General Surgery Flashcards
Surgical complications
Immediate(intra-op/<24hrs)/early(<30days)/late(>30days)
Immediate (intra-op / within 24hrs);
- Anaesthetic complications
- Bleeding - 1° / reactionary
- Basal collapse / atelectasis
Early (within 30 days);
- Bleeding - 2°
- Infection
- Urinary retention
- Immobility - DVT, sores
- Paralytic ileus
- Pain
- Basal collapse / atelectasis
Late (>30 days)
- Infection
- Failure / Recurrence
- Scarring
- Herniation
- Adhesions
Post-op infection
Risk factors
(preop/intraop/postop)
-
Pre-op
- Age
- Comorbidities (DM)
- Pre-exist infection (appendix perf)
- Pt colonisation (MRSA)
- Immunosuppression
-
Intra-op
- Op classification (emerg / elective)
- Duration;
- Technical aspects (pre-op abx)
- Post-op
- Contamination of the wound
Causes of post op hypoxia/SOB
lung/systemic/exac
-
Lung related
- PE / DVT
- Pneumothorax
-
Systemic
- Infection - sepsis or LRTI
- Resp depression - Pain or opiates
-
Exacerbation of pre-existing condition
- COPD
- HF & Fluid overload
Causes of post op fever (7Cs)
Persistent, >38°, >24hrs post surgery
Persistent, >38°, >24hrs post surgery
Infection / fever (7Cs)
- Cut - infection / wound dehiscence
- Chest - pneumonia
- Collection (subphrenic, pelvic; anastomotic leak)
- Catheter - UTI
- Cannula - superficial thrombophlebitis
- Central line / CVP
- Calves (DVT)
What types of healing do you know
primary/secondary/tertiary
Primary intention:
- Most surgical wounds
- Excision and closure (sutures / staples) - edges approximated
- Minimizes scarring
Secondary intention: e.g. pressure ulcers
- Wound left open, granulation from bottom up
- When wound edges cannot be approximated
- Can pack wound with gauze or use drainage system.
- Broader scar, slower healing process
Tertiary intention (combination of 1° & 2°):
- Purposely left open and closed at a later date
Definition of Wound dehiscence
Definition: Surgical complication in which wound RUPTURES along surgical suture.
Causesof poor wound healing
local/systemic
- Local:
- limited moisture
- mechanical factors
- ischaemia
- foreign bodies-drains
- oedema
- infection
- systemic
- metabolic
- DM
- mineral deficiencies (bit C)
- Drugs:
- steroids
- chemotherapy
- Tissue health
- radiotherapy
- underlying disease
- tissue hypoxia e.g. PVD
- Renal failure
- metabolic
Definition of a hernia
A protrusion of a viscus or part of a viscus through a defect in its walls into an abnormal position
List three complications of a hernia
Incarceration, strangulation, bowel obstruction
define incarceratoin of a hernia
An irreducible hernia
Often painful
Can lead to strangulation
define strangulated hernia
Impaired blood supply to the hernial contents
Surgical emergency - risk of perforation
definition of incisional hernia
and risk factprs; pre-op/op/postop
Extrusion of peritoneum and abdominal contents through a weak scar on the abdominal wall, representing a partial wound dehiscence where the skin remains intact.’
-
pre-op:
- age
- immunocompromise: steroids, renal failure, DM
- Obesity
- Malignancy
- Abdominal distension (obstruction/ascites)
-
Operative:
-
poor wound closure:
- too small bites
- inapropriate suture material
- placing drains through wounds
- site
- length of wound
-
poor wound closure:
-
Post-op:
- wound heamatoma
- wound infection
- early mobilization
- post-op atelectasis
- chest infection (raised intra-abdo pressure)
What’s the difference between indirect and direct inguinal hernias?
