Surgery Flashcards
Head injury
- When do we CT head?
CT head within 1hours
- GCS <13 on initial assessment
- GCS <15 at 2h post-injury
- ?open or depressed skull #
- ?basal skull # (haemotympanum, panda eyes, CSF leak ear/nose, Battle sign)
- Post-traumatic seizure
- Focal neuro deficit
- >1 episode of vomiting
CT head within 8 hours
- age >65yo
- Bleeding/clotting disorder or anticoags
- Dangerous mechanism (struck by vehicle, ejected from vehicle, fall from >1m or >5 stairs)
- >30mins retrograde amnesia of events immediately prior to HI
Colorectal Cancer
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Most develop from adenomatous polyps (10% of adenomas -> Ca)
- RFs: Adenomatous polyposis coli, Familial adenomatous polyposis, Hereditary nonpolyposis colorectal cancer (lynch syndrome), age, male, fm hx, IBD, low fibre diet, processed meat, smoking, alcohol
Screening
- FIT test 60-74yo every 2 years (1 in 10 w/ +ve result will be found to have Ca, 4 in 10 will have premalignant polyps)
Presentation
- Left sided: PE bleeding, change in bowel habit, tenesmus, palp mass LIF or on PR
- Right sided: IDA, abdo pain, palp mass RIF, often presents late
2ww Criteria
->40 w/ weight loss and Abdo pain
>50 w/ unexplained PR bleeding
>60 w/ IDA or change in bowel habit
also consider if rectal/abdo mass; unexplained anal mass or ulceration; <50 w/ rectal bleeding and abdo pain, change in bowel habit, weight loss, IDA
Investigations
- CEA (tumour marker) for monitoring
- Bloods - IDA
- Colonoscopy w/ biopsy
- CT for staging
- MRI rectum for rectal tumours to assess depth
Management
Surigcal options:
- Right Hemicolectomy/Extended Right Hemi - caecal or ascending colon (extended for transverse colon)
- Left Hemicolectomy (descending colon)
- Sigmoidectomy (sigmoid colon)
- Anterior Resection (high rectal >5cm from anus (leaves anal sphincter intact))
- AP Resection (low rectal, <5cm, leads to permanent coloscopy + lack of sphincters)
- Hartmann’s Procedure (emergency procedure eg. obstruction or performation)
Other: chemo, radiotherapy, palliative
Stomas
How to differentiate between ileostomy and colostomy
Ileostomy
- Location: RIF
- Spouted
- Liquid output
Colostomy
- Varying location (more likley left side)
- Flushed to skin
- Solid output
- Loop = loop of bowel brought up to surface w/ two openings to stoma. Used to protect a more distal anastamosis. Can later be reversed.
- End = bowel is brought up to the abdo walll. More permanent procedure.
PR Bleeding
Describe typical presentation and management of the following causes of PR bleeding
- Haemorrhoids
- Solitary Rectal Ulcer
- Angiodysplasia
- Anal Fissure
Other causes: Diverticulitis, UC (bloody diarrhoea), Gastroenteritis, Colorectal/Anal cancer
Haemorrhoids
- Pres: painless rectal bleeding, pruritis (pain if thrombosed)
- Types: external (below dentate line, prone to thrombosis), Internal (above dentate line, painless)
- Grading: I (NO prolapse), II (prolapse BUT spontaneous reduction), III (manually reduced), IV (NO reduction)
- Thrombosed - pain, purple, oedematous
- Management:
Most: conservative, soft stools, anusol
More: rudder band ligation
Thrombosed: if present in 72h -> excision. Otherwise conservative.
Solitary Rectal Ulcer
- Associated w/ chronic straining and constipation
- Histology -> mucosal thickening, lamina propria + smooth muscle
Angiodysplasia
- AV malformation. Common esp >60yo + in hereditary haemorrhagic telangiectasia
- –> Painless occult PR bleeding in most, 15% -> acute haemorrhage
- Diagnosed w/ colonscopy OR mesenteric angiography if acutely bleeding
- Mx: endoscopic cautery, tranexamic acid, eostrgoens
Anal Fissure
- <6/52 = acute, >6/52 = chronic
- RF: constipation, IBD, sexually transmitted infections (HIV, syphilis, herpes)
- Pres: painful, bright red, rectal bleeding
- N.B. 90% found on posterior midline (if not then ?Crohns or alternative path)
- Mx:
- Acute: soften stool, lubricants, topical anaesthetic + analgesia
- Chronic: GTN topical (if nil effect after 8/52 refer for ?surgery (sphincterotomy) or botulinum toxin
Preparation for surgery
- Which tests are done pre-op?
