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General Surgery Flashcards

1
Q

Acute Abdo

- S+S

A

Acute Abdo S&S

  1. Pain
    • Visceral/somatic
    • Midline
    • Referred
  2. Vomit
  3. Bowel alteration
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2
Q

Visceral abdo pain features

A

Visceral abdo pain

  1. Midline
  2. Autonomic
  3. Nausea
  4. ‘Organ pain’
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3
Q

Acute abdomen

- Causes

A

Causes of acute abdo

  1. Generalised peritonitis
    • eg. Infective
  2. Localised peritonitis
    • eg. Appendicitis
  3. Motility disorder
    • eg. Obstructive cause
  4. Ischaemia
    • eg. Infarct/torsion/necrosis
  5. Other
    • eg. AAA
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4
Q

Complex surgical patients

- Four possibilities

A

Surgical complexity

  1. Diabetes
  2. Steroids
  3. Anti-coagulation
  4. NBM
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5
Q

Surgical emergent complications

A

Surgical complications

Early

  1. Bleed
  2. Cardiopulmonary emergency

Later

  1. DVT
  2. Ileus
  3. Sepsis
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6
Q

Acute abdomen

- Extrinsinc DDs

A

Acute abdomen extrinsic DDs

  1. Thoracic cause
  2. Neuropathology
  3. Metabolic
  4. Toxic
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7
Q

Abdo pain

- 8 common DDs

A

Common Abdo DDs

  1. Appendicitis
  2. Cholecystitis
  3. Pancreatitis
  4. Diverticulitis
  5. Obstruction
  6. KUB
  7. Gynaecological
  8. Non-specific
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8
Q

General Surgery

- History structure

A

General history

  1. HPC
    • SQUITARS
    • GI Sx
    • GU/Gyn Sx
  2. PMH/DHx/Allergy
  3. FHx, SHx, SR
  4. Last Meal
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9
Q

Abdo Exam Structure

A

Abdo Exam Structure

  1. General exam
  2. Abdo
    • Start Peripherally
    • I,P,P,A
    1. Completion
      - Groin/Hernial Orifices
      - PR/PV/Scrotal
      - Systemic
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10
Q

GI Perforation

- Causes

A

GI Perforations

  1. UGI
    • Ulcer
  2. LGI
    • Iatrogenic
    • Diverticular
    • Tumour
  3. Other
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11
Q

GI Perforation

- S&S

A

GI Perforation

  1. Pain
    • Constant
    • Sharp
  2. Nausea
  3. Suddenly more severe
    • Peritonism
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12
Q

Acute Abdo Investigations

A

Acute Abdo

  1. Bedside
    • ABG
  2. Bloods
    • Most
  3. Imaging
    • CT
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13
Q

Acute abdomen

  1. Surgical considerations
  2. Surgical approaches
A

Acute abdomen surgery

  1. Performance status
    • Mortality
  2. Options
    • UGI
      - Closure
    • LGI
      - Resection
      - Colostomy
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14
Q

Abdo Obstruction

- Symtoms

A

Abdo obstruction Sx

  1. Colicky pain
  2. Distension
  3. Vomiting
  4. Bowel stasis
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15
Q

Closed Loop Bowel

- Features

A

Closed Loop Obstruction

  1. Sigmoid obstruction
  2. Ileocecal competence
  3. Distension and perforation
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16
Q

Bowel obstruction

- Layers

A

Bowel obstruction categories

  1. Intraluminal
  2. Luminal
  3. Extraluminal
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17
Q

Bowel obstruction DDs

A
  1. Intra luminal
    • FB
  2. Luminal
    • Tumour
    • Diverticulitis (20% LBO)
    • Hirschprungs
    • Achalasia
  3. Extra luminal
    • Adhesions (50-75% SBO)
    • Hernia (20% SBO)
    • Malignancy (65% LBO)
    • Volvulus
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18
Q

