Surgery Flashcards
What should be assessed when looking at a patients airway in the ABCDE approach?
Look: Signs of obvious airway obstruction e.g. vomit, Chest wall excursion, See-saw breathing
Feel: Breath
Listen: Stridor, Gurgling
What can be done to treat if a patient is having a problem with their airway?
Head tilt and chin lift
Jaw thrust
Adjuncts: Guedel airway, Nasopharyngeal airway, Laryngeal mask airway
Definitive airway
What is the definition of a definitive airway?
Requires a tube present in trachea with cuff inflated, tube connected to some form of oxygen enriched assisted ventilation and airway secured with tape
What are the different types of definitive airway?
Endotracheal (ET) tube Nasotracheal tube Surgical airway (tracheostomy or cricothyroidotomy)
What can you look for to assess a patient’s breathing?
Central/peripheral cyanosis Chest wall deformity Abnormal chest expansion: Asymmetry, Flail, See-saw breathing Tracheal tug Accessory muscle usage
What can you feel for to assess a patient’s breathing?
Asymmetric chest expansion
Deviated trachea
Displaced apex beat
Percussion
What can you listen for to assess a patient’s breathing?
Auscultation: Absent breath sounds, Crackles, Wheeze
What can you measure to assess a patient’s breathing?
Respiratory rate
O2 saturations
ABG
CXR
What can you measure to assess a patient’s circulation?
Heart rate Capillary refill Blood pressure Temperature Urine output: 0.5 ml/kg/hr
What are the different types of shock?
Hypovolaemic
Cardiogenic
Distributive: anaphylactic, septic, neurogenic
Obstructive
What are signs of hypovolaemic shock?
Tachycardia
Tachypnoea
Cool peripheries
Altered mental state
Why should you not use BP as a measure of hypovolaemic shock?
BP is a reasonably late change so look for urine output/HR changes first. Can have lost 2L blood before any change
What is the difference between neurogenic and spinal shock?
Neurogenic: lose sympathetic tone
Spinal: temporary spinal paralysis
What is the SIRS criteria?
2 or more of the following: HR: 90 or above RR: over 20 or PaCO2< 4.3kPa Temp: below 36 or above 38 WCC: <4x109 cells/L OR >12x109 cells/L OR >10% immature neutrophils
What is lactic acid and what is it an effective measure of?
Formed when glucose is broken down, then oxidised to pyruvate
Reduces NADH to NAD+, which enables respiration to continue
When cells are in a hypoxic state, they are forced to metabolise glucose anaerobically. Leads to a build up of lactic acid
Good indicator of tissue perfusion/hypoxia
What is the enhanced recovery after surgery strategy?
Combination of evidence-based peri-operative strategies which work synergistically to expedite recover after surgery
What are pre operative recommendations for enhanced recovery after surgery?
Pre op counselling and training
Curtailed fast: 6h solids, 2h clear liquids, pre op carb loading
Avoidance of mechanical bowel prep
DVT prophylaxis using LMWH
Single dose of prophylactic abx covering aerobic and anaerobic pathogens
What are peri-operative recommendations for enhanced recovery after surgery?
High (80%) oxygen concentration in peri operative period
Prevention of hypothermia
Goal directed intra operative fluid therapy
Preferable use of short and transverse incisions for open surgery
Avoidance of post op drains and NG tubes
Short duration of epidural analgesia and local blocks
What are post operative recommendations for enhanced recovery after surgery?
Avoidance of opiates, use of paracetamol and NDSAIDs
Early commencement of post op diet
Early and structured post op mobilisation
Administration of restricted amounts of IV fluid
Regular audit
What factors are on the surgical safety checklist when patient signs in?
Patient confirms identity, site, procedure, consent
Site marked
Anaesthesia safety check completed
Pulse oximeter on patient and functioning
Allergies?
Airway/aspiration risk?
Risk of over 500ml blood loss? (7ml/kg in child)
What factors are on the surgical safety checklist before any skin incision?
Confirm all team members have introduced themselves by name and role
Surgeon, anaesthetist and nurse verbally confirm patient, site and procedure
Anticipated critical surgical events: operative duration, expected blood loss
Anticipated critical anaesthetic events: patient specific concerns
Anticipated critical nursing events: sterility confirmed, equipment issues
Abx prophylaxis been given in last 60 mins?
Is essential imaging displayed?
What factors are on the surgical safety checklist when patient signs out?
Nurse verbally confirms: procedure, instrument needle and sponge counts are correct, how specimens are labelled, whether there are any equipment problems to be addressed
Surgeon, anaesthetist and nurse review key concerns for recovery and management of this patient
What details should be included on a surgical consent form?
Procedure, side, location (joint)
How should limb marking for surgery be carried out?
Clear arrow
Indelible ink
Not at site of incision
What are benefits of minimally invasive surgery?
Increased safety: less blood loss, less trauma, less pain
Faster recovery
Decreased length of hospital stay
Decreased scarring
What are problems with minimally invasive surgery?
Depth of Field Limited view 2-D vision Paradoxical movement: fulcrum effect Long, rigid instruments: Amplify tremor, fewer degrees of freedom
What different forms of robotic surgery are there?
Computer Assisted Surgery: surgeon generally holds tools and computers might help in planning and positioning
Robotic surgery: Robots will hold tools, providing greater accuracy
and precision
Telerobotics: area of robotics concerned with the control of robots from a distance
What are benefits of robotic surgery?
3D vision Surgeon-controlled camera Articulated working tips – 7 degrees of Freedom Ergonomic Tremor abolition Motion Scaling
What are some problems with single incision laparoscopic surgery? And how can you overcome these?
Clutter of hands
Inadequate triangulation
Using instruments of different length
Using controllably flexible instruments
What is a NOTES procedure?
Natural Orifice transluminal endoscopic surgery
What are benefits of NOTES procedures?
No scars No wound infection Less pain No hernias No internal adhesions Can perform surgery under sedation
What are advantages and disadvantages of surgical simulation?
Advantages: Safe, Flexible, Objective feedback
Disadvantages: cost, integration into curriculum, assessment validity
What post op complications are we aiming to minimise by improving surgical safety?
Pain
Confusion
Venous-thromboembolism
Surgical site infection
What is the most common post op complication?
Surgical site infection
What is the most common hospital acquired infection?
Surgical site infection
On average how many more days in hospital does a post op surgical site infection cause?
7
How much is death rate increased by a post op surgical site infection?
2-11 times
What strategies are used to prevent post op surgical site infection?
Antimicrobial prophylaxis, Discontinue as soon as possible Do not remove hair Control blood glucose Maintain normothermia Optimise oxygenation Alcohol based skin prep
What is an acute abdomen?
Rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology that requires urgent surgical intervention
What questions are important when taking a Hx from a patient with an acute abdomen?
Pain: SQITAS Vomiting Bowels last open Urinary symptoms Bleeding Weight loss Anorexia Fevers Female: LMP, PV discharge, pregnant?
What aspects of the examination are important in a patient presenting with an acute abdomen?
Stable (Full examination) vs unstable (ABCDE)
End of bed inspection (jaundice, cachectic, lying still/writhing, vomit bowl, cigarettes)
Hands, face, lymph nodes, abdomen
Look, palpate, percuss, auscultate
Complete with hernial orifices and PR (with chaperone)
What can be inflammatory/infective causes of an acute abdomen?
Diverticulitis Pyelonephritis Appendicitis Cholecystitis Pancreatitis
What is a diverticulum?
Out-pouching of the colonic wall typically found on the sigmoid and descending colon
How will diverticulitis typically present?
Left iliac fossa pain
Fever
How might a perforated diverticulum which has formed a fistula present?
Recurrent UTI, PV brown discharge
How does appendicitis typically present? What sign might you look for?
Typically presents with migratory RIF pain
Tenderness and guarding in RIF
Anorexia
Rovsing’s sign: pressure in LIF increases pain in RIF due to bowel pushing onto inflamed appendix
Psoas sign: flexion of right leg causes irritation of peritoneum causing pain
What symptoms is a person with pyelonephritis likely to present with?
Flank pain
Urinary symptoms
Pyrexia
What investigation results would you get in a patient with pyelonephritis?
Raised WCC and CRP
Urine dip positive for leucocytes and nitrites
What is the management for a patient with pyelonephritis?
Treat with broad spectrum antibiotics and ensure renal function is not impaired. May require US KUB
What biliary problems could a patient have who is presenting with RUQ pain?
Biliary colic
Choledocholithiasis
Cholecystitis
Cholangitis
What is biliary colic?
Pain in the RUQ caused by gallstones
Stones become temporarily stuck in the cystic duct
What is choledocholithiasis?
Stone becomes stuck in the biliary tree
Causing pain without the presence of infection
How does Cholecystitis present?
