Surgery Flashcards
What artery supplies the Midgut?
Superior mesenteric artery
What artery supplies the hindgut?
Inferior mesenteric artery
What surgery is usually done for Crohn’s disease?
Ileocolic Resection
What are risk factors for colorectal cancer? (6)
Family History Age Diet - high in fats and meat and low in fibre Diabetes Atherosclerotic disease IBD
What is a adenoma?
A benign epithelial neoplasm
How can an adenoma become malignant?
Through loss of tumour suppressor genes
Oncogene activation
Loss of genes involved in DNA repair
What is the main management of adenomas?
Endoscopic Mucosal Resection (EMR) - removing polyps by colonoscopy.
As well as long term surveillance as there is a 50% risk of recurrence
What is the difference between a Panproctocolectomy and a subtotal colectomy?
Panproctocolectomy = removal of the colon and the rectum. - Ileoanal pouch is formed
Subtotal colectomy = removal of the colon and not the rectum. Joined via an anastomosis.
A patient has a right transverse incision, what are the possible surgeries they may have had?
Right hemicolectomy
Gallbladder or Liver surgeries (can be more oblique)
What is the scar for appendectomy surgery?
Right iliac fossa transverse incision (Lanz incision)
Name general surgical complications?
Infection Cardiac event - stroke Bleeding VTE Chest Infection
Name specific colorectal complications?
Anastomotic leak - doesn't get better Nerve damage - sexual or urinary dysfunction Poor bowel function Stoma: prolapse, hernia, high output ileostomy
What surgery may be performed for rectal cancer?
Anterior resection - all of rectum and some of sigmoid removed with a defunctioning temporary stoma.
What is Hartmann’s procedure and when might it be used?
Emergency = perforated diverticulitis or a obstruction
As well as in elderly patients with cancer to aid incontinence.
Removes problem bowel and a stoma is put in.
It is reversible.
What is the enhanced recovery programme and why is it used? (3 parts)
Aids patients to have better and faster recoveries
Eat and Drink ASAP
Early mobilisation - physio and catheter removed ASAP
Pain relief used but to avoid epidurals
Name some causes of colonic perforation?
Appendicitis Diverticulitis Tumour Foreign body Stercoral (impacted faeces) Anastomotic leak - post surgery abdo pain and fever --> CT Colitis - toxic megacolon --> colectomy pseudo-obstruction - dilatation of the colon (caecum - Laplace's law)
Name some causes of colonic obstruction?
Tumour
Colo-colonic intussusception
Volvulus - twisting of mesentery (closed loop). E.g. sigmoid coffee bean sign
Hernia - inguinal, incisional, paraumbilical
Where is colonic ischaemia most likely to happen and why?
Griffiths point - due to it being the watershed area between the SMA and IMA (at the splenic flexure)
Causes of ischaemia in the bowel?
AAA, Trauma, embolus, low flow state (chronic disease)
What is the management of mild and severe bowel ischaemia?
MIld = supportive cardiovascular optimisation Severe = resection and stoma
Name some causes of colorectal haemorrhage?
Diverticulosis Angiodysplasia Haemorrhoids Tumour polypectomy Aortoenteric fistula
Management options of colorectal haemorrhage?
Conservative
Mesenteric angiogram embolisation
Surgery - dependent on if you know blood source
Colonoscopy haemostasis
What are causes of perianal sepsis/
Abscess
Necrotising fasciitis
Fournier’s Gangrene
What is a pilonidal abscess?
A anorectal cyst containing hair
What is angiodysplasia? And how does it usually present?
Arteriovenous malformations
commonly in the caecum and ascending colon
Painless PR occult bleeding otherwise can be asymptomatic
What are the 3 main causes of acute limb ischaemia?
Embolisation = Proximal thrombus occludes a distal artery.
Thrombosis-in-situ = plaque in artery ruptures and forms a cap (acute on chronic)
Trauma (compartment syndrome)
What increases the risk of a embolisation ?
AF
Post MI
AAA
Prosthetic valve
What is the presentation of acute limb ischaemia (6P’s)
Pain Pallor Paresthesia Paralysis Pulselessness Perishingly cold
A acute ischaemic limb is suspected what are the possible differential diagnosis?
Chronic Limb ischaemia
DVT
Spinal/peripheral nerve compression
How would a acute limb ischaemia be diagnosed?
Bloods - serum lactate, Group and save and if under 50 a thrombophilia screen
ECG
Doppler
CT - angiography
Acute limb ischaemia has been diagnosed and the limb has been thought to be viable or marginal what is the treatment?
Prolonged heparin and review. Monitor APPT.
What is the initial management of acute limb ischaemia?
High flow O2 and IV Heparin (bolus)
If the limb is immediately threatened in acute limb ischaemia what is the treatment?
Embolectomy or bypass surgery.
Thrombolysis, angioplasty or bypass surgery.
Dependent on the cause.
What is the possible complication of acute limb ischaemia treatment?
Reperfusion injury –> compartment surgery (immediate fasciotomy)
Due to the release of potassium, hydrogen and myoglobin from the damaged muscle tissue.
