General Surgery Flashcards
What are causes of hyperamylasaemia?
Acute Pancreatitis
Pancreatic Pseudocyst
Mesenteric Infarct
Bowel Perforation
Acute cholecystitis
Diabetic Ketoacidosis
What are the borders of the femoral canal?
Lateral - Femoral vein
Medial - Lacunar ligament
Anterior - Inguinal ligament
Posterior - Pectineal ligament
What is a Meckel’s diverticulum?
Congenital abnormality resulting from incomplete obliteration of the vitello-intestinal duct.
What is the arterial supply of meckel’s diverticulum?
omphalomesenteric (vitelline) artery
What is the rule of 2s associated with a meckel’s diverticulum?
2% of population
2 inches long
2 feet proximal to the ileocaecal valce
2 times more common in men
2 types of tissue involved (ileal mucosa and ectopic gastric mucosa)
What are the complications of diverticular disease?
Diverticulitis
Haemorrhage
Fistula
Abscess
Faecal peritonitis
Diverticular phlegmon
What is Goodsal’s rule?
Anterior fistulae (9 o’clock to 3 o’clock) will tend to have an internal opening opposite to the external opening
Posterior fistulae (3 o’clock to 9 o’clock) tend to have a curved track that passes towards the midline ie 6 o’clock
What is the purpose of the femoral canal?
to allow for the physiological expansion of the femoral vein which lies lateral to it
What is a Littres hernia?
Hernia containing meckel’s diverticulum
What structures lie in the transpyloric place?
L1 vertebra
Pylorus of stomach
D1 of duodenum
Duodeno-jejunal flexure
Fundus of gallbladder
Neck of pancreas
Root of transverse mesocolon
Hepatic flexure of colon
Splenic flexure of colon
Hilum of spleen
Hila of kidneys
9th costal cartilage
Root of superior mesenteric artery
Splenic vein meets superior mesenteric vein to form portal vein
Termination of spinal cord and start of cauda equina
Cisterna chyli
What are the 4 physiological constrictions to the oesophagus?
A - arch of the aorta
B - Bronchus (left main stem)
C - Cricoid cartilage
D - Diaphragmatic hiatus
What is the arterial supply to thoracic oesophagus?
Branches of the thoracic aorta and inferior thyroid artery (a branch of the thyrocervical trunk)
What is the venous drainage of thoracic oesophagus?
Azygous vein and inferior thyroid vein (systemic venous drainage only)
What is the arterial supply of the abdominal oesophagus?
Left gastric artery and left inferior phrenic artery
What are the 2 venous drainage routes of the abdominal oesophagus?
Portal circulation via left gastric vein
Systemic circulation via azygous vein
What structures lie anterior to the thoracic oesophagus?
Trachea
Left recurrent laryngeal nerve
Pericardium
Thymus
What structures lie posterior to the thoracic oesophagus?
Thoracic vertebral bodies
Thoracic duct
Azygous veins
Descending aorta
What abdominal structures are considered intraperitoneal (completed covered by visceral peritoneum)?
Stomach
D1 of duodenum
Jejunum
Ileum
Transverse colon
Sigmoid colon
Liver
Spleen
What structures are retroperitoneal?
S - Suprarenal glands
A - Aorta + IVC
D - Duodenum (except proximal 3cm)
P - Pancreas (except tail)
U - Ureters
C - Colon (ascending and descending)
K - Kidneys
E - (O)eseophagus
R - Rectum
What is the communication between the lesser and greater sac called?
Foramen of winslow or epiploic foramen
What level is the celiac trunk located?
T12
What is the arterial supply of the lesser curvature of the stomach?
Right gastric artery (coeliac trunk->common hepatic artery->hepatic proper artery->right gastric artery)
Left gastric artery (directly from coeliac trunk)
What is the arterial supply of the greater curvature of the stomach?
Right gastroepiploic artery (coeliac trunk->common hepatic artery->gastroduodenal artery->right gastroepiploic)
Left gastroepiploic artery (coeliac trunk->splenic artery-> left gastroepiploic artery)
What is a richter’s hernia?
When the anti-mesenteric wall of the intestine protrudes causing strangulation without obstruction
When might Rovsing’s sign be absent in appendicitis?
retrocaecal appendicitis
What part of the duodenum is most likely to get duodenal ulcers?
D1
Which part of the duodenum is intraperitoneal?
Proximal 3cm of D1
Macroscopic features of the jejunum that differ from ileum
Located in LUQ rather than RLQ
Thicker intestinal wall
Longer vasa rectae
Less arterial arcades
More red in colour rather than pink
More plicae circulares
What artery supplies arterial blood to the midgut?
Superior mesenteric artery
What artery supplies arterial blood to the hindgut?
Inferior mesenteric artery
At what level does the superior mesenteric artery arise?
L1
What muscle controls the upper oesophageal sphincter? And what is it’s innervation?
Cricopharyngeas muscle
Pharyngeal plexus from recurrent laryngeal nerve (+/- the external branch of the superior laryngeal nerve)
Why are the transverse colon and sigmoid colon more mobile?
Because they are intraperitoneal structures with their own mesentary (transverse mesocolon and sigmoid mesocolon)
What characteristics of the large bowel differentiate it from the small bowel?
Omental appendicies - pouches of peritoneum, filled with fat (more abundant in sigmoid colon)
Teniae coli - 3 longitudinal muscles that converge at root of the appendixe
Haustra - sacculations of colon, formed due to contraction of teniae coli
Larger diameter
Where is the junction between the embryological midgut and hindgut?
