Surgery 1 Flashcards by Akash Srinivasan

List some different types of myocutaneous flap.

Latissimus dorsi
Transverse rectus abdominis myocutaneous (TRAM)
Deep inferior epigastric perforator (DIEP)

NOTE: TRAM is supplied by the inferior epigastric arteries or internal thoracic artery, lat dorsi is supplied by thoracodorsal and subscapular arteries

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Which special test should you be careful about performing in a patient with a hip replacement?

Thomas’ test - checking for fixed flexion deformity
There is a chance that you can dislocate it
ALWAYS ask whether they have had surgery before you hyperflex the hip joint

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List some complications of hernia repair surgery.

EARLY
- urinary retention 
- haematoma 
- infection 
- intra-abdominal injury (laparoscopy)
LATE
- recurrence 
- ischaemic orchitis (due to thrombosis of pampiniform plexus) 
- chronic groin pain

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What are sebaceous cysts and what are the two histological subtypes?

Epithelial-lined cysts containing keratin arising from hair follicles
Epidermal cyst: arise from hair follicle infundibulum
Trichilemmal cyst: air from hair follicle epithelium, often multiple

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What are the two ways in which a dislocated shoulder can be reduced?

Should be done under sedation
Hippocratic: longitudinal traction with arm in 30 degree abduction and counter traction at the axilla
Kocher’s: external rotation of adducted arm, anterior movement, internal rotation

NOTE: rest arm in a sling for 3-4 weeks, physiotherapy

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What are the main things you need to elicit in a patient with a hernia?

Is it reducible?
Is it tender?
What do you think is in the sac (colon, small bowel, preperitoneal fat or omentum)?
How big is the defect? Is there a mesh?

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EPONYMOUS OPERATIONS: lower oesophageal cancer

Ivor-Lewis oesophagectomy - two-stage oesophagectomy (lateral thoracotomy and midline laparotomy)
McKeown oesophagectomy - three-stage (lateral thoracotomy, midline laparotomy and neck)
Transhiatal - only upper midline laparotomy and neck incision

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How is inflammatory bowel disease investigated?

AXR - toxic megacolon (UC), small bowel obstruction (CD)
Contrast - gastrograffin enema (UC), barium follow-through (CD)
MRI - perianal disease in CD
Endoscopy: ileocolonoscopy and biopsy, capsule endoscopy

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What are the advantages and disadvantages of EVAR?

ADVANTAGES: reduced perioperative mortality (1% vs 5%), reduced hospital stay, better cosmetically
DISADVANTAGES: no mortality benefit after 5 yrs, significant late complications, not better than medical treatment in unfit patients (i.e. not fit for open repair)

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What is the ulnar paradox?

Closer to the paw the worse the claw

Proximal lesions cause paralysis of flexor digitorum profundus which causes less clawing of the hand

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What is a major complication of pelvic fractures?

Urethral injury leading to urinary retention

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What are the X-ray features of osteoarthritis?

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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What is a cystic hygroma?

Congenital multicystic lymphatic malformation usually seen in the posterior triangle of infants

NOTE: it transilluminated brilliantly and is soft and fluctuant

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How are paraumbilical hernias managed?

Surgery is advised due to high risk of strangulation 
Mayo repair (mobilise sac and reduce contents)

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List some abdominal wall or soft tissue masses that can affect any part of the abdomen.

Sebaceous cyst
Lipoma
Sarcoma

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What is myositis ossificans?

Ossification of muscles at sites of haematoma formation leading to restricted painful movement (usually affects elbows and quads) and requires excision

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What are the main motor and sensory areas supplied by the radial nerve?

Motor: metacarpophalangeal joint extension
Sensory: 1st dorsal web space

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What are the layers of tissue that are cut in an abdominal incision?

Skin 
Camper's fascia (fatty layer or superficial fascia)
Scarpa's fascia (membranous layer of superficial fascia) 
External oblique deep fascia 
Internal oblique deep fascia 
Transversus abdominal deep fascia 
Transversalis fascia 
Extraperitoneal fat 
Parietal peritoneum

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List some differentials for anterior neck lumps.

Lymphnodes 
Chemodectoma
Goitre
Parotid tumour (e.g. mumps) 
Branchial cyst 
Laryngocele

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What is the first-line investigation for suspected prostate cancer?

Multiparametric MRI

This has superseded TRUS biopsy

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What is a radical cystectomy?

Men: bladder, prostate and iliac lymph nodes
Women: bladder, ovaries, uterus, cervix and anterior wall of vagina

What is a Monteggia fracture?

Fracture of proximal 1/3 of ulna shaft + anterior dislocation of radial head at capitulum

NOTE: can cause palsy of deep branch of radial nerve (wrist drop but no sensory loss)

EPONYMOUS OPERATIONS: rectal prolapse

Delorme procedure - perineal approach with mucosal excision

List some complications of thyroid surgery.

