ILOs Flashcards
What are the 9 areas of the abdomen
Common laparotomy incisions (13)
Common laparoscopic incisions (3)
anatomy of the inguinal canal
- which direction does it travel
- it is superior and parallel to ewhich structure
- serves as a pathway between where?
- clinical significance?
- contents of the inguinal canal (4)
- travels inferomedially
- it is superior and parallel to the inguinal ligament
- pathway between abdominal cavity and the external genitalia
- site of potential weakness in the abdo wall, 75% of anterior abdo wall hernias
- spermatic cord (males only), round ligament (females only), iliolinguinal nerve,genital branch of genitofemoral nerve
inguinal hernias can be split into (2)
how do you differentiate between them?
- Indirect – where the peritoneal sac (and potentially loops of bowel) enters the inguinal canal through the deep inguinal ring. More common. Congenital weakness.
- direct- where the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal (termed Hesselbach’s triangle). They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
Both types of inguinal hernia can present as lumps in the scrotum or labia majora.
Differentiation
differentiated at the time of surgery by identifying the inferior epigastric vessels – indirect hernias will be lateral to the vessels whilst direct hernias will be medial to the vessels.
To differentiate between types of inguinal hernias the examiner must reduce the hernia and then place pressure over the deep inguinal ring (located mid point of the ligament) before asking the patient to cough.
If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia
Whereas if the hernia doesn’t protrude then this indicates an indirect hernia. This assessment is often unrealiable.
6 locations for hernia
Things that increase the risk of incidence in general anaesthesia (13)
- smoking
- diabetes
- COPD
- CKD
- frailty
- cognitive dysfunction
- obesity
- age
- aneamia
- recent cold
- recent heart attack
- recent stroke
- allergies
what test is done to assess fitness for general anaesthesia?
cardiopulmonary fitness test
cycle on bike
For consent to be valid (3)
what is capacity. what are the 4 factors of it
young people are assumed to have capacity to give consent at what age
- patient must UNDERSTAND what the procedure entails
- consent must be given VOLUNTARILY
- the patient must be COMPETENT- i.e. they have capacity
Capacity- the ability to use and understand information to make a decision, and communicate any decision made.
- UNDERSTAND the decision
- RETAIN information relevent to their decision long enough to give consent
- WEIGH UP relevent info
- COMMUNICATE their decision
capacity at 16+, if younger look on a case by case basis
what are some things you should include when gaining consent for surgery
- The patient’s diagnosis and prognosis
- Options for treatment, including non-operative care and no treatment
- The purpose and expected benefit of the treatment
- The likelihood of success
- The clinicians involved in their treatment
- The risks inherent in the procedure, however small the possibility of their occurrence,side effects and complications. The consequences of non-operative alternatives should also be explained.
- Potential follow up treatment
Complications of surgery and anaesthesia (12)
How would you identify them?
- Shock- qSOFA score.
- Haemorrhage- tachycardia, dizziness, agitation, decreased urine output
- Nausea and vomiting
- Pain- - objectively tachycardia, tachypnoea, hypertension, sweating
- Pyrexia- raised body temp above 37.5*
- Wound infection- fever, clammy, sweaty, discolouration
- DVT- pain, swelling, tenderness, redness
- PE- Rapid or irregular heartbeat, Lightheadedness or dizziness, Excessive sweating, Fever, Leg pain or swelling, or both, usually in the calf caused by a deep vein thrombosis, Clammy or discolored skin (cyanosis)
- Urinary retention-
- Reaction to anaesthesia-
- Delirium- disturbed consciousness and altered cogitive function
- Decreased sodium
Complications of abdo surgery (15)
- haematoma amnd seroma (serouds fluid)
- Surgical site infection
- Fascial dehiscence
- nerve injury
- intra-abdominal bleeding
- herniation
- mechanical bowel obstruction
- sepsis
- peritonitis
- c. diff infection
- pneumonia
- urinary retention
- uti
- DVT
- failure of surgery
possible complications of vascular surgery (4)
- Haemorrhage
- Early thrombosis of a graft or vessel nerve injury
- Graft infection
- Renal failure
staging system for colorectal cancer
what are the 2 systems
explain the different stages of them
Duke’s staging system
Stage (A-D), descrption of containment and 5 year survival rate