Pain in the RUQ
Often present with fever
What would you see on USS of a patient with Cholecystitis?
Thick walled gallbladder
How is Cholecystitis managed?
Abx and IV fluids
What is charcots triad of ascending cholangitis?
Fever
Jaundice
Abdominal pain
What is the management for ascending cholangitis?
Abx, IVI and ERCP
Cholecystectomy when the condition has settled
What are some causes of bowel obstruction?
Intraluminal: foreign body, constipation, bezoar, gallstone
Intramural: Ca, stricture, volvulus, intersusseption
Extramural: Hernia, adhesions, Ca
If vomiting was the first symptom of a patient presenting with bowel obstruction, where is the obstruction likely to be?
Small bowel
How can you recognise a small bowel obstruction on an X-ray?
Centrally located multiple dilated loops of gas filled bowel
Valvulae conniventes - lines all the way across
Thin bowel wall
What vascular pathologies can present as an acute abdomen?
Mesenteric ischaemia
Ischaemic colitis
Ruptured AAA
What lactate result suggests vascular compromise in an acute abdomen setting?
Can be raised in biliary colic, but if greater than 7, likely to be vascular compromise
When looking for a perforation, what imaging modalities can be used? And what do you see?
Look for pneumoperitoneum on CXR
Lateral decubitus is more sensitive
CT is best
What are some medical causes of an acute abdomen?
Lower lobe pneumonia
Inferior MI
DKA
Porphyria
What investigations should be done for an acute abdomen?
Observations and simple bedside tests
Bloods: FBC, U and Es, CRP, Amylase, Clotting, G&S/X-match, VBG/ABG
Imaging: xray (erect chest, abdominal), USS, CT KUB and CT abdo/pelvis
Diagnostic laparoscopy
What are management steps for an acute abdomen?
ABCDE approach
IV access with bloods
Patient is likely to require fluid resuscitation not just maintenance fluids
Urinary catheter
Analgaesia according to WHO analgaesia ladder
Antiemetic
Obstruction or significant vomiting – NG tube
Abx
Consider NBM
SENIOR REVIEW
What is McBurney’s point?
1/3 distance from ASIS to umbilicus
Most common location of appendix
What would be your differentials for a 20 year old female with right iliac fossa pain?
Appendicitis Ectopic pregnancy Ruptured/torted ovarian cyst Crohn's disease Meckels diverticulum
What is the most sensitive marker for pancreatitis?
Lipase
What are some causes of pancreatitis?
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hypercalcaemia/hyperlipidaemia ERCP Drugs (Azothiaprine, simvastatin)
What is the Glasgow score for pancreatitis severity?
Score of 3 or more - high risk of severe pancreatitis (death, surgery or complications) PaO2 <8kPa Age >55 Neutrophils – WCC >15 Calcium <2.0 Renal – Urea >16 Enzymes – AST/ALT >200 or LDH >600 Albumin <32 Sugar – Glucose >10
How do you manage pancreatitis?
IVI
UO monitoring
Analgaesia
What would be your differential list for a ruptured AAA?
Ruptured AAA Inferior MI Appendicitis Diverticulitis Pancreatitis Gallstones Large bowel obstruction Small bowel obstruction Peptic ulcer disease
What is the management for a ruptured AAA?
Informing senior and vascular consultant early
Establishing 2 x large bore access in ACFs
Full set of bloods including xmatch for 4-6 units
Consider major haemorrhage protocol
Careful fluid resuscitation (target 90-100 sys BP)
Theatre
What are the gold standard best practice guidelines for patients with neck of femur fractures?
Time to surgery within 36h from arrival in ED or time of diagnosis to start of anaesthesia if an inpatient
Admitted under joint care of geriatrician and orthopaedic consultant
Admitted under assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthetics
Assessed by geriatrician in post op period within 72 h of admission
Post op geriatrician directed MDT rehab team
Fracture prevention assessments - falls and bone health
What are the criteria for recommendation for liver transplant?
Arterial pH <7.3
Arterial lactate >3 after fluid rehydration
Within 24h: PT >100, creatinine >300, grade III/IV encephalopathy
What are extrahepatic/obstructive causes of jaundice?
Bile duct obstruction
Pancreatic cancer
Bile duct carcinoma
Gall stones
What are hepatic causes of jaundice?
Hepatitis EBV Metastatic disease Primary hepatoma Alcoholic cirrhosis Primary biliary cirrhosis Autoimmune hepatitis
What are the causes of abdominal pain in nephrotic syndrome?
Peritonitis
Renal vein thrombosis
Hypovolaemia
What bugs can commonly cause septic arthritis?
Staphylococci
Streptococci
Gonococci - young sexually active
Pseudomonas - immunocompromised, IVDU
What is the clinical presentation of septic arthritis?
Pain
Pseudoparalysis
Pyrexia
Which joints are most commonly affected in septic arthritis?
Knee - 50%
Hip - 20%
What are your important differential diagnoses for septic arthritis?
Inflammatory arthritis Crystal arthropathy Reactive arthritis Osteoarthritis Trauma
What is Kochers criteria for septic arthritis?
Pyrexia >38.5 °C Inability to weight bear WCC >12.5 ESR >40 If 1 present, 1% chance If 2 present, 40% chance If 3 present, 93% chance If 4 present, 99% chance
What investigations would you do for septic arthritis?
Bloods (WBC, ESR, CRP, cultures)
Routine imaging (plain films, ultrasound)
Specialised imaging (CT, MRI, radionuclide)
Gold Standard is joint aspirate for microscopy and culture + tissue samples if possible
Do NOT give antibiotics unless patient in septic shock
What do you look for on a joint aspiration in septic arthritis?
Microscopy and Gram stain (only 60% positive)
WCC >50,000/microL, 75% polymorphonuclear leukocytes
What is the general management for septic arthritis?
Diagnosis (no antibiotics yet) Surgery for debridement IV antibiotics Oral antibiotics Follow up
What surgery should be done in septic arthritis?
Arthroscopic or open washout of native joint infections
Prosthetic joint infections, artificial joint may be preserved in early infections but is usually revised in late infection
What role do antibiotics have in septic arthritis?
NOT until joint has been aspirated unless patient in septic shock
Initially broad spectrum to cover common organisms then adjust according to culture and sensitivities
IV until patient clinically and biochemically improving then prolonged course of oral antibiotics (4 to 6 weeks commonly recommended)
Consider dose and concentration in bone/joint
Consider poly antimicrobial therapy
Close liaison with medical microbiology
Multi-disciplinary care
Long-term antibiotic suppression in certain cases
What is compartment syndrome?
Increased pressure within a closed fascial compartment leading to impaired tissue perfusion
Which compartments are the most commonly affected in compartment syndrome?
Lower leg
What percent of tibial fractures are complicated by compartment syndrome?
Between 1% and 9%
How is the diagnosis of compartment syndrome made?
Clinical diagnosis
Pain most important initial symptom, exacerbated on passive stretch of the muscles that traverse the affected compartment
Paraesthesia, Pallor, Pulselessness and Paralysis are late features
How do you diagnose compartment syndrome in those who are comatose or who cannot communicate pain?
Confirmed by compartment pressure monitoring
Pressure of 30mmHg or within 20mmHg of diastolic BP
What is the management of compartment syndrome?
Release all casts, splints and dressings down to skin
Elevate limb
Analgesia
Keep NBM but don’t delay surgery for fasting
Emergency Fasciotomy (full, open release of all compartments in the limb segment affected)
What is an open fracture?
A broken bone that is in communication through the skin with the environment
What is the golden hour in polytrauma?
Highest likelihood that prompt medical treatment in this time will prevent death
What is the gustilo classification of open fractures?
I Low energy, wound less than 1 cm
II Wound greater than 1 cm with moderate soft tissue damage
III High energy wound greater than 1 cm with extensive soft tissue damage
IIIA Adequate soft tissue cover
IIIB Inadequate soft tissue cover
IIIC Associated with arterial injury
What is the management framework for severe open fractures?
Boast 4
IV abx ASAP, in 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy
Vascular and neuro status of limb assessed, repeated at intervals, particularly after reduction of fractures or application of splints
Vascular impairment requires immediate surgery and restoration of circulation using shunts, ideally in 3-4 hours, with a max acceptable delay of 6 hours warm ischaemia
Compartment syndrome - immediate surgery, with 4 compartment decompression via 2 incisions
Urgent surgery in some multiply injured patients with open fractures or if wound is heavily contaminated by marine, agricultural or sewage matter
Combined plan for management of soft tissues and bone by plastics and orthopods
Wound handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation
Limb, including knee and ankle, is splinted
Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for early transfer of patient to an appropriate specialist centre
Primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in non-specialist centre if patient cannot be transferred safely
Wound, soft tissue and bone excision (debridement) performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of injury unless there is marine, agricultural or sewage contamination. 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) administered at wound excision, continued for 72 hours or definitive wound closure
If definitive skeletal and soft tissue reconstruction is not to be undertaken in single stage, vacuum foam dressing or antibiotic bead pouch applied until definitive surgery
Definitive skeletal stabilisation and wound cover are achieved within 72 hours and should not exceed 7 days
What is the difference between subluxation, dislocation and a fracture dislocation?
