Lecture 8: Common Abdominal & Chest Surgeries Flashcards
Main difference between laparotomy vs laparoscopy
- Laparotomy/Open surgery = single, LARGE, multi inch incision
- Laparoscopic = multiple incision less than a 1/4 inch
What do we consider primarily in deciding between laparotomy vs laparoscopy?
- Overall health
- BMI
- Prior surgeries
What score is used to help determine suspicion for appendicitis?
Alvarado score
RLQ tenderness and leukocytosis are 2
Initial imaging for appendicitis
- Adults: CT w/ IV con
- Children: U/S
Add on oral contrast if concerned for perforation
MCC of appendicitis
Fecalith
ABX for non-op appendicitis
Rocephin + Metro
OR positioning and setup for laparoscopic appendectomy
- Trendelenburg + left side down (toes up)
- Pneumoperitoneum (insufflating abdomen)
- 3 ports! (1 cam, two graspers)
What structure are you looking for in a laparoscopic appendectomy?
Cecum
Appendix can be hidden, but you can follow cecum to appendix
What tool removes the appendix from the cecum in laparoscopic appy?
Endoscopic stapler
Describe the order of layers you cut through in a appendix laparotomy. (10)
- Skin
- SQ fat
- Camper’s fascia
- Scarpa’s fascia
- External Oblique aponeurosis
- External Oblique muscle
- Interal oblique muscle fascia
- Transversus abdominis fascia
- Transversalis fascia
- Peritoneum
What tool is used to make the peritoneum incision in an appendix laparotomy?
Metzenbaum scissors
What suture is suitable for ligating the appendiceal artery?
3-0 vicryl
twice
Post-op abx for a perforated lap appy
Rocephin + Metro x5-7d
Same as pre-op if you don’t operate.
No post-op abx for uncomplicated.
Indications for Cholecystectomy
- Symptomatic cholelithiasis
- Asymptomatic cholelithiasis w/ high risk of GB carcinoma or complications
- Acalculous cholecystitis
- Gallbladder polyps > 0.5 cm
- Porcelain GB
CI to performing cholecystectomy
- Diffuse peritonitis
- Hemodynamic compromise
- Uncontrolled bleeding diathesis
When do you choose to do an open chole over a lap chole?
- Can’t safely/effectively do a lap chole
- Highly suspect cancer
- Pt is too compromised to tolerate an intraop pneumoperitoneum.
What makes up Calot’s triangle?
- Inferior edge of liver
- Common hepatic duct
- Cystic duct
How many ports does a lap chole need?
4
What are the 3 timeouts during a lap chole?
- Identification of landmarks
- Re-identification of landmarks
- Confirming the cystic duct and artery are properly identified
What is the MC complication associated with a cholecystectomy?
Common Bile Duct injuries or obstructions
2-10 days postop
Fever/abd pain
How do we confirm post-op complications of a chole?
- CT (most sensitive)
- U/S
How do you treat post-op CBD injuries/leaks/obstructions?
U/S guided perc drainage + ERCP w/ stent
Last resort is to reopen
What two symptoms are MC after cholecystectomy?
- Persistent dyspepsia
- Diarrhea
How soon can you D/C an uncomplicated lap chole?
Same day discharge
How do you manage an open/complicated chole?
- 1-3 days admit
- Only abx if contaminated
What divides a right colectomy vs a left?
The center of the transverse colon
What surgery would remove the entire colon + anus?
Total proctocolectomy
What is the difference between a subtotal colectomy vs a total colectomy?
Subtotal does not include sigmoid colon
When is colon surgery indicated? (4)
- Tumors
- UC
- Diverticulitis/Perf
- Ischemic Colitis
What are the two biggest downsides of laparoscopic colectomies?
- Far more time consuming
- Surgeon must be specially trained in it
Main complications of a colectomy? (4)
- Anastomotic leak
- Intra-abdominal abscess
- Bleeding
- Bowel Obstruction
What is a colostomy?
Piece of colon diverted to artificial opening in abd wall to bypass a damaged part of the colon
When are colostomies indicated? (5)
- Gangrenous/perforated bowel
- CRC
- IBD
- Trauma
- Fecal diversion (paralyzed pts with decubitus ulcers)
What is the diet progression post colectomy?
- 1st day: NPO
- 2nd day: full liquids
- 3rd day+: regular
When do you f/u in office after a colectomy?
10 days Postop
5-7 days after discharge prob for a lap colectomy
What are the 5 locations for a herniorraphy?