- A- confined to bowel wall only (75-90)
- B- Through bowel wall (55-70)
- C- Any with +ve lymph node involvement (30-60)
- D- Any with metastases (5-10)
TNM
based on 3 components:
- Extent (size) of the tumour- How far has the tumour grown into the wall of the colon or rectum? T1-4 stages of invasion of bowel wall
- N- spread to nearby lymph nodes- N0/1/2, no/up to 4/more than 4 lymph nodes involved
- M- spread to distant sites- such as lungs or liver
Additional TNM codes
TX- Main tumour cannot be assessed due to lack of information
T0- No evidence of a primary tumour
NX- regional lymph nodes cannot be assessed due to lack of information
Explain the principles of surgical treatments for colorectal cancer
list 6 procedures for general surgery
Curative treatmements are suitable for technically resectable tumours with no evidence of metastases (or metastases potentially curable by liver or lung resection)
Surgery is the mainstay of curative management for localised bowel cancer. The general plan in most surgical management plans is suitable regional colectomy, to ensure the removal of the primary tumour with adequate margins and lymphatic drainage, followed either by primary anastomosis or formation of a stoma
- Right hemicolectomy or extended right hemicolectomy
- Left hemicolectomy
- Sigmoidcolectomy
- Anterior resection
- Abdominoperineal resection
- Hartmann’s procedure
explanation of these procedures:
Right hemicolectomy or extended right hemicolectomy
-Used for caecal tumours or ascending colon tumours, extended version used on transverse colon tumours. During the procedure the ileocolic, right colic and right branch of the middle colic vessels (branches of SMA) are divided and removed w their mesenteries.
Left hemicolectomy
-Used for descending colon tumours. Left branch of the middle colic vessels (branch of SMA/SMV), the inferior mesenteric vein and the left colic vessels (branches of the IMA/IMV) are divided and removed of their mesenteries
Sigmoidcolectomy
-Sigmoid colon tumours. IMA fully dissected out to ensure adequate margins are obtained
Anterior resection
-Used for low rectal tumours, typically <5cm from the anus
Excision of the distal colon, rectum and anal sphincters resulting in permanent colostomy
Abdominoperineal resection
- Used for low rectal tumours, typically <5cm from the anus. Excision of the distal colon, rectum and anal sphincters, resulting in permanent colostomy
Hartmann’s procedure
-Procedure used in emergency bowel surgery (e.g., bowel obstruction or perforation). Complete resection of the recto-sigmoid colon with the formation of an end colostomy and the closure of the rectal stump.
Explain the principles of adjuvant (1) or neoadjuvant treatment (1) of colorectal cancer
Aims to eradicate micro-metastatic cancer cells
Neoadjuvant therapy- given as a first step to shrink a tumour before the main treatment, which is usually surgery. Examples include Chemotherapy, Radiation therapy, Hormone therapy. It is a type of induction therapy. Also lets the MDT see if they respond to that kind of chemotherapy.
Adjuvant therapy: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy.
What is a stoma
Identify the different types of stomas (3)
A stoma is a surgical joining of a lumen onto the anterior abdominal wall., They are red in colour as they are mucous membranes. They don’t have any sensation so shouldn’t be painful to the touch.
- what is a colostomy?
- where are they usually placed?
- what is the output, what is it like?
- what are the 2 types of colostomy?
- A colostomy is created from a part of the colon
- Usually placed on the left-hand side of the navel (descending colon)
- The output is faeces that are usually firm and formed. Stools in this part of the intestine are solid and will need to be collected using a stoma pouch.
1) End colostomy- If parts of your colon or rectum have been removed the remaining colon is brought to the surface of the abdomen to form a stoma. An end colostomy can be temporary or permanent
2) Loop colostomy- Typically, temporary used in acute situations.
- What is an ileostomy?
- usually where is it?
- stool content?
- 2 main kinds?
- In an ileostomy operation, a part of your small bowel called the ileum is brought to the surface of your abdomen to form the stoma. Typically, when the end part of the small bowel is diseased
- Right hand side of the abdomen
- Stools are generally liquid
1) End ileostomy- Often done when part of your large bowel (colon) is removed (or simply needs to rest) and the end of your small bowel is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.