Subluxation – incomplete luxation or dislocation; although a
relationship is altered, contact between joint surfaces remains
Dislocation – abnormal separation in the joint, where two or more bones meet
Fracture dislocation - fracture of a bone near a joint, also involving
dislocation
What are potential problems with joint dislocation?
Joint damage AVN Soft tissue damage Pain Neuro –vascular complications
Where do fracture blisters most commonly occur?
Ankle, wrist elbow and foot
Areas where skin adheres tightly to bone with little subcutaneous fat cushioning
What are two orthopaedic approaches to polytrauma patients?
Damage control orthopaedics: acute phase - life saving procedures, second phase - control haemorrhage, temp stabilisation of major fractures, manage soft tissue injuries, third phase - monitoring in ICU, fourth phase - definitive fracture fixation
Early total care: definitive fixation of all fractures in one trip to theatre
Why are hip fractures important?
Common Vulnerable patients High mortality Financial burden Social burden
Why do we try and operate early on hip fractures?
Pain relief
Allow early mobilisation and discharge
What is the alternative to surgery for a hip fracture and what problems does this cause?
Bed rest / traction: Pressure sores, Pneumonia, Thromboembolism, UTI, Death
What is the national hip fracture database best practice tariff criteria for hip fractures?
Admitted to orthopaedic ward within 4 hours
Operation within 36 hours from arrival to ED or time of diagnosis if inpatient to start of anaesthesia
Admitted under joint care of orthopaedic surgeon and geriatrician
Geriatrician perioperative assessment review within 72 hours
Mental state assessment - 2 AMT test scores, before and after surgery
Falls assessment
Osteoporosis treatment
Which 4Ms are important in the history of a patient with a suspected hip fracture?
Mechanism
Medical History
Mobility
AccoMModation
What examination findings/underlying problems will you particularly look for in a patient with a suspected hip fracture?
Respiratory: Pneumonia, COPD
Cardiovascular: Murmur, Dehydrated
Neuro: Stroke, AMTS
Musculoskeletal: NV intact, Open #
What bedside tests would you do for a patient with a suspected hip fracture?
ECG
Urine dip
BM
What bloods would you do for a patient with a suspected hip fracture?
FBC U and Es Clotting Group and Save Bone Profile
What imaging or special tests might you send a patient for who has a suspected hip fracture?
CXR
Echo
Skeletal x-rays
What interventions would you do for a patient with a suspected hip fracture?
IV fluids Analgesia: Beware opioids but do not undertreat pain, Immobilisation, Nerve block Laxatives DVT prophylaxis Antibiotics Surgery
What landmark determines whether a hip fracture is intra or extracapsular?
Intertrochanteric line
Proximal to this is intracapsular: subcapital, transcervical, basicervical
Extracapsular: intertrochanteric and subtrochanteric
If an intracapsular neck of femur fracture is un-displaced, what is your management?
Fixation
What are pros and cons of fixation in intracapsular NOF fractures?
Pros: quick, non invasive, preserves own hip
Cons: 25% risk AVN, 15% risk non union
How does a patient’s age and function affect your management in a displaced intracapsular neck of femur fracture?
Young (<55): fixation
Old and poor function: Hemiarthoplasty
Old and good function: total hip replacement
What are differences between hemiarthroplasty and total hip replacements in terms of pros and cons?
Hemi: Smaller operation, Acetabular wear
THR: Bigger procedure, Dislocation
What is your management for an intertrochanteric hip fracture?
Dynamic hip screw
What is your management for a subtrochanteric hip fracture?
Intermedullary nail
What line will be disrupted in an intracapsular neck of femur fracture?
Shentons line
Inferior border of superior pubic ramus along inferomedial border of neck of femur
What childhood condition could be indicated by disruption of shentons line with no history of trauma?
Developmental dysplasia of the hip
What is the garden classification of hip fractures?
I: incomplete or impacted bone injury with valgus angulation of distal component
II: complete but undisplaced
III: partially displaced
IV: complete, totally displaced
At what diameter is the indication for surgery on an asymptomatic abdominal aortic aneurysm?
5.5cm and above
Which bone fracture can lead to fat embolism?
Long bone
Pelvic
What is the classic presentation of fat embolism?
Asymptomatic interval after long bone/pelvic fracture
24-48h later - pulmonary and neurological manifestations with petechial haemorrhages
Which analgesic produces prompt but short lasting analgesia, is less constipating than morphine but even at high doses is a less potent analgesic?
Pethidine
What are indications for pethidine use?
Moderate to severe pain
Obstetric analgesia
Peri operative analgesia
What local side effects may occur from a fentanyl patch?
Rash
Erythema
Itching
Which analgesic is a WHO class 3 analgesic which produces analgesia by an opioid effect but also an enhancement of serotonin and andrengeric pathways?
Tramadol
What are some side effects of Tramadol?
Nausea Hypotension Anaphylaxis Hallucinations Confusion
A 60 year old patient who has a history of exertional calf pain presents with acute abdominal pain which radiates through to his back. On examination his pulse is 110 BP 90/60. What is the immediate management?
IV access and fluids - urgent but limited, over treatment of ruptured AAA can cause more bleeding - keep BP around 100 systolic and save blood for operation
Stabilise his condition prior to confirmation of diagnosis/urgent laparotomy
A 74 year old man has undergone an elective open abdominal aortic aneurysm repair. On the sixth post operative day he has not opened his bowels or passed flatus. On examination, he has a distended abdomen with no audible bowel sounds. What is likely going on?
Postoperative ileus
What exacerbates postoperative ileus?
Excessive bowel handling
Prolonged procedures
A 71 year old woman has undergone an elective right hemicolectomy for a Dukes B caecal tumour. On the fifth post operative day she has developed abdominal pain and a low grade pyrexia. On examination she is tender on the right side of the abdomen. Her white cell count has risen to 20. What is the likely diagnosis?
Anastomotic leak
What are reasons for anastomotic leaks?
Technical reasons: poor operative technique, ischaemia
Systemic reasons: hypotension, anaemia
If a renal calculus is confirmed in a patient, levels of what things should be checked?
Uric acid
Calcium
PTH
How might you confirm a diagnosis of a renal calculus?
IV pyelogram
CT KUB
What are important things to check in a patient with pyelonephritis?
Renal function - U and Es
USS to examine for dilated draining system which would require urgent nephrostomy for decompression
What can be a complication of mastitis which may result in a swinging fever?
Breast abscess
What is the common infective organism in mastitis/breast abscess?
Staphylococcus aureus
A 46 year old woman presents to clinic experiencing a painful right nipple. The retroareolar area is erythematous and there is nipple retraction. You also notice a thick blood stained green nipple discharge. On palpation the woman feels tenderness originating from behind the nipple. There is no lymphadenopathy. What is the likely diagnosis?
Duct ectasia
What is duct ectasia?
Widening of the major ducts just behind the nipple
What is a major differential diagnosis for duct ectasia which has caused nipple retraction?
Carcinoma
What is a galactocoele?
Smooth fluctuant lump in a lactating woman
Lactiferous duct becomes plugged with thick milk protein
How does trauma to the breast lead to fat necrosis?
Haemorrhage
Cystic degeneration
Calcification of cysts leading to firm lump tethered to skin
What are differentials for a femoral hernia?
Cyst of canal of nuck
Ectopic testis
Psoas abscess
Saphena varix
A 24 year old man attends ED with a cold and painful right forearm. He is an IVDU. The pain has been getting worse for 24h. He has injection site marks around his brachial artery. On examination the hand is cold and paralysed with ischaemic areas at the tips of the digits. The radial and ulnar pulses are palpable. What is the first line in management? Why?
Heparinisation
It is likely that they have embolised the digital arteries with bulking agent mixed with his heroin
Too distal for embolectomy so heparinisation whilst ensuring adequate hydration to prevent myoglobinuria
What is the gold standard test for a DVT?
Venogram
How do you treat DVT?
Anticoagulation
Initially heparin followed by warfarin due to the potential risk of embolisation
In which patients are paraumbilical hernias most commonly seen?
Obese, multiparous middle aged women
Where is the weakness in a paraumbilical hernia?
Linea alba
Why do patients with paraumbilical hernias often have nausea?
