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4th year blocks > Surgery > Flashcards

Surgery Flashcards

1
Q

most common metastasis sites of adrenal tumors?

A 
Think L3 
Liver
Lung 
Lymph 
Bone

make sure to scan for all these if carcinoma

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2
Q

Classification of a adrenal adenoma?

A 
Size is <4cm 
Regular shape and borders 
Contrast was out is > 50% after 10 min 
CT attenuation is < 10 HU 
MRI showes same shade as liver both in T1 and T2
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3
Q

Classification of a Adrenal Carcinoma?

A

Size > 4cm
Irregular shape and infiltrating borders
CT attenuation is > 20 HU
Contrast washout < 50% at 10 min
Increased vascularization
Calsification
MRI hypointense (black) compared to liver in T1

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4
Q

how can you confirmed it the adrenal carcinoma is a primary of metastatic tumor?

A

Take a FNAB

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5
Q

Process of deciding treatment of adrenal tumor

A
  1. is it functional or not (hormones)
  2. Overnight dexa test ( > 1.8ug/dl in morning is confirming)
  3. measure metanephrins in 24h urine (pheo)
  4. SURGERY
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6
Q

what is the surgical procedure in Adrenal tumor? when do you wait and when do you to in asap?

A

If non functional you monitor for 6-12 months, if it grows more then 1cm you remove

If it is a producing tumor then remove asap with No touch tech.

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7
Q

what to do before removing a pheo tumor?

A

2-3 weeks before - give A-blockers
2-3 days before - give B-blockers
right before - give glucocorticoids

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8
Q

location and bloodsupply of the adrenals?

A

12th IC space

  1. sup. suprarenal ( inferior phrenic)
  2. middle suprarenal (direct aorta)
  3. inferior suprarenal ( renal a.)
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9
Q

diseases caused by actively secreting adrenal tumor?

A

Conns (aldosteron)
Cushings (cortisol)
Pheochromocytoma (NE/epi)

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10
Q

contraindications for laparoscopic adrenalectomy?

A

tumor > 9cm
local invasive tumor
general contraindications for laparoscopic surgery

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11
Q

what is goiter?

A

irregular growth of the thyroid, either overall enlargement or nodules

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12
Q

symptomes of HYPERthyroidism

A
  1. weightloss
  2. tachycardia
  3. palpitations
  4. arrhythmias
  5. irritability, anxiety, nervousness
  6. heat sensitivity
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13
Q

symptomes of HYPOthyroidism

A
  1. weight gain
  2. bradychardia
  3. dry skin
  4. constipation
  5. fatigue, muscle loss
  6. puffy face
  7. hoarsness
  8. cold sensitivity
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14
Q

Ethiology of goiter?

A
  1. iodine deficiency
  2. Graves
  3. Hashimoto
  4. DeQuervian (subacute)
  5. tumor
  6. pregnancy
  7. Riedel thyroditis
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15
Q

types of Goiter?

A

Diffuse: symetric enlargment
Nodular: non symmetric enlargment

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16
Q

causes of nodular goiter

A

Thyroiditis
Graves
hypothyroidism

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17
Q

causes of diffuse goiter

A

cysts
autonomous nodules (adenomas)
degenerative nodules
tumors

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18
Q

Diagnosis of goiter

A 
anamnesis 
physical examination, palpitation 
sonography 
lab tests 
CT MRI 
FNAB
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19
Q

sonography findings in goiter - Benign lesions?

A 
Hyperechoic/anechoic
Halow sign 
Peripheral calcification 
< 1cm 
peripheral vascularization
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20
Q

sonography findings in goiter - Malignant lesions?

A 
Hypoechoic 
Star-sky calcification in nodule 
No halow sign 
> 2cm 
intranodal calcification
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21
Q

Define hypoechoic US?

A

darker then surrounding tissue but NOT black like vessles

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22
Q

define anechoic and hyperechoic?

A

Anechoic is black like vessles

Hyperechoic is white/lighter then surrounding tissue

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23
Q

the strong 3 indications of malignant thyroid nodules?