Bowel obstruction

  1. SBO common causes
  2. LBO common causes
A
  1. SBO
    • Adhesions (50-75%)
    • Herniation (20%)
  2. LBO
    • Malignancy (65%)
    • Diverticulitis (20%)
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19
Q

Bowel obstruction

- Signs

A

Bowel obstruction Signs

  1. Distension
  2. Hernia/scar visible
  3. BS tinkly/high pitched
  4. Sepsis/SIRS
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20
Q

Bowel obstruction

- Mx

A

Bowel Obstruction Mx
- Drip and suck

  1. Analgesia
  2. NBM
    • Aspiration risk
    • NG to release pressure
  3. Fluid balance
    • IVI
    • Catheter
  4. Imaging
    • Definitive DDx
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21
Q

Lower GI Bleed Mx

A

Lower GI Bleed Mx

  1. Conservative first line
    • STOP Anticoagulants
  2. Interventional radiology
    - Colonoscopy
    Clipping, diathermy, injection (epinephrine)
    - Trans catheter arteriography
  3. Surgical last line
    - Urgent laparotomy
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22
Q

Hernia

- Definition

A

Hernias are:

  1. Protrusion
  2. Through containing cavity
  3. Organ displaced
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23
Q

Hernia

- Locations

A

Hernias

  1. Inguinal
  2. Femoral
  3. Umbilical
  4. Incisional
  5. Epigastric
    - painful midline fat
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24
Q