Traction on the omentum entangled in the hernia sac
Why should paraumbilical hernias be repaired surgically?
Narrow neck so significant risk of irreducibility and strangulation
What are important diagnoses to consider in a patient with pain in the right iliac fossa?
Acute appendicitis UTI Right renal calculi Crohns ileitis PID Ruptured ectopic pregnancy
A 76 year old man underwent emergency repair of an abdominal aortic aneurysm five days ago. He has made a good recovery and is mobilising well. He suddenly develops diarrhoea which contains moderate amounts of fresh blood. What is the most important next diagnostic investigation?
CT angiography - aorta
Look for fistula between stent and bowel
What are cardinal features of critical ischaemia?
Ulceration
Gangrene
Foot pain at rest
What is Leriches syndrome? What are the symptoms?
Aortoiliac occlusive disease Blockage of abdominal aorta as it transitions into common iliac arteries Claudication of buttocks and thighs Absent or decreased femoral pulses Erectile dysfunction
What is Buergers disease? What is an important risk factor?
Thomboangitis obliterans
Segmental inflammation and thrombosis of small and medium sized arteries and veins of peripheral limbs
Heavy smoking risk factor
Presents as claudication in feet/hands at rest worse with cold/stress
Numbness, Raynauds, ulceration
What is the Fontaine classification for peripheral artery disease?
1: asymptomatic
2: intermittent claudication
3: ischaemic rest pain
4: ulceration/gangrene (critical ischaemia)
What are normal and abnormal results for ABPI?
Normal 1-1.2
Peripheral artery disease 0.5-0.9
Critical limb ischaemia <0.5
What imaging should you do for peripheral artery disease?
Colour duplex USS first line
MRA/CT angio if considering intervention
What are management options for peripheral artery disease?
Risk modification: quit smoking, treat HTN and hypercholesterolaemia, clopidogrel
Manage claudication: supervised exercise program to increase collateral blood flow, naftidrofuryl oxalate
Conservative fails/ severely affecting QOL/limb threatening: percutaneous transluminal angioplasty, surgical reconstruction
Amputation
In what time frame is surgery required to save the limb in acute limb ischaemia?
Emergency revascularisation surgery required in 4-6h
What may be some reasons for offering a woman a mastectomy rather than a wide local excision for treating breast cancer?
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
What are the criteria for offering post surgical radiotherapy to women with breast cancer?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision to reduce recurrence risk by 2/3
After mastectomy radiotherapy offered for T3-T4 tumours and those with 4 or more positive axillary nodes
Which adjuvant hormone therapy is used in post menopausal women with breast cancer?
Aromatase inhibitors such as anastrozole
What are some important side effects of tamoxifen?
Increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms
In which patients can Trastuzumab not be used? When is it used?
Cannot be used in those with Hx of heart disorders
Used to treat HER2 positive breast cancer
What should be done with regards to oestrogen containing contraceptive pills before elective surgery? What if this isn’t possible/hasn’t been done?
Preferably discontinued (adequate alternative arrangements made) 4 weeks before major elective surgery and all surgery to legs or surgery which involves prolonged immobilisation of a lower limb
Normally recommenced at first menses at least 2 weeks after full mobilisation
Progestogen-only contraceptive may be offered as an alternative and the oestrogen-containing contraceptive restarted after mobilisation, as above
If not possible, e.g. after trauma or patient admitted for elective procedure still on oestrogen-containing contraceptive, thromboprophylaxis (unfractionated or low molecular weight heparin and graduated compression hosiery) is advised
Which surgical patients are at increased risk of DVT?
Surgery greater than 90 minutes at any site
Greater than 60 minutes if procedure involves lower limbs/pelvis
Acute admissions with inflammatory process involving abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
Thrombophilia
Previous thrombosis
BMI >30
Taking hormone replacement therapy or contraceptive pill
Varicose veins with phlebitis
What are options for mechanical thromboprophylaxis in surgical patients?
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices
How can you reverse the effects of unfractioned heparin?
Protamine sulphate
What is Dabigatran?
Orally administered direct thrombin inhibitor
What are medical indications for circumcision?
Phimosis
Recurrent balanitis
Balanitis xerotica obliterans
Paraphimosis
What are benefits of circumcision?
Reduces risk of penile cancer
Reduces risk of UTI
Reduces risk of acquiring sexually transmitted infections including HIV
Which types of renal stones are radio-lucent and therefore might not show up on an X-ray?
Urate stones
Cystine stones- semi opaque
Xanthine stones
Which infections predispose to the formation of staghorn calculi?
Ureaplasma urealyticum and Proteus infections
What is a staghorn calculi?
In renal pelvis and extend into at least 2 calyces
The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area. There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?
Refer to paediatric surgery for repair due to risk of incarceration
What is a spigelian hernia?
Lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (aponeurotic layer between rectus abdominis muscle medially and semilunar line laterally)
What is a richter hernia?
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
What are risk factors for abdominal wall hernias?
Obesity
Ascites
Increasing age
Surgical wounds
What is a normal aortic size and what is considered aneusymal?
After age of 50 years normal diameter of infrarenal aorta is 1.5cm in females and 1.7cm in males
Diameters of 3cm and greater, are considered aneurysmal
How does Paget’s disease of the nipple differ from eczema?
Paget’s involves the nipple primarily and only latterly spreads to the areolar, the opposite occurs in eczema
What is Riglers sign (double wall sign)? And what does it show is present?
Presence of air on both sides of the intestine on an abdominal X-ray
Shows pneumoperitoneum suggesting perforation
However, a false double wall sign can result from two loops of bowel being in contact with one another
Which medical patients are at risk of DVT?
Mobility significantly reduced for 3 or more days
If expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor
What are VTE risk factors?
Active cancer or cancer treatment
Age over 60
Critical care admission
Dehydration
Known thrombophilia
Obesity
One or more significant medical comorbidities
Personal Hx or first degree relative with history of VTE
Use of HRT
Use of oestrogen containing contraceptive
Varicose veins with phlebitis
What are the general rules with VTE prophylaxis for medical and surgical patients?
Medical patients: pharmacological VTE prophylaxis unless contraindication
Surgical: mechanical offered for patients at risk. Pharmacological given if risk of major bleeding is low
What are pharmacological VTE prophylaxis options?
Fondaparinux sodium
Low molecular weight heparin
Unfractionated heparin (for patients with renal failure)
What are mechanical VTE prophylaxis options?
Anti embolic stockings
Foot impulse devices
Intermittent pneumatic compression devices
What length of post procedure VTE prophylaxis is given for elective hip and knee replacement and hip fracture?
Elective hip: 28-35 days
Elective knee: 10-14 days
Hip fracture: 28-35 days
What are the borders of the femoral canal?
Lateral: femoral vein
Medial: lacunar ligament
Anterior: inguinal ligament
Posterior: pectineal ligament
What are the contents of the femoral canal?
Lymph vessels
Cloquets lymph node
What is the physiological significance of the femoral canal?
Allows femoral vein to expand to allow for increased venous return to the lower limbs
What is the triad of symptoms of Leriche syndrome?
Claudication of buttocks and thighs
Atrophy of musculature of legs
Impotence due to paralysis of L1 nerve
A 72 year old man has just undergone surgery to repair a ruptured AAA. Pre op he was taking aspirin, clopidogrel and warfarin. Intra op he received 5000 units unfractioned heparin prior to application of aortic cross clamp. His blood results on admission to crit care show: Hb 8, platelets 40, WBC 7.1. His fibrin degradation products are markedly elevated. What is it?
Disseminated intravascular coagulation
Describe the pathophysiology of DIC
Tissue factor release after vascular damage binds with coagulation factors and triggers the extrinsic pathway via factor VII which then also triggers the intrinsic pathway (XII to XI to IX)
How many days before surgery should clopidogrel be stopped?
Elective procedures when antiplatelet effect is not needed, discontinue 7 days before surgery
A 19 year old female presents with severe anal pain and bleeding which occurs post defecation. On examination she has a large posteriorly sited fissure in ano. What is the appropriate management?
Stool softeners Topical diltiazem or GTN for 6 weeks Botox Sphincterotomy Advancement flap
A 43 year old male has been troubled with symptoms of post defecation bleeding for many years. On examination he has large prolapsed haemorrhoids, colonoscopy shows no other disease. What is the appropriate management?
Stool softeners
Avoid straining
If haemorrhoid complex is largely internal: stapled haemorroidopexy
Large external component: Milligan Morgan stole conventional haemorroidectomy
What are adverse effects of a stapled haemorroidopexy?
Urgency
Recurrence
What is a potential adverse effect of Milligan Morgan style haemorroidectomy?
Anal stenosis
Post op pain
What are potential problems with a sphincterotomy to treat fissure in ano?
