Surgery 5 Flashcards by Akash Srinivasan

What is enhanced recovery after surgery (ERAS) and how is it achieved?

Aims to optimise patients before surgery and reduce the risk of adverse outcomes
PRE-OP: aggressive physiological optimisation, smoking cessation for > 4 weeks, avoid prolonged fast, carb loading
INTRA-OP: short-acting anaesthetics, epidural, minimally invasive, avoid drains and NG tubes
POST-OP: aggressive pain/nausea management, early mobilisation and physiotherapy, early resumption of oral intake, remove drains and catheters ASAP

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Outline the management of meniscal tears.

Symptomatic (analgesia)
Arthroscopic or open partial meniscectomy/meniscal repair

IMPORTANT: the lateral 1/3 of the meniscus has a rich blood supply so tears may heal by themselves or with surgery; the medial 2/3 has a poor blood supply so requires meniscectomy

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Which changes in the skin give rise to a seborrhoeic keratosis?

Hyperkeratosis - thickening of corneum
Acanthosis - thickening of spinosum
Hyperplasia of basal cells

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List the special tests used in a shoulder exam and state the anatomical structure that is being tested.

Jobe’s empty can test: supraspinatus
Forced external rotation of shoulder with elbow at 90 degrees: infraspinatus + teres minor
Gerber’s lift off: subscapularis
Scarf test: acromioclavicular joint dysfunction
Hawkin’s test: impingement
Apprehension test: glenohumeral joint instability

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Which investigation should be requested in suspected renal tract cancer?

Renal tract ultrasound

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List some differentials for RIF masses.

Transplanted kidney 
Caecal cancer 
Appendix mass 
Incisional hernia 
Ovarian tumour/fibroid uterus 
Ectopic kidney 
Iliac artery aneurysm

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What adjacent structures can be damaged during a fracture?

Nerves
Vessels
Ligaments
Tendons

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List some different types of bypass surgery for chronic limb ischaemia.

Anatomical: femoral-popliteal, femoral-distal, aorto-bifemoral
Extra-Anatomical: axillo-fem, fem-fem crossover

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What are the two main techniques used for hip replacement? Describe them.

Posterior Approach: involves reflecting the short external rotators, good access, higher dislocation rate, sciatic nerve injury (footdrop)
Anterolateral Approach: incision over greater trochanter dividing fascia lata, abductors are reflected, lower dislocation risk, superior gluteal nerve injury (Trendelenburg gait)

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What features of a fracture can be described from a plain X-ray?

Location (which bone) 
Pieces (simple, multifragmentary?)
Pattern (transverse, oblique, spiral)
Displaced/undisplaced (speaking about the distal end)
Translated/angulated 
Plane of radiograph

NOTE: translated means lateral movement of the fracture’ (lateral, medial, anterior, posterior) and angulation is rotation of the fracture component (varus or valgus)

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What are the boundaries of Hesselbach’s triangle?

Medial: rectus abdominis muscle
Lateral: inferior epigastric artery
Inferior: inguinal ligament

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List some types of non-absorbable suture.

Silk (used to secure drains)
Prolene (skin wounds and arterial anastomosis)
Ethilon (skin wounds)
Metal (skin wounds, sternotomy closure)

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What does limited active movement but normal passive movement suggest?

Either a muscular problem (e.g. tendon rupture) or an innervation issue

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List some contraindications for IV urography.

Contrast allergy 
Renal impairment 
Pregnancy 
Severe asthma 
Metformin

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List some causes of thoracic outflow obstruction.

Cervical rib
Clavicle fracture
Pathological enlargement of 1st rib

NOTE: DDx - Raynaud’s, axillary vein thrombosis, cervical spondylosis, Pancoast tumour

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Describe the examination features of a sebaceous cyst.

Occur at sites of hair growth (e.g. scalp, face, neck, chest)
Central punctum
Firm, smooth and intradermal

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List some differentials for RUQ masses.

Hepatomegaly
Hepatic mass (e.g. cyst)
Gallbladder
Right kidney

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When should the COCP be stopped prior to elective surgery?

4 weeks

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What is a trigger finger?

Flexion of middle or ring finger
Caused by tendon nodule catching on the proximal side of the tendon sheath (usually FDS tendon)

NOTE: managed with steroid injections or sheath incision

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At what vertebral levels do the coeliac trunk, SMA and IMA branch off the aorta?

Coeliac trunk: L1
SMA: L1
Renal arteries: L2
IMA: L3
Bifurcation of aorta: L4/L5

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List some gastrointestinal causes of clubbing.

Cirrhosis
Crohn’s disease
Coeliac disease
GI lymphoma

Describe two types of urostomy.

Ileal conduit (incontinent) - ureters are attached to a portion of resected ileum which is exteriorised as a stoma (remaining ileum is re-anastomosed)

Indiana pouch (continent) - pouch created from 2 feet of resected ascending colon and portion of ileum including the ileocaecal valve. Ureters anastomosed to colonic end and ileal end is exteriorised. IC valve prevents leak, patient self-catheterises to drain into a pouch.

NOTE: there are two types of ileal conduit - Bricker (2 ureters straight into the ileal conduit) and Wallace (2 ureters joined together before entering the ileal conduit)

Outline the management of arterial ulcers.