- Epigastric
- Incisional
- Direct/Indirect inguinal
- Umbilical
- Femoral
RFs for hernias
- Straining
- Fascial weakness (usually surgery)
- Obesity
- Male
How do you dx a hernia?
- Pain with movement
- Bulge/mass that worsens with straining
- Palpable mass/defect
Confirm with CT
Describe the location of a direct, indirect, and femoral hernia relative to the inguinal canal.
- Direct: above (in hesselbach’s triangle)
- Indirect: In inguinal canal
- Femoral: below inguinal canal in the femoral canal
Describe the location of a direct and indirect inguinal hernia to the inferior epigastric vessels.
- Direct: medial
- Indirect: lateral
What hernias ALWAYS need surgery?
- Inguinal
- Femoral
- Any female hernia
What do you need to identify when repairing an inguinal hernia?
- External oblique aponeurosis
- External ring
- Spermatic cord
- Sac of hernia
MC postop complications of a herniorraphy?
Hematoma/Seroma
What are the indications for a lumpectomy? (3)
- Lump (fibroadenoma)
- Ductal carcinoma in situ
- Invasive breast cancer
Indications for mastectomy
- Prior radiation to breast/chest wall
- Radiation therapy CI due to pregnancy
- Inflammatory breast cancer
- Diffuse suspicious malignancies
- Widespread disease
- Positive pathologic margin even after repeat excision
What tumor markers are associated with CRC?
CEA/CA 19-9
What tumor markers are associated with breast cancer?
- CA 15-3
- CEA
- CA 27/29
What are the two primary reconstruction options post mastectomy?
- Implant
- Flap
What does postop care look like post-mastectomy?
- 1-2 days admit
- Drain
- 1 wk f/u for drain removal
Why can winged scapular occur post-mastectomy?
Exposing long thoracic nerve during axillary lymphadenectomy
MCC for empyema
Underlying pneumonia
Indications for lung surgery (4)
- Empyema
- Lung cancer (SC vs NSC)
- Bullous lung (air space > 1 cm diameter)
- Lung reduction (COPD/Emphysema)
What tumor markers are associated with lung cancer?
- CEA
- SCC
- NSE
What is post-op care for lung surgery like?
- ICU admit with intubation
- Chest tube management
When is thoracotomy used for CABG? (5)
- Congenital defect repair
- 3 vessel blockage or left main stem artery stenosis (> 70% of LAD or proximal left Cx)
- Heart Valve dysfunction
- Infection (constrictive pericarditis)
- Pericardial tamponade/ventricular rupture
Where do vein grafts connect to on the heart?
Aorta
When do we use peripheral IV (PIV) lines?
- Short-term access for meds, blood, or hydration
- Good if you need frequent access or intermittent therapy.
When is PIV contraindicated? (4)
- Severe PVD
- Thrombosis in vein
- Cellulitis or infection over vein
- Collapsed or sclerosed veins
Potential complications of a PIV (4)
- Phlebitis
- Infiltration/extravasation
- Thrombophlebitis
- Infection at insertion site
What can a central line do that a PIV can’t do? (4)
- Chemo
- Prolonged ABX
- Parenteral Nutrition
- Hemodynamic monitoring
When are central lines CId? (4)
- Coagulopathy/bleeding disorder
- Infection at site
- Severe hypotension/shock
- Severe thrombocytopenia
What are the 3 locations for CVL insertion in adults?
- IJ
- Femoral (most compressible)
- Subclavian
IJ and Subclavian are best for direct access to RA via the SVC.
Femoral might be a good option for a high risk bleed pt.
Complications of CVL (8)
- CLABSI (central line associated bloodstream infection)
- Thrombosis
- Pneumothorax (upon insertion or movement)
- Hemorrhage
- Malposition
- Air Embolism
- Nerve Injury
- Skin irritation/breakdown
What kind of procedure is a CVL placement?
STERILE
Indications for cut-down venous access (3)
- Emergency (need rapid venous access)
- Inability to access veins (PIV inaccessible)
- Pediatrics (hard to get PIV in a kid)
MC vein for cut-down venous access?
Saphenous vein
What is unique about a cut-down venous access insertion?
You need to sedate/anesthetize the patient
If they can’t cooperate, you cant get it.
When are IOs indicated?
- Emergency access
- Cardiac arrest/shock
- Difficult PIV access
Straight into bone marrow cavity
MC sites of IO insertion (2)
- Proximal tibia (adults & kids)
- Distal femur