Incontinence to flatus
In females - pregnancy - faecal incontinence
What is the management for a fistula in ano?
If low, no sphincter involvement or IBD: lay open (fistulotomy)
If complex, high or IBD, assess with surgery and imaging, insert draining seton suture, if not IBD - advancement flap, LIFT procedure
What is the ginkgo leaf sign?
Chest plain radiography appearance which is seen with subcutaneous emphysema of the chest wall
Air outlines the fibres of the pectoralis major muscle and creates a branching pattern like a ginkgo leaf
What are some potential complications of laparoscopic surgery?
General risks of anaesthetic
Vasovagal reaction in response to abdominal distension
Extra peritoneal gas insufflation: surgical emphysema
Injury to GI tract
Injury to blood vessels: common iliacs, deep inferior epigastric
What are exclusion criteria for consideration of renal transplant?
Active malignancy Old age Infection Severe coronary artery disease Severe pulmonary disease FEV1 less than 1.25L/min Patient refusal
What type of incision is used for kidney transplant?
Rutherford Morrison incision
What is a common problem encountered in cadaveric kidneys which are used in organ transplant?
Acute tubular necrosis
How long do kidney transplants tend to last?
Cadaveric donors - 9 years
Monozygotic twin live donor - 25 years
What are some associations of sigmoid volvulus?
Older patients Chronic constipation Chagas' disease Parkinson's disease Duchenne muscular dystrophy Schizophrenia
What are some associations of caecal volvulus?
All ages
Adhesions
Pregnancy
What are features of a volvulus?
Constipation
Abdominal bloating
Abdominal pain
Nausea and vomiting
What is the management for sigmoid volvulus?
Rigid sigmoidoscopy with rectal tube insertion
What is the management of caecal volvulus?
Often require right hemicolectomy
What measures may increase the risk of surgical site infection?
Shaving the wound using a razor
Using non iodine impregnated incise drape
Tissue hypoxia
Delayed administration of prophylactic antibiotics in tourniquet surgery
Give some examples of surgeries where use of prophylactic antibiotics is not recommended
Tonsillectomy Inguinal hernia repair Laparoscopic removal of ectopic pregnancy Assisted delivery (forceps) Evacuation of incomplete miscarriage
What should be done for a low rectal cancer that is presenting with obstruction? Why?
Defunction with loop colostomy
Obstructed colon that would be used for anastamosis would carry high risk of dehiscence
Emergency presentation, staging may not be completed and so an attempted resection may compromise the circumferential resection margin with risk of local recurrence
What are complications of diverticulitis?
Abscess formation
Peritonitis
Obstruction
Perforation
What is the appropriate VTE prophylaxis for a patient undergoing an elective hip replacement?
TED stockings and dalteparin sodium started at least 6 hours post op
What is the gold standard investigation for suspected urolithiasis?
CT KUB
What is the management for biliary colic?
If imaging shows gallstones then laparoscopic cholecystectomy
What is the management for acute Cholecystitis?
USS and cholecystectomy ideally within 48 hours of presentation
What is Mirizzi syndrome?
Gallstone becomes impacted in the cystic duct or neck of gallbladder causing compression of the common bile duct or common hepatic resulting in obstruction and jaundice
What is Calots triangle? Why is it relevant?
Hepatobiliary triangle - anatomic space bordered by cystic duct inferiorly, common hepatic duct medially and the inferior surface of the liver superiorly
Cystic artery lies in this space which is useful to identify for a lap chole
What is the lymph node called that is located in calots triangle?
Mascagnis lymph node
What is the management for a gallbladder abscess?
Imaging with USS +/- CT scan
Ideally surgery although subtotal cholecystectomy may be needed if calots triangle is hostile
If unfit patient, percutaneous drainage
What is the management for cholangitis?
Fluid resuscitation
Broad spec IV Abx
Correct coagulopathy
Early ERCP
How does gallstone ileus present?
History of previous Cholecystitis and known gallstones
Small bowel obstruction, may be intermittent
What is the management for gallstone ileus?
Laparotomy and removal of gallstone from small bowel
Enterotomy made proximal to the site of obstruction
Fistula between gallbladder and duodenum should not be interfered with
What is the management for acalulous Cholecystitis?
If patient is fit, cholecystectomy
If unfit, percutanenous cholecystostomy
What are risks of ERCP?
Pancreatitis
Cholangitis
Duodenal perforation
Bleeding
A 65 year old male attends surgical outpatients with epigastric discomfort. He has been recently diagnosed with diabetes and is a heavy smoker. An OGD is normal. What is a possible diagnosis? What is a rarer alternative that may present with a bullous rash?
Pancreatic Adenocarcinoma
Glucagonoma
An obese 40 year old presents with episodes of anxiety, confusion and one convulsive episode. CT brain is normal. Abdominal CT shows a small lesion in the head of the pancreas. What is the likely diagnosis?
Insulinoma - episodes due to hypos
What are some associations of pancreatic cancer?
Increasing age Smoking Diabetes Chronic pancreatitis Hereditary non polyposis colorectal carcinoma Multiple endocrine neoplasia BRCA2
What are features of pancreatic cancer?
Painless jaundice
Anorexia
Weight loss
Epigastric pain
Loss of exocrine function - steatorrhoea
Back pain
Migratory thrombophlebitis - Trousseau sign
What is the management of pancreatic cancer?
Whipples resection - pancreaticoduodenectomy
Adjuvant chemotherapy
ERCP with stenting for palliation
What are the stages of wound healing? Describe each
Haemostasis: Minutes to hours following injury. Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich clot
Inflammation: days 1-5. Neutrophils migrate into wound (impaired in diabetes). Growth factors released. Fibroblasts replicate in adjacent matrix and migrate into wound. Macrophages and fibroblasts couple matrix regeneration and clot substitution
Regeneration: days 7 to 56. Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells.
Fibroblasts produce collagen network. Angiogenesis occurs and wound resembles granulation tissue
Remodeling: From 6 weeks to 1 year. Longest phase of healing. Fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction. Collagen fibres are remodeled. Microvessels regress leaving a pale scar
Give examples of drugs which impair wound healing
Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs
A 56-year-old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis?
Stone impacted in Whartons duct - sialolithiasis
After a complicated revision of a total hip replacement, an 80-year-old lady receives two units of packed red cells. Which drug should be prescribed between the units?
Furosemide - prevent fluid overload
When are packed red cells used for transfusion?
Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in cardiovascular compromise
When is platelet rich plasma used for transfusion?
Usually administered to patients who are thrombocytopaenic and are bleeding or require surgery
What does fresh frozen plasma contain?
Clotting factors, albumin and immunoglobulins
When is fresh frozen plasma used?
Usually used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery
What is the usual dose of fresh frozen plasma?
Usual dose is 12-15ml/Kg
What is cryoprecipitate?
Formed from supernatant of FFP
Rich source of Factor VIII and fibrinogen
Allows large concentration of factor VIII to be administered in small volume
What is SAG mannitol blood?
Removal of all plasma from a blood unit and substitution with: Sodium chloride Adenine Anhydrous glucose Mannitol
What steps should be taken if a patient on warfarin needs immediate or emergency surgery?
Stop warfarin
Vitamin K: IV 4-6h to work, oral 24h
Fresh frozen plasma: 30ml/kg. Only if human prothrombin complex not available
Human prothrombin complex: bereplex. Reversal in 1h
What is the sign in checklist before induction of anaesthesia?
Patient has confirmed: Site, identity, procedure, consent
Site is marked
Anaesthesia safety check completed
Pulse oximeter is on patient and functioning
Does the patient have a known allergy?
Is there a difficult airway/aspiration risk?
Is there a risk of > 500ml blood loss (7ml/kg in children)?
What is psoas sign/cope test?
Patient lies on their left side and clinician extends the right hip with the knee fully extended. Abdominal pain on this movement indicates irritation of iliopsoas and possible appendicitis. This test usually indicates an appendix that lies in the retrocaecal position
Up to what size of breast tumour can be removed by wide local excision?
4cm
What are some causes of early (day 0-5) post op pyrexia?
Blood transfusion Cellulitis Urinary tract infection Physiological systemic inflammatory reaction (usually within a day following the operation) Pulmonary atelectasis
What are some late (day 6 plus) causes of post op pyrexia?
Venous thromboembolism
Pneumonia
Wound infection
Anastomotic leak
What are risk factors for the development of aneurysms?
Smoking
HTN
Syphilis
Connective tissue disease: ehlers danlos type 1, marfans syndrome
What size of aortic dilation would be considered aneurysmal?
3cm and greater
What is the standard of care for people with symptomatic gallstones?
Elective cholecystectomy
Which cholecystectomy procedure is associated with more biliary injuries?
Laparoscopic
What are benefits to a lap chole rather than open?
