Surgery 2 Flashcards
What is a direct inguinal hernia?
passes through Hesselbach’s triangle in the abdominal wall
passes through superficial inguinal ring
What are the borders of Hesselbach’s triangle
inguinal ligament at base
lateral border of the rectus sheath
inferior epigastric vessels laterally
What is an indirect inguinal hernia
passes through patent process vaginalis through deep inguinal ring
Where is the deep inguinal ring found?
midpoint of the inguinal ligament
= between ASIS and pubic tubercle
What is found at the midinguinal point?
femoral artery
= between ASIS and pubic symphysis
What is the relation of the inguinal hernias to the inferior epigastric vessels
direct = medial to the inferior epigastric vessels indirect = lateral to the inferior epigastric vessels
What are the risk factors for inguinal hernias
heavy weight lifting chronic cough obesity chronic constipation male
what are the signs of an inguinal hernia
lump media and superior to the pubic tubercle
positive cough impulse
reducible?
if enters scrotum - can you get above it?
What is the treatment for an inguinal hernia
reduction - open or laparoscopic mesh
laparoscopic preferred for bilateral or recurrent inguinal hernias
What are the complications of an inguinal hernia repair
early: bruising, wound infection
late: chronic pain, recurrence
damage to vas deferens or testicular vessels
Define hernia
the protrusion of part or whole of an organ or tissue through the wall of the cavity that normally contains it.
What are the symptoms and signs of an irreducible or incarcerated hernia
painful, tender, and erythematous lump
features of bowel obstruction
What is an irreducible or incarcerated hernia?
bowel unable to return to original cavity
What is an strangulated hernia
compression of bowel has cut off blood supply to bowel, so ischaemia occurs
How can direct and indirect inguinal hernias be differentiated on examination?
reduce hernia occlude deep femoral ring at mid point of inguinal ligament cough impusle if hernia does not protrude = indirect if hernia still protrudes = direct
What is the differential diagnosis for an inguinal hernia
Femoral hernia Saphena varix Inguinal lymphadenopathy Lipoma Groin abscess Internal iliac aneurysm
What are the differential diagnoses for a mass in the scrotum
varicocoele
hydrocoele
inguinal hernia
testicular mass
When is an USS recommended when diagnosing an inguinal hernia
if there is diagnostic uncertainty
or to exclude other pathology.
What is the annual risk of strangulation of an inguinal hernia?
3%
What is a femoral hernia
protrusion of bowel through the femoral ring into the femoral canal
What are boundaries of the femoral ring
anterior = inguinal ligament
posterior = pectineal ligament
lateral - femoral vein
medial = lacunar ligament
What are risk factors for a femoral hernia
female
multiple pregnancies
obesity
chronic constipation or coughing
What are the signs of a femoral hernia
lump in groin
inferior and lateral to the pubic tubercle
below inguinal ligament
medial to femoral pulse
Why are femoral hernias prone to strangulation
tight ligament borders of the femoral ring
What are the differential diagnoses in femoral hernia
Low presentation of inguinal hernia Femoral canal lipoma Femoral lymph node Saphena varix Femoral artery aneurysm
What is the gold standard investigation for femoral hernia
USS
Why are all femoral hernias meant to be surgically managed
due to high risk of strangulation
What is the surgical management of a femoral hernia
reduction of the hernia
surgical narrowing of the femoral ring with the use of interrupted sutures
What is the risk of strangulation of femoral hernia at 3m and 21m after initial diagnosis
3m = 22% 21m = 45%
Describe a hiatus hernia
protrusion of the stomach into the thorax through the oesophageal hiatus
What is the difference between a rolling and sliding hiatus hernia
sliding = movement of oesophagus and gastroeosophageal junction upwards
rolling = GOJ in same place. fundus moves up to lie next to GOJ
Do you get symptoms of reflux in sliding or rolling hiatus hernia
sliding - GOJ compromised
what are teh symptoms of hiatus hernia
GORD vomiting weight loss hiccuping swallowing difficulties
What are the complications of hiatus hernia
incarceration
strangulation
volvulus
What is the conservative management of hiatus hernia
PPI
diet modification
weight loss
stop alcohol and smoking
What is the surgical management of hiatus hernia
curoplasty = reduction into abdomen
fundoplication = fundus wrapped arounf LOS and stretched to stregthen LOS
When would you consider surgical management of hiatus hernia
if conservative failed
if high risk of strangulation
if nutritional failure