A
  1. > 2cm
  2. calcification
  3. Solid structure
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24
Q

Types of thyroidectomy

A
  1. Lobectomy (one lobe)
  2. Hemithyroidectomy (lobe and ishtmus)
  3. Total thyroidectomy
  4. subtotal (leave 4g on each side to save nerve)
  5. Near total (leave 2g on each side)
  6. Heartly Dunhill (leave 4g on ONE side)
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25
Q

riskfactors of thyroid cancer?

A

radiation
family history
> 65 years

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26
Q

physical examination indications of thyroid cancer

A 
Nodules in patient < 25 yrs 
Dysphagia 
Hoarsness 
Firm on palpitation and not moving 
swollen, painless lymph nodes on one side
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27
Q

Diagnosis of thyroid nodules?

A
  1. Examination
  2. US
  3. Lab tests
  4. Scintigraphy (I-isotope uptake test with I133)
  5. FNAB
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28
Q

Thyroid scintigraphy procedure and results?

A

Give I-133 to patient, then use Gamma camera to look for nodules taking up the iodine, they will become darker if active and have no colore if not active

Active:
One nodule = toxic adenoma
multiple nodules = Multinodular Toxic goiter

Non-active:
High risk of malignancy - do FNAB of ALL nodules and US tripple positive sign

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29
Q

origin of thyroid tumor cells?

A

mostly from follicular cells except medullary which is from parafollicular C-cells

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30
Q

Types pf thyroid cancers?

A

Papillary 70% good prognosis
Follicular 20% good prognosis if removed
Anaplastic 5% poor prognosis
Medullary 2% Poore prognosis

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31
Q

what is spescial with the anaplastic thyroic cancer?

A

undifferentiated highly agressive cancer, no response ro RAI

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32
Q

morphology of papillary thyroid cancer?

A

often cystic with fibrosis and calcification
diagnosis based of orphan annie nucleus ( clear)
nuclear invaginations
can have papillary architecture
psammomma (calcified) bodies

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33
Q

metastasis nature of follicular thyroid carcinoma

A

hematogenous to liver, lung and bone, not lymph like papillary form

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34
Q

occurance of medullary thyroid cancer

A

mostly sporadic if not they are ass. with MEN 2a/2b and the person will have other cancers ass cell

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35
Q

nature of cells in medullary thyroid cancer?

A

they are spindle shaped neuroendocrine cells derived from the parafollicular C cells and secrete calcitonin BUT hypocalcemia is not present

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36
Q

anaplastic thyroid cancer comed from?

A

belived to be dedefferentiation of an already ongoing cancer ex. papillary. agressive with 100% death rate within 1 year

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37
Q

which thyroid cancer is most sees in young people?

A

papillary can happen at young ages as well

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38
Q

causes of Hyper parathyroidism?

A

adenoma (95%)
Primary hyperplasia
parathyroid carcinoma (1%)

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39
Q

pathogenesis of parathyroid tumor genes?

A

D1 cell cycle regulator relocation on the 11 chromosome to PTH gene expression site

MEN1 tumor supressor gene mutation

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40
Q

what can HPT due to bone?

A

increased metabolist by OC

in severe cases osteitis fibrosa cystica

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41
Q

HPT in GI?

A 
constipation 
neausea 
peptic ulcers 
pancreatitis 
gallstones
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42
Q

HPT in kidney?

A

polyuria

kidney stones

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43
Q

lab diagnosis of PHPT?

Imaging?

A

high PTH
high Calsium
Calciuria > 400mg/day

Scintigraphy with Tc-99m sestamibi washout method SPECT
MRI

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44
Q

treamt ment rules in HPT?

A
  1. Ca < 3.0mg/L and no symptomes = no treatment
  2. Ca - 3.0-3.5mg/L and no symptomes = no treatment but hydration
  3. Ca - 3.0-3.5mg/L but symptomes = must treat
  4. Ca > 3.5 = must treat regardless of no symptomes
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45
Q

What is the definit treatment for PHPT?

in first line is contraindicated then pharmacologic treatment of HPT?

A

THE ONLY CURATIVE TREATMENT FOR PHPT IS SURGERY

IF CONTRAINDICATED: 
Bisphosphatases 
Denosumab 
Calcitonin 
Loop diuretics (increase kidney excretion) 
Glucocorticoids (GI untake decrease)
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46
Q

what must you do before parathyroid gland surgery?

