Lecture 8: Common Abdominal & Chest Surgeries Flashcards
1
Q
Main difference between laparotomy vs laparoscopy
A
- SIZE
- Laparotomy/Open surgery = single, LARGE, multi inch incision
- Laparoscopic = multiple incisions less than a 1/4 inch (minimally invasive)
2
Q
What do we consider primarily in deciding between laparotomy vs laparoscopy?
A
- Overall health
- BMI
- Prior surgeries
3
Q
What score is used to help determine suspicion for appendicitis?
A
Alvarado score
RLQ tenderness and leukocytosis are 2
4
Q
Initial imaging for appendicitis
A
- Adults: CT w/ IV con
- Children: U/S
Add on oral contrast if concerned for perforation
5
Q
MCC of appendicitis
A
Fecalith
6
Q
ABX for non-op appendicitis
option for noncomplicated, non perforated appendicitis
A
Rocephin + Metro IV
followed by oral abx for 7-10 days
oral regimen: FQ+metro or 3rd gen cephalosporin + metro
7
Q
OR positioning and setup for laparoscopic appendectomy
A
- Trendelenburg + left side down (toes up)
- Pneumoperitoneum (insufflating abdomen)
- 3 ports! (1 cam, two graspers)
8
Q
What structure are you looking for in a laparoscopic appendectomy?
A
Cecum
Appendix can be hidden, but you can follow cecum to appendix
9
Q
What tool removes the appendix from the cecum in laparoscopic appy?
A
Endoscopic stapler
10
Q
Describe the order of layers you cut through in a appendix laparotomy. (10)
A
- 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
11
Q
What tool is used to make the peritoneum incision in an appendix laparotomy?
A
Metzenbaum scissors
12
Q
What suture is suitable for ligating the appendiceal artery?
A
3-0 vicryl
twice
13
Q
What determines a patient’s disposition after an appendectomy?
A
- D/C home same day w/ nonperforated/uncomplicated Lap Appy
- Admit for perforation or open technique
14
Q
Post-op abx for a perforated lap appy
A
Rocephin + Metro x5-7d
Same as pre-op if you don’t operate.
No post-op abx for uncomplicated.
15
Q
Indications for Cholecystectomy
A
- Symptomatic cholelithiasis
- Asymptomatic cholelithiasis w/ high risk of GB carcinoma or gallstone complications
- Acalculous cholecystitis
- Gallbladder polyps > 0.5 cm
- Porcelain GB
16
Q
CI to performing cholecystectomy
A
- Diffuse peritonitis
- Hemodynamic compromise
- Uncontrolled bleeding diathesis
17
Q
What workup is indicated for a cholecystectomy?
A
- RUQ U/S, labs
- +/- abdominal CT scan, MRCP, ERCP
18
Q
When do you choose to do an open chole over a lap chole?
A
- Can’t safely/effectively do a lap chole (MC)
- Highly suspect cancer
- Pt is too compromised to tolerate an intraop pneumoperitoneum.
19
Q
What makes up Calot’s triangle?
A
- Inferior edge of liver
- Common hepatic duct
- Cystic duct
i think arias trick was like … (cystic) duct..(common hepatic) duct….goose lol
20
Q
How many ports does a lap chole need?
A
4
21
Q
What are the 3 timeouts during a lap chole?
A
- Identification of landmarks
- Re-identification of landmarks
- Confirming the cystic duct and artery are properly identified
22
Q
What is the MC complication associated with a cholecystectomy?
A
Common Bile Duct injuries or obstructions
2-10 days postop
Fever/abd pain
may lead to peritonitis/infection
23
Q
How do we confirm post-op complications of a chole?
A
- CT (most sensitive)
- U/S
24
Q
How do you treat post-op CBD injuries/leaks/obstructions?
A
U/S guided perc drainage + ERCP w/ stent
Last resort is to reopen
25
What two symptoms are MC after cholecystectomy?
* Persistent dyspepsia
* Diarrhea
## Footnote
d/y complications of bowel injury, livery injury, intra abd abscess, bleeding
26
How soon can you D/C an uncomplicated lap chole?
Same day discharge
## Footnote
give PO pain meds. no abx needed
27
How do you manage an open/complicated chole?
* 1-3 days admit
* Only abx if contaminated
28
What divides a right colectomy vs a left?
The center of the transverse colon
29
What surgery would remove the entire colon + anus?
Total proctocolectomy
30
What is the difference between a subtotal colectomy vs a total colectomy?
Subtotal does not include sigmoid colon
31
When is colon surgery indicated? (4)
* Tumors
* UC
* Diverticulitis/Perf
* Ischemic Colitis
32
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
33
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
34
What are the two biggest downsides of laparoscopic colectomies?
* Far more time consuming..leading to greater expense
* Surgeon must be specially trained in it
35
Main complications of a colectomy? (4)
* Anastomotic leak
* Intra-abdominal abscess
* Bleeding
* Bowel Obstruction
36
What is a colostomy?
Piece of colon **diverted** to artificial opening in **abd wall** to **bypass** a damaged part of the colon
## Footnote
honestly very cute, here's a pic of mine
37
When are colostomies indicated? (5)
* Gangrenous/perforated bowel
* CRC
* IBD
* Trauma
* Fecal diversion (paralyzed pts with decubitus ulcers)
38
What is the diet progression post colectomy?
