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Surgery Clerkship > Notebook Flashcards > Flashcards

Notebook Flashcards

1
Q

Pre-Op Care:

EF < ______ is prohibitive with a 55-90% risk of MI perioperatively

A

35%

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2
Q

Golfman’s index of cardiac risk includes what factors

A

1) JVD
2) Recent MI –> defer for 6 months
3) CHF –> ACEi + BB + dig + diuretics before surgery
4) PVCs or other arrhythmias
5) Age > 70
6) Emergency surgery
7) Aortic valvular stenosis
8) Poor medical condition
9) surgery within the chest or abdomen

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3
Q

Hepatic risk is quantified with what factors?

A

A BEAP

Ascites
Bilirubin
Encephalopathy
Albumin
PT (INR)
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4
Q

Nutritional risk assessed with what 4 factors?

A

decrease in body weight by 20% over months
Serum albumin < 3
Serum transferrin < 200
Anergy to skin antigens

Nutritional support pre-surgery! Can check nutritional status with pre-albumin

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5
Q

When should you stop Warfarin?

A

3-4 days PTS (INR < 1.5 for high risk bleeding surgeries)

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6
Q

When should you resume LMWH or heparin after surgery?

A

12 hours post surgery

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7
Q

Main causes of post-op fever and timeframe (8)

A

1) Malignant hyperthermia (during surgery)
2) Bacteremia (right after surgery)
3) Atelectasis (POD 1)
4) Pneumonia (POD 3)
5) UTI (POD 3)
6) DVT (POD 5)
7) Wound infection (POD 7)
8) Deep abscess (POD 10-15)

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8
Q

What is the goal urine output?

A

0.5 mL/kg/hr

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9
Q

Paralytic ileus

A

POD 1-2
No bowel sounds, no passage of gas
mild distention, no or mild pain
SI and LI all dilated

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10
Q

Ogilvie syndrome

A

paralytic ileus of the colon

  • Elderly, sedentary, s/p surgery
  • Abd distention (Tense, nontender)
  • Massively dilated colon, small bowel NORMAL
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11
Q

Treatment of Ogilvie syndrome (3)

A

Colonoscopy
Long rectal tube
Neostigmine

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12
Q

Wound Dehiscence

A

salmon colored fluid (peritoneal fluid) - failure of the fascia –> hernia + fluid drainage
POD 5
TX: binders, decrease straining, reoperate

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13
Q

Cholecystitis

DX and TX

A

RUQ US, HIDA scan

NPO, IVF, IV abx
cholecystectomy (urgent 72-96 hours
Cholecystostomy if a nonsurgical candidate)

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14
Q

Choledocolythiasis

DX and TX

A

RUQ US, MRCP

TX: NPO, IVF, IV abx, urgent ERCP, elective cholecystectomy

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15
Q

Cholangitis

DX and TX

A

RUQ US

TX: emergent ERCP to drain infected bile with sphincterotomy and stent placement + urgent/elective cholecystectomy, IVF, IV abx, NPO

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16
Q

Which abx are used to treat galbladder pathology?

A

Cipro + Metronidazole

OR

Amp-Gent + Metronidazole

DO NOT use pip-tazo (works, but is too expensive and too broad)

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17
Q

Necrotizing surgical site infection

A
  • pain, edema, red beyond surgical site
  • fever, decreased BP, increased HR
  • paresthesia at wound edges
  • “dishwater drainage” - purulent, cloudy, gray
  • Subcutaneous gas, crepitus

TX = parenteral abx, urgent surgical debridement

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18
Q

Torus Palatinus

A

chronic growth on hard palate, benign bony growth

  • non-tender
  • can ulcerate due to thin epithelium over growth
  • surgery if symptomatic
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19
Q

Anterior mediastinal mass can be…

A

4 T’s:

Thymoma, Teratoma, thyroid neoplasm, terrible lymphoma

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20
Q

What other kinds of aneurysms are associated with AAA

A

popliteal and femoral aneurysms - no relation with brain aneurysms

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21
Q

Mechanism/pathophysiology of AAA

A

increased MMP activity
atherosclerosis –> decreased diffusion of nutrients
-poorly developed vaso vasorum (particularly at infrarenal aorta)
-CT disease (Marfan, Ehler’s), trauma, cystic medial degeneration, infection
-Increased diameter –> decreased velocity blood flow –> thrombus formation along wall

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22
Q

Phases of wound healing (3)