Hernias

- Complication recognition

A

Recognising hernia complication

  1. Obstruction
  2. Strangulation
    • Ischaemic pain
    • Erythematous skin change (translocation)
    • Non-reducible
    • Systemic symptoms
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25
HPB - Escalating differentials; Pain -> Fever
HBP 1. Biliary colic - Pain 2. Cholecystitis - Pain - Inflammation of gall bladder 3. Ascending cholangitis - Pain - Infection of biliary tree 4. Gallstone ileus - Fistula to duodenum - (2cm sized stones would not pass through tree)
26
Peri-anal abscess | - Presentation
Peri-anal abscess 1. Red 2. Fluctuant 3. Common presentation
27
Peri-anal abscess | - Management
Peri-anal abscess Mx 1. Surgery - Same day excision and drainage 2. SIRS -> ABx 3. At Discharge - Hygiene advice
28
Peri-anal abscess | - Complications and risk groups
Peri-anal abscess complications 1. High-risk patients - DM - Obese - Old - Immunocompromised 2. Necrotising fasciitis
29
Local anaesthesia | - Routes
LA Routes 1. Central neuraxial - Spinal - Intrathecal/subarachnoid - Epidural - Between ligamentum flavum and dura mater 2. Plexus blocks 3. Nerve blocks 4. Local anaesthesia
30
Neural plexuses of the gut?
1. Submucosal - MeisSNer's - Mucosa layer 2. MYentric - AUerbach's - Muscularis externa
31
Male Groin Lump | - Eight DDx
Male Groin Lump Vascular 1. Femoral pseudoaneurysm 2. Saphena varix 3. Inguinal lymphadenopathy GI 4. Inguinal hernia (Direct/indirect) GU 5. Ectopic/undescended testis 6. Hydrocele MSK 7. Psoas abscess 8. Lipoma
32
Hiatus hernia | - Presentation
Hiatus Hernia S&S 1. Heartburn/GORD 2. Dysphagia 3. Odynophagia 4. Hoarseness 5. Chest pain 6. SoB
33
Hernia repair | - Three Surgical Approaches
Hernia repair 1. Open non-mesh (primary tissue) 2. Open-mesh 3. Laparoendoscopic-mesh
34
Abdo Exam - Peritonitis Suspicion 1. Checks 2. Techniques
Abdo peritonitis suspicion Checks 1. Stuck tummy in and out 2. Cough Techniques 3. Palpate opposite to pain 4. Percussion tenderness instead of rebound tenderness
35
PID | - Three complications
PID Complications 1. Tubo-ovarian abscess 2. Infertility 3. Ectopic pregnancy
36
Uncomplicated adult Appendicitis | - Management
1. NBM 2. Fluids and analgesia 3. Involve obstetrics 4. Prophylactic antibiotics 5. Laparoscopy appendicectomy
37
Complicated adult appendicitis | - management
1. Supportive treatment 2. Emergency appendicectomy - Laparoscopic
38
Gallstone pancreatitis | - management
1. Fluid resus 2. Analgesia and oxygen 3. Antiemetic 4. Empiric ABx 5. ERCP
39
Alcohol pancreatitis | - Management
Alcohol pancreatitis 1. Fluids and oxygen 2. Analgesia and antiemetic 3. Empiric ABx 4. Vitamin replacement - Pabrinex 5. Anti withdrawal - Chlordiazepoxide 5. Calcium and magnesium
40
Active peptic ulcer | - Management
Peptic ulcer management 1. Evaluation and transfusion - Blatchford 2. Endoscopy 3. PPI 4. Repeat endoscopy 5. Interventional radiology 6. Surgery
41
``` Peptic ulcer (no bleeding) - Management ```
Peptic ulcer not bleeding 1. H Pylori eradication therapy - PPI - Clarithromycin/Metronidazole 2. Healing therapy - PPI 8 weeks - Amoxicillin
42
Inguinal hernia (stable) - Management
Inguinal hernia management 1. Watchful waiting 2. Elective repair - open mesh (Low risk low recurrence) Eg. Lichtenstein - Laparoscopic (Large mesh) 3. Prophylactic ABx - Cefazolin - Vancomycin - Clindamycin
43
Femoral hernia | Management
Femoral hernia 1. Surgery - Open - Lap
44
Crohn's disease | - Maintenance therapy
