General Surgery Flashcards
What is the optimal repair of a large duodenal ulcer perforation?
Jejunal patch (Thal patch), pyloric exclusion, and gastrojejunostomy.
How do symptoms of appendicitis differ from gastroenteritis?
Appendicitis: Anorexia –> abd pain –> n/v
Gastroenteritis: n/v –> abd pain
What is the Iliopsoas test?
pain with extension of right thigh when lying on side = retrocecal appendix
Obturator test
pain with internal rotation of the thigh = pelvic appendix
What are 2 ways to treat a
perforated appendix?
Immediate appendectomy - some evidence says increased risk of bowel obstruction, wound infection, and reoperation
or
Treat with abx and delayed appendectomy
Abx either ampicillin, gentamicin and clindamycin or metronidazole
The 2 most common bacteria associated w/ a perforated appendix?
E. Coli and Bacteroides
What criteria for operative SBO have a higher conversion rate of laparoscopic to open?
When are high-grade SBO’s are normally operated on?
Dilated small bowel > 4cm
If no relief after 2-3 days but post-operative SBO’s are different, prefer to wait 2-3 weeks.
What kind of closures are used for infected fields?
Staged.
Not formal closures
If in cholecystectomy the cystic duct and artery cannot be identified then …?
(3 options)
- Try maneuvers to improved visibility, ie: lateral retraction of infindibulum
- Intraoperative cholangiogram by injecting into infidibulum
- Convert to open
NOT ercp or cbde
Endoscopy stuff:
Pt position and when to rotate scope?
Type of scope?
What positions are ampulla of vater, CBD and pancreatic duct?
Patient starts in left lateral decubitis and then once scope reaches the duodenum the patient is rotated to prone.
A side viewing scope is used.
Ampulla of vater is a small longitudinal nubbin at the 12 to 1 o’clock position
CBD is at the 11 o’clock position
Pancreatic duct is found at 1 o’clock
ERCP’s most common complication is?
Pancreatitis. Usually from the contrast injection causing overfilling of ductules.
What is the optimal repair of a small duodenal ulcer perforation?
Small - primary repair and patch
What is treatment for 2nd portion duodenum strictures if short? If long?
Short are treated with stricturoplasty
Long are treated with gastrojejunostomy and selective vagotomy
What procedures are performed for strictures of small bowel if . . . 5-7cm segment 10-15 segment > 15cm segment Multiple segments
Excluding proximal duodenum? - these are bypassed with a gastrojejunostomy? Confusing. ***
5-7cm segment - Heinecke-Mikulicz stricturoplasty -
10-15 segment - Finney stricturoplasty -
> 15cm segment - Michelassi stricturoplasty -
Multiple segments - resection
How to manage large bowel strictures?
Resection because 7% of large bowel strictures are malignant
After splenectomy symptomatic pancreatic leaks are treated with?
Drainage and abx
What vaccines are given after splenectomy?
Pneumococcal 23 valent - booster dose 4-6 years later and again at 65 if > 5 yrs since last dose
Haemophilus infl vac - no need for repeat vaccination
Meningiococcal vac - booster dose every 5 years
Splenic artery aneurysms should be repaired via ______ in
pregnancy, liver transplant pts, and elderly?
catheter embolization due to increased risk of rupture
MC spleen anatomic variation is?
Short splenic trunk that splits into 6-12 branches entering the spleen, “distributed variant”.
Splenorenal ligament contains?
The splenic vessels and the tail of the pancreas
Describe the types of hernias
Bochdalek
Morgagni
Amyand
Littre
Richter
Indirect
Direct
Femoral
Bochdalek - posterior-lateral diaphragmatic hernia, more common
Morgagni - anterior-medial diaphragmatic hernia, less common
Amyand - assoc. with appendix
Littre - assoc. with a meckel’s diverticulum
Richter - only antimesenteric part of bowel wall
Indirect - patent processus vaginalis - lateral to epigastric vessels
Direct - weak conjoined tendon - medial to epigastric vessels
Femoral - defect in iliopubic tract - forms the anterior and medial border of the femoral canal - inferior to inguinal ligament.
Lichtenstein tension-free hernia repair key points to reduce recurrence and prevent pain?
- use large mesh, 7x15, extend 3-4cm above hesselbach’s triangle, 2cm medial to the pubic tubercle, 5-6cm lateral to the inguinal ring
- cross tails of the mesh behind the spermatic cord lateral to the internal ring
- keep the mesh in a tented or loose fashion
- secure mesh medially to conjoined tendon with 2 interrupted sutures, laterally to inguinal ligament with 1 continuous suture to prevent folding/displacement
- ID nerves throughout operation
- Ilioinguinal nerve (sensation to skin at penis base and upper scrotum) is over the spermatocord
- Iliohypogastric nerve is between the internal and external oblique muscles, visible when spreading these to make room for the mesh
- lateral branch supplies skin over glute
- anterior branch supplies skin above the pubis
- innervates internal and transverse abdominus muscles
- Genital branch of the genitofemoral nerve is under the cord structures. Protected from mesh contact by the cremasteric fascia (important to keep the cremasteric muscle intact if possible).
