Surgery 4 Flashcards
What are the advantages and disadvantages of monofilament sutures?
ADVANTAGES: reduced risk of infection, less friction against tissues
DISADVANTAGES: harder to handle, knots may slip, less tensile strength
What might require a thoracoabdominal incision?
Oesophagogastrectomy
List some anatomical structures that are found at the transpyloric plane of Addison.
Pylorus Fundus of gallbladder Origin of SMA Duodenojejunal junction Neck of the pancreas Hila of the kidneys L1 Formation of the portal vein 9th costal cartilage
NOTE: it is half way between jugular notch and syphysis pubis
Outline the screening programme for AAA.
Single ultrasound scan for males aged 65 years
< 3 cm = normal
3-4.5 cm = rescan in 1 year
4.5-5.4 cm = rescan in 3 months
>5.5 cm = 2 week vascular surgery referral
EPONYMOUS OPERATIONS: hydrocele
Lord’s repair - plication of tunica vaginalis
Jaboulay’s repair - eversion of tunica vaginalis
List some complications of surgical drains.
Infection
Damage caused by mechanical pressure or suction
Limit patient mobility
List some causes of varicose veins.
Primary (95%): prolonged standing, pregnancy, obesity
Secondary (5%): valve destruction (DVT), obstruction (pelvic mass), AV malformation, syndromes (Klippel-Trenaunay, Parkes-Weber)
Outline the management of chronic limb ischaemia.
CONSERVATIVE: optimise risk factors, clopidogrel and statin, foot care
INTERVENTIONAL: angioplasty, stenting, chemical sympathectomy
SURGICAL: endarterectomy, bypass grafting, amputation
List some complications of feeding NG tubes.
Nasal trauma
Malposition (cranium)
Blockage
Electrolyte imbalance (refeeding syndrome)
List some complications of gastrectomy.
PHYSICAL: increase gastric cancer risk, reflux/bilious vomiting, abdominal fullness, stricture, stump leakage
METABOLIC
- Dumping syndrome (abdo distension, flushing, fainting, sweating)
- Blind loop syndrome (malabsorption and diarrhoea)
- Vitamin deficiency (B12, iron and folate)
- weight loss due to malabsorption
What specific type of X-ray should be taken in orthopaedic patients with hip and knee problems?
Weight-bearing X-ray
NOTE: for knee, also take lateral and skyline X-rays to look for patelofemoral joint osteoarthritis
How does the angle of shoulder abduction at which pain is elicited relate to the cause of the pain?
60-120 degrees: impingement or rotator cuff tendonitis
140-180 degrees: acromioclavicular osteoarthritis
What are the contents of the inguinal canal in females?
Round ligament
Ilioinguinal nerve
Genital branch of the genitofemoral nerve
What is swinging of the chest drain?
The fluid level moves up and down with inspiration and expiration
If there is no bubbling, it either means that the lung is up, the air leak is sealed off or the drain is blocked
What is the investigation of choice for hydroceles?
Ultrasound
What demarcates the 9 quadrants of the abdomen?
Transpyloric plane: across L1 from the tip of the 9th costal cartilage
Supracristal plane: across L4 at the highest point of the iliac crest
What are the three compartments of the abdomen in which you may feel for masses?
Subcutaneous
Visceral
Retroperitoneal
List some causes of salivary gland swelling.
DIFFUSE - infection (parotitis) - Sjogren' syndrome - sarcoidosis - systemic (bulimia, anorexia, chronic liver disease) LOCALSED - calculus - lipoma - salivary gland neoplasm - lymphoma/leukaemia
What urine dipstick results would you expect to see in post-hepatic jaundice?
High bilirubin
No urobilinogen
What bony and soft tissue lesions may be seen on an X-ray in shoulder dislocation?
Bankart lesion: damage to glenoid labrum
Hill-Sachs lesion: cortical depression in posterolateral part of humeral head
What is gangrene and what are the different types?
Definition: irreversible tissue death from poor vascular supply
Wet: tissue death + infection
Dry: tissue death only
List some complications of using a laryngoscope.
Laryngeal and oropharyngeal trauma
C-spine injury (e.g. in atlanto-axial instability)
What is a dermatofibroma?
Benign neoplasm of dermal fibroblasts
Usually seen on the legs of women, firm, woody feel may look like malignancy
What is Admirand’s triangle?
A system outlining the conditions under which cholesterol crystallises to form gallstones
The following conditions favour the crystallisation of gallstones
Low lecithin
Low bile salts
High cholesterol
What is the main benefit of a port a cath?
Very low risk of infection as skin breech is minimal
Typically used for long-term administration of chemotherapy/antibiotics
EPONYMOUS OPERATIONS: refractory GORD
Nissen fundoplication - wrapping the fundus around the lower oesophageal sphincter
List some causes of problems with fracture union.