A

1) Inflammatory (0-2 days)
2) Proliferative
3) Remodeling (2-3 weeks)

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23
Q

Inflammatory wound healing stage

A

hemostasis, then inflammation
Neutrophils –> macrophages with PDGF, TGF-B growth factors

TGF-B can cause collagen overexpression and result in KELOID formation

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24
Q

Proliferative phase of wound healing

A

fibroblasts proliferate –> COLLAGEN III replaces fibronectin-fibrin matrix

  • -> angiogenesis
  • -> keratinocytes epithelialize wound
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25
Q

Remodeling phase of wound healing

A

fibroblasts produce COLLAGEN I (replaces III)
–> increases wound strength (tensile)

-Wound contraction by myofibroblasts, pull collagen fibers together

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26
Q

If you have less than ______ drainage a day from a wound drain, you can typically remove it

A

30 cc/day

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27
Q

Post-op complications of Lap Gastric Bypass (8)

A

1) Gallstones
2) Marginal ulcers
3) Anastomotic leak
4) stenosis of pouch/anastomosis
5) malnutrition
6) incisional hernia
7) splenic injury
8) iron or B12 deficiency

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28
Q

Peterson’s Hernia

A

internal hernia of small bowel through opening in omentum formed by the roux limb

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29
Q

Retroperitoneal structures

A

SAD PUCKER

Suprarenal (adrenal) glands
Aorta, IVC
Duodenum (2nd-4th parts)
Pancreas (except tail)
Ureters
Colon (descending and ascending)
Kidneys
Esophagus (thoracic portion)
Rectum (partially)
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30
Q

iron is absorbed in the ______ as _____

A

duodenum, Fe2+

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31
Q

B12 is absorbed in the ______ with ______

A

terminal ileum, with intrinsic factor

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32
Q

Falciform ligament

A

connects liver –> anterior abdominal wall

contains ligamentum teres hepatis (fetal umbilical vein)

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33
Q

Hepatoduodenal ligament

A

connects liver –> duodenum

contains portal triad (common bile duct, proper hepatic artery, portal vein)

*connects greater and lesser sacs

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34
Q

Gastrohepatic ligamen

A

connects liver to lesser curvature of stomach

contains gastric arteries (left and right)

separates greater and lesser sacs on the right

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35
Q

Gastrocolic ligament

A

connects greater curvature of the stomach to the transverse colon

contains gastroepiploic arteries

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36
Q

Gastrosplenic ligament

A

connects greater curvature to spleen

contains short gastrics, L gastroepiploic artery

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37
Q

Splenorenal ligament

A

connects spleen to the posterior abdominal wall

contains splenic artery/vein, and tail of pancreas

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38
Q

Layers of the gut wall (4 - and what they do)

A

1) Mucosa = epithelium, lamina propria, muscularis mucosa
2) Submucosa = Meissner’s nerve plexus, secretes fluid
3) Muscularis externa = Myenteric nerve plexus (Auerback), motility
4) Serosa (intraperitoneal) or Adventitia (retroperitoneal)

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39
Q

Types of diarrhea

A

1) Watery (osmotic, secretory, functional)
2) Fatty
3) Inflammatory

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40
Q

How to differentiate osmotic and secretory diarrhea

A

Stool osmotic gap = plasma osmolarity = 2x(stool Na + stool K)

Osmotic diarrhea = increase SOG (> 125 mOsm/kg)
Secretory = decreased SOG (< 50)

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41
Q

Common causes of secretory diarrhea

A

bacterial or viral infections, congenital disorders, ileocolitis, post surgical changes

s/p bowel resection or cholecystectomy when unabsorbed bile acids reach the colon and directly stimulate luminal ion channels

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42
Q

Pelvic fracture can lead to what injury in men?