2) Loop ileostomy
Urostomy aka ____?
when might a urostomy be done?
how is it carried out?
- AKA ileal conduit or a Bricker bladder
- If a problem occurs within the bladder, the bladder may be removed from the body and a new system for urine to be passed from the body must be made
- Surgeon takes 6-8 inches of the small bowel (ileum) and makes it into a conduit (pipeline) for urine. Remainder of the small bowel is reconnected so your bowel will function as it did before surgery. Ureters then connect into the ileum
10 factors of cancer development
- genome instability
- resisting cell death
- sustaining proliferative signalling
- evading growth suppressors
- enabling replicative immortality
- inducing angiogenesis
- activating invasion and metastasis
- reprogramming energy metabolism
- tumour-promoting inflammation
- evading immune destruction
genome instability and how it helps
- occasionally mutations are advantagous
- allows overgrowth and dominance
- instability leads to further istability so rates of mutation increase
6 steps of apoptosis
- produces nuclear fragmentation
- chromosomal condensation
- shrinking of the cell membrane
- cellular fragmentation
- formation of apoptopic bodies
- phagocytosed by neighbouring cells
resisting cell death
removal of survival factors
P53 supressed (increased expression of anti-apoptotic regulators, down-regulation of pro-apoptotic factors, short circuiting of extrinsic ligand-induced death pathway)
sustained proliferative signalling
- overproduction of growth factors
- faulty receptors- e.g., don’t need signal, perpetually on, amplified receptors, increased response
- CDK’s dysregulated
- cancer cells can produce growth factors for itself (EGDR and HER2 overexpresison)
*
4 stages of the cell cycle
- G1 (gap 1)
- S (DNA synthesis)
- G2 (gap 2)
- M (mitosis./ meiosis)
enabling replicative immortality
- normally telomeres shorten progressivley with successive cycles
- prevents cells from dividing after a certain point
- cancer cells ecpress high lvels of telomerase enzyme
*
inducing angiogenesis
blood vessels derived from tumour-mediated signalling VEGF and PDGF
Activation of invasion and metastasis
cadherin-1 expression decreased
reprogramming energy metabolism
cancer cells upregulate GLUT1 glucose transplrter favouring aerobic gyloclysis
tumour promoting inflammation
vasodilation reults in increased blood flow
increased permeability of vessels
exudation of plasma proteins and fluid into tissues
prognostic factors for breast cancer (9)
- Axillary lymph node status
- Tumor size
- Lymphatic/vascular invasion
- Patient age
- Histologic grade
- Histologic subtypes (eg, tubular, mucinous [colloid], or papillary)
- Response to neoadjuvant therapy
- Estrogen receptor/progesterone receptor (ER/PR) status
- HER2 gene amplification or overexpression
what is the triple assessment for?
what is the route for getting one?
what are the 3 stages briefly?
hospital based assessment clinic that allows for early and rapid detectoion of breast cancer and other breast diseases.
Women (and men) can be referred by a ‘one stop’ clinic by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if they have early intervention in the treatment of breast cancer.
- history and examination by breast surgeobn or associate specialist
- imaging
- histology
detailed explanation of triple assessment:
- history and examination
- imaging
- histology
history and examination
- Presenting complaint
- Potential risk factors (red flags: night sweats, cachexia, bloody discharge, change to eating habits)
- Family history
- Medication history
- Social history
imaging
Based around either mammography (X-rays) or ultrasound investigations. Which one is used will be determined by patient factors.
- Mammography- X rays- compression views of the breast across 2 views (oblique and craniocaudal), allowing for the detection of mass lesions or microcalcifications
- Ultrasound imaging- more useful in women <35 years and in men, due to density of the breast tissue in identifying anomalies. This form of imaging is also used to guide core biopsies
- _MRI- n_ot used in the mainstay of triple assessment however can be useful in the assessment of lobular breast cancers (and in assessing response to neoadjuvant therapy); whilst it has high sensitivity, it has a low specificity.
histology
- A biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy.