- PO fluids and fasting rules
- Drugs to stop pre-op
- Diabetes meds adjustment
- Steroids
Tests Pre-Op
- Bloods: FBC, U&E, LFTs, Clotting, G&S
- Urine analysis
- Pregnancy test
- Sickle Cell Test
- ECG/CXR
PO Fluids and Fasting Rules
PO fluids:
- clear fluids till 2h pre-op
- other stuff stopped 6h pre-op
Drugs to Stop Pre-op - CHOW
- Clopidogrel: stop 7d pre-op (aspirin can be continued)
- Hypoglycaemia (below)
- Oral contraceptives (COCP or HRT) - stop 4/52 pre-op
- Warfarin - stop 5d pre-op + start LMWH therapeutic dose (op only if <1.5 INR so can give PO vit K)
Diabetes meds adjustment
Oral hypoglycaemics
most managed by adjusting meds on day of surgery:
- Metformin - if BD take as normal, if TDS skip lunch dose
- Sulfonylureas: omit morning dose (+ afternoon dose if PM surgery)
- DPPIV inhibitors (gliptins) - take as normal
- GLP1 analgogues (tides) - take as normal
- SGLT2 inhibitor (flozins) - omit on day of surrgery
- Long-acting insulin - reduce dose by 20% day before + day of surgery
BD biphsasic or ultra-long-acting insulin - 1/2 normal morning dose
UNLESS >1 meal missed, poor glycaemic control, risk of renal injury —> VRII
If taking inuslin -> VRII
Steroids
- Continue. If cannot take PO then switch to IV.
Abdominal Aortic Aneurysm
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Dilatation = >3cm
- RFs: marfans, ehlers danlos, infection, trauma, atherosclerosis, inflammatory (takayusus aortitis), smoking, HTN, fam hx, male, age, hyperlipidaemia
- (Diabetes if actually protective)
Presentation
- Symptomatic AAA: Abdo pain, back/loin pain, distal emboli, aortoenteric fistula
- Pulsatile mass
- Ruptured AAA: syncope, vomiting, haemodynamic compromise, Abdo tenderness, pulsatile mass
- Screening: men age 65 abdo USS
Investigation
1st:USS
once confirmed on USS then CT contrast if >5.5cm (to plan management)
Management
Elective Management
<5.5cm - monitor w/ duplex USS + risk factor management (yearly if <4.4cm, 3/12 if >4.5cm)
Surgery if:
- >5.5cm
- OR expanding >1cm/yr
- OR symptomatic
- open or endovascular repair
Emergency Mx/Rupture
- Mx: O2, high flow IV access, Crossmatch
- Keep BP <100 (permissive hypotension)
- Transfer to vascular –> unstable -> open repair; Stable –> CT angio + open/endovasc repair
How do the following hernias present and what is done about them?
- Inguinal
- Femoral
- Umbilicus
- Paraumbilical
- Epigastric
- Incisional
- Spigelian
- Obturator
- Richter
Childhood
- Inguinal
- Umbilical
Inguinal Hernia - superomedial to pubic tubercle. Direct (through posterior wall defect in inguinal canal); indirect (via inguinal canal). Mx - if symptomatic offer surgical management. Asymp - monitor. N.B. in children all are managed surgically as higher risk complications
Femoral Hernia - more in women. Inferolateral to pubic tubercle. High risk strangulation. Manage surgically within 2/52.
Umbilical Hernia - symettrical bulge under umbilicus. **In infancts tend to resolve by 4-5yo. Monitor. Complications rare. **
Paraumbilical Hernia - asymmetrical bulge above/below umbilicus
Epigastric - Lump in midline between umbilicus + xiphisternum. RFs: physical training, coughing, obesity.
Incisional Hernia - in 10% of abdo ops
Spigelian Hernia (aka lateral ventral hernia) - older patients. Surgically managed.
