General Surgery Flashcards
Changing point of the external iliac to femoral
Once it passes the inguinal ligament becomes the common femoral
Vessels to avoid in laparoscopy
Inferior epigastric vessels - paired structures
Contents of the Inguinal Canal (Males)
Rule of 3
Arteries - vas, testicular, cremasteric
Nerves - genito-femoral, ilio-inguinal
Fascial Layers - external, cremasteric, internal
Other Things - pampiniform plexus, vas, lymphatics
What is contained in the femoral sheath?
Artery and vein
Nerve travels outside of the femoral sheath
What structures does the inguinal ligament run between?
Pubic tubercle and ASIS
Borders of the femoral canal
Problem with the femoral canal
Femoral vein Lacunar ligament Inguinal canal Pectineus These borders are rigid, there is little room for expansion, high risk of strangulation in femoral hernias
Incarcerated VS Strangulated Hernia
I = hernia is stuck, usually contained within it's sac S = disruption to the blood supply: first venous drainage disrupted then arterial supply > ischaemic
Types of Hernia Fixation (2)
Herniorronaphy = fix the hernia and fix the wall Herniotomy = fix the hernia, do nothing to the wall
Differential of Groin Lump in IVDU (not hernia)
1st. Groin Abscess
2nd. Pseudoaneurysm - will have a thrill and bruit
Clinical Test for Direct vs Indirect Hernia
Result
= control hernia at the deep ring, ask patient to cough
Re-Appears = direct
Doesn’t Re-Appear = indirect
Immediate Hernia Surgery Complications
Bleeding
Anaesthetic Reaction
Bowel Perforation
Early Hernia Surgery Complications
Infection Loss of Testicle (ischaemia) Haematoma Systemic Sepsis Procedure Failure
Late Hernia Surgery Complications
Chronic Pain
Recurrence
PE
Pathophysiology of Femoral Hernias
Most often in elderly ladies who were previously overweight and now are not
The femoral space is now empty and so a small section of bowel slips down
Presentation of Femoral Hernias
Colicky Midgut Pain
Normal AXR
Scrotal Lump VS Hernia
Can get above a scrotal lump
Differentiating Duodenal and Gastric Ulcer
Duodenal ulcer pain relieved by eating
Gastric ulcer pain made worse by eating
Choice of Ix in Appendicitis (Pregnancy)
MRI
Sensitivity of Mammogram and Age
Increases with age
Need to be >40 for mammogram to be helpful/effective
When to use MRI to investigate breast pathology
High risk young patietns
Previous surgery
Paralytic ileus =
= temporary impairment of peristalsis causing obstruction
Most common causes of small bowel obstruction
Adhesions
Incarcerated hernia
Most common causes of large bowel obstruction
Malignant tumours
Volvulus
Presentation of large bowel obstruction
Constipation occurs early
Vomiting occurs late
AXR Findings in Bowel Obstruction
Small bowel >3cm
Colon >6cm
Caecum >9cm
Gallbladder wall thickening =
= inflammation
Can differentiate between biliary colic and acute cholecystitis
Rosving’s Sign
Press in LIF feel pain in RIF with appendicitis
Charcot’s Triad
Fever
RUQ pain
Jaundice
Complications of ERCP (3)
Pancreatitis
Duodenal Rupture
Haemorrhage
Where does haemorrhage come from in ERCP?
Gastroduodenal artery
Risk in popliteal artery aneurysm
Thromboembolism
Infectious causes of aneurysm (2)
Luetic aneurysm - syphilis
Mycotic aneurysm - TB
Mirizzi’s Syndrome =
= gallstone becomes impacted in cystic duct causing extrinsic compression of common hepatic duct
Procedure to allow drainage of Gallbladder
Cholecystostomy
= stoma into gallbladder allows drainage
Stoma Types
Stoma Techniques
- Colostomy, ileostomy, urostomy
- End or loop
Complications of Stoma (5)
Leakage Retraction Prolapse Hernia Mucocutaneous Separation
Artery between SMA and IMA
Marginal artery of Drummond
Means that splenic flexure is at risk of ischaemic colitis
Mesenteric adenitis
= inflamed lymph nodes in abdomen in association with viral illness
Seen in kids
Tests for peritonism (3)
Jump - mainly kids
Cough
Percussion of abdomen
Definition of varicose veins
Dilated
Tortuous
Elongated superficial veins
What is CEA?
What is it raised in?
