Surgery 2 Flashcards
What is the benefit of using an uncuffed ET tube?
Avoids damaging the larynx
Typically used in children
Cuffed ET tubes are better at preventing aspiration
NOTE: in terms of size, men need 8.5 and women need 7.5
What are the clinical features of radial nerve palsy?
Wrist drop
Loss of sensation over the first dorsal interosseous (webbing)
May have sensory loss over dorsal forearm
Why does an anterior resection require a loop ileostomy?
Rectal blood supply is poor so the colorectal anastomosis must be rested and, hence, covered by a loop ileostomy
What rehabilitation support should be offered to patients with a stoma?
Aim for normal diet
Good skin care and hygiene
Psychosexual support
What is a subtotal colectomy?
All colon excised except distal sigmoid and rectum
Temporary end ileostomy
Rectosigmoid stump may be exteriorised as a mucus fistula
Can be reverse 3 months later with complete proctectomy + ileal pouch anal anastomosis/permanent end ileostomy OR ileorectal anastomosis
Other than the carpal tunnel, where else can the median nerve get trapped?
Pronator syndrome (between heads of pronator teres) Anterior interosseous syndrome (compression of anterior interosseous branch of median nerve in the deep head of pronator teres - causes muscle weakness only)
Describe the management of ileus.
Correct underlying abnormalities (electrolytes and drugS)
Consider the need for parenteral nutrition
What are the main indications for doing a total hip replacement as opposed to a hemiarthroplasty?
Mobilises with no more than 1 walking stick
Not cognitively impaired
Medically fit for anaesthesia and surgery (minimal comorbidities)
Outline how to examine a stoma.
Look at the stoma (colour, surface, bag, contents, surroundings, devices)
Examine the rest of the abdomen
Ask to examine the perineum
Palpate around and inside the stoma with your little finger (need gloves and lube)
REPORT: site, calibre, number of lumens, functioning, healthy
What does Thomas’ test look for?
Fixed flexion deformity in the knee
Causes: osteoarthritis, ACL injury, bucket handle meniscal tear, iliopsoas tightness
Outline the management of popliteal aneurysms and its indications.
Surgical Indications: symptomatic, aneurysms containing thrombus, aneurysms > 2 cm
ACUTE Rx: embolectomy, femoral-distal bypass
STABLE: excision bypass
What are some causes of intradermal lumps?
Sebaceous cyst
Neurofibroma
Dermatofibroma
NOTE: the skin cannot be drawn over the lump
What is the investigation of choice for suspected chronic pancreatitis?
CT scan with IV contrast (to look for pancreatic calcification)
What is the difference between a true and false aneurysm?
TRUE: dilation of the blood vessels involving all layers of the wall, fusiform or saccular
FALSE: collection of blood around a vessel wall that communicates with the lumen, usually iatrogenic (e.g. puncture)
List some associations of Terry’s nails.
Chronic liver failure Diabetes mellitus Congestive heart failure Hyperthyroidism Malnutrition
Describe how the location of varicose veins relates to the veins involved.
Medial and above or below the knee - great saphenous
Posterior and below the knee - short saphenous
Few varicosities with prominent skin changes - calf perforators
How should a breast lump be investigated further?
< 35 years: US
> 35 years: US + mammogram (oblique and craniocaudal)
MRI if multifocal disease or cosmetic implants present
Outline the management principles of claudication.
CONSERVATIVE: structured exercise programme, stop smoking, weight loss, foot care
MEDICAL: RF modification (BP, BM, lipids) , antiplatelets (clopidogrel), analgesia
INTERVENTIONAL: angioplasty, stenting
Under what circumstance is steroid injections for join pain contraindicated?
If they already have some form of join replacement (risks introducing infection)
What is the main indication for a loin incision?
Nephrectomy
How can you clear the C spine in a trauma patient?
CLINICAL: if any of the following are present (NEXUS criteria) then it cannot be cleared clinically and requires imaging
- Neurological deficit
- Spinal tenderness in the midline
- Altered consciousness
- Intoxication
- Distracting injury
RADIOLOGICAL: radiograph –> CT C-spine (if radiograph abnormal)
List some differentials for epigastric masses.
Gastric cancer Hepatomegaly Pancreatic cancer Pancreatic pseudocyst AAA
Which investigations are used for achalasia?
Barium swallow
CXR - wide mediastinum, double right heart border
Manometry - failure of relaxation
OGD - exclude cancer
Outline the management of wound dehiscence.
Cover in steril soaked gauze
IV antibiotics
Repair in theatre
What operation might require a transverse muscle splitting incision?
Right hemicolectomy (along with a midline laparotomy and laparoscopic ports)
What are the indications for operating on an AAA?
