General Surgery Flashcards
1
Q
Laparotomy =?
A
Open surgery of the abdomen (laparo = abdomen, otomy = open surgery))
2
Q
Colectomy =?
A
Removal of the colon (colo = colon, ectomy = removal)
3
Q
Cystoscopy =?
A
Endoscopic camera into the bladder (cysto = bladder, oscopy = viewing with a scope, or keyhole surgery)
4
Q
Myotomy =?
A
Cutting muscle tissue (myo = muscle, otomy = cut open)
5
Q
Orchidopexy=?
A
Fixing the testicle into the correct place (orchid = testicle, opexy = fixing something in place)
6
Q
Rhinoplasty =?
A
Changing the shape (plasty) of the nose (rhino)
7
Q
Thoracocentesis =?
A
Removing the air or fluid from the pleural space. Thoraco = chest, centesis = puncturing with a needle.
8
Q
Colostomy =?
A
Opening the colon onto the surface of the abdomen (Ostomy = creating a new opening)
9
Q
Laparoscopy =
A
Viewing the abdomen (laparo) with a scope, and/or keyhole surgery
10
Q
Adhesion =
A
Scar-like tissue inside the body that bind surfaces together
11
Q
Fistula =
A
Abnormal connection between two epithelial surfaces
12
Q
Tenesmus =
A
Sensation of needing to open the bowels without producing stools (often with pain)
13
Q
Hemicolectomy =
A
Removing a portion of the large intestine (colon)
14
Q
Hartmann’s procedure =
A
Proctosigmoidectomy - removal of the rectosigmoid colon with closure of the anorectal stump and formation of a colostomy.
15
Q
Anterior resection =
A
Removal of the rectum
16
Q
Whipple procedure =
A
Pancreaticoduodenectomy - removal of the head of the pancreas, duodenum, gallbladder and bile duct.
17
Q
Kocher incision =
A
Open cholecystectomy
18
Q
Chevron incision =
A
Rooftop incision. Liver transplant, Whipple procedure, pancreatic surgery or upper GI surgery.
19
Q
Mercedez Benz incision =
A
Liver transplant
20
Q
Midline incision =
A
General laparotomy, allows good access to abdominal organs
21
Q
Hockey-stick incision =
A
Renal transplant
22
Q
Battle incision =
A
paramedian incision - open appendicectomy
23
Q
McBurney/Gridiron incision =
Rutherford-morrison =
A
Oblique - open appendicectomy.
Rutherford morrison incision is an extended version that is also used for colectomy.
24
Q
Lanz incision =
A
Transverse - open appendicectomy
25
What incision is used for c sections?
Joel-cohen/pfannenstiel incision
joel-cohen is a higher incision now used more than the pfannenstiel which is a curved incision 2 finger widths above the pubic symphysis.
26
Diathermy =
High frequency electrical current to cut through tissues or cauterise small blood vessels to stop bleeding. Useful for making targeted incisions with minimal bleeding. Usually monopolar, which means one diathermy probe, and a grounding plate under the patient, the current becomes less intense as it distributes through the patient's body.
27
What are the two types of sutures? When is each used?
Absorbable eg vicryl. Used for tissues that will heal will and remain sealed, eg abdominal cavity.
Non-absorbable eg nylon - skin, drains and repairing tendons
28
How can the epidermidis be closed?
```
Staples - need removing
Interrupted sutures - need removing
Mattress sutures - need removing
Continuous - need removing
Subcuticular - absorbable.
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29
What is a drain and why would one be used after surgery?
A tube left inside a body cavity to allow air/fluid to drain away. Prevents air/pus/fluid collecting within a space. Eg chest drain removes air and fluid from pleural space.
30
When is the WHO surgical safety checklist carried out?
Before induction of anaesthesia
Before first incision
Before patient leaves theatre
31
What does a pre-operative assessment involve?
Fitness to undergo the operation - frailty status, cardiorespiratory fitness
Past medical history, smoking, alcohol, medications and allergies
Anaesthetic risk - previous responses
ASA grade
32
What are the ASA grades?