Obturator Hernia- through obturator foramen. More in women. Presents w/ bowel obstruction.
Richter Hernia - only the antimesenteric wall of the bowel herniates so -> strangulation without signs of obstruction
Complications
- Incarceration = irreducible
- Obstruction
- Strangulation = compromised blood supply - unwell, PR blood etc.
How do the following hernias present and what is done about them?
- Inguinal
- Femoral
- Umbilicus
- Paraumbilical
- Epigastric
- Incisional
- Spigelian
- Obturator
- Richter
Childhood
- Inguinal
- Umbilical
Inguinal Hernia - superomedial to pubic tubercle. Direct (through posterior wall defect in inguinal canal); indirect (via inguinal canal). Mx - if symptomatic offer surgical management. Asymp - monitor. N.B. in children all are managed surgically as higher risk complications
Femoral Hernia - more in women. Inferolateral to pubic tubercle. High risk strangulation. Manage surgically within 2/52.
Umbilical Hernia - symettrical bulge under umbilicus. **In infancts tend to resolve by 4-5yo. Monitor. Complications rare. **
Paraumbilical Hernia - asymmetrical bulge above/below umbilicus
Epigastric - Lump in midline between umbilicus + xiphisternum. RFs: physical training, coughing, obesity.
Incisional Hernia - in 10% of abdo ops
Spigelian Hernia (aka lateral ventral hernia) - older patients. Surgically managed.
Obturator Hernia- through obturator foramen. More in women. Presents w/ bowel obstruction.
Richter Hernia - only the antimesenteric wall of the bowel herniates so -> strangulation without signs of obstruction
Complications
- Incarceration = irreducible
- Obstruction
- Strangulation = compromised blood supply - unwell, PR blood etc.
What are the following?
- Peutz-Jegher Syndrome
- Lynch Syndrome
- Familial Adenomatous Polyposis
- Gardners Syndrome
Peutz-Jeghers Syndrome
Path - autosomal dominant. Numerous hamartomatous polyps in GI tract; freckles on lips, face, palms + soles.
Pres -> Small bowel obstruction due to intussuception. GI bleeding. Pigmented lesions/freckles.
Mx: conservative
N.B. altho polyps are NOT pre-malignant 50% of pts will die from GI Ca by age 60yo
Familial Adenomatous Polyposis
Path- rare, autosomal dominant. Hundreds of polyps by 30-40yo –> Ca.
Mx: total colectomy + ileo-anal pouch formation in their 20s
Gardner’s Syndrome
Path - Autosomal dominant. variant of FAP w/ osteomas of skull, mandible, retinal pigmentation, thyroid Ca and epidermoid cysts of the skin
Mx: colectomy as per FAP
Lynch Syndrome (aka hereditary non-polyposis colorectal cancer)
Path - autosomal dominant -> increased risk of colorectal + endometrial Ca at young age (<50y) (other: stomach, ovarian, small bowel, pancreatic, prostate, urinary tract Ca)
- increased colorectal Ca risk without polyps
Abdominal Wound Dehisence
- Pathophysiology
- Presentation
- Management
Pathophysiology
- Superficial = failure of skin wound
- Complete = failure of all layers w/ protrusion of viscera externally
- RFs: malnutrition, jaundice, steroid use, wound contamination, poor surgical technique, obesity, smoking
Presentation
- Visible wound opening (typically 5-7d post-op)
- Skin may be intact -> new bulging of the wound + seepage of pink serous or blood stained fluid (any increased wound discharge should be considered dehisence till proven otherwise)
Investigation
- Clinical diagnosis
- wound swab if concurrent infection
Management
- Analgesia
- Broad spectrum IV abx
- Cover the wound w/ saline soaked gauze + arrange urgent return to theatre for wound closure
Subarachnoid Haemorrhage
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Traumatic or non-traumatic (spontaneous)
- Causes: ADPKD, AV malformation, Ehler’s Danlos, Pituitary apoplexy
Presentation
- Sudden onset, thunderclap headache, max intensity within 1 minute
- N+V, meningism, coma, seizures, sudden death
- ECG can show ST elevation
Investigation
- CT head (-ve in 7%)
- LP at 12h (xanthachromia) (opening pressure can be normal or raised)
Management
- Refer immediately to neurosurgery.