2/3 way along the transverse colon
What are the branches of the inferior mesenteric artery?
Left colic artery - divides into ascending and descending branches of left colic artery
Sigmoid branches
Superior rectal artery
What is the most common position of the appendix?
Retrocaecal
Describe the pattern of pain in appendicitis
Inflammation of the appendix causes swelling and stretching of the visceral peritoneum. The visceral peritoneum receives its afferent nerve fibres from T10 so there is referred pain to umbilical region.
As the inflammation advances, it spreads to parietal peritoneum which localises the pain at McBurney’s point
Where is McBurney’s point?
1/3 of the way from the right ASIS to umbilicus
How can you find the appendix during surgery?
Trace the teniae coli back to their root as the 3 longitudinal muscles converge at the appendix
Which part of the large intestine do not have omental appendices?
Caecum
What blood vessels does the transverse mesocolon contain?
Middle colic artery and vein
Which artery provides collateral blood supply to the colon?
Marginal artery of Drummond
What separates the rectum from the sacrum, coccyx, sacral nerves, middle sacral artery and sacral veins?
Waldeyer’s Fascia
What type of epithelium lines the rectum?
Columnar epithelium
What type of muscle makes up the internal anal sphincter?
Smooth muscle
What muscle does the external anal sphincter blend into?
Puborectalis
Where are the anal glands located?
Behind the anal valves which are folds at the lower end of the anal columns (columns of morgagni)
Which part of the anal canal is surrounded by the external sphincter?
Lower 2/3
What is the dentate line?
Also known as the pectinate, it lies along the anal valves.
Separates the endoderm which is superior to the line and the ectoderm which is inferior.
Superior to the line is columnar epithelium and inferior to the line is non-keratinised squamous epithelium.
What type of carcinoma occurs inferior to the dentate line of the anus?
Squamous cell carcinoma
What is the blood supply of the anus superior to the dentate line?
superior rectal artery, branch of the inferior mesenteric artery
What type of carcinoma occurs superior to the dentate line?
Adenocarcinoma
What is the blood supply to the anus inferior to the dentate line?
Inferior rectal artery, branch of the internal pudendal artery
What spinal levels does the rectum lie between?
S3 - Coccyx
What are the 5 ligaments of the liver?
Right triangular ligament
Coronary ligament
Left triangular ligament
Falciform ligament
Ligamentum Teres (round ligament)
What is the ligamentum teres?
A cord like structure that runs between the falciform ligament and the umbilicus. It is a remnant of the fetal umbilical vein and attaches the anterior surface of the liver to the abdominal wall.
Where are the hepatic recesses?
Anatomical spaces where infection can collect and abscess can form.
Left and Right subphrenic space - split by the falciform ligament
Left subhepatic space - supracolic compartment, between inferior surface of liver and transverse mesocolon
Right subheptic space - Morison’s pouch
Morison’s pouch is deepest in supine position so common area for intestinal content to gravitate to in a perforation.
What lies in the porta hepatis?
Hepatic portal vein
Right and Left hepatic arteries
Right and Left hepatic ducts
+/- lymph nodes and nerves
What is the blood supply to the liver?
25% from the hepatic arteries (coeliac trunk -> common hepatic artery -> proper hepatic artery -> right and left hepatic arteries)
75% from hepatic portal vein
What are the borders of Calot’s triangle?
Medial – common hepatic duct.
Inferior – cystic duct.
Superior – cysticartery
What is the criteria for the critical view of safety in a cholecystecomy?
- The hepatocystic triangle is cleared of fat and fibrous tissue
- The lower one third (neck) of the gallbladder is separated from the liver to expose the cystic plate
- Two and only two structures should be seen entering the gallbladder
Where is the common bile duct formed?
Extrahepatic
What is the different between hepatocystic triangle and calot’s triangle?
The superior border in Calot’s triangle is the cystic artery where as the superior border in hepatocystic triangle is inferior surface of the liver
What are the content’s of hepatocystic triangle?
Right hepatic artery
Cystic artery
Lymph node of Lund
Lymphatics
What is the ROME IV criteria for IBS?
Recurrent abdominal pain or discomfort at 3 days per month for the past 3 months associated with two or more of the following:
- Improvement with defecation.
- Onset associated with a change in the frequency of stool.
- Onset associated with a change in the form of the stool.
What is Mirizzi syndrome?
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
What conditions are anal fissures associated with?
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery
What are the borders of the femoral triangle?
Superior - Inguinal ligament
Lateral - Medial border of the sartorius muscle
Medial - Medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle.
What are the extra-intestinal features of inflammatory bowel disease?
A - Aphthous Ulcers
P - Pyoderma Gangrenosum
I - Iritis
E - Erythema Nodosum
S - Sclerosing Cholangitis
A - Arthritis
C - Clubbing
What causes diarrhoea in Crohn’s disease?
Bile salt diarrhoea secondary to terminal ileal disease
Entero-colic fistula
Short bowel due to multiple resections
Bacterial overgrowth
What microscopic feature might be found in a gallbladder that has recurring episodes of cholecystitis and gallstones?
Aschoff-Rokitansky sinuses
Where in the gut is zinc absorbed?
Duodenum and jejunum
What are the features of an obturator hernia?
More common in females, multiparous or those who have recently lost weight
Abdominal contents through obturator foramen
Usually presents with bowel obstruction
Leg held in semi flexion
Pain radiates to ipsilateral knee