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American Society of Anesthesiologists grading system - classifies physical status of patient for analgesia.
I- normal healthy patient
II- mild systemic disease
III- severe systemic disease
IV- severe systemic disease that constantly threatens life
V- moribund (expected to die without op)
VI - brain-dead (organ donation)
E- emergency
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33
What investigations are needed prior to surgery?
Group and save if lower probability of needing blood
Crossmatch if high probability of needing blood
MRSA screening - everyone (usually done by nurses, also COVID test)
ECG if >65/ cardiovascular disease
Echo is heart murmurs, cardiac symptoms or HF
Lung function tests if ?resp disease
ABG if ?resp disease
HbA1C within last 3 months if diabetic
U+E if at risk of AKI/electrolyte abnormality (eg diuretics)
FBC if ?anaemia, cardiovasc or kidney disease
Clotting if ?liver disease
34
What are group and save and crossmatch tests for?
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G+S = testing blood group, valid for about 1 week
Crossmatch = Assigning unit of blood to a patient so it's ready to go
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35
What are the fasting requirements for most operations?
2 hours no clear fluids (fully NBM)
(4 hours no breastmilk in infants)
6 hours no food
Always put patients who may need emergency surgery NBM until assessed by senior.
36
Which medications need to be stopped before major surgery?
Anticoagulants - warfarin stopped about 5 days
Treatment dose LMWH infusion used for bridging anticoag in patients at high risk eg valve/VTE
DOACs stopped about 1-3 days before surgery
Oestrogen (COCP/HRT) needs to be stopped 4 weeks before
Remember VTE prophylaxis eg LMWH, stockings
37
What constitutes major surgery and minor surgery?
Major surgery = damage to tissues, high risk infection, open surgery (organ transplant, joint replacement)
Minor = minimally invasive, laparoscopy, cataracts, dental
38
What happens with long term corticosteroids and surgery?
Long term steroids (>5mg oral pred) - IV hydrocortisone at induction in first 24hrs, doubled dose once eating again
39
How is diabetes managed in surgery? Which meds do you stop/change/start?
Surgery increases blood sugar but fasting reduces it. Risk of hypoglycaemia is greater.
Sulfonylureas (gliclazide) cause hypoglycaemia - omit until eating
Metformin - lactic acidosis, caution in renal impairment
SGLT2Is eg dapagliflozin - DKA in dehydration/unwell
Insulin - continue at 80% of long-acting and stop short-acting until eating again. Start VRII alongside glucose, NaCl and K infusion ('sliding scale).
40
What is a lasting power of attorney (LPA)?
Person legally nominated by a patient to make decisions on their behalf ONLY if they lack capacity.
41
What is a DoLS?
Deprivation of liberty safeguards - a legal framework which protects patients who are not allowed to leave a hospital/care home (they are deprived of liberty). The hospital/care home applies for this to allow them to provide care and treatment to someone who lacks capacity.
42
What is consent form 1 used for?
Standard consent form for a procedure
43
What is consent form 2 used for?
Parental consent on behalf of a child
44
What is consent form 3 used for?
Where patients won't have consciousness impaired, eg, breast biopsy. However form 1 is often still used.
45
What is consent form 4 used for?
When patient lacks capacity.
46
What is enhanced recovery and what are the principles?
Aims to get patients back to pre-op condition as quickly as possibly by encouraging independence, early mobility and appropriate diet.
Principles:
good prep for surgery eg diet and exercise
minimally invasive surgery - keyhole/local anaesthetic
adequate analgesia --> mobilisation, ventilation (reduce risk of infections and atelectasis), oral intake
good nutritional support around surgery
Early return to oral diet and fluid intake
early mobilisation
Avoid drains and NG tubes where possible, remove catheters early
Discharge asap --> better outcomes.
47
When are NSAIDs contraindicated/used with extra caution?
Asthma, renal impairment, heart disease, stomach ulcers
48
What is patient-controlled analgesia (PCA)? How does it work and what monitoring is needed?