A

posterior urethral injury

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43
Q

posterior uretheral injury presentation and DX

A

abrupt upward shift of bladder and prostate –> urethral tearing of MEMBRANOUS urethra at bulbomembranous junction (between anterior and posterior urehtra)

**blood in meatus, inability to void, perineal or scrotal hematoma, high riding prostate

DX: retrograde urethrogram (look for extravasation of contrast from urethra or no contrast in bladder)

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44
Q

Tracheobronchial perforation

A

secondary to blunt thoracic trauma

R main bronchus (most commonly injured)
SX = persistent pneumothorax despite chest tume, pneumomediastinum, subcutaneous emphysema

DX = CT, bronch, surgical exploration

TX = surgical repais

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45
Q

Duodenal hematoma

A

secondary to blunt abdominal trauma of duodenum against vertebral column

More common in children
-Blood collects between submucosal and muscular layers of duodenum –> partial/complete obstruction

TX = NG tube, parenteral nutrition, +/- surgery or percutaneous drainage

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46
Q

3 components of an inhalation injury

A
  1. Upper airway edema
  2. Acute respiratory failure
  3. CO poisoning (nml PaO2, decreased SaO2)

Suspect with carbonaceous sputum, change in voice quality, facial burns, or singed nasal hairs

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47
Q

Curling’s ulcer

A

ulcer of duodenum in severe burns

due to decreased intravascular volume and decreased perfusion of GI tract

*give PPO or H2 blocker as ppx

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48
Q

Most common organisms in burn wound infections?

A

1) Pseudomonas
2) Staph aureus
3) Strep pyogenes
4) Fungal later on in recovery (Candida)

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49
Q

How do you diagnose an inhalational injury?

A

fiberoptic bronchoscopy

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50
Q

appropriate fluid resuscitation in burns:

A

total fluid volume = 4cc/kg x weight (kg) x TBSA%

*use LR

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51
Q

Alkalai bruns

A

full thickness
skin appears pale
feels slippery

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52
Q

Acid burns

A

partial thickness

develop erythema and erosion

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53
Q

Acute epidural hematoma

A 
modest trauma
lucid interval
LENS shaped
coma, ipsilateral fixed/dilated pupil, contralateral hemiparesis
meningeal arteries
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54
Q

Acute subdural

A

big trauma
crescent shape
monitor ICP, elevate head, hyperventilate (PCO2 35), avoid fluid overload, mannitol/furosemide or emergency surgery
-venous injury

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55
Q

How do you define a massive hemothorax that requires surgery?

A

> 1.5 L with chest tube OR > 600 mL over 6 hours from chest tube

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56
Q

traumatic rupture of the aorta should be suspected when? what happens?

A

occurs at junction of arch and ascending aorta

suspect with: 1st rib, scapula, sternum fractures or widened mediastinum

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57
Q

Bladder injury:

-Extraperitoneal leak

A

at base of bladder, tx with foley catheter

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58
Q

Bladder injury:

-Intraperitoneal leak

A

surgical repair with suprapubic cystostomy

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59
Q

Reducible hernia

A

contents pushed back through defect

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60
Q

incarcerated hernia

A

contents stuck in hernia sac

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61
Q

strangulated hernia

A

incarcerated hernia with compromised blood flow to herniated organ

*requires prompt surgical intervention

  • irreversible ischemia/necrosis –>SIRS
  • redness of overlying hernia, pain
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62
Q

Direct inguinal hernia - how does it form?

A

protrude through abdominal wall due to acquired weakness in the TRANSVERSALIS fascia

-bulges through parietal peritoneum MEDIAL to inf. epigastric vessels, but LATERAL to the rectus abdominus muscle in HESSELBACH’s TRIANGLE

  • occur in old men who chronically strain
  • least likely to incarcerate
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63
Q

What covers a direct vs. indirect inguinal hernia vs. femoral hernia?

A

direct - peritoneum
indirect - all 3 layers of spermatic fascia (external spermatic fascia, cremasteric fascia, internal spermatic fascia)

femoral - peritoneum

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64
Q

Indirect inguinal hernia

A

protrude through internal inguinal ring (LATERAL to inf. epigastric vessels) through superficial (external) inguinal ring, then into scrotum

-due to failure of processus vaginalis to close (can also cause a hydrocele)
= CONGENITAL - follows spermatic cord/round ligament

-most common hernia in men/women/children

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65
Q

Femoral hernia

A

occur in femoral canal, INFERIOR to inguinal ligament and MEDIAL to femoral vein (NAVEL = lat to medial)

  • 10% of hernias, more common in Women
  • highest rate of strangulation/incarceration

Risks = multiple pregnancies, dilate femoral veins –> widen femoral canal

66
Q

Umbilical hernia

A

pediatric population, congenital hypothyroidism
-Most asymptomatic and close spontaneously with no intervention

in adults, associated with increased intra abdominal pressure (pregnancy, ascites, weight gain)
-surgery if symptomatic

67
Q

repair of indirect inguinal hernia

A

open sac anteriorly, assess intestine viability, reduce contents

  • high ligation of internal ring of hernia sac (eliminates processus vaginalis)
  • excise distal sac or leave in situ if large
  • Reinforce floor of inguinal canal with tension free mesh
68
Q

repair of direct inguinal hernia

A

reduce sac, reinforce floor with tension free mesh = LICHTENSTEIN repair

  • DO NOT open sac
  • if in kids, don’t need mesh, and need to look bilateral
69
Q

Most commonly injured nerve in 20% of hernia repairs?

