Schofield surgery SAQs Flashcards
What is a diverticulum?
An outpouching of mucosa through the muscle wall.
Which section of colon are diverticula most common in?
Sigmoid colon
Higher intraluminal pressure as the majority of water has been reabsorbed from the faeces.
Define diverticulosis, diverticular disease and diverticulitis.
Diverticulosis - presence of diverticula in the GI, asymptomatic (usually found incidentally on imaging)
Diverticular disease - symptomatic diverticula
Diverticulitis - inflammation of diverticula
Investigations in diverticulitis?
FBC
CRP
Blood cultures
CT scan
Mainstay treatment of diverticulitis?
Analgesia
Abx
Adequate hydration
Complications of diverticulitis?
Perforation
Bleeding
Abscess
Strictures
Fistulas
Hernia definition
Protrusion of a structure through the wall of a cavity in which it is usually contained.
Location of inguinal vs femoral hernia?
Inguinal - superior and medial to pubic tubercle
Femoral - inferior and lateral to pubic tubercle
How do indirect inguinal hernias occur?
During foetal development, the testes descend following the processus vaginalis (attached by the gubernaculum).
If the connection to the peritoneal cavity fails to close, then a patent processus vaginalis is present through which indirect inguinal hernias can occur.
Complications post inguinal herniotomy? (open mesh repairs and laparoscopic mesh repairs)
Recurrence
Wound site infection
Mesh infection
Damage to intestines/bladder/spermatic cord
Hydrocele
Symptoms of haemorrhoids?
Bright red PR bleed
Anal itching
Mucous
Rectal fullness
Pain
Soiling
Investigations for haemorrhoids?
FBC
Proctoscopy
Sigmoidoscopy
Two procedures to manage haemorrhoids?
Rubber band ligation
Haemorrhoidectomy
Complication of haemorrhoids?
Ulceration
Stricture
Thrombosis
Infection
Anaemia
Skin tags
Acid-base disturbance associated with acute mesenteric ischaemia?
Metabolic acidosis
Acid-base disturbance in vomiting
Metabolic alkalosis with normal anion gap
Acid-base disturbance in diarrhoea
Hyperchloremic metabolic acidosis
Blood test abnormalities in acute mesenteric ischaemia?
Raised wcc
Raised lactate
Raised Hb
Raised amylase
Definitive imaging in Acute Mesenteric ischaemia?
CT abode with IV contrast
Aims of surgery for Acute Mesenteric ischaemia?
Resection of necrotic bowel
Revascularisation
Initial management of Acute Mesenteric ischaemia prior to surgery?
IV fluids
Antibiotics
Analgesia
Function of red pulp of spleen?
Acts as the filter and destroyed defunct red blood cells
Function of white pulp of the spleen?
White pulp is lymphoid tissue which acts as part of the body’s immune system.
Indications for splenectomy?
Trauma
Spontaneous rupture
Hypersplenism
Neoplasia
Cysts
Splenic abscess
Long term management post-splenectomy?
Lifelong prophylactic antibiotics
Vaccinations (pneumococcal and annual influenza)
Blood film post-splenectomy will show?
Howell-Jolly bodies
Target cells
What are Howell-Jolly bodies?
RBC in which the nuclear remnant is still seen
Causes of acute pancreatitis?
Alcohol
Gallstones
Trauma
Steroids
Scorpion sting
ECRP
Hypercalcaemia
Early complications of pancreatitis?
Shock
ARDS
Sepsis
DIC
Renal failure
Late complications of pancreatitis?
Pancreatic pseudocyst
Pancreatic necrosis
Abscess
Chronic pancreatitis
Acute pancreatitis management?
IV fluids
Analgesia
NG tube
Catheterisation
4 main features of SBO?
Constipation
Vomit
Colicky abdo pain
Distension
4 common causes of SBO?
Adhesions
Hernias
Tumour
Volvulus
Types of gallstones?
Pigment stones
Cholesterol stones
Mixed stones
Risk factors for gall stones?
Fair (Caucasian)
Forty
Fertile
Fat
Female
Acute cholecystitis investigations?
FBC
CRP
LFTs
Amylase
Trans-abdo USS
Acute cholecystitis management?
NBM
IV Fluids
Analgesia
Abx
Laparoscopic cholecystectomy <72hours
4 lobes of the liver?
Right
Left
Caudate
Quadrate
Which ligament divides the anterior of the liver into the two anterior lobes?
Falciform ligament
Cancers that commonly metastasise to the liver?
GI tract
Breast
Lung
Uterus
Causes of hepatocellular carcinoma?
Viral hepatitis
Cirrhosis
COCP
Tumour marker raised in hepatocellular carcinoma?
AFP
Causes of acute urinary retention?