Reduced pain Reduced wound complications Reduced pulmonary complications Shorted hospital stay Earlier return to work
What are common causes of nipple discharge?
Mammary duct ectasia
Duct papilloma
Galactorrhoea
What is a phyllodes tumour?
Rare variant of fibroadenoma found in older women
What are clinical features of fat necrosis of the breast?
Hard painful lump Irregular Tethering Bruising Spontaneously resolves
How do you treat intraductal papilloma?
Surgical excision of affected segment - microdochectomy
In a Chinese patient with jaundice, what might cause irregular filling defects in the biliary tree on USS?
Clonorchis sinensis infection
Hepatolithiasis
Choledocolithiasis
What may be causes of iatrogenic stricture formation after cholecystectomy?
Early: inadvertent clipping of the common duct
Late: burn injury
What is the management if a gallbladder polyp is identified?
Cholecystectomy as there is a risk of growth and transformation into a carcinoma
If polyp is large or has suspicious features, perform pre op CT as extended resection of gallbladder +/- liver may be required
How does an empyema form in the gallbladder?
Stone lodges in cystic duct orifice
Mucous continues to be produced forming a mucocoele
Stagnant mucous then becomes secondarily infected leading to an abscess
Why is pancreatitis pain relieved by sitting forward?
Allows stomach and small bowel to fall away from the pancreas in the retroperitoneum
Who is more likely to get lobular carcinoma in situ?
Younger women
White
A 56 yeard old man attends clinic for investigation of chronic epigastric pain, anorexia and weight loss. He also describes pale, loose, floating stool. What is the appropriate investigation at this point? What can be done to help?
Faecal elastase - chronic pancreatitis
Steatorrhoea indicates exocrine insufficiency - can be prescribed enzyme supplementation
If a diagnosis of pancreatic cancer is suspected, what imaging should be done? What are you looking for?
CT - identify primary tumour, examine for liver mets and large volume peritoneal disease
What blood tests are required to determine the severity of pancreatitis?
LDH WBC Glucose Urea Calcium ABG - pA02
A 65 year old woman has been diagnosed with a 3cm pancreatic carcinoma on CT following investigation of obstructive jaundice. There is some question of nodularity within the omentum of the upper abdomen. What should be done next?
Laparoscopy - need to ensure resectability in advance of laparotomy
If the question is of vascular invasion - endoscopic USS indicated
If a patient is suspected of having cholangitis secondary to gallstones, what should be done next?
ERCP to confirm diagnosis and allow insertion of stent or sphincterotomy to drain infected bile
What is the main early feature of compartment syndrome and how can you test for it?
Excessive pain made worse by passive stretch of the suspected group of muscles
When should fasciotomy be undertaken for compartment syndrome?
Difference between diastolic and measured compartment pressure is less than 30 mmHg
What are potential complications of compartment syndrome?
Necrosis of tissue Volkmanns ishcaemic contracture Nerve damage Muscle damage Rhabdomyolysis Renal failure
What is a Volkmanns ischaemic contracture?
Permanent flexion contracture of hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful. It is excruciatingly painful and disabling
Who is at risk of developing paraumbilical hernias?
Obese, multiparous, middle aged women due to weakness of linea alba
A 54 year old man is seen in clinic with a history of chronic right sided abdominal pain which is localised to the abdominal wall. On examination there is a small irreducible mass lateral to the rectus muscle at the level of the anterior superior iliac spines. What is the diagnosis?
Spigelian hernia - weakness in Spigelian fascia, which is aponeurotic layer between rectus abdominis muscle medially, and the semilunar line laterally
What is a volvulus?
Rotation of an organ around its mesentery
What is the most common site for volvulus formation? What are some other possible sites?
Sigmoid (75%)
Caecum
Transverse colon
Splenic flexure
What will an ABG of a patient with mesenteric ischaemia show?
Metabolic acidosis
Raised lactate
What is the definition of critical ischaemia?
One or more of:
Persistent rest pain for minimum of 2 weeks
Ulceration
Gangrene in conjunction with ankle systolic BP less than 50 mmHg
What is the management of critical ischaemia?
Pain control
Imaging to see if candidate for reconstruction
If not, amputation may be appropriate
What is the prevalence of AAA?
7.5% in men over 65
What are risk factors for AAA?
Male
HTN
Hypercholesterolaemia
Smoking
When should patients be offered a repair for a AAA?
5.5cm
What are common sources of emboli in context of acute vascular ischaemia?
AF
Mural thrombus
Aorta
Peripheral aneurysms
What is done to manage a femoral embolus?
Emergency embolectomy
What are common sites of valvular incompetence causing varicose veins?
Saphenofemoral junction
Saphenopopliteal junction
Perforator veins
What are predisposing factors for varicose vein formation?
Raised pelvic pressure: pregnancy, obesity, gynaecological malignancies
Prolonged standing: occupational
What are indications for surgery for varicose veins?
Cosmesis Pain Ulceration Bleeding Eczema Thrombophlebitis
How are varicose veins treated?
Ligation at level of incompetent vein +/- stripping of vein segment
What is a hamartoma?
Abnormal growth that consists of the same tissue from which it is derived
What is it called when hamartomas occur in multiple sites throughout the body?
Cowden disease
Where do papillomas develop in the breast?
Lactiferous ducts just below the nipple
What is mammary duct ectasia?
Benign breast condition
Milk ducts beneath nipple become dilated and sometimes inflamed
Presents with chronic inflammation of breast, creamy protein rich green discharge
What is a procedure specific risk which should be included on the consent form for low anterior resection and classically occurs at 5-7 days?
Anastamotic leak
How is an low anterior resection anastamotic leak managed if there is evidence of sepsis?
Urgent laparotomy
Repair or defunctioning by means of ileostomy
What should be done for cases of prolonged ileus?
Identify and correct any electrolyte abnormalities
Search for intra or extra abdominal infection
When is atelectasis most commonly seen after surgery?
Prolonged operations
Upper abdominal surgery
Elevated intra abdominal pressure
Smokers
How can you prevent the development of atelectasis?
Adequate analgesia
Optimal oxygenation
Physiotherapy
In post op bleeding, what is the difference between reactionary and secondary haemorrhage?
During the first 48 hours (reactionary haemorrhage) because a clot in a vessel has been displaced, or a ligature has slipped
8 to 14 days later (secondary haemorrhage) when the wound has become infected and eroded a vessel, usually quite a small one, sometimes a larger one
What causes a pilonidal sinus?
Ingrowing hairs
How can people be treated who are prone to pilonidal sinuses?
Waxing the affected region
A 52 year old man presents with a 3 week hx of increasing discomfort in the perianal region (he finds it extremely uncomfortable to sit down). He also complains of throbbing and swelling. What is the likely diagosis?
Perianal abscess
A 45 year old woman presents with tenderness in the perianal region and says she can feel a lump. On examination there is a small pea sized lump, bluish in colour which is painful. There is no hx of weight loss. What is the likely diagnosis?
Perianal haematoma
What are classic symptoms of rectal carcinoma?
Fresh blood
Mucus
Tenesmus
Diarrhoea
Why does leg pain occur in intermittent claudication?
Blood flow to muscles is reduced, possibly due to atherosclerosis
Oxygen demand cannot be met and therefore anaerobic metabolism occurs and leads to an accumulation of lactic acid
This is painful and causes cramping
What are risk factors for developing claudication?
Smoking
High total blood cholesterol or high LDL and low HDL
HTN
Obesity
Diabetes
FH of atherosclerosis, PAD or claudication
What are features of mild to moderate intermittent claudication?
Ceases with rest
Elicited by reproducible amount of exercise
No worse at night compared to day time
May be an indication for bypass surgery
What percent stenosis of the carotids requires operative intervention with a carotid endarterectomy?
Greater than 70%
A 22 year old man presents to ED following an accident at work. A piece of scaffolding fell onto his leg and trapped it. His peripheral pulses are present on arrival. He is admitted for observation when he becomes hypotensive with a poor urine output. What is the diagnosis?
Rhabdomyolysis leading to AKI
What procedure is used to treat a perforation?
Omental patch
What procedure is used to treat and active bleeding duodenal ulcer which fails to respond to adrenaline injection?
Laparotomy with under running of the ulcer
What should be done to treat a patient with a pyloric stenosis secondary to longstanding duodenal ulcers?
Gastroenterostomy
An otherwise fit 80 year old lady presents with an 8 hour hx of acutely ischaemic right arm with severe pain in the hand and fingers. She has a hx of AF for which she takes digoxin. On examination the hand is cold and pale but some movement and sensation are preserved. There is a good axillary artery pulse but distal pulses are impalpable. What is the correct management?
Surgical exploration and embolectomy using a Fogarty catheter
What is the inheritance pattern of osler Weber rendu syndrome? What is the other name for it?