Direct:
- Weak point in abdominal wall (Hesselbach’s triangle)
- Medial to inferior epigastric vessels (surgical landmark)
Indirect (>2/3 inguinal hernias)
- Patent processus vaginalis
- Lateral to inferior epigastric vessels
- Via deep ring
Inguinal hernias Hasselhoff’s triangle
Laterally: inferior epigastric artery
Medically: lateral boder of rectus abdominis
Inferiorly: base induinal ligament
Inguinal canal contents
male vs female
Male
- Spermatic cord
- Ilioinguinal nerve
Female
- Round ligament (-> gubernaculum in labia maj),
- genital branch of the genitofemoral nerve
- Ilioinguinal nerve
contents of spermatic cord
- Three arteries:
- Testicular (from aorta)
- Cremasteric (from inf epigastric)
- Artery to the vas (from inf vesical)
- Three veins:
- Pampiniform venous plexus (R-> IVC; L -> L renal vein)
- Cremasteric vein;
- Vein of the vas
- Two nerves:
- Genital branch of the genitofemoral nerve -> cremaster
- SNS & PNS from T10 & 11
- (Iliioinguinal nerve - runs on the spermatic cord after entering canal via the anterior wall)
- Three coverings (fascia):
- External spermatic - from ext. oblique aponeurosis
- Cremasteric - from int oblique aponeurosis
- Internal spermatic - from the transversalis fascia
- Three other things:
- Lymphatics;
- Vas deferens
- Obliterated processus vaginalis
2 nerves involved in inguinal hernias
route + supply?
-
Ilioinguinal nerve (L1)
- Enters inguinal canal directly, not through the deep ring
- Exits through superficial ring
- Supplies skin at root of penis & scrotum / labia majora, and skin of upper inner thigh
-
Genital branch of GF nerve (L1,2)
- Supplies cremaster muscle
- Scrotal skin / labia majora
How woulld you distinguish inguinal from femoral hernias
- Inguinal hernias
- SUPERIOR to the PT
- Cough impulse toward the groin
- Femoral hernias
- INFERIOR to the PT
- Cough impulse down
Clinically how would you distinguish indirect and direct inguinal hernias?
Reduce the hernia then put pressure at the deep inguinal ring (midway between pubic tubercle and anterior superior iliac spine). Allegedly, if it remains reduced it’s indirect
One study had 56% of direct hernia wrongly classified as indirect on clinical examination by cons surgeons –> SURGERY or IMAGING is definitive
What is a fistula
An abnormal connection between two epithelial surfaces Eg: Colo-vesical, colo-colic, entero-colic, mucous fistula, vascular, Cholecystoenteric (Mirizzi synd), anal
What are some causes of fistulae (4)
- Malignancy
- Diverticular disease
- Crohn’s
- Abscess
What is the management of a fistula:
SNAP
S - sepsis (ABC; S6)
N - nutrition
A - anatomy (imaging)
P - planning (op)
They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall’s rule in relation to internal and external openings
What is a sinus
Blind ended tract between an epithelial surface and a cavity lined with granulation tissue
What does this barium swallow show
Distal oesophageal malignancy
RF for the two types of oesophageal malignancy
- Adenocarcinoma (Cauc; M>F)
- Barrett’s oesophagus
- GORD
- Alcohol & smoking (more SCC)
- Obesity & prior radiation
- SCC
- Alcohol & smoking
- Dietary nitrosamines - pickled food, BBQ
- Achalasia, coeliac, Plummer-Vinson (Paterson-Kelly)
- HPV
Management of oesophageal malignancy
(early and advanced disease)
-
Early disease (curative intent)
- Surgical resection +/- neoadjuvant CT
- +/- Radiotherapy for SCC
-
Advanced stage (palliative mx)
- Dilatations, stenting
- Tumour ablation (laser or Ar beam)
- CT & RT
What do you see?
What for?
