Generic surgical topics Flashcards
Definition, cause and managment of Abdominal Compartment Sydrome?
1) Sustained intra abdominal pressure coupled with new organ dysfunction/failure 2) Intestinal ischmia or following a surgical procedure. Diagnosed by transvesical pressure measurements 3) Gastric decompression, muscle relaxants/sedation for increase in abdominal wall compliance, Drain abdominal fluid collections, consider fluid restriction/diuretics if clinically indicated. 4) Failure of non surgical treatment, laparatomy,laparostomy, delayed closure
Borders of the femoral canal
Laterally- Femoral vein Medially- Lacunar ligament Anteriorly- Inguinal ligament Posteriorly- Pectineal ligament
Spigelian hernia
Interparietal hernia occurring at the level of the arcuate line Rare May lie beneath internal oblique muscle. Usually between internal and external oblique Equal sex distribution Position is lateral to rectus abdominis Both open and laparoscopic repair are possible, the former in cases of strangulation
Lumbar hernia
The lumbar triangle (through which these may occur) is bounded by: Crest of ilium (inferiorly) External oblique (laterally) Latissimus dorsi (medially) Primary lumbar herniae are rare, most are incisional hernias following renal surgery - Direct anatomical repair with or without mesh re-enforcement is the procedure of choice
Obturator hernia
Herniation through the obturator canal Commoner in females Usually lies behind pectineus muscle Elective diagnosis is unusual most will present acutely with obstruction When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated)
Richters hernia
Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type) They do not present with typical features of intestinal obstruction as lumenal patency is preserved Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate)
Incisional hernia
Occur through sites of surgical access into the abdominal cavity Most common following surgical wound infection To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described
Bochdalek hernia
Typically congenital diaphragmatic hernia 85% cases are located in the left hemi diaphragm Associated with lung hypoplasia on the affected side More common in males Associated with other birth defects May contain stomach May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high
Morgagni Hernia
Rare type of diaphragmatic hernia (approx 2% cases) Herniation through foramen of Morgagni Usually located on the right and tend to be less symptomatic More advanced cases may contain transverse colon As defects are small pulmonary hypoplasia is less common Direct anatomical repair is performed
Paraumbilical hernia
Usually a condition of adulthood Defect is in the linea alba More common in females Multiparity and obesity are risk factors Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation
Umbilical hernia
Hernia through weak umbilicus Usually presents in childhood Often symptomatic Equal sex incidence 95% will resolve by the age of 2 years Surgery performed after the third birthday
Littres hernia
Hernia containing Meckels diverticulum
Resection of the diverticulum is usually required and this will preclude a mesh repair
Common causes of Biliary disease in HIV
sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV
Mnemonic for the assessment of the severity of pancreatitis: PANCREAS
P a02 < 60 mmHg A ge > 55 years N eutrophils > 15 x 10/l C alcium < 2 mmol/l R aised urea > 16 mmol/l E nzyme (lactate dehydrogenase) > 600 units/l A lbumin < 32 g/l S ugar (glucose) > 10 mmol/l >3 means severe
Parotid- What is Benign pleomorphic adenoma? How is it treated?
Most common. Pleomorphic adenomas a usually benign tumours. However, they will enlarge over time and a proportion can undergo malignant transformation. superficial parotidectomy
Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)
Second most common Biilateral enlargement of parotid glands Marked male as compared to female predominance Occurs later in life (sixth and seventh decades)
Monomorphic adenoma
Account for less than 5% of tumours Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas
Haemangioma
Should be considered in the differential of a parotid mass in a child Accounts for 90% of parotid tumours in children less than 1 year of age Hypervascular on imaging Spontaneous regression may occur and malignant transformation is almost unheard of
Nerves at risk of Branchial cyst excision?
Greater auricular Mandibular branch of facial nerve accessory nerve
What is the blood supply of dura?
Middle meningeal, passing through foramen spinosum
Ruptured ACL presentation
Sport injuries High twisting force applied to a bent knee Typically presents with oud crack, pain and rapid joint swelling (Haemoarthrosis) Poor Healing Mx: Physio or surgery
Ruptured posterior cruciate ligament
Hypertension in juries Tibia sinks back Paradoxical anterior draw test
Ruptered medial collateral
Forced valgus via force Knee unstable when put inot valgus
Menisceal tear
Rotational sporting injuries Delayed knee swelling Joint locking when knee extended
Recurrent episodes of pain and effusions Minor trauma
Dislocation of patella
Traumatic primary event, Either through direct trauma or through severe contraction of quadriceps with knee valgus and external rotation Genu valgum, tibial torsion and high riding patella are risk Skyline x-ray views of patella are required, although displaced patella are risk factors An osteochondral fracture is present in 5% The condition has a 20% recurrence rate
Fractured patella
2 types 1) Direct blow to patella causing undisplaced fragments 2) Avulsion fracture
Tibial plateau fracture
occur in elderly Knee forced to valgus or varus, but the knee fractures before the ligaments rupture Varus injruy affects medial plateau and if valgus injury,late depressed fracture occurs
Schatzer Classification?
