Pics Flashcards
S/p contrast- where is the contrast and where is it not?
CT of SBO- see the contrast stops (doesn’t progress) b/c it’s functionally obstructed!
- see air fluid levels (b/c lack of peristalsis means air and fluid separate out)
- also can see collapse of distal colon (in yellow)
Differentiate the three chambers of a pleur-evac
- Collection chamber
- Water seal chamber = one-way valve, ensures no backwards flow back into the chest
- Suction control chamber- ensures a max limit on the negative suction pressure applied to the chest
Differentiate levels of nodes in breast cancer dissection
Level I = lateral to pec minor
Level II = under pec minor
Level III = medial to pec minor
Give brief overview of FAST exam
FAST = focused assessement w/ sonography during trauma
3 P’s: pericardial, pleural, and peritoneal spaces to assess for fluid/blood/air
What are the inguinal rings holes in?
Deep inguinal ring is a hole in the transversalis fascia
Superficial inguinal ring is a hole in the aponeurosis of the external oblique
Name and differentiate the 4 classifications of hip fractures
Hip fractures classified by anatomic location and fracture type- split into
- Intracapsular: at the femoral neck or femoral head
- Extracapsular: intertrochanteric or subtrochanteric
What is this showing…?
SBO 2/2 hernia
-see dilated bowel (blue and yellow) up to rapid transition point, w/ collapsed bowel (red) right after herniated portion of bowel
Most common primary cutaneous neoplasm
Squamous cell carcinoma
Differentiate fusiform vs. saccular aneurysm
Fusiform = symmetric enlargement
Saccular = asymmetric enlargement
-associated w/ infection and trauma
Associated malignancy
Dx = necrolytic migratory erythema
Associated tumor = glucagonoma
Differentiate sigmoid vs. cecal volvulus
Volvulus = obstruction due to twisting or knotting of the GI tract
- cecum = at the jxn of the SI and LI
- sigmoid = at the end of the LI
Dangerous b/c of the risk of ischemia, necrosis, perforation
Describe how to visualize appendix on axial CT slice of the abdomen
Locate appendix btwn the cecum (will be filled w/ contrast and gas) and the right psoas muscle
-joins the cecum btwn 2-6 oclock
Dx
Dilated large colon (peripherally located and haustra don’t go wall to wall) proximally
-large bowel obstruction
Keloid- scar formation where tissue extends beyond the border of the original wound
Name the 4 boundaries of the inguinal canal
Anterior wall = aponeurosis of the external oblique (contains the superficial inguinal ring)
Posterior wall = transversalis fascia (contains the deep inguinal ring)
Roof -=internal oblique and transversus abdominis
Floor = inguinal ligament, medial ligament on end
Artery most commonly injured in pelvic fracture
Superior gluteal artery
Etiology of this SBO?
The arrow showing a rapid transition point btwn dilated (proximal) and collapsed (distal) bowel
-w/ no other etiology this is diagnostic for SBO 2/2 adhesion
Name 3 places on ultrasound during FAST to assess for peritoneal fluid
- Morrison’s pouch = hepatorenal recess (space btwn liver and kidney)
- perisplenic- btwn spleen and other (ex: diaphragm)
- Pouch of Douglas = space btwn bladder and rectum
Describe location of needle decompression tube to treat tension pneumothorax
Tension pneumothorax- air in the pleural spcae compressing the lung (causes mediastinal shift and pt is unable to breathe)
Needle decompression- right above the 5th rib (avoid the neovascular bundle) at the nipple line, halfway btwn anterior axillary and midaxillary line
Overweight 13 yo boy w/ groin pain found to be limping
Dx
Tx
SCFE = slipped capital femoral epiphysis
- orthopedic emergency b/c further slippage may cut off blood supply => avascular necrosis
- need surgical treatment pins in the femoral head to hold in place: can do external pinning or internal reduction w/ pinning
Describe the spacial relationship of the two inguinal rings
Spermatic cord enters the inguinal canal laterally thru the depp inguinal ring (opening in the internal oblique and transverse abdominal muscle, or transversalis fascia?)