A

lateral femoral cutaneous nerve (lateral thigh to knee sensation)

70
Q

inguinal ligament is formed by what?

A

aponeurosis of external oblique

71
Q

layers of the abdominal wall ABOVE the arcuate line

A

1) Skin
2) subcutaneous fat (camper’s fascia)
3) scarpa’s fascia (first identifiable named, subcutaneous layer)
4) anterior layer of rectus sheath
5) External oblique/aponeurosis
* *Rectus abdominus muscle**
6) Internal oblique/aponeurosis
7) posterior layer of rectus sheath
8) transversus abdominus/aponeurosis
9) transveraslis fascia
10) parietal peritoneum

72
Q

Layers of the abdominal wall BELOW the arcuate line

A

1) Skin
2) subcutaneous fat
3) superficial abdominal fascia
4) Rectus sheath
5) External oblique/aponeurosis
6) Internal oblique/aponeurosis
7) transversus abdominus/aponeurosis
* *Rectus abdominus muscle**
9) transveraslis fascia
10) parietal peritoneum

73
Q

what is the arcuate line?

A

the inferior edge of the posterior layer of the rectus sheath

74
Q

Indications for laparoscopic repair of hernia

A

1) bilateral inguinal hernias
2) recurring hernia
3) need to resume full activity ASAP

75
Q

first subcutaneous vein ligated in open inguinal hernia repair?

A

superficial epigastric vein

76
Q

Inguinal ligament attaches from the ________ to the _________

A

ASIS to the pubic tubercle

77
Q

Nerves involved in the inguinal hernia repair (3)

A

1) ilioinguinal
2) iliohypogastric
3) genital branch of genitofemoral nerve

78
Q

Ilioinguinal nerve

A

found ON TOP of spermatic cord
damage causes numbness of inner thigh or lateral scrotum (resolves in 6 months usually)

-can be purposely cut in order to avoid risk of entrapmentand post op pain

79
Q

Genitofemoral nerve

A

travels IN spermatic cord

80
Q

Boundaries of the FEMORAL canal

A
  1. Coopers ligament (posterior)
  2. Inguinal ligament (anterior)
  3. Femoral vein (lateral)
  4. Lacunal ligament (medial)
81
Q

boundaries of the inguinal canal

A
  1. external oblique aponeurosis (anterior wall
  2. internal oblique muscle and transversus abdominis (roof)
  3. Transversalis fascia and parietal peritoneum (posterior wall)
  4. Inguinal ligament (aka aponeurosis of external oblique) = floor
82
Q

deep inguinal ring

A

outpouching of the transveralis fascia, lateral to the lateral umbilical fold (containing inferior epigastric vessels

83
Q

derivation of internal spermatic fascia, cremaster muscle, and external spermatic fascia?

A

internal spermatic fascia = transversalis fascia
cremaster muscle/fascia = internal oblique
external spermatic fascia = external oblique

84
Q

The rectus sheath is created by the….

A

fusion of the aponeurosis of the transversus abdominis and abdominal oblique muscles

85
Q

The rectus sheath is created by the….

A

fusion of the aponeurosis of the transversus abdominis and abdominal oblique muscles

86
Q

Most common causes of SBO (7)

A
  • Crohn’s
  • Gallstone ileus
  • Hernia
  • intra-abdominal adhesions (60% of SBO in USA)
  • intussusception
  • neoplasm
  • volvulus
87
Q

small bowel has _______ while large bowel has ________

A

small bowel - plicae circularis (lines on imaging all the way around the bowel)

large bowel - haustra (lines halfway through the bowel on imaging)

88
Q

Portal venous gas

A

air in periphery of liver due to centrifugal portal flow

LATE presentation of pneumatosis with air in portal venous system

89
Q

management of partial and complete SBO

A

fluids, electrolytes, NG tube for gastric decompression, indwelling catheter to monitor Uop

  • partial SBO –> initial non-op management (unlikely to strangulate)
  • complete SBO –> can delay and observe for 12-24 hours
90
Q

Charcot’s triad

A

RUQ pain, jaundice, fever = cholangitis

91
Q

Acidemia and alkalemia at pH of what?