Pain management 
Risk factor modification 
Clopidogrel
IV prostaglandins 
Chemical lumbar sympathectomy

How can you confirm the location of an NG tube?

Aspirate gastric contents and check pH (< 5.5)
Insufflate air and auscultate for bubbling (do not do this in bowel obstruction)
CXR - tip below the diaphragm

NOTE: contraindicated in basal skull fracture

List some indications for using an oropharyngeal or nasopharyngeal airway.

Airway adjunct in patients with impaired consciousness

EPONYMOUS OPERATIONS: varicose veins

Trendelenberg - saphenofemoral junction ligation | Cockett - perforator ligation

List some complications of surgical management of varicose veins.

EARLY: haematoma, wound sepsis, nerve damage (long saphenous) LATE: superficial thrombophlebitis, DVT, recurrence

List some complications of pancreatitis.

EARLY: hypovolaemia (shock), SIRS, hyperglycaemia, hypocalcaemia LATE: pseudocyst, pancreatic necrosis, infection, abscess, bleeding, thrombosis, fistula

How can varicose veins be treated?

CONSERVATIVE: weight loss, avoid prolonged standing, compression stockings, emollients Injection sclerotherapy Endovernous laser or radiofrequency ablation Surgery

Which operations are likely to require an end colostomy?

Permanent: AP resection (colon cancer) Temporary: Hartmann's (diverticulitis)

How can a seminoma be distinguished from a teratoma?

Seminoma: usually normal markers Teratoma: high AFP + high bhCG NOTE: seminomas are treated with radiotherapy of para-aortic nodes and combination chemo (BEP); teratomas are treated with combination chemo (BEP) alone NOTE: BEP = bleomycin, etoposide, cisPlatin

What causes Trendelenburg sign?

Weakness of hip abductors (mainly gluteus medius) | May be caused by superior gluteal nerve injury

List some causes of spider naevi.

More than 3 is abnormal Chronic liver disease Pregnancy COCP

Which Foley catheters tend to be used in men and women?

Male: 16-18 French Female: 12-14 French NOTE: French is the diameter of the catheter in mm

What is the main reason for using external fixation?

When there is extensive soft tissue injury (open fracture) or a complex periarticular fracture You don't want to put hardware in if there's no soft tissue or if the tissue is contaminated - wait for inflammatory response to stop

What are the pros and cons of an anterolateral approach to hip replacement as opposed to a posterior approach?

Anterolateral: lower dislocation rate but higher risk of trendelenberg gait Posterior: higher dislocation rate but you don't go through abductors so you do not get a trendelenberg gait

Outline the management of compartment syndrome.

Elevate and remove any bandages/cast | Fasciotomy

Describe the tourniquet test/Trendelenberg test for venous insufficiency.

Position the patient supine, elevate their legs and milk their veins Apply the tourniquet as high up as possible or compress the SFJ Stand the patient CONTROLLED: incompetence above tourniquet, release tourniquet to confirm filling UNCONTROLLED: incompetence below tourniquet

List some differentials for posterior neck lumps.

Lymph nodes Cervical rib Cystic hygroma Pharyngeal pouch

What are the main indications for adenoidectomy?

OSA in children Glue ear with failed grommets Malignancy

What is a Galeazzi fracture?

Fracture of radial shaft between middle and distal 1/3 + dislocation of distal radio-ulnar joint

What is the Parkland formula for fluid resuscitation in burns?

Fluid resuscitation in the first 24 hours = % surface area x weight x 4 mL

List some complications of Nissen fundoplication.

Gas-bloat syndrome (can't belch or vomit) | Dysphagia (if wrap around is too tight)

What are the features of critical limb ischaemia?

Ankle artery pressure < 40 mm Hg Rest pain or tissue loss Symptoms for > 2 weeks NOTE: classified using Fontaine classification (1 - asymptomatic, 2 - claudication, 3 - rest pain, 4 - ulceration and gangrene)

What are some key differences between hypertrophic scars and keloids?

Hypertrophic scars are confined to the wound margins and appears soon after injury and regress spontaneously Keloids extend beyond the wound margin, appear months after injury and continue to grow

Outline the criteria for having a tonsillectomy.

Clinically significant tonsillitis 7 or more times for 1 year, 5 or more times for 2 years or 3 or more times for 3 years

What are the surgical management options for BPH?

TURP HoLEP (holmium laser enucleation of the prostate) Urolift (involves stapling back the lateral lobes of the prostate - lower risk of retrograde ejaculation so better for younger people) NOTE: HoLEP is used for very big prostates

Outline the management of Raynaud's phenomenon.

Wear gloves and avoid cold Stop smoking CCBs (e.g. nifedipine) IV prostacyclin

What is the normal range of flexion in a knee joint?

0-140 degree

List some complications of stomas.

``` EARLY - haemorrhage - ischaemia - high output (hypokalaemia - use loperamide/codeine) - parastomal abscess - stoma retraction DELAYED - parastomal hernia - obstruction (adhesions, herniation) - dermatitis - stoma prolapse - stenosis or stricture - fistulae - psychosexual dysfunction ```