What are the signs and symptoms of gastric volvulus
Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube
What increases the risk of an incisional hernia
obesity midline incisions age pregnancy cough diabetes steroids smoking
What is the definition of a peptic ulcer
break in the mucosal surface of the stomach or duodenum that extends to the muscularis mucosae
What is the most common location for a peptic ulcer
first part of the duodenum
lesser curvature of the stomach
What are the causes of PUD
Helicobacter pylori infecion NSAIDs alcohol smoking ZE syndrome steroids
What class of bacteria is H pylori
gram negative bacillus
spiral shaped
urease producing
What enable H pylori to survive in the stomach
urease: urea to ammonium. creates neutral environment for the bacteria to survive in
Why does H pylori infection leads to PUD
causes inflammation of the mucosa
stimulates G cells to secrete gastrin, leading to increased acid production
atrophy
imbalance between acid and protective mucus
Why do NSAIDs cause PUD
inhibition of prostaglandin synthesis causes reduction in mucus priduction
imbalance between acid and protective mucus
What are the symptoms of PUD
epigastric pain - worse on eating (gastric) or 2-4h after (duodenal) nausea anorexia weight loss tiredness malaena
What are the red flag symptoms for gastric cancer which require urgent OGD
new onset dysphagia
> 55 with weight loss
+ abdo pain, reflux or dyspepsia
What investigations should be carried out in suspected PUD
FOB
FBC, U+E,
Urease breath test - must stop PPI at least 2 weeks prior
What is the management of PUD
lifestyle interventions
PPI for 4-8weeks
if proven H pylori - triple therapy
OGD to check resolution
What are some lifestyle interventions for PUD
stop smoking less alchohol small meals not eating for 3 hours before bed Lose weight Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty or spicy foods.
What is triple therapy for H pylori
PPI eg lansoprazole
amoxicillin
clarithromycin
7 days
if penicillin allergic = clarithromycin + metronidazole
What are the complications of PUD
haemorrhage perforation gastric outlet obstruction malignancy - H pylori increases risk anaemia
What artery is most likely to cause haemorrhage in PUD
gastroduodenal
What is an AAA
dilation of the abs=dominal aorta >3cm (normal - 1.5cm)
What is the pathophysiology of AAA
loss of elastic proteins and extracellular matrix in intima and media of the AA due to proteolytic activity and lymphocytic infiltration
What are the risk factors for AAA
male age HTN hyperlipidaemia smoking FH
What are the signs and symptoms of AAA
none!
back/.abdo/loin pain
distal emboli
pulsating mass above umbilicus
What is the ddx of AAA
renal colic IBD/IBS diverticulitis appendicitis GI haemorrhage
Describe the screening programme for AAA
abdominal USS for men aged 65
small 3-4.4cm USS every year
medium 4.5-5.4cm USS every 3m
large >5.5cm offer surgery
Define small medium and large AAA
small 3-4.4cm
medium 4.5-5.4cm
large >5.5cm
What investigations are done in suspected AAA
USS abdomen
CT with contrast if >5.5cm for operative planning
What is the conservative management of AAA
stop smoking
weight loss
control BP
statin and aspirin
When should the DVLA be informed of an AAA
when it is greater than 6cm
need to stop driving due to risk of rupture
What benefits does stopping smoking have in AAA
slows rate of progression
decreases risk of rupture
When is surgery offered in AAA
if >5.5cm
if expanding at >1cm/year
if symptomatic
What are the surgical options in AAA
endovascular repair
open repair
What are the risks and benefits of endovascular aneurysm repair (EVAR) of AAA
risks: endoleak, increased risk of reintervention and rupture. will need regular CT angiograms to monitor
benefits: reduced 30 day mortality, reduced hospital stay
same long term outcomes as open
What is an endovascular leak
a leak around a graft used in endovascular repair
State the types of endovascular leak
1 = leak around edge of graft 2 = filling by branch vessel 3 = leak through defect in graft 4 = leak through porous material of graft 5 = no obvious site of leakage, but the aneurysm is expanding
What increases the risk of AAA rupture
smoking
female
HTN
FH
What are the symptoms and signs of AAA rupture
back/abdo pain (most are retroperitoneal) vomiting syncope low BP raised HR pulsatile abdo mass abdominal tenderness
how should an AAA rupture be managed
high flow oxygen 2x large bore cannulae bloods - FBC, amylase, cross match ECG o-ve blood keep BP below 100 CONTACT VASCULAR TEAM
Why does the blood pressure need to be maintained below 100mmHg in AAA rupture
prevents excessive blood loss
reduces risk of rupturing contained leak
When should warfarin be stopped pre-operatively?