* 1st day: NPO
* 2nd day: full liquids
* 3rd day+: regular
## Footnote
remember ALL colectomy patients will be admitted min 4 days
39
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
40
When do you f/u in office after a colectomy?
10 days Postop
| 5-7 days after discharge prob for a lap colectomy
41
What are the 5 locations for a herniorraphy?
* Epigastric
* Incisional
* Direct/Indirect inguinal
* Umbilical
* Femoral
42
RFs for hernias
* Straining
* Fascial weakness (usually surgery)
* Obesity
* Male
43
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
44
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
45
Describe the location of a direct and indirect inguinal hernia to the inferior epigastric vessels.
* Direct: medial
* Indirect: lateral
46
What hernias ALWAYS need surgery?
* Inguinal
* Femoral
* Any female hernia
47
Who are femoral hernias more common in?
Elderly women
## Footnote
my grandma has one
48
T/F a strangulated/incarcerated hernia is always considered an emergency
TRUE omg get them to the OR STAT!!!!!
49
What do you need to identify when repairing an inguinal hernia?
* External oblique aponeurosis
* External ring
* Spermatic cord
* Sac of hernia
50
MC postop complications of a herniorraphy?
| dont stop there....give me the other 4 complications
Hematoma/Seroma
## Footnote
Chronic pain (post hernia neuralgia, m/c w/ open)
Infection
Hernia recurrence
mesh erosion, infection
51
What are the indications for a lumpectomy? (3)
* Lump (fibroadenoma)
* Ductal carcinoma in situ
* Invasive breast cancer
52
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
53
What tumor markers are associated with CRC?
CEA/CA 19-9
## Footnote
this card shouldve been up top
54
What tumor markers are associated with breast cancer?
* CA 15-3
* CEA
* CA 27/29
55
What are the two primary reconstruction options post mastectomy?
* Implant
* Flap
56
What does postop care look like post-mastectomy?
* 1-2 days admit
* **Drain**
* 1 wk f/u for drain removal
57
complications of breast surgery
* infection
* DVT
* Hematoma/seroma
* delayed healing
* Abnormal scar formation
* Winged scapula
## Footnote
honestly these make sense and its kinda an annoying list but just wanna see it once or twice before the exam
58
complication with flap/implant
flap ischemia
fat necrosis
capsular contracture
implant failure
59
Why can winged scapular occur post-mastectomy?
Exposing **long thoracic nerve** during axillary lymphadenectomy
## Footnote
Adkins was asking this while grading people for the MSK shoulder assessment so this is 100000% on the exam i think
60
Indications for lung surgery (4)
## Footnote
BELL
1. Bullous lung (air space > 1 cm diameter)
2. Empyema
3. Lung cancer (SC vs NSC)
4. Lung reduction (COPD/Emphysema)
## Footnote
Your lungs look like a BELL
61
MCC for empyema
Underlying pneumonia
62
What tumor markers are associated with lung cancer?
* CEA
* SCC
* NSE
63
What is post-op care for lung surgery like?
* ICU admit with intubation
* Chest tube management
## Footnote
pain control, wound care
64
What complications can arise from lung surgery
Pneumothorax
infection
bleeding
a fib
dyspnea
65
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
66
Where do vein grafts connect to on the heart?
Aorta
67
Post op complications for CABG
a fib
bleeding
bradycardia
death
DVT
infection
Pleural effusion/PNA
## Footnote
honestly im not memorizing this but look at it twice and move along
68
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.
69
When is PIV contraindicated? (4)
* Severe PVD
* Thrombosis in vein
* Cellulitis or infection over vein
* Collapsed or sclerosed veins
70
Potential complications of a PIV (4)
* Phlebitis
* Infiltration/extravasation
* Thrombophlebitis
* Infection at insertion site
71
What can a central line do that a PIV can't do? (4)
## Footnote
CHP(P) is central in law enforcement
* Chemo
* Hemodynamic monitoring
* Prolonged ABX
* Parenteral Nutrition
72
When are central lines CId? (4)
* Coagulopathy/bleeding disorder
* Infection at site
* Severe hypotension/shock
* Severe thrombocytopenia
73
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.
## Footnote
Femoral might be a good option for a high risk bleed pt.
74
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
75
What kind of procedure is a CVL placement?
STERILE
76
What flushing solutions are used when establishing a central line?
Heparin
NaCl
77
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)
78
MC vein for cut-down venous access?
Saphenous vein
79
Cut-Down Venous Access CIs
infection @ incision site
thrombosis or vascular compromise
patient refusal or inability to tolerate procedure under local anesthesia
80
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.
## Footnote
this is bold and blue so lock it in!!!!
81
What is an intraosseous line?
whats it sound like.....insert a needle into bone marrow cavity to access the systemic circulation
82
When are IOs indicated?
* Emergency access
* Cardiac arrest/shock
* Difficult PIV access
| Straight into bone marrow cavity
83
MC sites of IO insertion (2)
* Proximal tibia (MC used in adults & kids)
* Distal femur