What are the main risks for chronic limb ischaemia/peripheral vascular disease?
Smoking Obesity Diabetes increased age hypertension hyperlipidaemia family history
Fontaines classification is used to determine PVD staging. What are the 4 stages?
1 = asymptomatic 2 = intermittent claudication 3 = ischaemic rest pain 4 = ulceration or gangrene
Is a patient is experiencing pain on walking in the butt and hip which artery/arteries are responsible?
Aortoiliac
Is a patient is experiencing pain on walking in the thigh which artery/arteries are responsible?
Common femoral or aortoiliac
Is a patient is experiencing pain on walking in the calf which artery/arteries are responsible?
Superficial or popliteal
What is Buergers test?
Used for CLI
Lift the leg until pale if <20° then is severe
What are the 3 criteria points for critical limb ischaemia and the extra signs?
Ischaemic rest pain for more than 2 weeks that requires opiate pain relief
Ischaemic lesion or gangrene
ABPI <0.5
+ Hair loss, skin change, thick nails, weak pulse, pale.
What is the management for chronic limb ischaemia?
Lifestyle
Statin
Anti-platelet
Praxilene - new drug which is very beneficial
When would surgery be done for chronic limb ischaemia?
If symptoms not improved or experiencing chronic limb ischaemia. Angioplasty (without a stent if femoral or below, with a stent if iliac or above)
Or a bypass graft by harvesting the great saphenous vein.
What is the definition of abdominal aortic aneurysm?
Dilatation of the AA more than 3cm.
What are the risk factors for AAA?
Atherosclerosis
trauma
Infections
CT disease - marfan’s syndrome
Inflammatory disease - Takaysu’s aortits
Smoking, hypertension, increased age, hyperlipidaemia, FH, male
What is the investigations for AAA and how does treatment differ from a AAA under and over 5.5 cm?
USS or CT with contrast (5.5cm)
<5.5cm = duplex, BP control, lifestyle, aspirin, statin
>5.5cm = surgery (also if increased 1cm or more in a yr or symptomatic)
= EVAR - stent via femoral artery. S/E leaking can occur.
= Open - midline laparotomy remove the segment and put in a prosthetic
What are the symptoms and management for a AAA rupture?
Pain in abdo and back. Syncope. Vomiting. Pulsating mass. Hemodynamically unstable.
High flow O2 2 bore cannulas bloods and 6U crossmatched Keep BP under 100 (prevent blood loss) if unstable = open. If stable = EVAR.
What is carotid artery disease and how could it present?
Atherosclerotic plaque build up in common/internal carotid causing it to be stenosed or occluded.
Majority are asymptomatic.
TIA or Ischaemic stroke
Over 50% reduction in artery
What is the pathophysiology of carotid arterial disease?
Fatty streak –> lipid core and fibrous cap.
BIfurcation increases risk as there is turbulent flow.
What are the differential diagnoses of carotid artery disease?
Carotid dissection - under 50, CT disease or trauma
Thrombotic occlusion
Vasculitis
Fibromuscular dysplasia - under 50 and usually in renal arteries.
If carotid artery is over 50% stenosed what is the treatment and possible complications?
Carotid endarterectomy - plaque and tunica intima is removed.
Complications = stroke, bleeding in neck, nerve damage, MI
A patient has a ulcer on their leg. O/E it is on the gaiter region and is shallow with a granulated base and irregular borders. As well as this you notice atrophie blanche on their legs. What investigations and management would you suggest based on the most likely diagnosis?
Venous ulcer
Duplex, ABPI (rule out arterial) and swab culture (if infection likely).
Elevate leg, increase exercise and lifestyle advice. Antibiotics if a infection is present. Compression bandage (ABPI must be >0.6)
Why do arterial ulcers occur?
Decreased perfusion = decreased healing.
A patient has a ulcer on their leg. O/E there are small deep lesions on their leg with clear borders and a necrotic base. They also mention they have been having pain on walking that goes with rest recently. You find the ankle pulses hard to palpate. What investigations and management would you suggest based on the most likely diagnosis?
ABPI, Duplex, CT angio, MRA
Most likely to be a arterial ulcer
Lifestyle, statin, antiplatelet (clopidogrel or aspirin) and BP control (if needed)
Angioplasty or bypass graft may be needed if severe
Skin graft can be done if damage is severe.
A patient has a ulcer on their foot. They have noticed a burning in their feet recently and the ulcer has a ‘punched out’ appearance. The muscles in their foot look slightly wasted. What are the risks for the most likely diagnosis. Also what would your next steps be?
Diabetes, B12 deficiency. Loss of sensation = painless ulcers.
Glucose, ABPI/Duplex (arterial check), Swab (if infected), X-ray if believe there to be deformity.
Lifestyle - glucose control, Chiropody, Antibiotic.
If severe may need surgical debridement or amputation.
What is charcot’s foot?
Deformity of foot - loss of transverse arch. Due to repeated trauma usually following peripheral neuropathy. Come in with pain but not as bad a injury is.