UTI
BPH
Constipation
Drugs (anticholinergics, opiates, antidepressants)
Post-anaesthesia
Alcohol
In acute urinary retention, apart from abdo exam what other exam should be performed?
Peripheral nervous system
Assess for CES
Important things to undertake with regards to post-catheterisation care? (acute urinary retention)
Document residual volume
Take specimen for CSU
How does the catheter drainage vol help distinguish between acute and chronic urinary retention?
Chronic is more likely to hold higher vol and be painless 1.5L+
Following catheter drainage of patient with acute urinary retention if lots of urine produced what is this called?
Post-obstructive diuresis
> 200ml per hour for 2 consecutive hours OR 3L in 24 hours
Monitor urine output hourly and replace losses with IV fluids.
Drugs used in BPH?
Tamsulosin: alpha-1 receptor antagonist. Relaxes prostatic smooth muscle
Finasteride: 5-alpha reductase inhibitor. Reduces prostate size.
Causes of macroscopic haematuria?
UTI
Renal tract trauma
Renal tract tumour
Renal stone
Schistosomiasis
Nephritic syndrome
Investigations for macroscopic haematuria (non-infective)?
Renal tract USS
Flexible cystoscopy
Urine cytology
Risk factors for bladder cancer?
Smoking
Aromatic amines
Schistosomiasis
Cyclophosphamide
Management of bladder cancers?
TURBT - transurethral resection of bladder tumour
Radical cystectomy
Where may bladder tumour metastasise?
Local (pelvic structures):
Uterus
Rectum
Pelvic side wall
Haematogenous:
Liver
Lungs
Bone
Lymphatic: Iliac and paraaortic lymph nodes.
What is the definition of sensitivity vs positive predictive value?
Sensitivity - number of people who have the disease who test positive
Positive predictive value - number of positive tests who actually have the disease.
What effect does low PPV have on patients?
More patients would have to undergo unnecessary secondary (possibly invasive) investigations for a disease that they don’t have.
Criteria for a screening programme?
- Course of the disease should be known
- Early symptoms should be present in the individual
- Treatment for the condition should be available to all patients
- Prompt treatment should be of more benefit than delayed treatment
Score to evaluate prostate cancer prognosis?
Gleason
Active surveillance meaning in prostate cancer?
Regular monitoring of PSA to assess if disease has progressed.
Layers of the scrotum?
Skin
Dartos fascia (scarpa)
External spermatic fascia
Cremaster muscle
Internal spermatic fascia (tunica vaginalis)
Tunica albuginea
Why is it BILATERAL orchidopexy for testicular torsion?
Protect the other testis from later episode of torsion.
Why might someone have raised Hb in renal tumours?
Some renal tumours are associated with increased EPO release that causes a raise in Hb.
Risk factors for renal cell carcinoma?
Smoking
Dialysis
Hypertension
Obesity
Polycystic kidneys
Von Hippel-Lindau disease
Investigation for renal colic?
CT KUB with no contrast
Emergency treatment with impacted kidney stone?
Percutaneous nephrostomy
Anatomical basis of hydrocele?
Hydroceles arise in the tunica vaginalis.
Risks of TURP and functions that may be lost?
Urinary incontinence
Unable to get an erection
TURP syndrome
Retrograde ejaculation
Clot retention
Advantages of spinal anaesthesia over GA?
Costs less
Less chance of respiratory complications
Quicker time to discharge
What is TURP syndrome?
Irrigation fluid from the operation enters the intravascular space and expands it. Causes fluid overload and hyponatraemia.
Differentiate between stress and urge incontinence?
Stress: urine leaks due to increased intra-abdo pressure and pelvic floor muscles weak.
Urge: involuntary urine leak preceded by sudden urge to micturate. Due to overactive nerves supplying the bladder.
What is oxybutinin and some side effects?
Anticholinergic - reduces spasmodic activity.
SE - Dry mouth, constipation, blurred vision, drowsy and dizzy
Causes of recurrent UTIs in men?
Immunosupression
Colovesical fistula
Bladder outflow obstruction (BPH, indwelling catheter, urethral stricture)
Common UTI organisms
E.coli
Staphylococcus saprophyticus
Klebsiella
Causes of urethral stricture?
Insertion of foreign body into urethra
Pelvic trauma
Perineal trauma
Long term catheter
LUTS Storage symptoms?
Increased urinary frequency
Nocturia
Increased urgency
Urge incontinence
LUTS Voiding symptoms?
Poor flow
Terminal dribble
Hesitancy or straining in micturition
Feeling of incomplete emptying
Investigations for urethral stricture?
Cystoscopy
U&Es to assess renal function
Urinalysis MC&S
Urodynamic studies
Complications of urethral stricture?
Calculus formation in urinary tract
Chronic infx leading to prostatitis, epidiymitis or Fournier’s gangrene
Renal impairment due to obstruction
Treatment for urethral stricture?