Stages of fracture healing
Bleeding vessels in the bone and periosteum
- Clot and haematoma formation
- The clot organises over a week (improved structure and collagen)
- The periosteum contains osteoblasts which produce new bone
- Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture
- Connective tissue + hyaline cartilage = callus
- As the new bone approaches the new cartilage, endochondral ossification occurs to bridge the gap
- Trabecular bone forms
- Trabecular bone is resorbed by osteoclasts and replaced with compact bone
Monteggia’s fracture
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
Causes of avascular necrosis
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
Catterall staging
Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity
SALTER HARRIS GRADING
I ‘S’ = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II ‘A’ = Above. The fracture lies above the physis, or Away from the joint.
III ‘L’ = Lower. The fracture is below the physis in the epiphysis.
IV ‘TE’ = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V ‘R’ = Rammed (crushed). The physis has been crushed
What is the Kocher Criteria?
Kocher criteria
- Non weight bearing on affected side
- ESR > 40 mm/hr
- Fever
- WBC count of >12,000 mm3
- When 4/4 criteria are met, there is a 99% chance that the child has septic arthritis
The Kocher criteria do not consider blood culture results.
What is Holstein Lewis fracture?
A HolsteinLewis fracture is a fracture of the distal third of the humerus resulting in entrapment of the radial nerve.
The radial nerve is one of the major nerves of the upper limb. It innervates all of the muscles in the extensor compartments of the arm.
Conservative treatment includes reduction and use of a functional brace
Vascular injury may require open surgery
Risks of abdominal aortic aneurysm rupture (over 5 years):
5-5.9cm = 25%
6-6.9cm= 35%
7cm and over = 75%
Superior Laryngeal Nerve supplies?
What would its damage cause?
Cricothyroid
Damage causes abnormalities in pitch
Inability to sing with smooth changeover to higher pitch
Recurrent laryngeal nerve supplies?
Intrinsic laryngeal muscles
a. Opening vocal folds (as in breathing, coughing)
b. Closing vocal folds for vocal fold vibration during voice use
c. Closing vocal folds during swallowing
Extradural Haematoma
Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure
Some patients may exhibit a lucid interval
Subdural haematoma
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Intracerebral haematoma
Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion which fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated.
Subarachnoid haemorrhage
Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
Intraventricular haemorrhage
associated with severe head injuries.
In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.
Heberdens nodes
Distal interphalangeal joint
(outer heberdees)
Usually painful onset at first then nodes appear
Bouchards nodes
PIP OA
What factor is directly related to graft survival in Renal transplant?
Warm ischaemic time - begins at the time of removal of the procured organ from storage ice and ends with the initiation of graft reperfusion,
Hyperacute rejection
occurs immediately through presence of pre formed antibody (such as ABO incompatibility).
Risk factors include major HLA mismatch and ABO incompatibility. The rejection occurs almost immediately and the macroscopic features may become manifest following completion of the vascular anastomosis and removal of clamps. The kidney becomes mottled, dusky and the vessels will thrombose. The only treatment is removal of the graft, if left in situ it will result in abscess formation.
Acute rejection
Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Most cases can be managed medically.
Chronic rejection
Occurs after the first 6 months. Vascular changes predominate
all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants.
What are Osler’s nodes and what are the causes?
Purple raised lesions on finger
Usually associated with acute endocarditis
other causes include
SLE, gonorrhoea, typhoid and haemolytic anaemia.
How is HLA system classified
Class 1 - HLA A, HLA B, HLA C
Class 2 - HLA DP, DP, DQ
HLA matching for a renal transplant the relative importance of the HLA antigens
DR > B > A
Cushing reflex
When intra cranial pressure exceeds mean arterial pressure, compression of cerebral arterioles occurs. This results in cerebral ischaemia.
Increases in ICP results in stepwise activation of the sympathetic nervous system initially. This raises peripheral vascular resistance and results in hypertension. Cardiac output is also increased. These haemodynamic changes are detected by aortic arch baroreceptors and this results in activation of the parasympathetic nervous system. These parasympathetic effects comprise the second stage of the Cushing reflex. The Cushing reflex is a serious development that indicates imminent coning or other terminal events if not resolved quickly.
Homonymous hemianopia
Incongruous defects: lesion of optic tract
Congruous defects: lesion of optic radiation or occipital cortex
Macula sparing: lesion of occipital cortex
Homonymous quadrantanopias
Superior: lesion of temporal lobe
Inferior: lesion of parietal lobe
Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
Lesion of optic chiasm
Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
How does Ciclosporin work
Inhibits calcineurin, a phosphatase involved in T cell activation
Nephrotoxic
Monitor levels
How does Azothioprine work?
Metabolised to form 6 mercaptopurine which inhibits DNA synthesis and cell division
Side effects include myelosupression, alopecia and nausea
How does Mycophenolate mofetil (MMF) work
Blocks purine synthesis by inhibition of IMPDH
Therefore inhibits proliferation of B and T cells
Side-effects: GI and marrow suppression
Monoclonal antibodies
Selective inhibitors of IL-2 receptor
Daclizumab
Basilximab
Sirolimus (rapamycin)
Blocks T cell proliferation by blocking the IL-2 receptor
Can cause hyperlipidaemia
Lateral Medullary syndrome
ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss
Syndrome associated with Oesophageal atresia?
VACTERL
combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL. Problems that occur during feeding are more suggestive of proximal pathology.
What is Von Hippel Lindau syndrome and What are the features
Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3
Features
cerebellar haemangiomas
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts: epididymal, pancreatic, hepatic
endolymphatic sac tumours
