Lecture 8: Common Abdominal & Chest Surgeries Flashcards
Main difference between laparotomy vs laparoscopy
- SIZE
- Laparotomy/Open surgery = single, LARGE, multi inch incision
- Laparoscopic = multiple incisions less than a 1/4 inch (minimally invasive)
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
option for noncomplicated, non perforated appendicitis
Rocephin + Metro IV
followed by oral abx for 7-10 days
oral regimen: FQ+metro or 3rd gen cephalosporin + 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
You camp OUTSIDE Scars run DEEP Salt and Pepper are the last 2 things you put (transversalis and peritoneum)
i do not understand this but enoch suggested it and if it helps at least one person i will be happy
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
What determines a patient’s disposition after an appendectomy?
- D/C home same day w/ nonperforated/uncomplicated Lap Appy
- Admit for perforation or open technique
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 gallstone complications
- Acalculous cholecystitis
- Gallbladder polyps > 0.5 cm
- Porcelain GB
CI to performing cholecystectomy
- Diffuse peritonitis
- Hemodynamic compromise
- Uncontrolled bleeding diathesis
What workup is indicated for a cholecystectomy?
- RUQ U/S, labs
- +/- abdominal CT scan, MRCP, ERCP
When do you choose to do an open chole over a lap chole?
- Can’t safely/effectively do a lap chole (MC)
- 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
i think arias trick was like … (cystic) duct..(common hepatic) duct….goose lol
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
may lead to peritonitis/infection
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
d/y complications of bowel injury, livery injury, intra abd abscess, bleeding
How soon can you D/C an uncomplicated lap chole?
Same day discharge
give PO pain meds. no abx needed
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 is included in the workup for a colon surgery?
PE: palpable mass
Labs: tumor markers (CEA/CA 19-9)
Colonoscopy
CT abdomen and pelvis w/ IV and oral contrast
What are some benefits of laparoscopic sx, compared to open colectomy
laparoscopic sx associated w/
* dec. post op pain analgesia req.
* faster return of bowel function
* earlier resumption of PO intake
* shorter hospital stay
* better cosmesmis
What are the two biggest downsides of laparoscopic colectomies?
- Far more time consuming..leading to greater expense
- 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
honestly very cute, here’s a pic of mine
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
remember ALL colectomy patients will be admitted min 4 days
T/F Make sure to wait until patient is fully healed before introducing enteral feedings
False! better outcomes seen with sooner introduction to enteral feeding
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? (3)
+what imaging do you need to confirm?
- 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: passes thru inguinal canal and into the scrotum
- Femoral: below inguinal ligament 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
Who are femoral hernias more common in?
Elderly women
my grandma has one
T/F a strangulated/incarcerated hernia is always considered an emergency
TRUE omg get them to the OR STAT!!!!!
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?
dont stop there….give me the other 4 complications
Hematoma/Seroma
Chronic pain (post hernia neuralgia, m/c w/ open)
Infection
Hernia recurrence
mesh erosion, infection
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
this card shouldve been up top
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
complications of breast surgery
- infection
- DVT
- Hematoma/seroma
- delayed healing
- Abnormal scar formation
- Winged scapula
honestly these make sense and its kinda an annoying list but just wanna see it once or twice before the exam
complication with flap/implant
flap ischemia
fat necrosis
capsular contracture
implant failure
Why can winged scapular occur post-mastectomy?
Exposing long thoracic nerve during axillary lymphadenectomy
Adkins was asking this while grading people for the MSK shoulder assessment so this is 100000% on the exam i think
Indications for lung surgery (4)
BELL
- Bullous lung (air space > 1 cm diameter)
- Empyema
- Lung cancer (SC vs NSC)
- Lung reduction (COPD/Emphysema)
Your lungs look like a BELL
MCC for empyema
Underlying pneumonia
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
pain control, wound care
What complications can arise from lung surgery
Pneumothorax
infection
bleeding
a fib
dyspnea
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
Post op complications for CABG
a fib
bleeding
bradycardia
death
DVT
infection
Pleural effusion/PNA
honestly im not memorizing this but look at it twice and move along
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)
CHP(P) is central in law enforcement
- Chemo
- Hemodynamic monitoring
- Prolonged ABX
- Parenteral Nutrition
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
What flushing solutions are used when establishing a central line?
Heparin
NaCl
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
Cut-Down Venous Access CIs
infection @ incision site
thrombosis or vascular compromise
patient refusal or inability to tolerate procedure under local anesthesia
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.
this is bold and blue so lock it in!!!!
What is an intraosseous line?
whats it sound like…..insert a needle into bone marrow cavity to access the systemic circulation
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 (MC used in adults & kids)
- Distal femur
