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Clin Med - II (Surgery) > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Major Layers of the Abdominal Wall

A

Superficial Fascia
Deep Fascia
Peritoneum

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2
Q

Layers of the Superficial Fascia

A

Camper’s

Scarpa’s

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3
Q

Layers of the Deep Fascia

A 
External Oblique
Internal Oblique
Transversus
Abdominus
Transversalis fascia
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4
Q

Right Upper Quadrant

A

Liver
GB
Duodenum

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5
Q

Left Upper Quadrant

A

Spleen

Stomach

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6
Q

Right Lower Quadrant

A

Appendix
Ascending Colon
SI
GU

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7
Q

Left Lower Quadrant

A

LI
SI
GU

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8
Q

Abdominal Arteries

A 
Superior Epigastric
Inferior Epigastric
Superficial Circumflex iliac
Superficial epigastric
External pudendal
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9
Q

Superior Epigastric A.

A

Arises from internal thoracic

Anastomoses with inferior epigastric

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10
Q

Inferior epigastric A.

A

Arises from external iliac

Anastomoses with superior epigastic

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11
Q

Supreficial Circumflex iliac A.

A

Arises from femoral

Anastomoses with deep circumflex iliac

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12
Q

Superficial epigastric A.

A

Arises from femoral

Runs toward umbilicus

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13
Q

External pudendal A.

A

Arises from femoral

Runs toward pubis

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14
Q

Abdominal incision characteristics

A 
Exposure
Flexibility
Closure
Speed
Cosmesis
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15
Q

Flexibility in an incision

A

Ability to extend incision

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16
Q

Closure in terms of abdominal incisions

A

Re-establish strength

Prevent hernia

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17
Q

Cosmesis in terms of incisions

A

Langer’s lines

Skin tension

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18
Q

Abdominal incision - opening

A

Only required exposure
Divide muscle in fiber direction (except rectus)
Avoid nerves
Retract toward NV supply

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19
Q

Abdominal incision - Closing

A 
Midline - Fascia to fascia
Transverse
- Close fascial layers
- Big bites
- Approximate, don't strangulate
- appropriate suture
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20
Q

Common Abdominal Incision - General

A 
Transverse
Vertical
Subcostal
McBurney / Rocky-Davis
Pfannenstiel
Paramedian
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21
Q

Transverse Incision

A 
More physiologic
Along Langer's lines
In direction of muscle tension
Less dehiscence / herniation
Less flexible
Transection of vascular structures
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22
Q

Vertical Incision

A 
Midline (trauma, exlap)
Good exposure
Extendable
No vascular structures
Scarring
More tension on repair
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23
Q

Subcostal Incision

A

Good for upper abdominal organs

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24
Q

McBurney / Rocky-Davis Incision

A

Appendectomy

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25
Q

Pfannenstiel Incision

A

GYN procedures

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26
Q

Paramedian Incision

A

Time consuming
Denervation risk
Weak closure

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27
Q

Laparoscopy - In general

A

Access via ports in the abdomen with video assistance

Dx and therapeutic

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28
Q

Laparoscopy - Types

A

Hasson

Closed Via Visiport

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29
Q

Laparoscopy - Advantages

A 
Less post-op pain
Fewer wound complications
Often outpatient or 1 night stay
Quicker return to ADLs
Decreased ileus
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30
Q

Laparoscopy - Disadvantages

A

Hand-eye coordination
Camera Driver
Limited movement

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31
Q

Laparoscopy - Contraindications

A 
Potential for adhesions
PG
Severe cardiopulmonary dz
Inability to tolerate general anesthesia
Uncorrectable coagulopathy
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32
Q

Laparoscopy - Complications

A

Trocar site bleeding
Injuries upon entry
CO2 embolus
Hernia

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33
Q

Appendectomy - S/s

A 
Periumbilical pain
N/V
Anorexia
RLQ pain
Positive Rosving's
Positive McBurney's Point
Mild leukocytosis
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34
Q

Appendectomy - Clinical dx

A

Hx

PE

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35
Q

Appendectomy - Incision

A

Laproscopic > Open

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36
Q

Appendectomy - Procedure

A

Appendix held up to retraction
Appendix transsected with a GIA stapler
Drain if perforated