- A core biopsy provides full histology (as opposed to fine needle aspiration (FNA) which only provides cytology), allowing differentiation between invasive and in-situ carcinoma.
- The test can generate important information about tumour grading and staging, and has a higher sensitivity and specificity than FNA for detecting breast cancer.
at each stage of the triple assessment the suspicion of malignancy is graded to create an overall risk index
explain the principles of surgical treatment of cancer of the breast
- breast conserving
- mastectomy
- axillary surgery
Breast conserving surgery
- Only suitable for individuals with localised operable disease and no evidence of metastatic disease.
- Wide local excision (WLE) is the most common breast conserving treatment and involves excision of the tumour, typically ensuring a 1cm margin of macroscopically normal tissue is taken as well.
- Suitable for smaller focal cancers but is also dependant on the location and relative size of the breast.
- Better asthetics
Mastectomy
- multifocal disease
- high tumour: breast tissue ratio
- disease recurrence or patient choice
- Removes all of the tissue of the affected breast, along with a significant amounts of superficial skin
- Leaves muscle layer intact
Axillary surgery
- Commonly done alongside WLE and mastectomies in order to assess nodal status and remove any nodal disease
- Sentinel node biopsy- removing first lymph node into which tumour drains. They are identified by injecting blue ink and radioisotope.
- Axillary node clearance- removing all nodes in the axilla, ensuring to not damage any associated important structures in the axilla, which are then sent
Explain the relevance of the assessment of the axilla in the management of breast cancer
- Lymphatic fluid drains into lymph nodes, its contents including biomarkers and inflammatory markers.
- Cancer cells can break off from the main tumour and circulate through the lymphatic system or through blood vessels.
- Some of these cells can grow in the lymph nodes or drain to elsewhere in the body.
- Breast is largely drained by the axillary (armpit) lymph nodes.
- Sentinel lymph node, the first lymph node through which a certain area of tissue drains into. If you can rule out sentinel lymph node involvement then you reduce the need for axillary lymph node dissection.
Explain hormonal treatments for cancer of the breast
Name the commonly used hormones
Many cancer cells get an overly strong, uncontrolled signal to proliferate. This often comes in the form of a mutated gene coding for cell receptors.
- Most common are oestrogen (ER) or progesterone (PR) positive tumours. HER2.
- Hormonal therapy aims to stop the growth of hormone sensitive tumours by blocking the body’s ability to produce hormones or by interfering w the effects that the hormones have of the cancerous cells.
1) Blocking ovarian function:
- Ovaries main source of oestrogen in premenopausal women. Blocking ovarian function = ovarian oblation. This is done surgically or radiologically.
2) Block oestrogen production
- Aromatase inhibitors block aromatase enzyme used to create oestrogen
3) Blocking oestrogen’s effect
- Tamoxifen- selective oestrogen receptor modulator used to treat oestrogen receptor positive breast cancer
- Aromatase inhibitors- e.g., letrozole, anastrozole, exemestane
- Goserelin (Zoladex) e.g., synthetic analogue of luteinizing hormone-releasing hormone, reducing secretion of gonadotropins from the pituitary.
- Leuprorelin (Prostap)peptide-based GnRH receptor superagonist
- Fulvestrant (Faslodex)- estrogen receptor antagonist used to treat HR+ breast cancer that may also be HER2-.
which populations are offered breast screening
Anyone registered with a GP as female every 3 years between 50-71
- Trans man/ woman or a non-binary person you may be invited automatically.
- Those over 71 aren’t automatically invited but can still get screened every 3 years.
- advantages
- disadvantages of breast screening
benefits
- allows you to catch a cancer that is too small to find
- catch cancers early- more succesful treatment and breast preservation
drawbacks
- can’t always tell if a tumour is life-threatening or not, therefore you could undergo traumatic treatment for something that wouldn’t have killed you
- false negative- missing a cancer that is there
- flase positive- undergo unneccessary treatment
- exposure to xrays from mammogram
management of PVD (6)
Conservative management
- Supervised exercise programme- reduce symptoms by inrceasing collateral blood flow
- vasoactive drugs- naftidofural oxylate
- percutaneous transluminal angioplasty- for disease limited to one artery (balloon)
- surgical reconstruction
- amputation
- future therapies