IV infusion of strong opiate (morphine, oxycodone or fentanyl) attached to patient controlled pump which administers a small bolus, and has a set time interval between doses. Only the patient should press the button.
Monitoring - anaesthetist, access to naloxone, antiemetics, atropine (for bradycardia). Avoid other PRN opiates while PCA in use.
49
Give 5 risk factors for PONV.
```
Post op nausea and vom:
Common in 24hrs after operation.
Female
Motion sickness/PONV history
NON smoker
use of post-op opiates
younger age
volatile anaesthetic use
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50
Give 3 antiemetics used for prophylaxis of PONV, and one contra-indication for each.
Ondansetron (5HT3 antagonist) avoid in long QT
Dexamethasone (corticosteroid), caution in diabetes/immunocompromise
Cyclizine (antihistamine) - caution in HF/elderly.
Droperidol (anti-D2) - avoid in parkinsons)
51
What can be used as 'rescue' anti-emetics for PONV?
Prochlorperazine (anti D2) - avoid in Parkinsons
Cyclizine, ondansetron
P6 acupuncture point on inner wrist
52
When and how are catheters removed?
When patient can mobilise to toilet. TWOC = trial without catheter. Look out for urinary retention, especially in male patients, who need to be re-catheterised.
53
What is a PEG tube?
A tube from surface of abdomen to the stomach. This still counts as an enteral feed because the food is going to the GI tract.
54
What is TPN?
Total (full nutritional requirements)
Parenteral (not the gut - central line into the blood. Irritant to veins so never peripheral)
Nutrition (carbs, fats, proteins, vitamins and minerals)
55
What is atelectasis?
Lung collapse due to under-ventilation
56
What is wound dehiscence?
Separation of surgical wound
57
What is ileus?
Reduced/no bowel peristalsis
58
What causes post-operative anaemia? How is it treated?
Hb under 100g/l - start oral iron eg ferrous sulphate 200mg TDS 3 months
Hb under 80h/l - blood transfusion
59
How is fluid distributed in the body?
FLUID
1. Intracellular space - 2/3
2. Extracellular space - 1/3
a) intravascular (20%)
b) interstitial (80%)
c) third space - where fluid shouldnt be - peritoneal, pleural, pericardial cavities and joints. Also refers to excessive fluid in interstitial space (oedema)
60
What is third-spacing? How might it present?
3rd space = places where fluid shouldnt be - peritoneal, pleural, pericardial cavities and joints, or excessive fluid in interstitial space (oedema)
Third-spacing = fluid shifting into this non-functional third space. Eg oedema, ascites, effusions or other non-functional fluid collections within the body.
Can result in signs of both hypo and hypervolaemia eg hypotension and reduced perfusion of tissues as well as oedema.
61
Give 3 sources of fluid intake and 3 sources of fluid output
Oral fluids
Nasogastric or PEG feeds
Intravenous fluids (including IV medications)
Total parenteral nutrition
Urine output
Bowel or stoma output (particularly diarrhoea)
Vomit or stomach aspiration
Drain output
Bleeding
Insensible loss - respiration, stool, burns, sweating
62
Give 6 signs of hypovolaemia.
```
Hypotension (systolic < 100 mmHg)
Tachycardia (heart rate > 90)
Capillary refill time > 2 seconds
Cold peripheries
Raised respiratory rate
Dry mucous membranes
Reduced skin turgor
Reduced urine output
Sunken eyes
Reduced body weight from baseline
Feeling thirsty
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63
Give 4 signs of fluid overload.
```
Peripheral oedema (check the ankles and sacral area)
Pulmonary oedema (shortness of breath, reduced oxygen saturation, raised respiratory rate and bibasal crackles)
Raised JVP
Increased body weight from baseline (regular weights are an important way of monitoring fluid balance)
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64
What are the indications of IV fluids?
Resuscitation (e.g., sepsis or hypotension)
Replacement (e.g., vomiting and diarrhoea)
Maintenance (e.g., nil by mouth due to bowel obstruction)
65
Explain the different types of fluids and when they are used.