A

you have to localize the 4 grands

  1. US
  2. Scintigraphy SPECT
  3. CT
  4. MRI
  5. selective arteriography
  6. selective venous sampling
  7. methionine PET CT
  8. SPECT-CT
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47
Q

the 10 rules of parathyroid by J. Norman

A
  1. NO drugs can cure
  2. all have symptomes
  3. symptomes not correlated with Ca2+ level
  4. all patient have Ca and PTH fluctuations
  5. all get osteoporosis
  6. drugs will not help bones in long run
  7. gets worse over time
  8. only treatment of PHPT i surgery
  9. mininal invasive surgery can cure all
  10. sucsess rate repends on surgeon skills
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48
Q

surgical approach in PTH surgery

A
  1. Bilateral exploration without localization - this is a open surgery and the most used type, where the surgeon does not know where the glands are before surgery
  2. Unilateral ecploration after preopeative localization
  3. minimal access surgery with pre and intraoperative diagnostic procedure.
    this one can be converted to open surgery during procedure if the level of PTH is not decreased during operation
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49
Q

How do we measure intraoperativly the PTH leven during minimal access surgery?

A

we measure the level at the beginning of surgery. The half life of the PTH is 5 minutes so measuring the level of PTH in veins after 10 minutes should show a decrease

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50
Q

etiology of GERD

A
  1. hyperacidity ( Zollinger-Ellison, H. pylori, hypergastrinemia
  2. Smoking (relaxes LES)
  3. obesity
  4. Pregnancy
  5. Alcohol
  6. Hiatal hernia
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51
Q

diagnosing GERD?

A
  1. endoscopy
  2. esophageal pH monitoring
  3. barium swallow test
  4. esophageal monometry (strength and muscle coordination of your esophagus)
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52
Q

treatment of GERD

A
  1. PPI
  2. H2I
  3. lifestyle
  4. Fundoplication
  5. endoscopic mucosectomy
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53
Q

Fundoplication surgery?

A

part of stomach fundus is pulled up and secured around the lower esophagus. causing stronger LES.

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54
Q

Endoscopic mucous resection in GERD

A

we go in through the mouth down to esophagus, sucks mucous and submucousa into endoscope device. puts ring around creating pollyp and cuts it off.

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55
Q

GERD complications

A
  1. barret
  2. refluc esophagitis
  3. esophageal strictures and schatzki rings
  4. aspiration pneumonia
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56
Q

Saint triad

A

combination of cholelithiasis, diverticulosis, hiatal hernia (seen in 1.5%)

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57
Q

diagnosis of hiatal hernia

A
  1. barum swallowing test
  2. endoscopy (check Z line - squamocolumnar separation of esophaugus and stomach)
  3. CXR
  4. CT
  5. esophageal manometry
  6. pH monitoring
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58
Q

treatment of hiatal hernia

A
  1. open fundoplication and hiatoplasty

2. gastropexy/fundopexy if type II, III, IV

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59
Q

what is gastropexy

A

Gastropexy is a surgical operation in which the stomach is sutured to the abdominal wall or the diaphragm.

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60
Q

cause of zenkers diverticulum

A

impaired relaxation of cricopharyngeal muscles

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61
Q

location of zenkers diverticulum?

A

killians triangle

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62
Q

classification of esophageal divertcula - location

A

UED - killians
MED - trachea biforcation
LED - epiphrenic

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63
Q

classification of esophageal divertcula - histology

A

TRUE - all layers

FALSE - mucosa and submucosa

64
Q

classification of esophageal diverticula - pathophysiology

A

Pulsion - increased intraluminal pressure, only mucosa and submucosa

Traction - scarring and retraction from inflammation, with all layers involved

65
Q

treatment of esophageal diverticulums

A

SURGERY

  1. zenker: cricopharyngeal myotomy
  2. epiphrenic: esophageomyotomy

NON-SURGIAL IF CI
1. botox + PPI

66
Q

what is achalasia?

