Surgery Flashcards
what layers are cut through in a midline laparotomy
skin campes fascia (subcutaneous fat) scarpa's fascia (membraneous) linea alba transversalis fascia pre-peritoneal fat peritoneum
what is a midline laparotomy used for?
emergency: perforated DU
trauma
ruptured AAA
hartmann’s
elective:
colectomy
AAA
Vascular bypass
pros and cons of midline laparotomy?
good access
bloodless line
minimal nerve and muscle injury
long scar
increased pain
how is midline laparotomy closed?
PDS
blunt J suture
Jenkins rule: length of suture = 4x length of incision
1cm bite, 1cm apart
what is a Kocher’s (subcostal) incision used for?
open cholecystectomy
L Kocher’s used for splenectomy
What is a rooftop incision used for?
hepatobiliary surgery liver whipples liver resection gastric surgery
what is a pfannenstiel incision used for?
gynaecologist surgery
lower urinary tract
what layers do a mcburneys/lanz incision go through?
skin campers fascia scarpas fascia external oblique internal oblique transversus transversalis fascia pre-peritoneal fat peritoneum
indications for mcburneys/lanz incision?
appendicectomy
features mcburneys/lanz?
mcburneys: oblique
lanz: transverse (favoured)
risk of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia
indications thoracoabdominal incision?
oesophagogastrectomy
indications transverse muscle splitting?
right hemicolectomy
features of transverse muscle splitting
limited access cf midline incision
decreased damage to recuts
segmental nerve supply means the muscle can be cut transversely without weakening
indications for inguinal hernia incision?
open inguinal hernia repair
orchidectomy
features of inguinal hernia incision?
inions over the inguinal ligament
follows Langer’s lines
high rates of chronic neuropathic pain
indications for McEvedy modified incision?
emergency femoral hernia
features of McEvedy modified incision?
allows inspection of peritoneal cavity
easy conversion to laparotomy if necessary
‘half pfannenstiel’
indications for loin incision?
nephrectomy
indications for vascular access?
bypass embolectomy EVAR/TEVAR stent inserion femoral endarterectomy angioplasty
Where do laparoscopic cholecystectomy port scars go?
x4 periumbilical subxiphoid medial subcostal lateral subxiphoid
indications for median sternotomy?
mainly open heart surgery transplant valve surgery congenital cardiac defect corrections CABG
where is anterolateral thoracotomy and what for?
under breast
left = open chest massage
what is axillary thoracotomy used for?
pneumothorax
pleurectomy
pulmonary resections
what is posterolateral thoracotomy used for ?
most common
pulmonary resections
oesophageal surgery chest wall resection
cut through intercostal speech beginning inferomedially to tip of scapula
what is Benz modification and wha tis it used for
chevron + incision and break through xiphisternum
diaphragmatic hernia gastrectomy oesophagectomy bilateral adrenalectomy hepatic resections liver transplant
Indications for rutherford morrison incision?
extension of lanz kidney transplant colonic resection caecostomy sigmoid colostomy
What are the ASA grades?
ASA I: normal healthy patient
ASA II: patient with mild systemic disease (smoker/more than minimal drinking, controlled HTN etc), obesity
ASA III: severe systemic disease (diabetes, HTN etc)
ASA IV: severe systemic disease that is constant threat to life (recent hx of MI, CVA, TIA)
ASA V: moribund patient who is not expected to survive without the operation (ruptured abdominal or thoracic aneurysm, bleed with mass effect)
ASA VI: patient already declared brain dead/transplant removal
N.B. BMI >40 = ASA III
addition of E means emergency surgery
types of LA?
Lidocaine
Cocaine
Bupivicaine
Prilocaine
indications for lidocaine?
LA
anti arrhythmic
effects of lidocaine od?
CNS overactivity -> depression
arrhythmias
antidote to lidocaine OD?
IV 20% lipid emulsion
lidocaine drug interactions?
beta blockers
ciprofloxacin
phenytoin
dose of lidocaine plain and with adrenaline?
3mg/kg
7mg/kg
dose of bupivacane plain and with adrenaline?
2mg/kg
2mg/kg
dose of prilocaine plain and with adrenaline?
6mg/kg
9mg/kg
when can people eat and drink up to before surgery?
no food <6 hours before surgery
no drink <2 hours before surgery
[same rules for diabetes & pregnant]
how to ensure correct endotracheal tube placement?
clinically - equal and symmetrical chest expansion and air entry, fogging mask
observations - spO2 maintained, CO2 reading
radiological - CXR shows ET tube just above carina
what are some contraindications of neuromuscular blockers [suxamethonium]?
hyperkalaemia in burns/trauma patients
spinal cord trauma causing paraplegia, and previous suxamethonium allergy.
increased IOP
Complications of suxamethonium?
suxamethonium apnoea (pseudocholinesterase deficiency)[AD] malignant hyperthermia (>40)
Mx suxamethonium apnoea?
re-intubate and wean off
Mx malignant hyperthermia?
dantrolene
Suxamethonium CI?