Colloid eg albumin - increases oncotic pressure, used eg in decompensated liver disease but not often
Crystalloid: water + salts/glucose. Eg:
HYPOTONIC:
5% Dextrose (1L = 50g of glucose)
0.18% NaCl in 4% glucose (31mmol NaCl, 40g glucose in 1L)
ISOTONIC: for fluid resus.
0.9% NaCl - 1L contains 154mmol of sodium and chloride. Risk acidosis with hypernatraemia.
Hartmann's (mimics human electrolytes - Na, Cl, K, Ca, lactate to reduce risk of acidosis
PlasmaLyte (Na, Cl, K, Mg, acetate+gluconate to buffer)
HYPERTONIC:
3% saline
66
What is normal serum osmolality?
275-295mOsmol/kg
67
How much fluid and electrolytes do people need daily?
25-30ml/kg/day water
1mmol/kg/day Na, K, Cl (don't add potassium to fluids)
50-100g/day glucose (to prevent ketosis, not to meet nutritional needs)
Based on IDEAL body weight
68
What are the risks of IV fluids?
```
Circulatory overload
DILUTION -->
Hyponatraemia if hypotonic solutions
Hypokalaemia if no K
Hypocalcaemia, hypomagnasaemia, low hb, low hc, coagulopathy (low clotting factors, platelets and fibrinogen)
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69
What is 'acute abdomen? How can you classify the causes?
recent, rapid onset of urgent abdominal or pelvic pathology, usually presenting with abdominal pain
Classify by area (although be aware pain may not be localised/may radiate) eg generalised, RUQ, Epigastric, central, RIF, LIF, suprapubic, loin to groin, testicular
70
3 causes of generalised abdo pain?
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
71
3 causes of RUQ pain?
Biliary colic
Acute cholecystitis
Acute cholangitis
72
3 causes of epigastric pain?
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
73
3 causes of central abdo pain?
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis
74
3 causes of RIF pain?
```
Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis
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75
3 causes of LIF pain?
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
76
3 causes of suprapubic pain?
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
77
3 causes of loin to groin pain?
```
Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis
```
78
3 causes of testicular pain?
Testicular torsion
Epididymo-orchitis
Trauma
79
What is peritonitis and what are 4 signs?
Iinflammation of the peritoneum, the lining of the abdomen.
Guarding – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below
Rigidity – involuntary persistent tightness / tensing of the abdominal wall muscles
Rebound tenderness – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself
Coughing test – asking the patient to cough to see if it results in pain in the abdomen
Percussion tenderness – pain and tenderness when percussing the abdomen
80
3 causes of peritonitis?
Localised - organ inflammation eg appendicitis or cholecystitis.
Generalised - perforation of an abdominal organ (e.g., perforated duodenal ulcer or ruptured appendix) releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.
Spontaneous bacterial peritonitis (SBP):spontaneous infection of ascites in patients with liver disease.
81
Give 6 blood tests you would do in acute abdomen and why.
FBC - bleeding (drop in Hb) and inflammation (raised WBC).
U&Es - electrolyte imbalance and kidney function (?contrast)
LFTs - biliary and hepatic system.
CRP - inflammation
Amylase - inflammation of the pancreas in acute pancreatitis.
INR - synthetic function of the liver, establishing coagulation prior to procedures.
Serum calcium - used to score acute pancreatitis and for other reasons (e.g., clotting and cardiac function).
Serum hCG - pregnancy
ABG - lactate (an indication of tissue ischaemia) and pO2 (used for scoring in acute pancreatitis).
Lactate - ischaemia, anaerobic respiration, dehydration, hypoxia.
Group and save prior to theatre in case the patient requires a blood transfusion.
Blood cultures if infection is suspected.
82
What is the use of an AXR in acute abdomen?
Bowel obstruction - shows dilated bowel loops
83
What is the use of erect CXR in acute abdomen?
Erect CXR shows air under the diaphragm - pneumoperitoneum (intra abdominal perforation)
84
What is the role of abdo uss in acute abdomen?