A

motility disorder of the esophagus due to inadequate relaxation of LES and destruction of inhibitory neurons causing loss of peristalsis

67
Q

ethiology of secondary achalasia

A
  1. esophageal cancer
  2. gastric cancer
  3. chagas disease
  4. amyloidosis
  5. neurofibromatosis type 1
  6. sarcoidosis
68
Q

achalasia treatment

A
  1. pneumatic dilation with ballon in LES
  2. LES myotomy (HELLER)
  3. if CI surgery then botox and CCB
69
Q

esophageal injuries

A
  1. fistula
  2. esophageal web
  3. diverticulum
  4. mallory-wess
  5. varices
  6. achalasia
  7. barret esophagus
  8. GERD
  9. perforation
70
Q

boerhaave syndrom?

A

spontaneous rupture of the esophagus. can be seen in mallory-wess syndrom

71
Q

treatment of esophageal rupture

A
  1. stabilization: IV fluids, electrolytes, AB

2. surgery: suture, muscle or pleural flap, fundoplication, resection, delayed reconstruction

72
Q

location of peptic ulcers

A

stomach and duodenum

73
Q

difference between erosion and ulcer?

A

ulcer involves more the the muscularis mucosa

74
Q

surgical treatment for peptic ulcers

A
  1. vagotomy

2. partial gastrectomy (billroth)

75
Q

types of partial gastrectomy - Billroth I

A

Billroth I
distal gastrectomy with end-end or side-end gastroduodenostomy by removing gastric atrum and pyloris and the duodedal loop is freed from the peritoneum and sutured together

76
Q

types of partial gastrectomy - Billrot II

A

lower 2/3 of stomach is removed and the duodenum is left with a stump end. The remaining stomach is sutured to jejunum - gastrojejunostomy in a side-side manner (prevents bile to enter stomach)

77
Q

total gastrectomy with Roux-en-Y anastomosis?

A

remove stomach except cardia and funcus. cut dudenum and leave stump end, other end is sutured to lower down jejunum in a end-side manner. The upper jejunum is sutured to stomach in a side-side manner

78
Q

Virchow’s node

A

An enlargement of a supraventricular lymphnode can be the first sign of gastric cancer due to the association between left supraclavicular lymphadenopathy and gastric cancer.

79
Q

paraneoplastic signs of gastric cancer

A

seborrheic keratosis
acanthosis nigricans
thromboplebitis migricans

80
Q

drug in HER2 positive gastric cancer?

A

traztuzumab

81
Q

drug treatment with TK inhibitor is GIST?

A

imitinib or dasatinib

82
Q

surgucal treatment of GIST?

A

tumor < 2cm - drugs and observe

tumors > 2cm surgical excision + drugs

83
Q

gastric tumors?

A 
adenocarcinoma
GIST 
MALT 
neuroendocrine tumor 
sarcoma
84
Q

post gastrectomy complications

A

malnutrition
dumping syndrom (early/late)
reoccurance of cancer

85
Q

what i early dumping syndrom?

A 
premature gastric emptying with early symptomes (10 min) causes water do be pushed fro blood into bowel to dilute causing distention of bowel. 
Hypotention 
bloted 
cramps 
diarrhea
86
Q

what is late dumping syndrom?

A

premature gastric emtying with late symptomes (1h). Increased sugar absorption trigger increased insulin release causing hyperglycemic induced hypoglycemia

87
Q

Murphy sign

A

Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.

88
Q

CI for cholecystectomy?

A
  1. hemodynamic unstable
  2. respiratory unstable
  3. history of extensive abdominal surgery
  4. cirrhosis
  5. portal HTN
  6. extreme obesity
  7. acute phase cholangitis
89
Q

what is MRCP and ERCP (bile)

A

Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures.

90
Q

labfindings in cholelithiasis?

A

Normal

91
Q

Lab findings in choledocolithiasis?

A
  1. high bilirubin
  2. high GGT
  3. high ALP
  4. high ASAT, ALAT
92
Q

Lab findings in cholecystitis

A

fever
high CRP
high WBC

93
Q

benign liver tumors

A
  1. cavernous hemangiomas
  2. focal nodular hyperplasia
  3. hepatic adenomas
94
Q

which benign liver tumor should you not take a biopsy from?

A

hemangiomas due to bleeding risk

95
Q

what does the pancreas do?

A

enocrine hormones

exocrine digestive enzymes

96
Q

etiology of acute pancreatitis? I GET SMASHED

A 
Idiopathic 
Gallstones 
Ethanol 
Trauma 
Scorpion sting 
Mumps 
Autoimmune 
Steroids 
Hyper TG an Ca 
ERCP 
Drugs
97
Q

what are the three things happening in pancreas under Acute pancreatitis? and what is the result?