5 days before op
When should clopidogrel be stopped pre-operatively?
5 days before op
Why are pre-medications given in surgery
decrease gastric volume
decrease post op N+V
decrease anxiety
Define the ASA grades
1 = normal healthy 2 = mild systemic disease 3 = severe systemic disease 4 = severe systemic disease that is a constant threat to life 5 = moribund who is not expected to survive without op
What are the criteria for discharge form the recovery room to the ward
patient fully conscious, able to maintain a clear airway
respiration and oxygenation satisfactory
CVS stable - BP, pulse, perfusion
pain and emesis controlled - analgesia and anti=emetics prescribed
temperature within acceptable limitis
o2 and IV fluid therapy prescribed if appropraite
What are patient factors that increase the risk of PONV
female
motion sickness
prev PONV
non-smoker
What are surgical factors that increase the risk of PONV
laparascopic
abdominal or pelvic
middle ear o intracranial
long operation
What are anaesthetic factors that increase the risk of PONV
NO opiods long anaethesia spinal intra op dehydration overuse of bag+mask
What are the main classes of antiemetics
antihistamines
dopamine antagonists
5HT3 antagonist
What causes nausea
visceral stimulation in response to distention/irritation detected by mechano/chemoreceptors
chemoreceptor tigger zone in response to drugs, hormones or toxin in blood
higher neurological inputs in response to psychological stress, CNVIII and CN IX gag reflex
What neurotransmitters do the mechano/chemoreceptors in the viscera use?
Where do these act
5-HT3 and dopamine
vagus nerve simulates vomiting centre in medulla oblongata
Where is the chemoreceptor trigger zone
in teh fourth ventricle floor outside blood brain barrier
What neurotransmitters does the CTZ use?
5-HT3 and dopamine
What neurotransmitters does the CTZ use?
Where do these act?
ACh, histamine
at CTZ -> vomiting centre
How do antihistamines act as an antiemetic
block H1 receptor in vomiting centre
Give an example of an antihistamine used as an antiemetic
cyclizine
When is cyclizine best used as an anti-emetic
pregnancy
labyrinthine disorders
How do dopamine antagonists act as an antiemetic
inhibition at CTZ
Give an example of an dopamine antagonist used as an antiemetic
metaclopramide,
domperidone
When are dopamine antagonists best used as an anti-emetic
in decreased gut motility (they stimulate)
also for nausea caused by drugs, cytotoxins
How do 5HT3 antagonists act as an antiemetic
block 5HT3 receptors in gut and CTZ
Give an example of a 5HT3 antagonist used as an antiemetic
ondansetron
When are 5HT3 antagonists best used as an anti-emetic
PONV - opiod induced
chemo
Describe teh analgesic pain ladder
non-opiate
weak opiate eg codeine, tramadol
strong opiate eg morphine, diamorphine
What are the main side effects of an epidural
decrease BP
loss of bladder control
sickness
headache
What layers does an epidural needle go through
superficial tissues
supraspinous ligament
interspinous ligament
ligamentum flavum
stops before dura and arachnoid
Name the 9 areas of the abdomen
right hypochondrium epigastrium left hypochondrium right flank periumbilical left flank right iliac fossa suprapubic left iliac fossa
What bacteria are most likely to cause a wound infection
staph aureus
strep pyogenes
enterococci
What is the antibiotic treatment for a wound infection
flucloxacillin
teicoplanin IV if more severe
How is C diff treated
metronidazole/vancomycin
How much of a crystalloid fluid will remian in the intravacular space
25%
How much a 0.9% dextrose solution will remain in the extravascular space
1/12th
What is the difference between hypovolaemia and dehydration
hypovolaemia = loss of Na+ and water. haemodynamically unstable
dehydraion = loss of water. hypernatraemic, hypertonic plasma
How should hypovolaemia be treated?
IV fluid bolus
How should dehydration be treated?
oral fluids
slow IV fluids
Whjat are an adult’s daily fluid, glucose and electrolyte requirements
25ml/kg/hr water
50g/day glucose
1 mmol/kg/day Na+ and K+
What antibodies and antigens does A blood have
antigens = A antibodies = B
What antibodies and antigens does AB blood have
antigens = A B antibodies = none
What antibodies and antigens does B blood have
antigens = B antibodies = A
What antibodies and antigens does O blood have
antigens = none antibodies = A B
What does cross matching of blood involve
mixing a bit of the patient’s blood with the donor’s
takes about 40mins
What are the indications for O-ve blood
blood group unknown
o-ve pt
What gauge cannulae are used for blood transfusions
Green 18G
Grey 16G
What is the definition of a massive blood transfusion
replacement of >1x blood volume in 24h
>50% volume in 4 hours
blood volume = 75ml/kg
> 40ml/kg in children
What is FFP and what is it used for?
fresh frozen plasma
used to correct clotting disorders eg warfarin, DIC, liver disease
What is cryoprecipitate and what is it used for?
made from FFP. contains fibrinogen, vWF, factors VIII and XIII and fibronectin
used in hypofibrinogenaemia von Willebrand’s disease.
