Surgery 5 Flashcards
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
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
Which changes in the skin give rise to a seborrhoeic keratosis?
Hyperkeratosis - thickening of corneum
Acanthosis - thickening of spinosum
Hyperplasia of basal cells
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
Which investigation should be requested in suspected renal tract cancer?
Renal tract ultrasound
List some differentials for RIF masses.
Transplanted kidney Caecal cancer Appendix mass Incisional hernia Ovarian tumour/fibroid uterus Ectopic kidney Iliac artery aneurysm
What adjacent structures can be damaged during a fracture?
Nerves
Vessels
Ligaments
Tendons
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
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)
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)
What are the boundaries of Hesselbach’s triangle?
Medial: rectus abdominis muscle
Lateral: inferior epigastric artery
Inferior: inguinal ligament
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)
What does limited active movement but normal passive movement suggest?
Either a muscular problem (e.g. tendon rupture) or an innervation issue
List some contraindications for IV urography.
Contrast allergy Renal impairment Pregnancy Severe asthma Metformin
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
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
List some differentials for RUQ masses.
Hepatomegaly
Hepatic mass (e.g. cyst)
Gallbladder
Right kidney
When should the COCP be stopped prior to elective surgery?
4 weeks
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
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
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