- They will CT intracranial angio to identify lesions + guide Mx
- Intracranial aneurysms –> Coiling within 24h (until treated keep pt on bed rest w/ well controlled BP + avoid straining)
- 21d course nimodipine (to prevent vasospasm)
- If hydrocephalus developed then external ventricular train or VP shunt used
Complications
- Vasospasm (21d of nimodipine to prevent)
- Hydrocephalus
- Seizures
- Hyponatraemia (SIADH)
- Re-bleeding (10%) - most common in 1st 12h. Repeat CT is suspected. High mortality.
What are the following?
- Ogilvie’s Syndrome
- Brain death
- Rectal Prolapse
Ogilvie’s Syndrome = acute colonic pseudoobstruction
- RFs: pelvic surgery, trauma, puerperium
- Presentation mimics mechanical obstruction
- Mx: neostigmine or colonic decompression
Brain Death
- Criteria for testing: Deep coma of known non-reversible cause, no sedation, normal electrolytes
- Testing done by 2 doctors on 2 separate occassions (both >5yr experience + 1 must be consultant, neither can be on transplant team)
- Look for: fixed pupils, no corneal, oculo-vestibular or gag reflect, no response to supraorbtal pressure. No resp effort when disconnected from ventilator+ pCO2 >6.0)
Rectal Prolapse
- Partial (rectal mucosa protrudes); complete (rectal wall)
- RFs: chronic training, vaginal deliveries
- Presents -> mucous discharge, faecal soiling, PR bright red blood on wiping, ulceration, rectal fullness/tenesmus
- Managed surgically in most
Superficial Thrombophlebitis
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Inflammation of superficial veins (NOT infective, altho can get secondary infection -> septic thrombophlebitis)
- 20% have underlying DVT at presentation (esp if >5cm of vein affected)
Presentation
- Typically long saphenous vein
- Vein inflamed + painful
Investigation
- Doppler USS if proximal long saphenous vein affected to exclude concurrent DVT
Management
- Anti-embolism stockings (w/ ABPI first)
- LMWH prophylactic dose for 30 days OR fondaparinux or 45d (N.B. longer course of 6-12/52 if at sapheno-femoral junction)
- if LMWH contraindicated then 12 days of PO NSAIDs
Hiatus Hernia
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology - herniation of part of stomach above diaphragm
- Sliding (95%) - gastroesophageal junction moves above diaphragm
- Rolling (paraoesophageal): junction remains below but different bit of stomach herniates through oesophageal hiatus
RF: obesity, ascites, pregnancy
Presentation
- Heartburn, Dysphagia, Regurgitation, chest pain
Investigation
- Barium swallow most sensitive
- (altho many pts end up having endoscopy first to rule out ca etc)
Management
- Conservative: weight loss
- Medical: PPI
- Surgical: if not responding to above OR if complications (N.B. any signs obstruction, strangulation or volvulus needs NG decompression prior to surgery). Options: cruroplasty or nissens fundoplication.
General Anaesthetic Agents
What are they used for (induction vs maintenance), give typical side effects and advantages.
- Volatile Liquid Anaesthetics (iso-, des-, sevo-flurane)
- Nitrous Oxide
- Propofol
- Thiopental
- Etomidate
- Ketamin
Volatile Liquid Anaesthetics
- Induction + maintenance
- SEs: Myocardial depression, Malignant Hyperthermia
Nitrous Oxide
- For maintenance and analgesia
- SE: can diffuse into gas-filled body compartments so increasing their pressure (avoid in pneumothorax)
Propafol
- induction ALSO anti-emetic
- SE: pain on injection, hypotension
Thiopental
- SE: laryngospasm, hypotension
Etomidate
- SEs: adrenal supression + myoclonus
- BUT less hypotension than prop/thiopental so good in haemodynamic instability
Ketamine
- SEs: disorientation and hallucinations
- No BP drop so good in trauma
Malignant Hyperthermia
- Autosomal Dominant. Triggered by fluranes.
- Ca2+ released from sarcolemma –> muscle rigidity + hyperthermia
- Managed A-E plus dantrolene