Internal urethrotomy
Urethroplasty
Cause of septic arthritis if metal prosthesis was in situ?
Staphylococcus epidermis
Risk factors for septic arthritis?
Intra-articular injections
RA
Diabetes mellitus
Immunosuppression
Penetrating injury
Where does the supraspinatus attach to the humerus?
The greater tubercle
Two muscles innervated by the accessory nerve?
Teres minor
Deltoid
Specific tests for rotator cuff tears?
Jobe’s test (supraspinatus) - empty can test
Gerber’s lift off test (subscapularis)
Posterior cuff test (infraspinatus and teres minor)
Investigations for rotator cuff tear
Urgent plain film radiography to exclude fracture.
US and MRI to establish presence, size and location.
What adjunct to maintain airway in emergency with possible basal skull fracture?
Oropharyngeal airway (Guedel airway)
Below what GCS is the airway at risk of not being maintained?
<8
Tension pneumothorax management
Needle decompression, a wide bore cannula into 2nd ICS MCL then insert chain drain into safety triangle
Dull percussion on lung following stabbing?
Haemothorax - wide bore chest drain
How do you test the collateral ligaments of the knee?
Valgus-varus stress test
What makes up the ‘unhappy triad’
ACL tear
Medial collateral ligament tear
Medial meniscus tear
Why is the medial meniscus commonly damaged alongside the MCL?
The medial meniscus tightly adheres to the medial collateral ligament.
What test is positive with a meniscal tear?
McMurray’s test
What imaging do you do to assess damage of the medial meniscus?
MRI
Which cruciate ligament attaches anteriorly to the tibial plateau?
Anterior cruciate ligament
Which arteries supply the femoral head?
Medial and lateral circumflex femoral arteries.
Ligamentum teres
What part of the radius is fractured in a Colles’ fracture?
Distal metaphysis
How is a Bier’s block performed?
The affected arm is exsanguinate and a tourniquet is applied to the proximal part of the arm.
Local anaesthetic is injected intravenously and once it has taken effect the procedure can be performed.
The tourniquet is released after 20-30 mins to prevent pain occuring due to the occlusion.
Why must X rays be repeated after a cast/reduction?
To check it has been adequately reduced
How long does a Colles’ fracture take to heal?
6-8 weeks
What is an open fracture?
Communication between the fracture and the outside world.
What system is used to classify open fractures?
Gustilo-Anderson Classification
Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C: All injuries with vascular injury
Management for open fractures?
Fluid resus
Analgesia
Assess neurovascular status and soft tissue damage
Photograph wound
Surgical debridement
Surgical fracture stabilisation
Wound closure
What is the termination of the spinal cord known as?
Conus medullaris
At what vertebral level does the spinal cord terminate?
L2-L3
In newborns L4-L5
Reasons to consider joint arthroplasty in OA?
Reduced QoL
Symptoms not responding to non-surgical management
Name of area on anterior nasal septum where epistaxis commonly originates?
Kiesselbach’s area
Why do FBC in epistaxis?
Hb may have dropped due to epistaxis
Low platelets may be the cause of the epistaxis
Tonsillitis symptoms?
Sore throat
Odynophagia
Fever
Anorexia
Headache
Ear pain
Abdo pain
Differentials for tonsillitis?
Infectious mononucleosis
Scarlet fever
Agranulocytosis
Malignancy
Why do we give penicillin V rather than amoxicillin in tonsillitis?
Amoxicillin will cause a maculopapular rash if the cause of the symptoms is infectious mononucleosis instead of acute tonsillitis.
What is Barrett’s oesophagus?
Metaplasia of squamous to columnar epithelium in the lower oesophagus.
Risk factors for oesophageal carcinoma?
Barrett’s oesophagus
Smoking
Alcohol
Obesity
Achalasia
Coeliac disease
Increasing age
Plummer Vinson syndrome
Which cranial nerve is the recurrent laryngeal nerve a branch of?
Vagus nerve
Which side is recurrent laryngeal nerve palsy more common and why?
Left side
Longer course than the right therefore more susceptible to damage.
Causes of unilateral facial weakness?
Stroke
Tumours
Acoustic neuromas
Multiple sclerosis
Ramsay Hunt syndrome
Bell’s palsy
Trauma
What is vertigo?
The illusion of movement - in true vertigo the patient should be able to tell you in which direction the movement is occurring
Causes of vertigo?
BPPV
Meniere’s disease
Acoustic neuroma
Cholesteatoma
MS
Vestibular neuronitis
Otitis media otoscopy findings?
Red bulging TM
Components of eardrum?
Pars flaccida
Pars tensa
Organisms in otitis media?
Streptococcus pneumonia
Haemophilus influenzae
Moraxella catarrhalis
What tuning fork is used in Rinne and Weber’s?