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37
Q

Appendectomy - Closure

A

Buried SQ stitch to close skin

May need to close fascia to pt is thin

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38
Q

Appendectomy - No perforation

A

Outpatient

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39
Q

Appendectomy - Perforation

A

Requires at least 1-2 days of IV abx

Then 7-10 days of oral abx

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40
Q

Cholecystectomy - S/s

A 
Pain
- RUQ
- Epigastric 
- Back Pain
Increase after eating 
- N/V/D
- Reflux
Positive Murphy's sign
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41
Q

Cholecystectomy - dx

A

US - RUQ
HIDA Scan
Hx
PE

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42
Q

Cholecystectomy - Incision

A

Laparoscopic > Open

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43
Q

Cholecystectomy - Number of ports & reasons for variation

A

3-4 ports

Cholecystitis vs. cholelithiasis
Pt anatomy & Size

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44
Q

Cholecystectomy - Procedure

A

GB neck is dissected to clearly visualized the cystic duct and cystic A.
Clips are placed & these are ligated
GB separated from the liver via electrocautery
Drain may be placed if bleeding or excessive bile spilage occurs

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45
Q

Cholecystectomy - clousure

A

Buried SQ stitch to close skin

May need to close fascia if pt is thin

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46
Q

Triangle of Calot

A

Common hepatic duct (medially)
Cystic Duct (inferiorly)
Inferior edge of the liver (superiorly)

The cystic A. normally passes through the triangle as well as the Node of Calot

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47
Q

Inguinal Hernia Repair - S/s

A

Inguinal pain
Bulge
Incarceration / strangulation

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48
Q

Inguinal Hernia Repair - Direct

A

Through the posterior inguinal wall
No association with processus vaginalis
Hesselbach’s triangles

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49
Q

Hesselbach’s Triangle

A

Rectus Sheath
Inferior epigastric vessels
Inguinal ligament

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50
Q

Inguinal Hernia Repair - Indirect

A

Through deep inguinal ring & Canal
Protrusion of peritoneum along the spermatic cord
Congenital when processus vaginal remains patent

51
Q

Inguinal Hernia Repair - Procedure

A

Outpatient
Mesh repair most common
Lichenstein
Mesh plug

52
Q

Inguinal Hernia Repair - Lichtenstein

A

Msh sewn in place over the internal oblique but below the external oblique
Slit cut for spermatic cord

53
Q

Inguinal Hernia Repair - Mesh-plug

A

Plug placed into defect (tip first)

54
Q

Inguinal Hernia Repair - Post-op pain

A

6-13% have chronic pain

55
Q

Nissen Fundoplication - S/s

A

Reflux Hernia
Hiatal Hernia
Paraesophageal hernia

56
Q

Nissen Fundoplication - dx

A

Endoscopy
Barium esophagram
24h pH study
Esophageal manometry

57
Q

Nissen Fundoplication - Procedure

A

Laparoscopic > Open
Hernia reduced
Diaphragm repaired
Cauterization of short gastrics

58
Q

Nissen Procedure

A

Fundus wrapped behind the stomach
Upper portion of greater curvature brought up to meet the fundus
Sutures placed

59
Q

Nissen Fundoplication - Post-op

A

1 night stay

Diet restrictions - 2 weeks

60
Q

Small bowel resection - S/s

A 
Abdominal pain
Leukocytosis
SBO
Mass
Free air
Air-fluid levels
Bleeding of unknown origin
Transition point
61
Q

Small bowel resection - Cause

A

Ischemia

Adhesions

62
Q

Small bowel resection - dx

A

XR
SBFT
CT (PO / IV)
Clinical presentation

63
Q

Small bowel resection - Procedure

A

Exploratory laparotomy
Vertical midline incision
GIA stapler used to transect bowel on both sides of the diseased bowel
Ends reattached with stapler