A 
Acidemia = pH < 7.36
Alkalemia = pH > 7.44
92
Q

non-anion gap metabolic acidosis causes

A

HARD UPS

Hyperalimentation
Acetazolamide
Renal tubular acidosis
Diarrhea
Uretro pelvic shunt
Post-hypocapnea
Spironolactone
93
Q

causes of metabolic alkalosis

A

CLEVER PD

Contraction
Licorice
Endocrine (cushing's, Conn's, Bartter's)
Vomiting
Excess alkalai
Re-feeding alkalosis
Post diuresis
94
Q

Cancer that can cause obstructive jaundice?

A

1) cholangiocarcinoma
2) Duodenal
3) Head of pancreas
4) Ampullary

95
Q

what must you do before endoscopy with biopsy when you suspect esophageal cancer?

A

barium swallow

96
Q

anal fissures are usually located where?

A

posterior midline

97
Q

Fibroadenoma

A

YOUNG women, firm, rubbery, moves with palpation

DX = FNA or US
TX = removal optional
98
Q

Cystosarcoma phyllodes

A

late 20’s, can become very large
benign, but have potential for malignant transformation to sarcoma

TX: must remove
DX: core or incisional bx (FNA not sufficient)

99
Q

Fibrocystic disease (aka mammary dysplasia)

A

related to menstrual cycle - come and go, multiple lumps, worse in last 2 weeks of cycle

DX: aspiration (NOT FNA)
only bx or do cytology if mass persists or bloody fluid

100
Q

Intraductal papilloma

A

young women, bloody nipple discharge

DX: not shown by mammography

101
Q

Breast abscess

A

only in lactating women, otherwise considered CA until proven otherwise

TX: I&D with biopsy of abscess wall

102
Q

what is the daily fluid requirement?

A

30 mL/kg/day (approx 125 cc/hr)

103
Q

Volvulus

A

sigmoid or cecal, TWISTING of the bowel

can see “whirl sign”

TX = “DETORSION” - attempt untwisting of volvulus via endoscopy or contrast enema (high recurrence rate)

104
Q

Cecal volvulus

A

thought due to congenital problem when R colon/cecum not fixed

105
Q

Sigmoid volvulus

A

acquired with progressive stretching

“coffee bean sign”

increased risk with anticholinergic drugs, neuro/psych diseases, CF, chagas, high fiber diet, constipation

106
Q

Malrotation

A

congenital condition, bowel not in normal positions

can predispose to volvulus

bowel/mesentery not properly fixed/attached –> twisting, obstruction

107
Q

Possible complications of diverticulitis

A

abscess, perforation, fistula (colovesical or colovaginal), stricture, LBO

108
Q

Drainage of esophageal veins that leads to varices?

A

esophageal veins –> SVC

esophageal veins also –> L gastric vein –> portal veins

109
Q

Acute gastritis

A

EROSIVE superficial inflammation of the lining of the stomach

secondary to dysfunction of mucosal defenses = Prostaglandins, bicarb, somatostatin. HCl is NOT a major mechanism

110
Q

Chronic gastritis

A

NON EROSIVE inflammation of gastric mucosa

type A vs. type B

111
Q

Chronic gastritis: type A vs. type B

A

Type A: FUNDUS dominant –> pernicious anemia auto-ab to parietal cells

Type B: ANTRAL dominant –> H. pylori–> PUD, MALT lymphoma

112
Q

Bleeding in PUD can be due to what 3 vessels?

A

1) Splenic artery –> gastric ulcer, posterior wall of the stomach
2) L gastric artery –> gastric ulcer, lesser curvature
3) Gastroduodenal artery –> duodenal ulcer, posterior wall of 1st part of duodenum

113
Q

Triple therapy

A

PPI + clarithromycin + amoxicillin

114
Q

How do you typically repair a duodenal perforation? gastric perforation?

A

Duodenal perf –> primary closure with omental patch

Gastric perf –> primary closure, biopsy, omental patch vs. wedge resection
—–must rule out malignancy

115
Q

Endoderm is responsible for the formation of what in the GI tract….