Then spermatic cord enters medially out the superficial inguinal ring (opening in the external oblique aponeurosis)
37 yo F, 6 mo s/p lap gastric band operation p/w sudden onset severe epigastric and retrosternal chest pain
- vomitting, tachycardic, TTP w/o guarding
(a) Most likely diagnosis?
(b) Next step?
(a) Slipped gastric band- stomach herniates thru the band (can potentially be caused by overeating if pt’s stomach is forced to stretch)
- causes gastric outlet obstruction
(b) Needs emergency decompression to prevent ischemia/necrosis or gastric perforation
Give brief overview of steps of thyrodectomy
- Incision 2cm above sternal notch
- dissect around strap muscles (sternothyroid), reflect sternothyroid laterally and reflect thyroid lobe medially
- See carotid artery laterally, locate recurrent laryngeal coursing under inferior thyroid artery. Preserve nerve, ligate vessels (both inferior and superior arteries) then resect lobes
- Ligate inferior thyroid artery branches distal to where parathyroid supply comes off to preserve (or attempt to preserve) parathyroid arteries)
- Interupted sutures to reapproximate midline fasia, close skin incision
Name the three nerves in the groin region susceptible to injury during hernia repair
- Genital branch of the genitofemoral nerve = most common nerve damaged in hernia repair
- goes thru internal ring - ilioinguinal nerve
- iliohypogastric nerve
Describe the two grafts used in CABG and where they go
- Saphenos vein (harvested from leg) used to connect aortic arch to distal RCA (distal to the blockage)
- Internal mammary/thoracic artery (coming from subclavian artery) is relocated off the chest wall and connects distally to the LAD (distal to the blockage)
- so leave internal mammary connected to subclavian proximally, then relocate from chest wall and reconnect to distal LAD
Describe the measurements of the GI tract after a gastric bypass surgery
- Gastric pouch of 15mm made
- divide jejunum 40 cm distal to the ligament of Treitz
- Roux limb of 75-150 cm depending on the BMI of the pt
-
Differentiate true from false aneurysm
True aneurysm = thinning/weakening of all 3 layers of arterial wall causing excessive localized enlargement of the artery
False aneurysm = blood extravascating w/o arterial wall, hematoma from a leak in an artery that is contained by surrounding tissues
-continues to communicate w/ the artery
Ultrasound findings of acute cholecystitis- give 4
- Sonographic murphy’s sign- murphy’s sign (inspiratory pause in breathing) w/ pressure of ultrasound transducer
- gallbladder wall thickening (considered thickened if greater than 3 mm)
- presence of gallstones w/ shadowing
- presence of pericholecystic fluid (fluid around the GB)
Name some radiographic findings of acute appendicitis
- increased enhancement and thickening of appendix wall (over 1mm)
- surrounding inflammation w/ visible lymph nodes
Swan-Ganz catheter
(a) Function
(b) Location
Swan Ganz catheter- thread thru right heart to terminate (balloon) in the pulmonary artery
(a) measures pulmonary capillary wedge pressure = indirect measure of left atrial pressure
Name the 4 layers of the colon
Lumen
- Mucosa
- Submucosa
- Muscularis propria
- Serosa
Overview of steps of laparoscopic gastric bypass
- Place 6 trocars, elevate liver w/ retractor
- Make a 15 mm gastric pouch w/ linear staples
- Divide jejunum 40 cm distal to the Ligament of Treitz (w/ linear staples)
- Roux limb of 75-150 cm (depending on pt’s BMI)
- Roux-en-Y anastamosis = side to side small bowel anastamosis w/ linear stapler
- Bring roux-limb up to the gastric pouch and anastamose the two w/ sutures and staples
- Confirm patency of anastamosis and check for leaks via Upper GI endoscopy
Differentiate appearance of small vs. large bowel on abdominal Xray
Large bowel:
- haustra: markings don’t extend from wall to wall
- peripherally located
Small bowel:
- valvulae conniventes extend across the lumen and are spaced closer together
- centrally located
Three parts of the portal triad
Portal triad
-huge portal vein posteriorly
Then anteriorly:
- hepatic vein medially
- common bile duct laterally
Most common location in the spine for breast cancer mets
Vertebral pedicles (connect body and lamina of vetebrae
GIve overview of steps of exploratory laparotomy for operative SBO
- midline incision
- start exploration at cecum and work backwards towards Ligament of Trites (want to start distally and move proximally, b/c want to minimize manipulation of dilated loops of bowel)
- full exploration includes SI from lig of Treitz to the ileocecal jxn - lyse (cut/bluntly dissect) all adhesions along the way
How to calculate amount of fluid to give to a burn victim
Ex: How much fluid to give 100 kg pt w/ 10% 1st degree burn, 10% 2nd degree burn, 5% 3rd degree burn