Crohn's maintenance 1. Azathioprine (or mercaptopurine) 2. Parenteral methotrexate (If CST dependent) 3. TNF if needed to induced remission - Vedolizumab - Ustekinumab 4. Infliximab and adalimumab - growing evidence
45
Acute Crohn's | - Mild - Moderate Mx
Acute Crohn's 1. Mild - Budesonide 2. Moderate - Budesonide - ABx - Azathioprine/Mercaptopurine - Biologics (Infliximab, adalimumab, Vedolizumab)
46
Acute Crohn's | - Severe Mx
Severe Crohns Mx 1 Hospitalisation 2 IV steroids - Prednisolone/Hydrocortisone Methylprednisolone 3 ABx in sepsis 4 Biologics 3 Surgery
47
Ulcerative colitis | - Moderate-severe flareup
UC Mx Moderate 1 Oral CST Budesonide/Prednisone 2 Biologic - Infliximab/adalimumab - Golimumab/vedolizumab - Ustekinumab 3 Immunomodulator - Aza/merca/metho 4 JAK-1i Tofactinib 5 Colectomy Severe 1 Hospital admission 2 Hydrocortisone/Methylprednisolone 3 Ciclosporin/infliximab 4 Surgery
48
Ulcerative colitis mx | - Mild acute
Mild UC Mx 1 Aminosalicylate - Mesalazine 2 Topical steroid 3 Oral Budesonide 4 Oral prednisolone
49
Uncomplicated Diverticulitis | - Mx
Uncomplicated Diverticulitis Mx 1. Analgesia - Paracetamol (Perf with NSAIDs and Opioids) 2. Antispasmodic - Dicycloverine (musc.) 3. Oral antibiotic - Co-amox 4. Low-residue diet (low fibre eg. refined bread, white rice)
50
Diverticulitis w/ rectal bleeding | - Mx
Bleeding diverticulitis 1. Unstable - Resuscitate - CT - Endoscopy 2. Stable - Colonoscopy - Injection, thermal - Band ligation 3. Fluids and Analgesia (Ideally paracetamol) 4. IV ABx - Co-amox - Cefuroxime + met - Gent+met+amox
51
Diverticulitis management 1 W/ Abscess 2 W/ Perforation
Complicated diverticulitis 3cm+ abscess 1. Radiological drainage - CT or USS 2. Surgery if necessary Perforation 1. Laparoscopic lavage 2. Resection - If faecal peritonitis 3. Emergency surgery - Colectomy - Hartmann's
52
Cholelithiasis - Management
Cholelithiasis Mx 1. Analgesia 2. Anti-spasmodic - Hyoscine (buscopan) 3. Elective lap. chole. - No ABx
53
Choledocholithiasis - Management
Choledocholithiasis 1. ERCP 2. Lap chole 3. Analgesia 4. Anti-spasmodic - Hyoscine (buscopan)
54
Cholecystitis | - Management
Cholecystitis Mx 1. Analgesia 2. Fluids 3. Antibiotics - If evidence of infection 4. Lap chole
55
Severe Cholecystitis | - Mx
Severe Cholecystitis Mx 1. ICU admission and fluids 2. Analgesia 3. ABx 4. Percutaneous Cholecystectomy - Empyema - Unfit for GA 5. Delayed Cholecystectomy - Fit for GA
56
Acute Cholangitis | - Management
Acute Cholangitis Mx 1. IV Broad spec - Tazocin (Pip/tazo) - Primaxin (Imi/cilastatin) - Cefur+met 2. Biliary decompression - ERCP (+-sphincerotomy) - PTC (percutoenous trans-hepatic cholangiography) 3. Lithotripsy 4. Opioid + paracetamol 5. Surgical decompression - Lap choledochotomy or chole
57
Small bowel obstruction | - Alternative DDx
SBO DDx 1. Constipation (pseudo-obs) - Amytriptyline/imipramine 2. Ileus 3. LBO 4. Gastroenteritis 5. Apendicitis 6. Pancreatitis
58
Small Bowel Obstruction | - Mx (no complications)
SBO Mx (no complications) - Drip and suck 1. Fluids and analgesia 2. NG Decompression 3. Exploratory lap - Refractory
59
Small Bowel Obstruction (complex) | - Mx
Small bowel obstruction - Mx 1. Fluids, analgesia 2. NG decompression 3. CT Underlying cause - Consider endoscopic ballon - Eg. Appendix, tumour, hernia 4. Surgery within 6 hours - Ischaemia - Strangulation - Peritonitis
60
Hartmann's Procedure | - Indications
Hartmann's Procedure Indications - Emergency bowel obstruction 1. Sigmoid perforation - Diverticulitis 2. Sigmoid obstruction - Malignancy
61
Hartmann's Procedure | - Result
Hartmann's Procedure - Result 1. Sigmoid colectomy 2. End colostomy
62