A

1) Epithelial lining

2) specific cells –> glands, hepatocytes, exocrine/endocrine cells of the pancreas

116
Q

Visceral mesoderm is responsible for the formation of what in the GI tract…

A

stroma (connective tissue for glands), muscle, connective tissue, peritoneal components of the wall of the gut

117
Q

Dorsal mesentery:

A

extends from lower esophagus to cloacal region of hind gut

= GREATER OMENTUM (Mesogastrium= mesoduodenum, mesocolon, mesentary proper)
–> grows down from greater curvature to transverse colon where it fuses with the mesentery of transverse colon

118
Q

Ventral mesentery:

A

LESSER OMENTUM = extend from lower esophagus, stomach, upper duodenum to liver

FALCIFORM LIGAMENT = extend from liver the ventral body wall

119
Q

Development of stomach

A
  • rotates 90 degrees around longitudinal axis –> LEFT side faces ANTERIOR, right side faces posterior –> left vagus = anterior branch, right vagus = posterior
  • Posterior stomach grows faster = greater curvature
120
Q

How is the lesser sac formed?

A

Rotation of the stomach pulls the dorsal mesogastrium (greater omentum) to left and creates a space behind the stomach

121
Q

Development of the pancres

A

formed by the DORSAL and VENTRAL buds originating from endodermal lining of duodenum

-when the duodenum rotates to the right and becomes C shaped, the ventral pancreatic bud moves dorsally until it is behind the dorsal bud –> fusion of buds

122
Q

Dorsal pancreatic bud

A

close to the dorsal mesentary

forms remaining head, body, and tail, as well as main pancreatic duct –> major papillae

123
Q

Ventral pancreatic bud

A

close to bile duct

forms uncinate process, inferior head of pancreas, can also form the accessory pancreatic duct –> minor papillae (santorini)

124
Q

Hindgut embryology

A

ENDODERM of hind gut also forms the internal lining of the bladder and urethra

125
Q

_______ forms the caudal anal canal, while ________ forms the cranial anal canal

A

ECTODERM forms the caudal anal canal (inferior rectal artery –> internal pundendal arteries), while ENDODERM forms the cranial anal canal (superior rectal artery, IMA)

pectinate line delineates endoderm/ectoderm

126
Q

Aortic Arches:

1st -

A

maxillary artery

127
Q

Aortic Arches:

2nd

A

stapedial artery

128
Q

Aortic Arches:

3rd

A

common carotid artery, proximal internal carotid

129
Q

Aortic Arches:

4th

A

Left –> aortic arch
Right –> R subclavian artery

–> L recurrent laryngeal nerve loops around aortic arch, R. recurrent laryngeal loops around R subclavian

130
Q

Aortic Arches:

6th

A

proximal pulmonary arteries, ductus arteriosus

131
Q

Dumping syndrome

A

caused by rapid distribution of food into SI due to abscence of pyloric sphincter regulation

–> hyperosmolar in intestines –> increased H2O secretion, diarrhea, hypotension

132
Q

Management of anastamotic leaks

A

NO peritonitis –> upper GI with gastrograffin –> contrast extravasation confirms leak

-GET SOURCE CONTROL - can re-operate and salvage initial operation most of the time instead of resecting and revising the anastomosis

133
Q

Margins required for colon cancer resection?

How many lymph nodes do you need?

A

margins at least 5 cm
For R hemisection, length of ileum resected does NOT effect local recurrence

Regional lymphadenectomy: gives prognostic info, guides chemos, need at least 12 nodes assessed for adequate staging

90% of recurrences occur within 3 years of surgery for colorectal cancer

134
Q

Liver capsule

A

Glisson’s capsule

135
Q

What divides the R and L lobes of the liver

A

Cantle’s line

136
Q

Blood supply to the liver

A

75% from portal vein (splenic vein + SMV)

25% from proper hepatic artery (celiac trunk –> common hepatic)

137
Q

Falciform ligament

A

connects liver to anterior abdominal wall

contains obliterated umbilical vein, ligamentum teres

138
Q

Coronary ligament

A

attaches liver to diaphragm, “crown” on top of liver

139
Q

How many liver segments are there?

A

8

140
Q

Venous drainage of liver

A

drained by R, middle, L hepatic veins –> IVC

141
Q

Blood supply to the thyroid

A

superior thyroid artery (1st branch of external carotid)
inferior thyroid artery (branch off thyrocervical trunk)

drained by superior, middle, inferior thyroid veins

142
Q

where should you look for the recurrent laryngeal nerve during a thyroidectomy?

what happens if you damage this?