A

liquification
hemorrhage
Digestion

causes Liquifactive hemorrhagic necrosis

98
Q

external signs of acute pancreatitis?

A 
Grey turner sign (hip) 
Cullen sign (periumbilical)
99
Q

complication in acute pancreatitis?

A
  1. Psaudocyst which can either rupture releasing enzymes causing massive inflammation or become infected by e.coli cuasing abcess
  2. bleedign due to destruction of vessle causing hypovolemic shock
  3. ARDS
100
Q

surgical treatment of acute pancreatitis?

A

urgent ERCP, spinchterotomy in choledocolithiasis or cholangitis followed by cholecystectomy

101
Q

cholecystokinin test or secretin test or both together

A

cerulin or secretin given to patien IV and a tube in duodenum measures secretion of bicarbonate and pancreatic enzymes, low levels proves pancreatin insufficiancy

102
Q

surgical treatment of chronic pancreatitis and why do we want to operate?

A

surgery is the most effective long term treatment of pain

  1. psaudocyst drainage
  2. endoscopic stent therapy if obstruction
  3. ERCP
  4. whippel procedure
103
Q

courvosier sign?

A

enlarged non-tender gallbladder indicates pancreatic malignancy

104
Q

Trousseau sign

A

superficial palpable thrombophlebitis ass. with pancreatic tumors

105
Q

Lab markers for pancreatic cancer?

A

CEA

CA 19-9

106
Q

Imaging of choice in pancreatic cancer

A

abdominal contrast CT

107
Q

treatment of pancreatic cancer?

A

surgery is only curative treatment but can only be done if no metastasis

108
Q

types of surgery in pancreatic cancer?

A

if tumor is in head: Whippel (pancreas, duodenum and gallbladder removed
if in body or tail: Traverso-longmire (spleen, pancreas and some times duodenum is removed)

109
Q

whats a hemorrhage? when do they become pathological?

A

normal physiological structures acting as cushions for feces when passing through the rectum. They become pathological when they get swollen

110
Q

what divides the rectum from the anus?

A

Pectinate or dentate line

111
Q

classification of internal hemorrhoids

A
  1. no protrusion outside
  2. protrude but retracts when pressure decrease
  3. prolapsed - protrude without retraction but can be pushed in manually
  4. . prolapsed - protrude without retraction but can NOT be pushed in manually
112
Q

hemorrhoid complications?

A

anemia due to bleeding
spinchter spasms causing strangulation and necrosis
thrombotic hernia

113
Q

classification of hemorrhoids based on location?

A

In respect to the dentate line

  1. internal
  2. external
  3. mixed
114
Q

CT disorders causing hemorrhoids?

A

Ehlers-Danlos

Scleroderma

115
Q

Location dependent pain in hemorroids?

A

external are somatically innervated so they are painfull but external may be painless even though they bleed

116
Q

diagnosing hemorrhoids?

A

PDE
anoscopy
sigmoidoscopy
barium enema to exclude malignancy

117
Q

treatment of hemorrhoids grade I-II

A 
lifestyle 
diet
analgestics 
topical agents 
stool softeners 
sitz bath 
antispasmodic agents
118
Q

hemorrhoid treatment grade III

A

Rubber band ligation
Sclerotherapy
infrared coagulation

119
Q

Hemorrhoid treatment grade IV

A

other treatmets have been trie but does not work then we do surgery
1. subcutaneous hemorrhoidectomy
(closed - Ferguson/open - Millian-Morgan)
2. Staple hemorrhoidopexy

120
Q

parts of a staple hemorrhagiopexy?

A

anal dilator
optorator
sutures
stapler

121
Q

complications of internal hemorrhoids?

A

prolaps and accumulatin of mucus and fecal debris in external anal tissue - local irritation and inflammation

122
Q

ecternal hemorrhagic complication

A

thrombosis of the hemorr. causing necrosis of overlying skin and bleeding

123
Q

anal abcess

A

mostly due to obstruction of the anal glands by debris causing puss filled cavity that most commonly is due to bacteria accumulation and infection in a anal crypt.