Gallstones, biliary duct dilatation, gynae pathology
85
Explain the pathophysiology of appendicitis.
tldr: inflamed appendix. The appendix is a small, thin tube arising from the caecum where the three teniae coli meet (longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end.
Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel --> infection and inflammation --> gangrene and rupture --> faecal contents and infective material go into the peritoneal cavity --> peritonitis (inflammation of the peritoneal lining).
86
Give 4 signs of appendicitis.
Low grade fever
Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
Guarding on abdominal palpation
PERITONITIS (rupture):
Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
Percussion tenderness (pain and tenderness when percussing the abdomen)
87
Give 4 symptoms of appendicitis.
Central abdominal pain moving to RIF within first 24 hours
Tenderness at McBurney's point (1/3 from ASIS to umbilicus)
Anorexia
N+V
Fever
88
How is appendicitis diagnosed?
Clinical + raised inflammatory markers
May use CT to confirm if diagnostic uncertainty (Meckel's diverticulum, mesenteric adenitis)
USS to exclude gynae pathology (ectopic pregnancy - pregnancy test, ovarian cyst) or in children where CT is a lot of radiation
Diagnostic laparotomy if symptoms fit but negative investigations
89
What is Meckel's diverticulum?
Malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception.
90
What is mesenteric adenitis?
Inflamed abdominal lymph nodes. It presents with abdominal pain, usually in younger children, and is often associated with tonsillitis or an upper respiratory tract infection. No specific treatment is required.
91
What is an appendix mass?
An appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa. This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.
92
What is the definitive management of appendicitis?
Appendicectomy - usually laparoscopic
93
Give 5 complications of appendicectomy.
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Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
```
94
What causes bowel obstruction?
Big Three:
adhesions, hernias (small)
malignancy (large)
Other: volvulus (large), diverticular disease, strictures (eg Crohn's), intussusception (young children aged 6 months to 2 years)
95
What are adhesions? give 4 causes.
Adhesions are pieces of scar tissue that bind the abdominal contents together. Can cause kinking or squeezing of the bowel, leading to small bowel obstruction.
Causes include:
Abdominal or pelvic surgery (particularly open surgery)
Peritonitis
Abdominal or pelvic infections (e.g., pelvic inflammatory disease)
Endometriosis
Rarely: congenital or secondary to radiotherapy treatment.
96
What is closed-loop obstruction?
Two points of obstruction along the bowel; meaning that there is a middle section sandwiched between two points of obstruction. Eg due to:
Adhesions that compress two areas of bowel
Hernias that isolate a section of bowel blocking either end
Volvulus where the twist isolates a section of intestine
A single point of obstruction in the large bowel, with an ileocaecal valve that is competent
A competent ileocaecal valve does not allow any movement back into the ileum from the caecum. When there is a large bowel obstruction and a competent ileocaecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction.
Contents cannot drain and decompress. Will inevitably continue to expand, leading to ischaemia and perforation -requires emergency surgery.
97
Give 5 features of bowel obstruction.
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
“Tinkling” bowel sounds may be heard in early bowel obstruction
98
What would you see on X ray with bowel obstruction?
Distended loops of bowel.
The upper limits of the normal diameter of bowel are:
3 cm small bowel
6 cm colon
9 cm caecum
Valvulae conniventes are present in the small bowel and are mucosal folds that form lines extending the full width of the bowel. These are seen on an abdominal x-ray as lines across the entire width of the bowel.
Haustra are like pouches formed by the muscles in the walls of the large bowel. They form lines that do not extend the full width of the bowel. These are seen on an abdominal x-ray as lines that extend only part of the way across the bowel.
99
How is bowel obstruction managed?
```
Do VBG - Lactate for bowel ischemia, met alkalosis from vomiting
U+Es for electrolytes imbalances - correct
Drip and suck: NBM, NG tube, IV fluids
Surgery:
Adhesions - adhesiolysis
Hernias - surgical repair
Malignancy - emergency resection
Stents
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