= carcinoembryonic antigen
- Can be raised in bowel cancer and smokers
Drug which can trigger/worsen IBD flares
NSAIDs
Pressure dependent organs (3)
Brain
Kidneys
Heart
Mild Flare of UC
<4 bowel movements a day
No systemic features
Moderate Flare of UC
4-6 bowel movements a day
No systemic features
Severe Flare of UC
>6 bowel movements a day Temperature >37.8 Heart Rate >90 Abdominal Distension CRP >30 Hb <10.5g/dL
Colon Cancer and UC
If UC >10 years need annual colonoscopy due to ++ cancer risk
Ileal Involvement in UC
Can affect the ileum if there is an incompetent ileo-caecal valve
Surgical Indications in UC
Acute Colitis
Chronic Symptomatic Colitis
Perforation
Neoplasia
Surgical options in UC
- Proctocolectomy with ilionanal pouch formation - most common
- Pan proctocolectomy with end ileostomy - needs a stoma
- Subtotal colectomy with ileostomy - emergency situations
Scoring System Used in Upper GI Bleeding
Rockall Scoring System
Urea in Upper GI Bleed
Disproportionately high compared to kidney function
= GI tract digests the blood producing urea
Dark PR Bleeding + Isolated High Urea
= urgent OGD
Stage of shock associated with confusion
Stage 4
GI bleeding is a risk factor for…
Decompensation of existing liver disease
RIF discriminator
Appetite - reliably reduced in appendicitis
Appendicitis Presentation but Older Age Group
Perforated Caecal Cancer
Reversing Warfarin
Time taken to work
Oral Vitamin K - takes 24 hours
IV 10mg Vitamin K - takes approx 4 hours
INR needed to operate
<1.5
Association of Ovarian Pain
Often mid-cycle, associated with ovulation
Where is McBurney’s Point?
2/3rds between the ASIS and umbilicus
Ix of Choice for Ovarian Pathology
USS
Especially if suspected ovarian torsion
Scoring System Appendicitis
Alvarado’s Score
Especially useful in children - try to avoid imaging children if possible
What is Hartmann’s Procedure?
Reversibility
Uses
= resection of the rectosigmoid colon with closure of anorectal stump
Results in formation of end colostomy
= reversible
Use to treat colon cancer or inflammation
Management of ER+VE Breast Cancers
Pre and perimenopausal - tamoxifen
Post menopausal - anastrozole
Iliac VS Femoral Claudication
Buttock pain = iliac
Calf pain = femoral
Finding in Takayasu’s Arteritis
Pulseless peripheries
Calcium and Glasgow Score
Hypocalcaemia is part of the scoring system
Indicates increased severity
Indications for Endarterectomy
<14 days from event
70-99% stenosis of carotid
Don’t do endarterectomy in 100% stenosis: no risk of embolism
What is amaurosis fugax?
= clot in the ophthalmic artery
An indication for endarterectomy as O.A is a branch of the internal carotid
What is diaphragmatic splinting?
= diaphragm not moving down as much due to abdominal pain or increased abdominal pressure
When do you give antibiotics in pancreatitis?
Only give in necrotising pancreatitis
Formal boundary between upper and lower GI tracts
Duodenojejunal junction
Marked by the ligament of Treitz
Association with Lynch Syndrome
RIGHT sided colon cancers
Associated with achlasia
Squamous cell carcinoma of oesophagus
Nature of carotid occlusive disease
Mostly embolic
Indications for excision of fibroadenoma
> 3cm
Medication used in PAD
Clopidogrel
Findings in amoebiasis (3)
Colonic ulceration
Abdominal pain
Bloody diarrhoea
Association of Primary Gastric Lymphoma
H. pylori
Anatomical source of rectal varices
Superior rectal veins
Signet ring sign
Gastric adenocarcinoma
Complications:
- Crohn’s
- UC
Crohn's = fistulae, abscesses UC = bowel cancer, toxic megacolon
Non-Medical Method to Induce Remission in Crohn’s
Exclusive enteral nutrition
Femoral hernia relative to the pubic tubercle
Below and lateral
Inguinal hernia relative to the pubic tubercle
Above and medial
Borders of Hesselbach’s Triangle
Medial = rectus abdominus Lateral = epigastric vessels Inferior = inguinal ligament
Direct VS Indirect Hernia
Direct goes through the wall of the inguinal canal, will reappear on reduction and occlusion of the deep ring
Indirect goes through the canal itself
INR needed to perform surgery
<1.5