Parkland Formula: count 2nd and 3rd degree burns (not 1st degree burns, psh you don’t fluid resuscitate for a sunburn)
Total fluid = (4ml) x (15 %BSA burned) x (100 kg) = 6,000 total
- 3,000cc (3L) over first 8 hrs
- then next 3,000 ml (3L) over the next 16 hrs
Benign pulmonary nodule w/ popcorn appearing calcification = hamartoma
Type of fracture that will occur: child falls on outstretched arm
Supracondylar fracture of the humerus 2/2 hyperextension of the elbow
-need to monitor closely for vascular and nerve integrity b/c very vulnerable brachial artery (ischemia due to damage to brachial artery => claw hand)
Surgical procedure for medical refractory GERD
Laparoscopic Nissen fundoplication
-wrap fundus of stomach around the LES to narrow the lower esophageal sphincter
2 nerves you have to watch out for during mastectomy
- long thoracic nerve
- thoracodorsal nerve
Give brief overviews of steps of carotid endarterectomy
Carotid endarterectomy
- Skin incision at anterior border of the SCM
- Divide platysma and deep cervical fascia, reflect SCM laterally
- Open carotid sheath, divide common facial vein btwn ties to expose carotid bifurcation
- Control internal (first), then external, then common carotid
- internal first to prevent any dislodged clots from getting into the brain - Open internal carotid and remove plaque (intima and media, leave behind adventitia)
- Sew in polyester patch
- Unclamp external and common, then internal last
- Close in layers: deep cervical fascia, superficial cervical fascia (platysma), and skin
Name the 4 port sites used in a laparoscopic cholecystectomy
- Umbilical trocar = camera
- High epigastric/subxiphoid, insert just right (pt’s right) of the falciform ligament)
- for surgeon’s right hand - Right midclavicular just below liver edge
- surgeon’s left hand - Mid axillary line 1/2 way btwn costal margin and ASIS (anterior superior iliac spine)
- assistant’s hand, used to grasp fundus of gallbladder and retract it (and the liver) superiorly
Final option for medically refractory BPH
TURP = transurethral resection of the prostate (also for prostate cancer)
Percent of body surface area by areas of the body
- Aka how much body surface area is affected if both legs are burned? the font?
- in a child?
Rule of 9’s for adults: 9 for head, each arm. 18 for each leg, front, and back
For kids (head is bigger): 18 for head, 9 for each arm, 18 for each leg, front/back, each leg is 14
Overview of surgical hernia repair
- Incision in line of skin crease
- Excise subQ tissue (scarpa’s fascia), make excision in the aponeurosis of the external oblique and cut thru the external inguinal ring
- Identify, pull out, and retract ilioinguinal nerve
- Mobilize cord structures, free hernia sac via blunt dissection and replace it back into the peritoneum
- Place and suture mesh surrounding the internal ring- replacing the sling fibers that usually hold the ring closed
- Close the wound in three layers: aponeurosis, scarpia’s fascia, skin
How to differentiate upper vs. lower GI tract
Split by the ligament of Treitz = suspensatory ligamnet of the duodenum
39 yo F, 3 mo s/p Roux-ey-Y gastric bypass w/ 2 weeks of nausea, early satiety, and epigastric pain
- upper endoscopy findings:
(a) Dx
(b) Mgmt
(a) Marginal ulceration- nausea, early satiety, epigastric pain s/p bypass
(b) Mgmt = antiulcer medical therapy (sucrafate) and PPI
Describe the critical view of safety in a lap choley
Identify single duct and single artery entering the gallbladder and completely dissect inferior margin of GB from the liver bed
Go over the brief steps of a laparoscopic left adrenalectomy
Laparoscopic removal of the adrenal gland
- mobilize and reflect left colon and splenic flexure, cauterize splenocolic ligament
- clip and cut left renal vein
- ligate/cauterize the three small arteries
- fully divide then remove gland from abdomen in endocatch (plastic bag thing)
Benign pigmented coin lesion w/ a ‘stuck on’ appearance
Seborrheic keratosis
-not actinic keratosis which is premalignant
Describe CT findings of diffuse axonal injury after head trauma
Diffuse axonal injury CT: blurring of the gray-white matter interface w/ multiple small punctuate hemorrhages
Normal ultrasound of the gallbladder
(a) Wall thickness
(b) CBD diameter
(c) fluid
Normal gallbladder ultrasound findings
(a) GB wall less than 3mm thick
- distended (unless just ate fatty meal)
(b) CBD diameter under 7 mm (does increase w/ age)
(c) No pericholecystic fluid (fluid around the gallbladder)
Dx and mgmt
The U-shaped portion of bowel = closed loop obstruction = surgical emergency 2/2 risk of strangulation
-U shape is caused by tethering of the bowel
Dx
- distended small bowel loops
- air fluid levels
= SBO
What is a HIDA scan?