Haemorrhage 
Recurrent laryngeal nerve palsy 
Hypocalcaemia (parathyroid damage) 
Thyroid storm 
Hypothyroidism and hypoparathyroidism 
Recurrence 
Keloid

List some peripheral stigmata of thyroid disease.

``` Agitated or lethargic Body habitus Sweating Skin and hair (loss suggests hypothyroidism) Thyroid acropachy Palmar erythema Tremor AF ```

What are the key aspects of a history you need to focus on in a patient with suspected osteoarthritis?

Pain - exertional, rest, night Disability - walking distance, stairs, giving way Deformity

What are the four types of thyroid cancer and which is most common?

``` Papillary (80%) Follicular Medullary Anaplastic (Lymphoma) ```

What are the advantages and disadvantages of braided sutures?

ADVANTAGES: easier to handle, knots slip less, greater tensile strength DISADVANTAGES: increased risk of infection, increased friction on tissues

What are the three main reasons for having vascular bypass surgery?

Trauma Aneurysm Occlusion

How do you test the reaction of a hernia to raised intra-abdominal pressure in a patient with a tracheostomy?

Lie them flat and ask them to lift their legs up

List some reasons for having vascular access scars in the groin.

``` Bypass Embolectomy Endovascular aneurysm repair Stent insertion Femoral endarterectomy Angioplasty ```

List some key differences between ileostomy and colostomy.

Ileostomy: RIF, spouted, watery contents Colostomy: LIF, flush, formed faeces (may be in RUQ - transverse loop colostomy) NOTE: ileostomy may be seen on the left side in patients who have previously had an ileostomy on the right (look for scar)

Describe the classification of operative haemorrhages.

PRIMARY: continuous bleeding starting during surgery REACTIVE: bleeding within 48 hours post-op SECONDARY: bleeding at 7-10 days post-op (usually due to infection)

Describe an antalgic gait.

Shortened stance-phase on the affected side

What is the difference between a total and subtotal gastrectomy?

Total: entire stomach is removed, oesophagus is joined to jejunum with Roux-en-Y oesophagojejunostomy Subtotal: part of fundus of stomach is left, oesophagus is joined to jejunum with Roux-en-Y oesophagojejunostomy

Outline the management of hydroceles.

Non-Surgical: watch and wait, aspiration for symptomatic relief Surgical - Lord's repair (plication of tunica vaginalis) - Jaboulay's repair (eversion of the sac)

If you hear a bruit over a varicosity what does that suggest?

AV malformation

What are some causes of subcutaneous lumps?

Lipoma Ganglion Lymph nodes NOTE: can move the skin over the lump

What is the Monroe-Kelly doctrine?

The cranium is a rigid box, therefore the total volume of intracranial contents must remain constant if ICP is not to change An increase in the volume of one constituent required a compensatory reduction in another (usually CSF vs blood) These mechanisms allow a volume change of ~100 mL before ICP starts to rise

What is the point of tunnelling a central line?

Cuffs promote tissue reaction which creates a better seal | The tunnel helps keep the catheter in place and reduces the risk of infection

Why is acute on chronic limb ischaemia less time urgent than acute limb ischaemia?

Patients with established peripheral vascular disease will have developed collaterals that enable some perfusion even if a major artery is occluded (they will develop paraesthesia and paralysis later on)

Which investigations are used for patients with intermittent claudication?

Exercise treadmill ABPI Duplex ultrasound (look at velocity of blood flow through artery) Angiography NOTE: with exercise ABPI, you measure the pressure and after exercise once they start complaining of calf pain (ABPI will have dropped after exercise)

During an operation, how can a direct inguinal hernia be distinguished from an indirect inguinal hernia?

INDIRECT: arise lateral to the inferior epigastric vessels DIRECT: arise medial to the inferior epigastric vessels through Hesselbach's triangle NOTE: pantaloon hernias are both direct and indirect

List some forms of definitive airway.

Orotracheal airway Nasotracheal airway Tracheostomy Cricothyroidotomy

List some indications for using a disposable rigid sigmoidoscope.

Allows endoscopic examination of rectum and recto-sigmoid junction with biopsy if necessary Used to investigate rectal bleeding, colonic neoplasia and inflammatory bowel disease Complications: perforation (mechanical or pneumatic), bleeding

List some complication of using a shouldered syringe to inject haemorrhoids.

IMMEDIATE: pain if injected below the dentate line, damage to nearby structures, primary haemorrhage LATE: prostatitis, impotence

List some causes of knee locking.

Meniscal tear Cruciate ligament injury Osteochondritis dissecans Loose body

How are thyroglossal cysts treated?

Sistrunk operation - removal of thyroglossal tract through transverse incision just above thyroid cartilage

What is a triple phase CT scan and what is its purpose?

Used to further evaluate renal tumours Initial non-contrast phase (look for fat in the tumour) Arterial phase Venous phase NOTE: tells you location of tumour, size, renal vein involvement, lymph nodes, distant mets, state of contralateral kidney

What should be offered to patients with chronic urinary retention who want to avoid surgery?

Intermittent self-catheterisation NOTE: if this fails, a long-term catheter can be offered