Name surgeries?
indications for oesophagectomy (4)
- Malignancy
- Carcinoma (early) - middle (sub-carinal) and distal third
- Barrett’s with high grade dysplasia
- Neuromotor dysfunction
- Achalasia, oesophageal spasm / dysmotility
- Trauma / irritation
- Caustic injury / burn
- Acute perforation
- Recurrent reflux / hiatal hernia
- Narrowing
- Stricture
- Scleroderma
Pancrestits: (summarised)
types/cause/comp
- Types; Acute and chronic
- Causes
- I GET SMASHED
- Alcohol and gallstones mainly
- Complications
- Of the pancreatitis
- Acute - recurrence, chronic disease, sepsis, necrosis
- Chronic - pseudocyst formation, haemorrhage, pain
- Of the cause
- Alcohol - affects multiple systems
- Gallstones - biliary disease
- Of the pancreatitis
Biliary tree anatomy (and site of gallstones)
*
Biliary disease; gallstones (summarised)
- Imaging -
- Signs and symptoms:
- Mx:
- Imaging - CT and USS; not radiopaque
- Signs and symptoms: RUQ pain + Courvoisier’s law - pancreatic ca vs gallstones
- Mx:
- Conservative, medical, surgical
- Cholecystectomy - open (5%) or laparoscopic
- MCRP / ERCP - if suspect stone in CBD
- Percutaneous cholecystostomy
Complications of gallstones disease:
of stones
Of intervention
gallstones comp:
- Pancreatitis
- Cholecystitis
- Ascending cholangitis;
- Charcot’s triad - Fever + RUQ pain+ Jaundice
- confusion & shock -> Reynold’s pentad
- Empyema
Of interventions
- Cholecystectomy - General & specific
- Damage to local structures
- CBD, hepatic artery, hepatic duct
- Damage to local structures
- ERCP
- Perforation (duodenum)
- Pancreatitis
- Percutaneous cholecystostomy
- Surgical complications
lable the colonic resections
What procedure is this?
indications and signs
Hartmans
indications: perforated diverticulus/obstruction
signs: midline scar + end colostomy LIF/Scar (if reversed) + anus intact
What procedure is this
indications
signs
anterior resection of the sigmoid
indication: elective sigmoid malignancy
signs: midline/laparoscopic scars (+/- ileostomy/scar in RIF)
What is this procedure
indications
signs
abdominoperineal resection of the rectume
indications: low lying <2-5cm sigmoid/rectal malignancy
signs: miline/lap scar + end colostomy + anus overswen
- R hemicolectomy
- Indication - caecal / asc colon ca
- Signs - midline / laparoscopic scars
- L hemicolectomy
- Indication -
- Signs -
- Subtotal colectomy
- Indication -
- Signs -
- Total colectomy (Panproctocolectomy)
- Indication -
- Signs -
- R hemicolectomy
- Indication - caecal / asc colon ca
- Signs - midline / laparoscopic scars
- L hemicolectomy
- Indication - desc colon ca
- Signs - midline / laparoscopic scars; +/- loop ileostomy
- Subtotal colectomy
- Indication - UC, toxic megacolon
- Signs - midline scar; end ileostomy; +/- mucous fistula; anus intact
- Total colectomy (Panproctocolectomy)
- Indication - Toxic megacolon (non-acute; completion); ischaemic bowel; AFP (malignancy risk; monitoring)
- Signs - midline scar; end ileostomy; anus oversewn
Stomas assessment
Stoma indications
Ileostomy
- Site:
- Appearance:
- Lumens:
- Single -
- Double -
- Output:
- Indication
- Temporary :
- Permanent (end ileostomy):
- *
- Temporary :
Ileostomy
- Site: Usually right iliac fossa
- Appearance: Spout of bowel protrudes ~3cm (irritant small bowel contents)
- Lumens:
- Single - end ileostomy
- Double - defunctioning loop ileostomy
- Output: Liquid faeces, alkaline pH
- Indication
- Temporary (defunctioning loop ileostomy):
- Protect distal anastomosis - Sub-total colectomy, anterior sigmoid resection, Hartmann’s reversal
- Bowel rest in Crohn’s
- Permanent (end ileostomy):
- Panproctocolectomy (excision of colon & rectum), unless pouch reconstruction (IPAA)
- UC (toxic megacolon), FAP, ischaemic bowel