Increases IOP
CI in patients with penetrating eye injuries or acute narrow angle glaucoma
Common post-op complications?
day 1: atelectasis
day 3: UTI
day 5: SSI [s.aureus most common], anastomotic leak
day 7: DVT/PE
S/S and Mx of atelectasis?
pyrexia
reduced o2 sats
reduced breath sounds at bases
Mx: sit up, chest physio
Classification of post-op haemorrhage?
primary: continued bleeding starting during surgery
reactive: bleeding <= 48 hours of surgery
secondary: bleeding >= 48 hours of surgery (7-10 days, usually due to infection)
Absorbable sutures and indications?
catgut MVP
catgut
monocryl - subcuticular skin closure
vicryl [braided]- subcuticular skin closure, bowel anastomosis
PDS - abdominal wall closure
Non absorbable sutures and indications?
SEE Prolene
Silk [braided] - secure drains
Ethibond [braided]- soft tissue approximation
Ethilon - skin wounds
Prolene - skin wounds, arterial anastomosis
exceptions form MRSA screening before surgery?
TOP patients
ophthalmic surgery
psychiatric inpatients
management MRSA prophylaxis?
nose - mupirocin 2% in white soft paraffin TDS for 5 days
Skin - chlorhexidine gluconate OD for 5 days all over body
ileostomy location, appearance, output?
RIF
spouted
liquid
colostomy location, appearance, output?
left side but varies
flushed
solid
stoma indications?
faecal - perforation - permanent - diversion - decompression feeding bladder
examination of stoma?
site inspection
lumens (1= end ileostomy/colostomy, 2= loop)
spout (spouted = small bowel, flush = large bowel)
stoma output/bag contents
surrounding skin
digitation
abdomen
perineum
complications of stoma?
early: haemorrhage ischemia high output -> vol depletion, electrolyte and acid base disturbance (metabolic acidosis) parastomal abscess stoma retraction
delayed: parastomal hernia obstruction (adhesion, herniation) dermatitis stoma prolapse stenosis, stricture fistula psychosexual dysfunction
Type of resection and anastomosis for caecal, ascending or proximal transverse colon?
right hemicolectomy
ileocolic
Type of resection and anastomosis for distal transverse, descending colon?
left hemicolectomy
colo-colon
Type of resection and anastomosis for sigmoid colon?
high anterior resection
colo-rectal
Type of resection and anastomosis for upper rectum?
anterior resection (TME) colo-rectal
Type of resection and anastomosis for low rectum?
anterior resection (low TME) Colorectal +/- defunctioning stoma
Type of resection and anastomosis for anal verge?
abdomino-perineal excision of rectum
none
what are the types of urostomy?
ileal conduit (incontinent diversion) ileal pouch (continent diversion)
types of ileal pouch?
KIMI Kock Indiana Mitrofanoff Ileal neobladder
which structures are on the transpyloric plane?
end of spinal cord L1 body SMA origin origin portal vein neck of pancreas stomach pylorus 2nd part duodenum sphincter of oddi hilum of each kidney duodenojejunal flexure funds of gall bladder tips of 9th costal cartilages
what is found at L1, L2 and L3?
L1: SMA, coeliac trunk
L2: renal, gonadal arteries
L3: IMA
What are the horizontal planes for the 9 regions of the abdomen?
trans-pyloric - end of 9th costal cartilage
intertubecular - tubercle of crest of ilium
scars for right hemicolectomy?
midline laparotomy
transverse muscle splitting
laparoscopic ports
scars for left hemicolectomy?
midline laparotomy
laparoscopic ports
What is a hartmann’s procedure?
emergency procedure
sigmoid coletomy
proximal bowel exteriorised as an end colostomy
distal bowel oversewn to form rectal stump
may be reversed after 3-6m
indication for hartmann’s?
obstruction or perforation secondary to singled tumour or diverticulitis
scars for hartmann’s?
midline laparotomy
previous stoma scar in LIF if it has been reversed
stoma for hartmanns?
single lumen colostomy in LIF
MOA nitrous oxide?
May act via a combination of NDMA, nACh, 5-HT3, GABAA and glycine receptors
Adverse effects of nitrous oxide?
May diffuse into gas-filled body compartments → increase in pressure. Should therefore be avoided in certain conditions e.g. pneumothorax
what is nitrous oxide used for?
Used for maintenance of anaesthesia and analgesia (e.g. during labour)