Hereditary haemorrhagic telangiectasia
Autosomal dominant
What is the triad of features of hereditary haemorrhagic telangiectasia?
Telangiectasia
Recurrent epistaxis
Positive family history for the disorder
What is the most common finding on screening mammography?
Ductal carcinoma in situ - microcalcification
What proportion of DCIS will progress to invasive cancer?
25%
What is Paget’s disease of the nipple?
Invasion of the nipple by malignant cells from an underlying neoplasm
How is a lactational breast abscess treated?
USS guided aspiration and antibiotic therapy
If it recurs then formal incision and drainage is required
What is the condition where lipomas are multiple and familial?
Dercums disease
What is the most common soft tissue sarcoma in children?
Rhabdomyosarcoma
How can the risk of painful neuromas developing after amputation be reduced?
Cutting (not tying) nerves as short as possible and keeping the ends away from scar tissue
What is a Desmoid tumour?
Highly vascularised fibrous tissue
Not malignant
Found in abdominal wall
Can be associated with FAP
What are some reasons for post op ankle swelling?
Poor mobility
Low albumin and protein levels
DVT
Why does anastamotic dehiscence occur?
Poor knotting
Poor suturing
Too much tension
Diabetic patients - ischaemia
If traubs space is dull to percussion, what does that suggest?
Splenomegaly not yet large enough to be palpated abdominally
What might a new onset umbilical hernia in an adult indicate?
Malignancy
Ascites
Multiple pregnancy
Peritoneal dialysis
Where is the defect with an epigastric hernia?
Linea alba
What are predisposing factors for incisional hernias?
Malnutrition - protein, vitamin C, zinc Jaundice Uraemia COPD Smoking Obesity Steroids Post op: distension, wound infection, haematoma Poor technique: suture type, suture placement
What factors increase the risk of cholelithiasis?
Haemolysis
Pregnancy
Oral contraceptive therapy
Octreotide therapy
Which bugs are patients at risk of post splenectomy?
Pneumococcus
Haemophilus
Meningococcus
Capnocytophaga canimorsus
Which vaccines should patients have if they have had a splenectomy?
2 weeks prior to surgery if elective Hib Meningitis A and C Annual influezna vaccine Pneumococcal every 5 years
What antibiotic prophylaxis is recommended for post splenectomy patients?
Pen V
For at least 2 years and at least until patient is 16 years old
Majority are put on for life
Why does pen V not protect post splenectomy patients from haemophilus infection?
Production of beta lactamases by the organism
What are risks with carotid endarterectomy procedures?
Hypoglossal nerve neuropraxia/damage Perioperative stroke Haematoma MI Infection Restenosis
What is the management for uncomplicated sigmoid volvulus?
Endoscopy and decompression to relieve large bowel obstruction and prevent ischaemia
What is the significance of a patient having colicky abdominal pain rather than continuous in the context of bowel obstruction?
Colicky pain suggests uncomplicated obstruction
Continuous pain suggests peritonitis - ischaemia or perforation
For venous thromboembolism, how long should warfarin treatment be continued?
Provoked: 3 months
Unprovoked: 6 months
Who should be screened for MRSA?
All patients awaiting elective admissions
All emergency admissions
How should a patient be screened for MRSA?
Nasal swab and skin lesions or wounds
Swab wiped around rim of patients nose for 5 seconds
Microbiology form labelled MRSA screen
What is a trendelenburg test for varicose veins?
Patient supine, leg flexed at hip and raised above heart
Veins will empty due to gravity or with assistance of examiner’s hand squeezing
Tourniquet around upper thigh to compress superficial veins but not too tight as to occlude deeper veins. Leg is then lowered by asking the patient to stand
Normally superficial saphenous vein will fill from below within 30–35 seconds as blood from capillary beds reaches veins
If superficial veins fill rapidly with tourniquet in place there is valvular incompetence below level of the tourniquet in deep or communicating veins.
After 20 seconds, if there has been no rapid filling, tourniquet is released. If there is sudden filling at this point, it indicates that the deep and communicating veins are competent but the superficial veins are incompetent
How is MRSA suppressed if a patient is found to be a carrier?
Nose: mupirocin 2% in white soft paraffin, TDS for 5 days
Skin: chlorhexidine gluconate OD for 5 days particularly axilla, groin and perineum
Which antibiotics are commonly used in the treatment of MRSA infections?
Vancomycin
Teicoplanin
Linezolid
Which organisms are patients who have had a splenectomy at risk from?
Pneumococcus
Haemophilus
Meningococcus
Capnocytophaga canimorsus
Which vaccinations should patients undergoing splenectomy have?
2 weeks prior: Hib, Meningitis A and C
Annual influenza
Pneumococcal vaccine every 5 years
What are some causes of pseudo obstruction?
Hypothyroidism Hypokalaemia Diabetes Uraemia Hypocalcaemia
What is the Amsterdam criteria for aiding diagnosis of HNPCC?
At least 3 family members with colon cancer
Cases span at least 2 generations
At least one diagnosed before age 50
What investigation needs to be done in a patient with an abdominal wall haematoma?
USS abdomen
Coagulation studies
What is the Hinchey classification of diverticular perforations?
Hinchey I: localised abscess (para colic)
Hinchey II: pelvic abscess
Hinchey III: purulent peritonitis
Hinchey IV: faeculent peritonitis
What is the management for diverticulitis?
Increase dietary fibre
Mild attacks: conservatively with antibiotics
Pericolic abscess: drainage
Recurrent episodes requiring hospitalisation: possible segmental resection
Hinchey IV perf: resection and usually stoma, HDU admission
What is the management of fissure in ano?
GTN ointment 0.2% or diltiazem cream topically
Botox for those who fail to respond
Internal sphincterotomy for those who fail with Botox
What is the management of haemorrhoids?
Lifestyle advice
If small internal: injection sclerotherapy or rubber band ligation
For external: haemorrhoidectomy - HALO or stapled
What is leriches syndrome?
Aortoiliac occlusive disease
Blockage of abdominal aorta as it transitions into common iliacs
Presents with claudication of buttocks and thighs, absent or decreased femoral pulses and erectile dysfunction
What is Mondors disease?
Thrombophlebitis of superficial veins of breast causing tender subcutaneous cords
Self limiting
Treated with NSAIDs
What is a Kochers incision?
Under right subcostal margin
Used for open cholecystectomy
What is the name of the accessory bile duct which needs to be looked for when performing a cholecystectomy?
Duct of luschka present in 12-50% individuals
Which investigation should be done to make a diagnosis of acalculous cholecystitis?
HIDA scan - assessment of emptying of gallbladder in response to stimulation to see if non functional
Ejection fraction less than 30% diagnostic
What is a Rutherford Morrison incision?
Extraperitoneal approach to left or right lower quadrants
Gives access to iliac vessels and is approach of choice for first time renal transplant
What is a BI RAD score?
Mammogram findings and results Breast Imaging Reporting and Data System sorts the results into categories numbered 0 through 6 to assess likelihood of cancer
What features of an AKI make acute tubulointerstitial nephritis a likely cause?
Trigger - drugs or infections
Speed of deterioration
Eosinophilia
Which ages of women are offered breast screening? And how often are they offered?
47-73
Every 3 years
What is adsons sign?
Loss of radial pulse in arm by rotating head to ipsilateral side with extended neck following deep inspiration
Sign of thoracic outlet syndrome
Why might a patient with Crohn’s disease get gallstones?
Bile salts absorbed in terminal ileum
Impairment of this process and therefore gallstones
How long before surgery should the COCP be stopped?
4 weeks before and after restart 2 weeks after
What is Meigs syndrome?
Triad of ascites, pleural effusion, and benign ovarian tumor
When does duct ectasia commonly occur? What happens?
During breast involution that occurs during menopausal period
Ducts shorten and may contain insipidated material
How does intraductal papilloma present?
Single duct discharge
Clear fluid which may be bloodstained
Which drugs need to be stopped before surgery?
I LAC OA Insulin Lithium Aspirin/anticoagulants COCP Oral hypoglycaemics ACE inhibitors
What is mondors disease of the breast?
Localised thrombophlebitis of a breast vein
What are features of post thrombotic syndrome? What can be done to prevent it?
Painful heavy calves Pruritus Swelling Varicose veins Venous ulceration Prevention: compression stockings offered to all patients with DVT
What is may Thurner syndrome?
DVT of iliofemoral vein caused by compression of left common iliac vein by the overlying right common iliac artery
What is Klippel trenaunay syndrome?
Triad of naevus flammeus, venous and lymphatic malformations and soft tissue hypertrophy of affected extremity
What is Milroys disease?
Congenital lymphoedema caused by congenital aplasia of the lymphatic system
What is the pathophysiology of rhabdomyolysis?
