
Hartmann’s procedure involves resection of unviable bowel + formation of sigmoid colostomy + sewing over of the rectal stump.
This procedure is indicated in:
- obstructing malignancy
- uncontrolled diverticular bleeding
- perforation
What is SIGMOID DECOMPRESSION and when is it indicated?
Sigmoid decompression is indicated as soon as sigmoid volvulus is identified as the cause of LBO on gastrograffin enema.
This procedure involves passing a flexible sigmoidoscope or colonoscope and decompressing the sigmoid colon.
If unsuccessful, a flatus tube may have to be passed through the sigmoid colon to stent it.
Recurrence occurs in ~50% of cases.
RIGHT HEMICOLECTOMY
✔️ indications
✔️ organs removed
INDICATIONS
✔️ cecal tumours
✔️ ascending colon tumours
✔️ transverse colon tumours
ORGANS REMOVED ✔️ cecum ✔️ appendix ✔️ ascending colon ✔️ proximal transverse colon
LEFT HEMICOLECTOMY
✔️ indications
✔️ organs removed
INDICATIONS
✔️ transverse colon tumours
✔️ descending colon tumours
ORGANS REMOVED
✔️ transverse and descending colon
SIGMOIDCOLECTOMY
✔️ indications
✔️ organs removed
✔️ sigmoid colon tumours
The sigmoid colon only is removed.
ANTERIOR RESECTION
✔️ indications
✔️ organs removed
INDICATIONS
✔️ high rectal tumours (>5cm above the anus)
ORGANS REMOVED
✔️ sigmoid colon
✔️ rectum
ABDOMINAL PERINEAL RESECTION
✔️ indications
✔️ organs removed
INDICATIONS
✔️ distal rectal tumours (<5cm above the anus)
ORGANS REMOVED ✔️ sigmoid colon ✔️ rectum ✔️ anus ✔️ anal sphincters
Outline appropriante follow up for patients with colorectal cancer.
CEA and physical exam every 3 to 6 months
Abdominal and Chest CT every 6 to 12 months
Colonoscopy every 12 months
This should occur for five years follow surgery.