- genitofemoral nerve is responsible for both the sensory (femoral branch) and motor portions (genital branch) of the cremasteric reflex, which describes contraction of the cremasteric muscle when the skin of the superior medial part of the thigh is touched
What causes ischemic orchitis?
What is treatment?
Venous congestion of pampiniform plexus or disruption of testicular artery.
Tx is NSAIDs and pain relief. Can last up to 12 weeks.
For indirect inguinal hernia repair - the hernia sack is found where anatomically?
Found deep to the cremaster muscle and anterior & superior to the spermatic cord structures.
During laparoscopic inguinal hernia repair, where should you avoid stapling?
What should you do if an enterotomy is made?
The femoral, lateral femoral cutaneous and genitofemoral nerves are found inferior to the iliopubic tract
Can repair, then close and observe on IV abx. If no signs of sepsis then may do delayed mesh placement on POD 3 to 7.
Describe the anatomy of a:
Petit hernia
Grynfelt hernia
Inferior lumbar - External oblique muscle, latissimus dorsi muscle, and iliac crest
Superior lumbar - 12th rub, paraspinal muscle, internal oblique, external oblique
Describe: Rives-Stoppa-Wantz repair Intraperitoneal mesh Preperitoneal mesh Chevrel Onlay
Rives-Stoppa-Wantz repair- mesh goes between the rectus muscle and the posterior rectus sheath. Retrorectus position.
Intraperitoneal mesh - sub-lay of mesh
Preperitoneal mesh - similar sub-lay but mesh is separated from the bowel by peritoneum
Chevrel Onlay - mesh over the fascial repair
Femoral hernia occur mostly in women because?
Describe the anatomy.
What test incites pain?
Who requires repair?
What should be done to reduce the herniated bowel?
Wider bone structure of the female pelvis.
Through femoral canal - inguinal ligament anteriorly, pectineal ligament posteriorly, lacunar ligament medially, and the femoral vein laterally.
Pain with external rotation of thigh
All require repair
Inguinal ligament is often divided to fully reduce the herniated bowel.
What type of hernia repairs are better tolerated from an anterior approach?
epigastric hernia (unlike other types of ventral hernias)
Describe component separation
- elevate skin and subcutaneous tissue from underlying rectus and external oblique muscles, goes from costal margin to pubis and to the anterior axillary line and iliac crest
- incision in the external oblique aponeurosis 2cm lateral to the border of the rectus and external oblique muscles
- external oblique dissected from underlying internal oblique, don’t disrupt neurovascular supply in between internal oblique and the trasnversus abdominis
- IF flap is not sufficient then rectus muscle can be dissected free of its posterior sheath
20cm total release is possible
Image result for component separation steps
For component separation repairs, use of a ______ mesh can prevent recurrence.
If using an intraperitoneal mesh then make it a ______ mesh.
If a crohn’s dz then use a _____ mesh
Avoid _____ repairs due to higher recurrence rates.
prosthetic
composite mesh
retrorectus
Avoid inlay repairs due to higher recurrence rates.
What should you do If short bowel syndrome is a concern during operation?
Then place a gastrostomy tube to allow for continuous feeds if needed later.
What kind of tissue does the ileum contain?
The most prominent amount of lymphoid tissue; therefore, it is the likely location of a small bowel lymphoma.
Recurrence rate for appendicitis?
7%. Interval appendectomies are not done to prevent recurrence, they are more to rule out malignancy.
Lap Appendectomy trocar placement in pregnant patients in
1st trimester?
2nd trimester?
3rd trimester?
1st trimester - normal - Umbilicus, suprapubic, LLQ
2nd trimester - Umbilicus, RLQ, LLQ
3rd trimester - umbilicus, RUQ, RLQ
Lap cholecystectomy trocar placement in pregnant patients in
1st trimester?
2nd trimester?
3rd trimester?
1st trimester - umbilicus, subxiphoid, 2 below right costal margin
2nd trimester - umbilcal trocar moved higher?
3rd trimester - ???
MCC of small bowel bleeding is?
How is it diagnosed?
Treatment?
Associated w/ what disease?
Angiodysplasia.
Usually diagnosed via enteroscopy, but sometimes pill endoscopy is used, not angiography.
Treated with endoscopic directed SB resection.
Increased association with Osler Weber Rendu, vWF deficiency, and renal failure.
What duration qualifies at prolonged air leak?
What is indicated for treatment at this point?
> 4 days
VATS and pleurodesis is indicated.
Light’s Criteria for Exudative Effusions
Pleural:serum fluid protein ratio > 0.5
Pleural:serum fluid lactate dehydrogenase (LDH) ratio > 0.6
Pleural fluid LDH > 2/3 upper limit of normal
What are Glomus tumors?
How are they found?
What signs are used to diagnose them?
Treatment?
- Glomus tumors = AV shunts that respond to temperature changes
- MRI can localize the glomus tumor.
- Love sign (extreme pain on direct focal pressure) is positive.
- Hildreth sign is also positive, which is ablation of pain with proximal tourniquet inflation.
- Treat by Complete excision - results in rapid resolution of symptoms.