What are some early complications of a blood transfusion
pyrexia anaphylaxis fluid overload transfusion related acute lung injury acute haemolytic reaction
What are some late complications of a blood transfusion
infection
iron overload
graft versus host disease
post tranfusion purpura
What does a CVP monitor measure?
central venous pressur emonitor
measures pressure in RA and IVC
Which veins can be used for central venous access
internal jugular
femoral
subclavian
What are the indications for a central line
drugs
CVP monitoring
What are teh complications of a central line bein ginserted
infection bleeding from punctured artery pneumothorax phrenic nerve palsy air embolism thrmobus formation
State three features of an obstructed airway
unable to speak
no chest wall movement
respiratory distess
What can cause an obstructed aiway
external compression
swelling of airway
foreing body
What manoeuvres can be used to relieve an obstructed airway
jaw thrust
head tilt
State the colour cannulas in asceinding size
blue - 22G pink - 20G green - 18G grey - 16G orange - 14G
According to days post op, what is the most likely infection?
1-2 = resp 2-5 = urinary 5-7 = surgical site/abscess
any! = IV lines
What can cause a post op fever
infection
iatrogenic - dtugs, transfusion
VTE
pyrexia of unknown origin
What are important questions to ask a patient with post op pyrexia
cough, dyspnoea, chest pain, haemoptysis urinary freq, dysuria, urgency wound tenderness or discharge IV line tenderness or sicharge calf pain
What investifations should be done in a patient with post op fever
ECG, urine dipstick
FBC, U+E, CRP,
blood cultures, sputum culture, urine culture, swab culture
CXR ?CT if risk anatamotic leak
calculate Wells
What is the antibiotic treatment for a post op LRTI
co-amoxiclav 5d
What is the antibiotic treatment for a post op LUTI
trimethoprim 3d
What is the antibiotic treatment for a post op UUTI
co-amoxiclav 14d
What is the antibiotic treatment for a post op intraabdominal infection
cefuroxime + metronidazole IV
What is the antibiotic treatment for a post op infection of unkown origin
cefuroxime + metronidazole IV
+ STAT does gentamicin
How do gallstones causes pancreatitis
blockage of common bile duct means pancreatic secretions cannot pass into duodenum
thee secretions remain in the pancreas leading to inflammation and injury
enzyme mediated inflammation
Which organs most commonly perforate
large bowel
appendix
duodenum
Define peritonitis
inflammation of the peritoneum
What investigation should be performed in suspected peritonitis
what does this show?
if -ve, what test shuld be done next?
erect CXR
air under the diaphragm
CT abdo pelvis
What are the signs of peritonitis
prostration shock lying still positive cough test - pain on coughing tenderness - rebound, on percussion abdominal rigidity guarding no bowel sounds
How is peritonitis treated?
laparotmoy to diagnose and repair perforation
What can cause peritonitis
PUD perforation of small bowel or large bowel crohn's appendicitis diverticular disease SBO/LBO
Why might you need to form a stoma
bowel rest
not enough blood supply to area of bowel needing to be anastamosed
Distinguish between an ileostomy and a colostomy
ileostomy: spout, RIF, liquid contents, smaller lumen, mucosal folds
colostomy: flush to skin, LIF, solid contents, greater lumen diameter
What are the complications of TPN
thrombophlebitis
refeeding syndrorme
sepsis
thromobus formation - PE/SVC obstruction
When can nasogastric nutrition be used
if the oral route is not viable
When can nasojejunal nutrition be used
when pt at risk of aspiration (pulmonary regurgitation)
When can a gastrostomy be used for nutrition
if there is oesophageal dysfunction
When can a jejunostomy be used for nutrition
if the stomach is inaccessible or there is outflow obstruction of the stomach
What is a diverticulum
outpocketing of teh colonic mucosa through the muscular wall of teh colon at sies of entry of perforating arteries
What causes diverticulum to form
increased intraluminal pressure leads to weakness of the bowel wall over time
Where is it most common for diverticula to form?
