GENERAL SURGERY Flashcards
A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action?
The timeframe of 10 days makes attempts at proceeding with surgery hazardous even in experienced hands. However, the patient is unwell and this will not settle without some form of intervention. If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.
Abnormal coagulation
Heparin Prevents activation factors 2,9,10,11
Warfarin Affects synthesis of factors 2,7,9,10
DIC Factors 1,2,5,8,11
Liver disease Factors 1,2,5,7,9,10,11
Postoperative cognitive dysfunction management
Definition
Deterioration in performance in a battery of neuropsychological tests that would be expected in < 3.5% of controls
Or
Long term, possibly permanent disabling deterioration in cognitive function following surgery
Early POCD
Increasing age
GA rather than regional
Duration of anaesthesia
Reoperation
Postoperative infection
Late POCD
Increasing age
Emboli
Biochemical disturbances
LYMPHEDEMA
Due to impaired lymphatic drainage in the presence of normal capillary function.
Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening.
Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a ‘buffalo hump’ on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.
Milroy’s disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige’s disease develops AFTER birth.
OCULOGYRIC CRISIS
An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions
Features
Restlessness, agitation
Involuntary upward deviation of the eyes
Causes
Phenothiazines
Haloperidol
Metoclopramide
Postencephalitic Parkinson’s disease
Management
Procyclidine
Paediatric inguinal hernia
Inguinal hernias are a common disorder in children. They are commoner in males as the testis migrates from its location on the posterior abdominal wall, down through the inguinal canal. A patent processus vaginalis may persist and be the site of subsequent hernia development.
Children presenting in the first few months of life are at the highest risk of strangulation and the hernia should be repaired urgently. Children over 1 year of age are at lower risk and surgery may be performed electively. For paediatric hernias a herniotomy without implantation of mesh is sufficient. Most cases are performed as day cases, neonates and premature infants are kept in hospital overnight as there is a recognised increased risk of post operative apnoea.
NEUROFIBROMATOSIS
Neurofibromatosis type I. A hallmark finding is a plexiform neurofibroma, which is a sheet of neurofibromatosis tissue which encases major nerves. In children this attracts extra blood circulation, which can accelerate growth of the affected limb.
Other features include:
Schwannoma, > 6
Cafe au lait spots, axillary freckling, Lisch nodules, Optic glioma. Meningiomas, Glioma, or Schwannoma.
TROTTERS’ TRIAD
Trotter’s triad (diagnosis of nasopharyngeal carcinoma)
Unilateral conductive hearing loss
Ipsilateral facial & ear pain
Ipsilateral paralysis of soft palate
HLA AND TRANSPLANT REJECTION
Primary infection with CMV typically occurs 6 weeks post transplantation in a seronegative individual who receives an organ from a seropositive donor. Symptoms may occur as early as 20 days but can occur up to 6 months post transplant . Symptoms are often vague, retinitis can be pathognomonic, but is rarely seen in the transplant population. CMV disease is seen in 8% of renal transplant patients. Intravenous ganciclovir is the treatment of choice in such patients. Unfortunately, relapses are not uncommon
When HLA matching for a renal transplant the relative importance of the HLA antigens are as follows DR > B > A
Recurrence of original renal disease (MCGN > IgA > FSGS)
Normal intracranial pressure
The normal intracranial pressure is between 7 and 15 mm Hg. The brain can accommodate increases up to 24 mm Hg, thereafter clinical features will become evident.
PROSTHETIC HEART VALVES
The aortic and mitral valves are most commonly replaced and when a metallic valve is used, can be most readily identified on plain x-rays.
The presence of cardiac disease (such as cardiomegaly) may affect the figures quoted here.
Aortic
Usually located medial to the 3rd interspace on the right.
Mitral
Usually located medial to the 4th interspace on the left.
Tricuspid
Usually located medial to the 5th interspace on the right.
Please note that these are the sites at which an artificial valve may be located and are NOT the sites of auscultation.
AORTIC DISSECTION
Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan’s, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.
NORMAL ANION GAP ACIDOSIS
Normal Gap Acidosis: HARDUP
H - Hyperalimentation/hyperventilation
A - Acetazolamide
R - Renal tubular acidosis
D - Diarrhoea
U - Ureteral diversion
P - Pancreatic fistula/parenteral saline
REFEEDING SYNDROME
High risk for re-feeding problems
If one or more of the following:
BMI < 16 kg/m2
Unintentional weight loss >15% over 3-6 months
Little nutritional intake > 10 days
Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
If two or more of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10% over 3-6 months
Little nutritional intake > 5 days
History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
ACUTE HAEMOLYTIC TRANSFUSION
Haemolysis of the transfused cells occurs causing the combination of shock, haemoglobinaemia and loin pain. This may subsequently lead to disseminated intravascular coagulation. A Coomb’s test should confirm haemolysis. Other tests for haemolysis include: unconjugated bilirubin, haptoglobin, serum and urine free haemoglobin.
RECTAL CANCER SURGERY
The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.
TRANSFUSION REACTIONS
Pyrexia is the most common adverse event in transfusing packed red cells
Urticaria is the most common adverse event following infusion of FFP
RECTAL VARICES
Rectal varices are a recognised complication of portal hypertension. In the first instance they can be managed with medical therapy to lower pressure in the portal venous system. TIPSS may be considered. Whilst band ligation is an option, attempting to inject these in same way as haemorroids would carry a high risk of precipitating further haemorrhage.
Superior orbital fissure syndrome
Severe force to the lateral wall of the orbit resulting in compression of neurovascular structures. Results in :
Complete opthalmoplegia and ptosis (Cranial nerves 3, 4, 6 and nerve to levator palpebrae superioris)
Relative afferent pupillary defect
Dilatation of the pupil and loss of accommodation and corneal reflexes
Altered sensation from forehead to vertex (frontal branch of trigeminal nerve)
PSA
PSA levels may also be raised by**:
benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract
Feltys syndrome:
Rheumatoid disease
Splenomegaly
Neutropenia
HYPOKALEMIA
Hypokalaemia with alkalosis
Vomiting
Diuretics
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Hypokalaemia with acidosis
Diarrhoea
Renal tubular acidosis
Acetazolamide
Partially treated diabetic ketoacidosis
MIDDLE MENINGEAL ARTERY LIGATION
The auriculotemporal nerve is closely related to the middle meningeal artery and may be damaged in this scenario. The nerve supplies sensation to the external ear and outermost part of the tympanic membrane. The angle of the jaw is innervated by C2,3 roots and would not be affected. The posterior third of the tongue is supplied by the glossopharyngeal nerve.
Statistical error
Type 1 Error
A test rejects a true null hypothesis. Analogus to false positive. It usually equates to the significance level assigned to a test.
Type 2 Error
A test fails to reject a false null hypothesis. It is related to the power of a test.