124
Q

anal abcess classification

A

perianal
Ischiorectal
intersphincteric
supralevator

125
Q

anal fistular classification

A

intersphincter
transsphincter
suprasphincter
extrasphincter

126
Q

what is a anal fistula

A

connection between an abcess and the anal canal or the abcess to the perianal skin

127
Q

treatment of anal fistulas

A
  1. fistulotomy (most common)
  2. seton placement (like a rubber silicon band)
  3. fistula plug
128
Q

types of abdominal hernias

A
  1. groin
  2. ventral
  3. pelvic
  4. flank
129
Q

types of groin hernias?

A

inguinal (direct(indirect)

femoral

130
Q

location of a direct inguinal hernia?

A

hasselback triangle

131
Q

ventral henias?

A 
true umbilical 
peroumbilical 
epigastric 
spielian (linneasemilunaris)
inscisional
132
Q

classification of hernia nature?

A
  1. reducable - can be pushed in
  2. incarcerated - cannot be reduced back, risk of infection is higher
  3. strangulated - starts as incarserated, no bloodsupply
133
Q

differential diagnosis of hernia

A 
hydrocele
varicocele
lipoma 
lymphadenopathy 
tumor
cyst
134
Q

hernial surgery basic classification?

A
  1. open surgery or laporascopic

2. transperitoneal/preperitoneal

135
Q

types of hernia surrgery?

A

herniorraphy

hernioplasty

136
Q

placement of mesh in herniaplasty?

A
  1. onlay repair - subcutneous
  2. inlay repair - between edges of fascia as bridge gap
  3. sublay repair - before peritoneum
137
Q

usually we use hernioplasty with mesh what is the CI and what do we use then?

A

CI if there is an ongoing infection or necrosis of hernia tissue. then we do a herniorraphy surgery

138
Q

laparoscopic procedure in hernia name?

A 
transabdominal preperitoneal (TAPP) 
total extraperitoneal (TEP)
139
Q

umbilical repair of hernia name?

A

Mayo repair if < 4cm (double suture)

Mesh closure if < 4cm

140
Q

mechanical wounds

A 
inscision 
laceration 
abrasion 
puncture
penetrating 
animal bite 
gunshot
141
Q

N-block removal means?

A

removal of the tumor and the organs it is involved with

142
Q

markers for bacterial peritonitis with bowel perforation

A

high ALP and CEA

143
Q

marker for pancreatitis induced peritonitis?

A

high Amylase

144
Q

what is the most frequent cause of primary peritonitis?

A

liver cirrhosis with acitis

145
Q

types of appenticitis?

A

mucous
Phlegmous
necrotic

146
Q

ethiology of appendicitis?

A

lymphoid proliferation
fecalith
neoplasm
paracite

147
Q

appendicitis tests?

A

Hamburg - if no loss of appetite then no appendicitis
Blumsburg - rebound tenderness
rosving - contralateral side palpitation increase pain
psoas - flextion pain
adductor flexion pain

148
Q

Alvarao score i apendicitis

MANTREL-N

A 
Migrating of pain 
Anorexia 
Nausea vomiting 
Tenderness in RLQ 
Rebound tenderness 
Temprature > 38.5 
Leukocytosis
Neutropenia
149
Q

why is pancreatic transplant so complicated

A

due to 10 anastomosis sites vs kidney that have 3

150
Q

when do we remove sutures?

A

5 days normally

2 weeks for transplant

151
Q

complications post cholecyctectomy?

A

bile leakage

jaundice

152
Q

Anatomical landmark in cholecystectomy?

A

Calot triangle

153
Q

transplant when malignancy?

A

5 years after remission and no metastasis

154
Q

gold standar for liver staging?

A

MRI because cholangio cancinoma shows better in this imaging method so must be done

155
Q

child pugh score?

A 
liver staging 
billirubin 
albumin 
prothrombin time
encephalopaty
156
Q

liver resection rules

A

20-35% must be healthy (over 35 if fatty liver)

157
Q

ALPPS PROCEDURE

A

we want to get hepatotrophy before resection, sp ve ligate portal vein and after 9 days there should be around 10% increase in mass. ligation on side of tumor so health side grows

4th year blocks (6 decks)

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