Hepatobiliary scintigraphy = nuclear imaging study of the hepatobiliary tract
-radioactive tracer that w/in 1 hr should make its way to the GB w/in 1 hour, if GB nto visualized w/in 4 hrs after venous injection it indicates cholecystitis or cystic duct obstruction
Cricothyroidomy vs. Tracheostomy
Difference in location of the tubes and time frame
Cricothyroidomy = emergency surgical airway, puncture btwn thyroid and cricoid cartilage, anaesthetic not essential
Tracheostomy = hole cut in 2nd and 3rd tracheal rings, more permanent
Dx
String of pearls sign in the abdomen indicating trapped gas in fluid-filled lumen 2/2 small bowel obstruction
Boundaries of Hasselbach’s triangle
Medially- border of the rectus abdmoinis
Laterally- ilioinguinal ligament
Inferior epigastric blood vessels
Triad of aortoiliac occlusion
Leriche syndrome = occlusion at the aortic bifurcation of the common iliacs => b/l symptoms
- b/l buttock, thigh, and hip claudication
- impotence
- b/l LE atrophy 2/2 chronic ischemia
Arterial supply of the adrenal gland
Small branches from three arteries
- phrenic artery
- branches directly from aorta
- branches from renal artery
What is an escar?
Black leathery skin left over after third degree (full thickness burn)
Placement for central line w/ the lowest incidence of infection
Subclavian <3
- right subclavian vein meets internal jugular to feed into SVC
- left subclavian joins left internal jugular to form the left brachiocephalic which feeds into the IVC
What layer of the colon wall contains
(a) blood vessels
(b) enteric nervous system
Layers of the colon wall: mucosa, submucosa, muscularis propria (made of both circular and longitudinal muscle layers) and serosa
(a) Blood vessels, lymphatics, and glands are in the mucosa- the single layer that lines the lumen
(b) Enteric nervous system lay btwn the 2 muscle layers in the muscularis propria
6 yo boy w/ insidious developing of limping, decreased hip motion, and knee pain
Dx
Legg-Clave-Perthes disease = avascular necrosis of the capital femoral epihphysis
-idiopathic ischemia of the femoral head => osteonecrosis => loss of bone mass (flattening of femoral head), collapse, and deformity
Papillary thyroid cancer
- orphan annie eye nuclei = nuclei w/ uniform staining which appear empty
- psammoma bodies = round collection of calcium seen in papillary cancers, most common thyroid
What is a surgical airway?
Surgical airway = cricothyroidotomy
-puncture space btwn thyroid cartilage and cricoid cartilate (the cricothyroid membrane)
Gold standard tx for achalasia
Achalasia = incomplete LES relaxation/high LES tone
Tx = endoscopic baloon dilation of the lower esophageal sphincter
Urachal cyst
Connection btwn umbilicus and bladder
-remnant of the allantois from embryogenesis
So urine comes out the belly button…
Statistically most common type of hernia
Indirect inguinal hernia
Name the layers of the abdominal wall from superficial to deep
- Skin
- Subcuntaeous tissue made of
(a) Camper’s fascia = superficial fatty layer
(b) Scarpa’s fascia = deep membranous layer - Investing (deep) fascia
- Muscles w/ their aponeuroses (also can be considered additional layers of investing fasia)
- external obliques
- internal obliques
- transversus abdominis - traversalis fascia
- parietal peritoneum
Where is McBurney’s point?