256-512 kHz
Conditions that give unilateral swelling of the parotid gland?
Tumour
Parotitis
Mumps
Duct blockage
Most common tumour of the parotid gland?
Pleomorphic adenomas
Main differential diagnosis of vestibular schwannoma?
Meningioma
Name the paranasal sinuses?
Frontal
Maxillary
Ethmoidal
Sphenoid
True vs pseudoaneurysm?
True aneurysm involves all the layers of the vessel wall, whereas a pseudo aneurysm is an accumulation of blood between the tunica media and tunica adventitia due to a breach in the arterial wall.
Complications of surgery for AAA?
Bleeding
Infx
DVT/PE
MI
Spinal ischaemia
Renal failure
Mesenteric ischaemia
Death
What factors may make end-vascular aneurysm repair more favourable than open repair?
Multiple comorbidities making open surgery unacceptably risky.
Disadvantages of end-vascular repair for AAA?
High reintervention rate
Long-term follow up required.
Following open repair of AAA, patient develops mottled skin and darkened segments in his toes.
What is this phenomenon called and why?
Cholesterol embolism
Atheromatous debris is shed during surgery and travels and lodges in distal vessels causing local ischaemia.
Layers of arterial wall (inner to outer)
Endothelium/intima
Tunica media
Tunica externa
Serosa/adventitia
Why must acute limb ischaemia be managed urgently?
Irreversible tissue ischaemia occurs within 6 hours so limb-salvage surgery must occur before this time whilst leg is still viable.
Definitive treatments for acute limb ischaemia?
Thrombolysis
Angioplasty
Embolectomy
Arterial bypass
How does heparin work?
Heparin activates Anti-thrombin III, which in turn inactivates thrombin and factor Xa.
This prevents the clotting cascade from activating fully causing anticoagulation.
Complications of heparin use?
Increased risk of haemorrhage.
Long term use may cause osteoporosis.
Heparin-induced thrombocytopenia.
Medical therapy for critical limb ischaemia?
Clopidogrel 75mg OD
Atorvastatin 80mg OD
Optimise diabetes control
What location of arterial stenosis if buttock pain and impotence present?
Internal iliac artery stenosis
As pudendal and sup. gluteal arteries arise from here.
What does incidence rate mean?
Incidence rate is the number of new cases in a given population in a given time frame.
Risks of carotid endarterectomy?
Death
Major stroke
MI
Wound haematoma
What is an ulcer?
Abnormal break in an epithelial surface
Why must metformin be stopped 48hrs prior to angiogram?
Metformin can interact with IV contrast, precipitating lactic acidosis.
Difference between primary and secondary intention (wound healing)?
Primary: healing of epidermis and dermis occur without penetration and epithelialisation of the entire dermis - produces small scars
Secondary: wound is open and allowed to granulate from the bottom up. Scar is larger and takes longer to heal.
Clinical features of DVT?
Limb swelling and warmth
Pain
Erythema
Mild fever
Pitting oedema
Virchow’s triad?
Intravascular vessel wall damage
Stasis of flow
Presence of a hypercoaguable state
Complications of DVT?
PE
Venous gangrene
Chronic venous insufficiency
Indications for amputation?
Severe arterial disease
Major trauma
Severe venous disease
Gas gangrene
Uncontrolled sepsis
Necrotising fasciitis
Failed orthopaedic surgery
How do varicose veins arise?
Valves in superficial leg veins become incompetent so veins dilate and become tortuous.
Venous HTN makes the valve incompetence worse and further dilatation occurs.
Risk factors for varicose veins?
Obesity
Pregnancy
Prolonged standing
Fhx
Where is the saphenovenous junction?
5cm below and medial to the femoral pulse
Complications of varicose veins?
Bleeding
Pain
Ulceration
Superficial thrombophlebitis
What is a Whipple’s procedure? (pancreatic head cancer)
Removal of:
Head of pancreas
Antrum of stomach
1st & 2nd parts of duodenum
CBD
Gallbladder
Procedure for body/tail pancreas cancer?
Distal pancreatectomy and splenectomy
+ regional lyphadenectomy
What is a Hartmann’s procedure?
Sigmoid colectomy with end colostomy formation.
(usually emergency procedure - sigmoid perforation/sigmoid malignancy causing bowel obstruction)
What is an abdominoperineal resection (APRs) ?
For very low rectal cancers and severe perianal Crohn’s disease.
Exicision of anus, rectum and anal canal.
End colostomy
What is an anterior resection?
Remove the rectum and sigmoid colon
For sigmoid or rectal cancer
What is removed in a left hemicolectomy?
Splenic flexure
Descending colon
Portion of sigmoid colon
What is removed in a right hemicolectomy?
Terminal ileum
Caeum (incl. the appendix)
Ascending colon
Hepatic flexure