- Temporary (defunctioning loop ileostomy):
what is this (2 wordS)
end ileostomy
What is this
(2 words)
loop ileostomy
Colostomy
- Site:
- Appearance:
- Output:
- Lumens:
- Double -
- Single -
- Double -
- Indication
- Temporary:
- Permanent:
*
- Permanent:
- Temporary:
Colostomy
- Site: Usually LIF
- Appearance: Bowel mucosa lies flush with the skin
- Output: Solid faecal content
- Lumens:
- Double - defunctioning loop colostomy
- Transverse colostomy (RUQ) - ca rectum that is likely to obstruct
- Single - end colostomy
- Double - defunctioning loop colostomy
- Indication
- Temporary:
- Hartmann’s (rectum still intact) - sigmoid ca, diverticulitis, IBD involving colon
- Permanent:
- AP resection (anus sewed over)
- Temporary:
What do you see
(2 words)
end colostomy
what do you see (2 words/on the R what is also seen)
loop colostomy
loop colostomy -with plastic bridge
Complications of stomas
(stomas/around/systemic)
- stoma itself:
- prolapse
- retraction
- obstruction
- stenosis
- around the stoma
- parastomal herniation
- dermatitis
- systemic:
- high output electrolyte imbalance & dehydration
- psychological
What stoma complication do you see?
parastomal herniation
what stoma complication do you see?
ileostomy prolapse
What stoma complication do you see?
dermatitis
signs and diagnosis
- stoma in LIF
- flush to skin
- single lumen
- no bag- cannot comment on output
- midline scar:
- well healed
end colostomy and midline laparotomy scar
- differential:
- hartmann’s procedure
- abdominoperineal excision of the rectum (APER)
NOT an anterior resection of the sigmoit: AR does not bring out colostomy
MAY being out a defunctioning proximal stoma, more likely ileostomy
signs and diagnosis
- stoma in the RIF
- spouted
- single lumen
- no bag - cannot comment on output
- laparoscopic port sites on L of abdomen
- Drain
- Differential:
- subtotal colectomy
- panproctocolectomy
signs and differntial
- stoma LIF: healed
- Stoma: RIF: healed
- Midline scar: well healed
- Differential:
- Reveral of hartmann’s procedure:
- desc colon connected to rectal stump
- +/- defunctioning loop ileostomy
- reversed loop colostomy with healed loop ileostomy:
- post -obstruction but unlikely
- Reveral of hartmann’s procedure:
signs and diagnosis
- laparoscopic scars
- stoma: RIF
- healed-could have been end or defunctioning
differential diagnosis:
- anterior resection of the sigmoid, defunctioned and reversed
- panproctocolectomy with ileal pouch anal anastomosis (IPAA)
Indications for Panproctocolectomy with IPAA
- IBD- UC
- NOT CROHN’s
- disease would RECURR!!! in pouch and likely fistula between pouch and surrounding structures
four cardinal features of bowel obstruction
- abdo pain
- absolute constipation
- distension
- vomiting
bowel obstruction
- causes:
- *
- *
- *
- management
- conservative
- surgical
- *
- conservative
bowel obstruction
- causes:
- small bowel:
- adhesions, hernias, ileus
- large bowel
- volvulus, malignancy
- small bowel:
- complications
- perforations
- management
- conservative
- drip and suck
- surgical
- defunctioning
- 1 surgery - adhesionlysis
- volvulus decompression
- conservative
Aproach to small bowel obstruction; 1 liner
classification (2)
- Surgical emergency + call for help + ABC assessment
- classification:
- non-mechanical:
- post surgical ileus
- metabolic
- hypokalaemia
- uraemia
- hyperglycaemia
- hypothyroidism
- Mechanical:
- lumen
- gallstones
- meconium
- intussusception
- fb
- faecal impaction
- In the wall: (mural)
- strictures
- IBD
- diverticulitis
- cancer
- outside the wall:
- adhesions
- hernias
- volvulus
- cancer
- lumen
- non-mechanical:
Large bowel obsturction
causes
luminal/mural/extramural
- `luminal:
- `faecal impaction