64
Q

Small bowel resection - Closure

A

0 or 2-0 monofilament used to close fascia

Stapler to close skin

65
Q

Small bowel resection - Post-op

A

5-7 day hospital stay

66
Q

Colonoscopy - In general

A 
Most accurate dx tool for colonic pathology
Primary modality for evaluation of 
- Lower GI bleeding of unknown etiology
- Inflammatory bowel dz
- Stricture
- Post-tumor removal 
- Pseudo-obstruction
- Polyps
- Unequivocal barium enema findings
Allows visualization of the entire colon, rectum and last few cm of the terminal ileum
67
Q

Colonoscopy - Therapeutic options

A 
Polyp removal
Colonic decompression
Structure dilation
Hemorrhage control
Foreign body removal
68
Q

Colonoscopy - Preparation

A

Bowel Prep

Mild sedation

69
Q

Colectomy - Causes (in general)

A

Diverticulitis / Diverticulosis
Carcinoma
Volvulus
UC

70
Q

Colectomy - Diverticulitis / Diverticulosis

A

2 or more bouts that require hospitalization

May require temporary diverting colostomy

71
Q

Colectomy - Carcinoma

A

Type depending on location of tumor

72
Q

Colectomy - Closure

A

GIA stapler used on both sides of the affected tissue
Healthy bowel is reattached
Colostomy / ileostomy if needed

73
Q

Colectomy - Post-op

A

5-7 days

74
Q

LBO is almost always

A

A tumor

75
Q

When performing a colectomy for colon ca it is important to recall that operative resection is dictated by

A

Lymphatic drainage patterns that parallel the blood supply

76
Q

Diagnostic laparoscopy - In general

A

In the top 5 of all general sx performed

77
Q

Diagnostic laparoscopy - Indications

A

Abdominal pain of unkonwn origin

Everything has been r/o

78
Q

Diagnostic laparoscopy - Procedure

A

Look for adhesions and take them down
Run the bowel
Most often outpatient

79
Q

Breast bx - Indications

A

Lumpectomy if tumor <4cm

80
Q

Breast bx - Axillary staging

A

Noninvasive (DCIS) dz does not require axillary staging

81
Q

Breast bx - Contraindications

A

Dermal lymphatic involvement
Diffuse or multiple tumors
Unwillingness or inability to undergo radiation therapy
Expectation of an unacceptable cosmetic result

82
Q

Breast bx - Procedure

A

Outpatient

83
Q

Breast bx - Additional interventions

A

Mastectomy is an option / necessity

Chemo & radiation may be necessary

84
Q

Lesion / Mass excision - Indications

A

Used to remove a variety of lesions

  • Sebaceous cyst
  • Mole
  • Melanoma / other skin ca
  • Lipoma, etc
85
Q

Lesion / Mass excision - In office vs. sx suite

A

Office & OR

Depending on size and location as well as need for pain control or anesthesia

86
Q

Lesion / Mass excision - Incision

A

Linear - lipoma
Ellipse
- Removal of other lesions
- 4:1 or 3:1 ratio to ensure proper closure of skin (don’t be afraid to make a big incision)

87
Q

Lesion / Mass excision - Anesthesia

A

Once size of excision is determined, local anesthesia is administered

88
Q

Lesion / Mass excision - Procedure

A

Full-thickness skin and SQ tissue are excicsed in the case of a potentially malignant lesion

89
Q

Lesion / Mass excision - Closure

A

Closure of deeper tissue with absorbable suture
Skin closure with 4-0 monofilament for SQ stitch or 3-0 for running or interrupted sutures
Skin glue / steri-strips for buried closures

90
Q

Sleeve gastrectomy - in general

A

Weight loss sx

Laparoscopic

91
Q

Sleeve gastrectomy - procedure

A

About 85% of the stomach is removed creating a tube or sleeve
Includes the portion which produces ghrelin
No cutting or rerouting of intestine

92
Q

Ghrelin

A

Hunger stimulating hormone

93
Q

Sleeve gastrectomy - post-op

A

50-60% of excess weight in the first 8 months

94
Q

Roux-en-Y Gastric Bypass - In general

A

Weight loss procedure (can be done for other things / reflux after other failed sx)

95
Q

Roux-en-Y Gastric Bypass - Procedure

A

Stoma is created using the upper portion of the stomach, stapling off the rest
Ileum is divided as well
Distal segment of the ileum is attached to the stoma, bypassing the absorption, resulting in weight loss