Hartmann's Procedure | - Risks (general and specific)
Hartmann's Risks General 1. Bleeding and infection 2. Ileus and DVT Specific 3. Local damage - SB, KUB 4. Incisional hernia 4. Stump blow-out 5. Stoma - prolapse/hernia - retraction/stenosis 6. Irreversibility
63
Ivor Lewis Procedure | - Approach
Ivor Lewis Approach 1. Right thoracotomy 2 .Laparotomy
64
Oesophagectomy | - Result
Oesophagectomy result 1. Removal of tumour 2. Removal of top of stomach 3. Removal of lymph nodes 4. Production of 'conduit'
65
Ivor Lewis | - Risks
Ivor Lewis Risks Common 1. Bleeding and infection 2. DVT Specific 3. Anastomotic leak 4. Re-operation 5. Pneumonia 6. Death (4%)
66
Open inguinal repair | - Types
Open inguinal repair 1. Herniotomy - Infants - Ligation and excision 2. Herniorrhaphy - Suture repair of posterior wall 3. Hernioplasty - Reinforcement with mesh
67
Inguinal hernia repair | - Common method
Inguinal hernia repair - Lichtenstein tension-free mesh repair
68
Inguinal hernia repair | - Risks
Inguinal hernia repair risks Common 1. Bleeding and infection 2. DVT/Stroke/MI/Death 3. Anaesthetic - Teeth, throat - Reactions - Cardio-resp. Specific 1. Pain - 1/50: long -term - 3/50: worsened 2. Resection 3. Local damage - Bowel, bladder - Spermatic cord (vas def) 4. Seroma
69
Femoral hernia | - Presentation
Femoral hernia presentation 1. Small groin lump - infero-lateral 2. 30% emergency 3. Multiparous, female 4. Increasing age 5. Intra-abdominal pressure - Chronic constipation
70
Femoral hernia | - Emergency management
Femoral hernia emergency 1. Exploration in theatre 2. Rarely image - Risk of infarction
71
Small umbilical hernia | - Management
Small umbilical hernia 1. Watchful waiting 2. Elective repair - 4-5 yo - risk of incarceration
72
Large umbilical hernia | - Management
Large umbilical hernia 1. Elective repair 2-3 yo - 1.5-2cm+ unlikely to close 2. Earlier repair if Sx - Pain - Incarceration
73
Incarcerated umbilical hernia | - Management
Incarcerated umbilical hernia 1. Immediate attempt at reduction - Milk air or fluid out - Observe for peritonitis 2. Emergency repair - If strangulated - If peritonitic - Assess bowel integrity
74
Lower GI Bleeds 8 Common Causes
Lower GI Bleeds Common 1. Diverticulitis 2. Colonic angiodysplasia 3. Ischaemic colitis 4. IBD 5. Infectious colitis 6. Haemorrhoids/fissure 8. Colorectal cancer
75
Lower GI Bleeds 5 Uncommon Causes
Uncommon 1. Meckel's - Children or young 2. Telangiectasia - Radiation induced 3. Dieulafoy's lesion - Tortuous arteriole 4. Aorto-enteric fistula - Severe bleed 5. Vasculitis - SLE, PAN
76
Angiodysplasia of colon | - Presentation
Angiodysplasia presentation 1. Bleeding - Painless - Intermittent - Fresh or malaena - Self-limiting (can be massive) 2. 60+yo 3. Anaemic - SoB, Fatigue, Weakness
77
Colon angiodysplasia | - Emergency Management
Colon angiodysplasia emergency 1. Upper endoscopy - Exclude upper bleed 2. Embolisation - CT Angio - IV Access and support 3. Colonoscopy - Absence of angiography - Cautery - Clips - Epinephrine 4. Surgery - Life-threatening haemorrhage - Enteroscopy - Sub-total colectomy
78
Colonic angiodysplasia | - Stable Management
Stable angiodysplasia mx 1. Interventional endoscopy - Cautery, clips, epinephrine 2. Embolisation if negative endoscopy - CT Angiography 3. Wireless capsule - Enteroscopy - Alternative to angiogram 4. Surgery - If angiography not available 5. Medical mx - Octreotide (somatostatin analogue) - Oestrogens - Thalidomide (Immunomodulatory)
79
Ischaemic bowel peritonitic | - Embolic management