2/3 of the way from the umbilicus to the ASIS
Why are internal hemorrhoids not painful?
B/c there are no somatic pain fibers above the dentate line
Describe the location of femoral hernias
Lateral to medial: mneumonic NAVAL for the structures in the inguinal region: nerve –> artery –> vein –> femoral canal –> lymphatics
Opening to the femoral canal is the femoral ring, thru which intestines protrude in a femoral hernia
Benign liver tumor with central scar on CT
Focal nodular hyperplasia = benign liver tumor, often resected b/c difficult to differentiate from hepatic adenoma
-central scar is the artery supplying the region (will light up on Doppler)
What is a Hartmann’s procedure
Hartmann’s = proctosigmoidectomy = segmental colonic resection w/ end colostomy
- done in emergency to remove the perf/sepsis, then can come back later and do curative surgery
- resection of rectosigmoid colon w/ closure of rectal stump and formation of end colostomy
Describe supine and upright abdominal plain film findings of SBO
Supine: see dilation of proximal SB w/ no air in distal colon (if functional obstruction)
Upright: can now see the air fluid levels b/c liquid goes to bottom (2/2 gravity)
Briefly go thru steps of lap appy
Laparoscopic appendectomy
- Place 3 trocars and fill abdomen w/ gas: provider dependent, often one at umbilicus and two at hairline
- Find and grasp appendix
- Make window btwn base of appendix and mesentery via blunt dissection
- Dissect proximally first, then staple off distally, staple off mesentary and blood vessels
- Remove appendix in endocatch thru umbilical port site
- Irrigate to remove debris and ensure hemostasis
- Remove trocars and close port sites
25 yo F w/ 2mo h/o pigmented lesion under ring finger
Dx?
Melanoma! Irregular borders, new onset (not just a mole)
-not basal cell (pearly and white)
Nerve most commonly damaged in fracture of the midshaft of the humerus
Radial groove runs on the posterior surface of the humerus
Give brief overview of steps to a lap choley
- Place 4 port sites
- Gall bladder exposure and dissection: push GB and liver superolaterally to reveal infundibulum and porta hepatis
- remove adhesions - Dissection of hepatocystic triangle: obtain critical view = window btwn cystic artery and cystic duct with nothing but liver edge posteriorly
- Clip and cut cystic artery and cystic duct
- Dissection of gall bladder from the liver bed
- separate any CT adhering GB to lobes 4 and 5 of the liver - Extract GB in endocatch through umbilical port
- Close fascia of umbilical site (not just skin) to prevent hernia
Dx
Coffee-bean sign of sigmoid volvulus = type of large bowel obstruction where sigmoid colon gets twisted around the sigmoid colon
Treatment for circumferential thoracic burn w/ impaired ventilation
Tx for any circumferential third degree burn = escharotomy = surgical incision thru eschar (tough leathery tissue remaining after full-thickness burn)
During hernia repair the external oblique aponeurosis is opened, what should be found right beneath the external oblique?
Spermatic cord
Dividing the external oblique will expose the internal oblique layer everywhere except the groin, where it exposes the spermatic cord
Maneuver to limit hepatic inflow duirng trauma laparotomy
Pringle maneuver- basically compress the portal triad (hepatic artery, portal vein, CBD) to prevent inflow/outflow
Blood per rectum in a child
Meckel diverticulum until proven otherwise
= remnant of vitelline duct (yolk stalk), blind sac in the distal ileum
Name the 2 lymph node chains that breast cancer travels to first
Primarily the axillary nodes, but also the internal mammary chain
Describe CT findings of perforated appendicits
Perforated appendix- may end up w/ abscess = fluid and gas collection around a calcified appendecholith
Give aways = fluid in abdomen, calcification in appendix