- mural:
- `strictures
- IBD
- diverticulitis
- cancer
- extramural:
- `(adhesions)
- hernias
- volvulus
- cancer\
VSHiT
Volvulus Strictures Hernias Inflammatory Bowel Disease (Crohn’s, UC) Tumours
SBO management
conservative
medical
surgical
- Conservative:
- IV fluids
- NG ryles tube
- urinary catheterisation for fluid balance
- medical:
- iv antibiotics
- anti-emetics
- analgesia
- gastrograffin
- correct metabolic causes
- surgical:
- adhesiolysis
- hernia repair
SBO in VIRGIN abdo is indicated for diagnostic laparoscopy (pos band adhesion)
define:
- Diverticulosis;
- Diverticular disease;
- Diverticulitis;
- Diverticulosis; presence of diverticuli
- diverticular disease; presence of symptomatic diverticuli (recurrent abdominal pain)
- Diverticulitis;acute inflammation +/- perforation
Management of diverticular disease
cons
+
surgical
- Cons:
- abx - anaerobic and GN cover
- Surgical:
- Harmann’s
complications of diverticular disease
- of the disease;
- infection
- perf; sepsis and peritonitis
- haemorrhage
- abscess
- fistulae
- strictures
- of intervention:
- conservative-failure
- surgical - risks of surgery
Describe the scar
- 20-30 cm oblique incision over the R flank
- staples are still in situ
- indicating surgery was recent and certainly less than 10-14 days old
- the wound looks clean and dry with no disharge, pus or erythema
- This incision would be consistent with recent urolophocal surgery, perhaps a nephrectomy
classifications and indications for nephrectomy:
simple
radical
partial
nephrourectomy
-
Simple nephrectomy - removal of kidney; oblique scar/laparoscopic ports
- indications:
- non functioning - hydronephrosis, malignancy, pyelonephritis
- PKD - infection/h’gge into cyst
- donation of kidney
- to allow room for transplanted kidney
- indications:
-
Radical nephrectomy - removal of kidney, perinephric fat and adrenal
- paramedian scar with superior abdomen horizontal incision
- indications; renal malignancy
-
partial nephrectomy - removal of part of kidney only
- indications:
- solitary kidney/renal impairment
- indications:
-
Nephrouretectomy - removal of kidney and ureter
- indication:
- TCC
- indication:
Nephrectomy
complications
gen/spec
- General surgical complications
- e.g. pain bleeding, scarring, infection, recurrence, VTE
- Specific complications:
- urinary leak
- damage to local structures:
- nerves
- arteries & veins
- lymphatics
- viscera
Describe the scars
Laparoscopic donor nephrectomy
Pfannenstiel incision for removal
What is this?
Nephrostomy: artificial opening between skin and kidney at the level of the renal pelvis, alowing urinary drainage
(lowe level = urostomy)
Indications for nephrostomy
- hydronephrosis
- pyonephrosis
- stricture
- fistula
- stone: staghorn calculus
- obstructing malignancy- ovarian and colon
Say what you see
I note a well healed midline scar
there is a stoma, spouted in the RIF which looks pink and hgealthy
there is liquid output into a tapped bag
There may be an element of parastomal herniation but the stoma itself is not protruded or restracted
This would be consistent with urological surgery, perhaps an upper tract diversion, specifically an ileal conduit following cystectomy
What is an upper tract diversion (ileal conduit)
ureters joined to isolated segment of small bowel
brought out to right anterior abdominal wall
what is an upper tract diversion with reconstructed neobladder
small bowel pouch made into new ‘bladder’ and joined to urethra
upper tract diversion indications
bladder cancer requiring cystectomy
neurogenic bladder (threaten renal function)
severe radiation injury to the bladder
intractable incontinence in females
chronic pelvic pain syndromes
neobladder vs consuit; pt and bowel dependent