Embolic bowel ischaemia 1. Resus and support 2. IV ABx - Cef/levoflox and met 3. Surgery - Exploratory laparotomy - Embolectomy/reconstruction - Bypass +/- Resection 4. Post-op heparin - (after 48 hours)
80
Non-occlusive Mesenteric Ischaemia | - Management (Peritonitic)
NOMI Mx 1. Resus and support 2. IV ABx Cef/levoflox + met 3. Aetiology +-resection - CHF/Arrhythmia - Shock/HD 4. Post-op heparin
81
VT Ischaemic bowel | - Management (peritonitic)
Venous bowel ischaemia mx 1. Resus 2. IV ABx - Cef/levoflox + met 3. Anti-coagulate - Heparin - Warfarin (3-6/12) ``` 4. Surgery Infarction/peritonitis - Open - +/- Thrombectomy - +/- Resection ```
82
Ischaemic bowel management | - Fulminant colitis
Fulminant ischaemic colitis 1. Resus 2. IV ABx Cef/levoflox + met 3. Colectomy - Subtotal or total - Unresponsive to therapy - Hartmann's or Ileostomy
83
``` Ischaemic bowel (stable) - Embolic management ```
Embolic bowel ischaemia 1. Resus and support 2. Surgery - Consider thrombolytic therapy - Exploratory laparotomy - Embolectomy/reconstruction - Bypass +/- Resection 3. Post-op heparin - (after 48 hours)
84
``` Ischaemic bowel (stable) - Thrombotic management ```
Thrombotic bowel ischaemia 1. Resus and support 2. Angiography 3. Endovascular for chronic - Stenting - Aspiration thrombectomy - Local drug instillation 4. Surgery - Exploratory laparotomy - Embolectomy/reconstruction - Bypass +/- Resection 5. Post-op heparin - (after 48 hours)
85
Colorectal cancer | - Presentation
Colorectal cancer presentation 1. 55+ Obesity 2. Rectal bleeding 3. Change in BMs 4. Anaemia 5. Genetics - IBD - FAP/APC (Adenomatous polyposis coli) - Lynch (HNPCC) 6. Rectal mass - MRI/USS
86
Rectal cancer mx | - Suitable for surgery
Rectal cancer mx Stage I: 1. Local or radical excision - Transanal - TEM (Endoscopic microsurgery) 2. Radio +- chemo Stage II-III: 1. TNT (total neoadj) 2. Radical resection + Pre chemo-radio + Post chemo Stage IV: 1. Surgical resection - lung/liver 2. Local ablation - Needle inserted with radio waves 3. Chemo-radio
87
Rectal cancer mx | - Not suitable for surgery
Colorectal cancer mx Stage I-IV 1. Chemo + Stenting - oxaliplatin+flurouracil +folate - oxaliplatin + capecitabine 2. VEGFi or EGFRi - bevacizumab/cetuximab 3. Alternative chemo +stent - Nivolumab/ipilmumab - Entrectinib
88
Colon cancer mx | - Suitable for surgery
Colon cancer mx Stage I-III - Resection - Adjuvant Chemo Stage IV - Neoadj and resection + Local ablation - VEGF/EGFRi -Surgical resection (incl. lung or liver) + Local ablation + Post op chemo
89
Colon cancer mx | - Non-surgical
Colon cancer mx - Non-surgical Stage I-IV 1. Chemo +stenting - Oxaliplatin +fluorouricil +folate - Capecitabine + oxaliplatin 2. VEGF/EGFR 3. Alternative chemo + stenting
90
Non-occlusive mesenteric ischaemia 1. Aetiologies 2. Presentation
NOMI ``` Aetiologies 1. Cardiac disease Eg. MI 2. Systemic hypotension - Septic/haemorrhagic/cardiac 3. Blunt trauma 4. Iatrogenic - Dialysis - Thoracic surgery - Medication Vasospasm eg. Digoxin ``` Presentation 1. Critically ill patients 2. AF
91
Fulminant colitis 1. Aetiologies 2. Pathophysiology
Fulminant colitis Aetiologies 1. UC 2. Crohn's 3. Infective 4. Neutropenic 5. Ischaemic Pathophysiology 1. Gross inflammation - interleukins - NO 2. Loss of neurogenic tone 3. Severe dilation 4. Risk of perforation
92
LAR vs APR 1. Indications 2. Results
Lower anterior resection - Rectal sphincter spared 1. Rectal cancer 2. Diverticulitis 3. Proximal two-thirds of rectum Abdominoperineal resection - Permanent colostomy 1. Rectal cancer lower 1/3 2. Anal cancer

Year 3 - Surgery (7 decks)

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