Symptomatic
Asymptomatic but > 5.5 cm or expanding > 1 cm/year
What is the first-line investigation for diverticulitis?
CT scan
Other investigations for diverticulosis include gastrograffin enema/swallow and colonoscopy
List some conditions that are associated with carpal tunnel syndrome.
Hypothyroidism Pregnancy Rheumatoid arthritis Pregnancy Amyloidosis Diabetes mellitus
List some complications of urinary catheterisation.
Creation of false tract Urethral rupture Paraphimosis Haematuria Infection Blockage
NOTE: urethral injury is a major contraindication for urinary catheterisation
List the degrees of haemorrhoids.
1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation but reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced
What is the main indication for a shouldered/Gabriel syringe?
Injection of haemorrhoids with 5% phenol in almond oil (sclerosant)
Used with a proctoscope to allow visualisation of the haemorrhoids
List some complications of laparoscopic cholecystectomy.
Conversion to open procedure Common bile duct injury Bile leak Retained stones Intra-abdominal haemorrhage
If you see a stoma on examination, what else should you examine?
Perineum - do see if it is a permanent stoma or a temporary stoma or if the anus has been excised.
What are the features of acute limb ischaemia and which features are indications for immediate revascularisation?
Painful
Pulseless
Pale
Perishingly cold
Indications for immediate revascularisation: paralysis, paraesthesia
What classification system is used for peripheral nerve injury?
Seddon classification
Neuropraxia: temporary interruption in conduction
Axonotmesis: disruption of axon with preservation of connective tissue framework (recovery is possible)
Neurotmesis: disruption of entire nerve fibre (recovery incomplete)
What is refeeding syndrome?
Starvation (i.e. low carbs) leads to a catabolic state with low insulin and fat and protein catabolism leading to depletion of intracellular phosphate
Refeeding leads to a rise in insulin in response to the carbs resulting in increased cellular phosphate uptake
Hypophosphataemia –> rhabdomyolysis, respiratory insufficiency, arrhythmias, shock, seizures
NOTE: treated with phosphate supplementation
What are the advantages and disadvantages of the use of myocutaneous flaps for breast reconstruction?
ADVANTAGES: useful when little muscle/skin remaining, good cosmetic result
DISADVANTAGES: increased blood loss, increased operation time, late complications (e.g. flap necrosis)
What are the ways in which fractured can be held?
Closed –> plaster or traction (skin or skeletal)
Fixation
Which investigation would provide a definitive diagnosis of small bowel obstruction?
Abdominal CT
NOTE: AXR is first-line but not definitive
List some causes of gangrene.
Diabetes (most common) Embolism and thrombosis Raynaud's phenomenon Thrombangiitis obliterans Injury (e.g. extreme cold, trauma)
What is the main indication for hip resurfacing?
Young, active people who are expected to outlive the replacement
Why are varicoceles much more likely on the left side?
Left testicular vein drains into the left renal vein at a more vertical angle than the right testicular vein which drains into the IVC
Left renal vein can be compressed by bowel and renal pathology
Left testicular vein is longer than the right
Left testicular vein often lacks a terminal valve to prevent backflow
What are the most common causes of epigastric hernias?
Lipoma
Incisional hernia where you can’t see the incision (most commonly port site from lap chole)
Which classification system is used for intracapsular neck of femur fractures?
Garden classification 1 - incomplete and minimally displaced 2 - complete and non-displaced 3 - complete and partially displaced 4 - completely displaced with no engagement of two fragments
How should an NG tube be sized?
Measure from the tip of the nose to the epigastrium, going around the ear
List some indications for total parenteral nutrition.
Unable to swallow (e.g. oesophageal cancer) Prolonged obstruction or ileus Short bowel syndrome Severe Crohn's disease Severe malnutrition
NOTE: parenteral nutrition has a high osmolality and is toxic to veins so requires central venous access
List some complications of using ET tubes.
EARLY: oropharyngeal and laryngeal trauma, C-spine injury (atlanto-axial instability), oesophageal intubation, bronchial intubation
DELAYED: sore throat, tracheal stenosis, difficult wean
What do you ‘feel’ for when examining a joint?
Tenderness
Effusion
Temperature
NOTE: the joint should be moved in every direction possible, first actively then passively
Outline the conservative management of inguinal hernias.
Manage risk factors (e.g. chronic cough, constipation)
Weight loss
Hernia truss
How can the integrity of a surgical bowel anastomosis be checked?
Intra-operative: fill pelvic cavity with saline, insufflate rectum with air and look for bubbles in the saline
Post-operative: water-soluble contrast enema