96
Q

Roux-en-Y Gastric Bypass - Post-op

A

Rapid weight loss

60-70% of excess weight

97
Q

Thyroidectomy - Surgeon

A

Usually ENT

98
Q

Thyroidectomy - Indications

A

Tx

  • Thyroid ca
  • Thyroid nodules
  • Hyperthyroidism
99
Q

Thyroidectomy - Procedure

A

All of just a portion of the thyroid can be removed

100
Q

Thyroidectomy - Post-op

A

Total - requires thyroid meds

Subtotal - may or may not require thyroid meds

101
Q

Vascular sx - Overall

A

Tx via angiography, stenting, sclerotherapy & endovenous laser tx are rapidly replace major sx
Reduced stays, lower costs, lower morbidity & mortality
Sx still common for carotid stenosis, open AAA repair, ischemic limbs that are responsive to stenting artherectomy

102
Q

Maintenance Fluids - ml/h

A

4 x 1st-10kg
2 x 2nd-10kg
1 x remaining kg

103
Q

Maintenance Fluids - daily amount / 24h

A

100 ml x 1st-10kg
50 ml x 2nd-10kg
20 ml x remaining kg

104
Q

Carcinoma of the sigmoid colon causes high-graded obstruction. What is the classic finding on radiologic study?

A

Apple core leision

105
Q

S/S of damage to the Mandibular branch of the facial nerve

A

Inability to raise the corner of the mouth

106
Q

S/S of damage to the glossopharyngeal N.

A

Horner syndrome

Decreased gag reflex

107
Q

S/S of damage to the recurrent laryngeal N.

A

Hoarseness

108
Q

S/S of damage to the superior laryngeal N.

A

Voice fatiguability

109
Q

S/S of damage to the Hypoglossal N.

A

Deviation of the tongue to the side of injury

110
Q

What is the most common emergent sx procedure?

A

Appendectomy

111
Q

What determines whether or not a penetrating neck injury must be further investigated, ie taken to the OR?

A

Any kind of penetrating neck injury

112
Q

What anatomic landmark is located at the duodenal-jejunal junction?

A

Ligament of Treitz

113
Q 
Which of the following is indicative of appendicitis?
A. T103.5, WBC 19.2
B. T100.3, WBC 13.6
C. T97.4, WBC 18.1
D. 98.9, WBC 8.7
A

B

114
Q

What percentage fo breast ca develop in the upper outer quadrant?

A

50%

115
Q

Signs of necrotizing soft tissue infection

A

Rapid progression of soft-tissue infection
Marked hemodynamic response to infection
Apparent cellulitis with ecchymosis, bullae, dermal gangrene and crepitus

116
Q

What is the most important step in dx and tx necrotizing soft tissue infection?

A

Cut it out

117
Q

How could placement of a trocar through the epigastric vessel be avoided?

A

Illuminate the abdomen

118
Q

What organ is at greatest risk for injury during a laparoscopic nissen fundoplication?

A

Spleen

119
Q

Using an isotope injected in the tumor region can help identify the first LN drainage the area. This can be used to eval for metastatic dz. This node is called what?

A

Sentinel node

120
Q

Four basic parts of sx

A

Rounds
OR
Clinic
Call

121
Q

Rounds

A

May be expected to round each morning. You will need to pre-round & be done by the time the surgeon is ready to round.
Vitals, labs, I&Os, direct exam
Post-op pts - pain, N/V, flatus, BM, activity
Know diet, abx, culture, IV fluids
Present SOAP format, 1-2 min.

122
Q

OR

A

TEAMWORK
Look for opportunities to learn from the whole team, IV, foley, intubations, etc
ASK - if you want to learn
Be attentive during the case. Take your cues from the team, know when to speak and when to be be quiet & observe. Ask your questions later.
Introduce yourself to the OR staff
Get you gown & glove for the tech
Bring a lock for your locker!

123
Q

Clinic

A

W/o clinic you don’t have pts to operated on (Necessary evil)
Gives you a chance to follow pts through the entire process
Start by following the surgeon or the PA. You will be expected to do complete H&P’s and present your findings after a few days

Clin Med - II (Surgery) (10 decks)

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