sigmoid
Define diverticulosis
presence of diverticula, no sx
define diverticular disease
presence of diverticular + sx
define diverticulitis
inflammation of a diverticulum
What are the risk factors for diverticular disease
low fibre diet obesity smoking FH smoking NSAIDs
What are the symptoms of diverticular disease
pain in LIF - relieved by defecation
change in bowel habits
Nausea
flatulence
What are the symptoms and signs of diverticulitis
pain in LIF PR bleed N+V raised temp tenderness on palpation ? peritonitis
What investigation should be done in diverticular disease/diverticulitis
ECG FBC, U+E, LFT, ABG if perforation CT abdo plevis sigmoidoscopy AXR and erect CXR if perforation
What are the possible complications of diverticular disease
perforation fistulae hammorrhage strictures abscesses
What are the typical features of an abscess
swinging pyrexia
leucocytosis
How should diverticular disease be managed
increase fibre and oral fluids
pain relief - paracetamol NOT NSAIDs or opioids
weight loss
stop smoking
How should a mild episode of diverticulitis be managed
oral fluids
bowel rest
analgesia
antibiotics
How should a severe episode of diverticulitis be managed
admission analgesia NBM IV fluids IV abx
When is an episode of diverticulitis considered severe
pain not controlled with analgesics at home pt dehydrated PR bleed severe comorbidities presence of peritonitis >48hrs of symptoms
When is surgical treatment recommended in acute diverticulitis
perforation
sepsis
failure to improve with conservative management
What are the surgical optionsn in the management of acute diverticulits
resection - Hartmann’s
laparascopic peritoneal lavage
When is elecrtive surgery for diverticular disease recommended
stenosis
fistulae
recurrent bleeding
What are the common side effects of mesalazine
indigestion, nausea, abdo pain
Diarrhoea
Headache, muscle aches and pains
Why might mesalazine be contraindicated
allergy!
severe hepatic or renal impairment
What should be monitored in mesalazine therapy?
U+E, eGFR before starting and at 3 months of treatment, and then annually during treatment.
What info should be given to a patient before starting mesalazine therapy
need to monitor your kidney function
can cause blood disorders - report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment.
When is lanzoprazole contraindicated
pregnancy and breast feeding
How is lansoprazole meant to be taken?`
at least 30 minutes before a meal
Do not take indigestion remedies during the two hours before or during the two hours after you take lansoprazole as they can interfere with the way lansoprazole is absorbed by your body.
What are the common side effects of lansoprazole
nausea, stomach ache Diarrhoea Constipation Headache Feeling dizzy or tired Dry mouth or throat, itchy skin rash
What are some important things to remember when prescribing lansoprazole
Can increase the risk of fractures due to osteoporosis
; may increase the risk of gastro-intestinal infections (including Clostridium difficile infection);
may mask the symptoms of gastric cancer (in adults)
What are the potential causes of haematemesis
PUD oesophageal varices Mallory-Weiss oesophagitis gastritis
What are oesophageal varices
portosystemic anastamoses caused by portal HTN
What is a Mallory weiss tear
tear in oesophageal epithelium
What can cause oesophagitis
candida
GORD
bisphosphonates
What are the important aspects of a history following haematemesis
timing, frew, volume
prev dyspeosia, dysphagiaa or odynophagia
? alchohol/smoking
liver disease
NSAIDs, steroids, anticoagulation, bisphosphonates
What might be found on examination in a case of haematemesis
epigastric pain/tenderness
liver stigmata - hepatosplenomegaly, nodular liver, spider naevi,
What investigations should be done in a case of haematemesis
FBC, U+E, LFTs, clotting, ABG, G+S, cross match
erect CXR, CT abdomen with IV contrast
OGD
What does the Glasgow Blatchford Bleeding score calculate
the risk of needing an intervention in haematemesis
What does somatostatin do in the management of oesophageal varices
decreases sphlanchic blood flow
Describe the pathophysiology of achalasia
Failure of oesophageal peristalsis and of relaxation of LOS due to degenerative loss of ganglia from Auerbach’s plexus
What are the symptom of achalasia
dysphagia of sloids and liquids
varibale sx
reflux
regurgitation
What investigations hsould be done in achalasia
manometry - assess LOS function
barium swallow - see bird’s beak appearance
What is the treatment of achalasia
intra-sphincteric injection of botulinum toxin
What is Boerhaave syndrom
transmural perforation of the oesophagus
in Mallory-Weiss syndrome it is a nontransmural esophageal tear