A

tracheoesophageal groove, behind cricothyroid muscle

damage = hoarseness if unilateral - obstruction if bilateral
–> paralysis of laryngeal abductors

143
Q

what nerves at at risk for damage during thyroid surgery?

A
  • recurrent laryngeal nerves

- superior laryngeal nerves (damage results in change in voice pitch, lower voice)

144
Q

suspensory ligaments of breast

A

cooper’s ligament

invasion of CA into this causes retraction of skin around nipples

145
Q

boundaries of the axilla?

A 
axillary vein (superior)
floor of axilla (posterior)
latissimus dorsi (lateral)
pec minor (medial)
146
Q

nerves at risk during axillary dissection?

A

1) long thoracic (mid axillary line) –> serratus anterior –> winged scapula
2) Thoracodorsal (lateral to long thoracic) –> latissimus dorsi –> decreased internal rotation, extension, and abduction of shoulder
3) Medial pectoral (goes through pec minor, lateral to the lateral pectoral nerve) –> pec minor and major
4) Lateral pectoral nerve –> medial to medial pectoral nerve –> pec major only

147
Q

borders of the breast

A 
clavicle (superior)
inframammary fold (6th rib-ish) (inferior)
Pec major fascia (posterior)
Latissiumus dorsi (lateral)
Sternum (medial)
148
Q

Conn Syndrome

A

hyperaldosteronism

SX = HYPERTENSION, HYPOKALEMIA
TX = spironolactone (aldo antagonist) - before resection, must pre-treat with spiro and K+

(aldo = Na+ in, K+ out in DCT)

149
Q

Anterior Spinal Artery Syndrome (ASA)

A

loss of pain, temp, motor - retain dorsal columns

can be due to “burst” fx of vertebral bodies

150
Q

Most common vertebrae fractured in the neck?

A

C2 > C6 > C7

most common subluxation = C5-C6

151
Q

Above what level do you get diaphragmatic paralysis?

A

above C3 with complete spinal cord injury

152
Q

Why are thoracic spinal injuries less common?

A

injuries less common due to high facets and ribs –> decreased motion
-also have more canal space because no anterior enlargements

153
Q

Central cord syndrome

A

severe extension injury
weakness, decreased sensation in UE + proximal leg muscles, with sparing of distal LE

Why? spinal cord organized w/UE motor MEDIAL aspect of cord and LE motor lateral

154
Q

What drugs used by anesthesia/for intubation are contraindicated in head injuries?

A

ketamine and succinylcholine

use rocuronium and etomidate instead

155
Q

Central retinal artery occlusion appearance on fundoscopy and what sx?

A

cherry red spot on fundoscopy

sudden loss of vision in one eye, painless

Hollenborst plaques = cholesterol microembolis within retinal arterioles –> highly suggestive of embolization from plaque at carotid bifurcation

156
Q

Central retinal artery occlusion - caused by what?

A

embolization from internal carotid artery

157
Q

internal carotid vs. external carotid artery

A

ICA - has no branches in the neck –> opthalmic artery, ACA, MCA

ECA - branches into superior thyroid, ascending pharyngeal, lingual, fascial, occipital, posterior auricular, maxillary, superficial temporal

158
Q

Carotid endarterectomy for carotid stenosis - indications

A

symptomatic + > 70% stenosis
asymptomatic + > 80% stenosis
CEA NOT recommended for symptomatic patients with 100% stenosis of ICA

+ ASA, statin, +/- clopidogrel

159
Q

Spinal stenosis

A

generalized weakness of both legs that worsens with walking
-relieved by leaning forward

aka neurogenic claudication (nerve root compression)

160
Q

Claudication

A

pain with walking, relieved with rest, reproducible at same distance

  • ischemic rest pain associated with ABI < 0.4
  • calf muscle atrophy, hair loss, dry/scaly skin, shiny skin, ulcers
  • ABI < 0.9 (DM can falsely elevate ABI**)

-atherosclerotic plaque obstructing blood flow, typically at SUPERFICIAL FEMORAL ARTERY –> popliteal

161
Q

How is claudication classified?

A

Rutherford classification of chronic limb ischemia

162
Q

Buerger’s sign

A

sign of advanced chronic limb ishcemia

-foot turns pale when elevated ==> ruborous once down

Surgery Clerkship (2 decks)

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