Infection Ischaemia Interfragmentary movement Interposition of soft tissue Intercurrent illness
What is a Ryles nasogastric tube used for?
Draining the stomach (part of drip and suck)
Also used for persistent vomiting (e.g. pancreatitis)
NOTE: Ryles tubes are wide-bore, stiffer (prevent collapse during aspiration) and have a radio-opaque line with a metal tip (whereas feeding NG tubes are finer bore and made of soft silicone)
How can you check for correct positioning of an ET tube?
Inspect for symmetrical chest movements Listen over the epigastrium for gurgling Listen over each lung for air entry Use CO2 monitor CXR (should be just above carina)
List some causes of radial nerve palsy.
VERY HIGH (triceps paralysis + wrist drop + finger drop)
- compression just below brachial plexus (e.g. crutches)
HIGH (wrist drop + finger drop)
- mid-shaft humeral fracture
LOW (finger drop)
- occurring at elbow, only involves posterior interosseous nerve (sensation preserved), fracture or dislocation
What signs in the hand would you see in ulnar nerve palsy?
Partial claw hand (little and ring fingers)
Wasting of hypothenar eminence and dorsal interossei
Loss of sensation in ulnar distribution
What are the principles of dealing with any fracture?
Reduce (closed or open)
Hold (no metal or metal)
Rehabilitate (move, physiotherapy and use)
Outline the post-operative advice given to patients undergoing surgical hernia repair.
Pee before leaving Early mobilisation Provide effective analgesia Avoid constipation (lactulose) Keep the area clean and dry Can bathe immediately Work in 1-2 weeks (6 weeks if heavy lifting)
What electrolyte is an indicator of pancreatitis severity?
Hypocalcaemia
NOTE: hypercalcaemia causes pancreatitis
Why might the pedal pulses of a patient with diabetes be preserved until late in the disease?
Calcification in the walls of the vessel
NOTE: this also causes an abnormally high ABPI
Outline the surgical approaches to managing femoral hernias.
ELECTIVE: Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)
EMERGENCY: McEvedy High approach (approach through inguinal region to allow inspection and resection of non-viable bowel, then herniotomy/herniorrhaphy)
What are the two different techniques of breast reconstruction?
Implants
Myocutaneous flap
List some operations that may require a midline laparotomy.
EMERGENCY: perforated ulcer, trauma, ruptured AAA
ELECTIVE: colectomy, AAA, vascular bypass
NOTE: midline laparotomy offers good access, bloodless lien, minimal nerve/muscle injury but involves a long midline scar and pain
List some indications for using a disposable proctoscope.
Investigation of perianal pathology (e.g. haemorrhoids, low rectal cancer)
Examination or biopsy of anal canal and lower rectum
Therapeutic (banding or sclerotherapy)
List some complications of cannulation.
Haematoma
Malplacement
Blockage
Superficial thrombophlebitis
What is the upper limit of a post-void residual volume in patients under 65 yrs and over 65 yrs?
< 65 yrs = < 50 mL
> 65 yrs = < 100 mL
What are the roles of nerves L4, L5 and S1?
L4: foot inversion and dorsiflexion
L5: great toe dorsiflexion, great toe and medial dorsum sensation
S1: foot eversion and plantar flexion, ankle jerk, little toe and lateral sole sensation
Outline the management principles of osteoarthritis.
Modification of ADLS and risk factors (e.g. weight loss)
Physiotherapy, OT
Analgesia according to WHO ladder (paracetamol –> NSAIDs –> codeine –> morphine)
Steroid injection
Surgery (arthroplasty)
What are the consequences of depressed fractures of the zygoma?
Binocular vision post-facial trauma and pain on opening the jaw
Which veins can be used as access for central venous catheters?
Internal jugular vein
Subclavian vein
Femoral vein
They are inserted using Seldinger technique under local anaesthetic with ultrasound guidance. A CXR should be ordered after insertion to confirm correct placement.
EPONYMOUS OPERATIONS: Pharyngeal pouch repair
Dohlman procedure - minimally invasive endoscopic stapling
What is a PICC line?
Peripherally inserted central catheter
Inserted into a peripheral vein (e.g. cephalic vein) and it is advanced until the tip is in the SVC
List some indications for partial nephrectomy.
Solitary kidney
Bilateral renal masses
Renal impairment
NOTE: radiofrequency ablation and cryotherapy are minimally invasive way of treating small renal cancers
What are the main radiological features of rheumatoid arthritis?
Soft tissue swelling
Periarticular osteopaenia and erosions
Severe deformity
NOTE: fewer patients have deformities now because of adequate treatment
Outline the national bowel cancer screening programme.
Faecal immunochemical test (FIT) - all men and women aged 60-74 every 2 years (can be done at home)
FlexiSig - one-off test for all men and women ageed 55 years (if positive –> full colonoscopy)