Low ATP production results in high intra cellular myocyte calcium concentrations which impair function and promote protease activity
What are causes of pancreatitis?
I: idiopathic G: gallstones E: ethanol (alcohol) T: trauma S: steroids M: mumps/ malignancy A: autoimmune S: scorpion stings/ spider bites H: hyper-lipidaemia/Ca. /PTH (metabolic disorders) E: ERCP D: drugs
How is a diagnosis of pancreatitis made?
2/3 of the following
- Abd pain- Acute onset, persistent, severe, epigastric pain often radiating to the back
- S. Amylase / Lipase 3x normal
- If not 3x, imaging (CECT/ MRI/ USS)
What are the grades of severity of pancreatitis?
Mild acute pancreatitis: No organ failure, No local or systemic complications
Moderately severe acute pancreatitis: Organ failure that resolves within 48 h (transient organ failure) and/or Local or systemic complications without persistent organ failure
Severe acute pancreatitis: Persistent organ failure (>48 h), Single organ failure, Multiple organ failure
What is the Glasgow prognostic score for pancreatitis?
PaO2: less than 8kPa Age: over 55 years Neutrophils: (WBC) over 15 x109/l Calcium: less than 2mmol/l Renal function: (Urea) over 16mmol/l Enzymes: (AST/ALT) over 200 iu/l or LDH over 600 iu/l Albumin: less than 32g/l Sugar: (Glucose) over 10mmol/l 3 or more /8: Acute Severe pancreatitis 2: Acute Moderate Pancreatitis Less than 2: Acute Mild Pancreatitis
What are poor prognostic features with pancreatitis?
Clinical impression of severity
Obesity
APACHE II over 8 in the first 24 hours of admission
CRP over 150 mg/l
Glasgow score 3 or more
Persisting organ failure over 48 hrs in hospital
What are the 2 types of pancreatitis?
Interstitial oedematous pancreatitis (IEP) Necrotising pancreatitis (NP)
What are features of interstitial oedematous pancreatitis?
Diffuse inflammatory oedema of the pancreas
Contrast enhanced CT: Homogeneous enhancement and peri- pancreatic fat stranding +/- fluid collections
Resolves within a week
What are features of necrotising pancreatitis?
About 5–10%
Parenchymal necrosis
Peripancreatic necrosis
Combined type (most common)
Contrast enhanced CT: Patchy enhancement. Over 1 wk, any non-enhancing area - pancreatic parenchymal/ peri-pancreatic necrosis
More morbid course; may remain solid/ liquefy, sterile/ infected, persist/ disappear
What are the clinical phases of pancreatitis?
Early (1st week): systemic organ failure
Late (over 1st week): local complication / persistent systemic organ failure
At what points does pancreatitis severity need reassessing?
Reassess at 24hrs, 48hrs and 7days after admission
What are local and systemic complications of pancreatitis?
Local: (peri) pancreatic necrosis, sterile or infected
Systemic: organ failure, transient or persistent
What are early and late local complications of interstitial oedematous pancreatitis?
Early (less than 4 weeks): APFC (acute peripancreatic fluid collection)
Late (over 4 weeks): Pancreatic pseudocyst
What are early and late local complications of necrotising pancreatitis?
Early (less than 4 weeks): ANC (acute necrotic collection)
Late (over 4 weeks): WON (walled-off necrosis)
What are diagnostic criteria for hereditary haemorrhagic telangiectasia?
Epistaxis
Telangiectases: lips, oral cavity, fingers, nose
Visceral lesions: GI, pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM
Family history: 1st degree relative
Need 2 for possible diagnosis, 3 for definite
What are the management steps of pancreatitis?
Resuscitate
Risk Stratify
Prevent complications: Antibiotics, Enteral nutrition (NG feeds)
Remove gall stones: ERCP and Sphincterotomy and Stenting
Lap Chole (index admission / within 2 weeks of discharge)
Reduce Necrosis: HDU (Specialised centres with dedicated team)
If over 30% gd FNAC (7-14days), if infected, necrosectomy
If a patient has a positive wells score (2 or more), what should be done to manage their DVT?
Doppler proximal leg USS within 4 hours
If can’t be arranged within 4 hours, should be given LMWH to cover until scan
What is Meigs syndrome?
Benign ovarian tumour (usually fibroma) associated with ascites and pleural effusion
What is the most common benign ovarian tumour in women under 25?
Dermoid cyst (teratoma)
What is the most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
What is the hinchey classification for diverticular perforation?
1: para colonic abscess
2: pelvic abscess
3: purulent peritonitis
4: faecal peritonitis
What is the management of diverticular disease?
Increase dietary fibre
Mild attack: antibiotics
Peri colonic abscess: surgical or radiological drainage
Recurrent: segmental resection
Hinchey 4: resection and stoma
Other perfs: laparoscopic washout and drain insertion
What is the definition of toxic megacolon?
Transverse colon diameter >6cm
How are flares of UC classified?
Mild: less than 4 stools/day, no systemic disturbance, normal ESR and CRP
Moderate: 4-6 stools, minimal systemic disturbance
Severe: more than 6 stools, blood, fever, tachycardia, abdo tenderness, distension, reduced bowel sounds, anaemia, hypoalbuminaemia
What investigations need to be done for a patient presenting with an unprovoked DVT?
Routine bloods: FBC, calcium, LFT Chest X-ray Urinalysis Abdo pelvic CT/mammogram if over 40 Antiphospholipid antibodies Screen for hereditary thrombophilia if FH
What is an anal fissure?
Longitudinal or elliptical tears of squamous lining of distal anal canal
What is the difference between an acute and chronic anal fissure?
Less than 6 weeks acute
More than 6 weeks chronic
What are risk factors for anal fissure?
Constipation
IBD
STIs: HIV, syphilis, herpes
What is the management of an acute anal fissure?
Dietary advice: High fibre diet, high fluid intake
Bulk forming laxative
Lubricant before defecation
Topical anaesthetic
What is the management of a chronic anal fissure?
Continue management of acute
Add topical GTN
If not effective after 8 weeks, secondary referral for surgery or Botox
What caecal diameter is pathological?
> 8cm
What amount of small bowel dilatation is pathological?
3cm or more
What are the common causes of small bowel obstruction?
Hernia
Adhesions
What amount of large bowel dilatation is pathological?
6cm or above
9cm caecum
What are common causes of large bowel obstruction?
Cancer
Diverticular disease
What is riglers sign?
Air on both sides of the bowel wall
What is lead pipe colon a sign of?
Lead pipe colon
Prolonged inflammation - loss of haustral markings due to mucosal destruction
What is thumb printing a sign of?
Inflamed haustra - chronic inflammation
What is riglers triad?
SBO, pneumbilia, gallstone in RIF
Sign of Gallstone ileus
What hormonal therapies are given for breast cancer?
ER/PR positive, Pre menopausal: tamoxifen for 5 years
Her 2 positive: herceptin
ER/PR positive, post menopausal: anastrozole (aromatase inhibitor)
What are features of post thrombotic syndrome?
Painful heavy calves Pruritus Swelling Varicose veins Venous ulceration
What should be done for patients with a DVT in order to reduce occurrence of post thrombotic syndrome?
Offer below knee graduated compression stockings with ankle pressure greater than 23mmHg a week after diagnosis or when swelling is reduced sufficiently, if there are no contraindications and:
Advise them to be worn for 2 years
Replace 2 or 3 times per year
Need to only be worn on affected leg
What is a wells score?
Determine likelihood of DVT
Active cancer
Paralysis/immobilisation of lower extremities
Bedridden for 3 days or more or major surgery within 12 weeks
Localised tenderness along deep veins
Entire leg swollen
Calf swelling at least 3cm larger than asymptomatic side
Pitting oedema on symptomatic leg
Collateral superficial veins
Previous DVT
Alternative diagnosis at least as likely (-2)
How does a wells score change management of a DVT?
DVT likely, score 2 or more: proximal leg vein USS within 4 hours and if negative, d dimer. If USS cannot be performed, d dimer and LMWH administered while waiting for scan
DVT unlikely, 1 point or less: d dimer, if positive arrange USS within 4 hours
What is the management of DVT?
LMWH or fondaparinux given after diagnosis, continued for 5 days or until INR is above 2 for 24 hours
Warfarin given within 24 hours of diagnosis, continued for 3 months, consider longer if unprovoked and recurrence risk high (6 months)
Which bugs cause acute cholecystitis?
E. coli
Klebsiella
Enterococci
Enterobacter
What is leriche syndrome?
Atherosclerotic occlusive disease involving abdo aorta and of the iliac arteries
Claudication of buttocks and thighs
Atrophy of leg muscles
Impotence (due to L1 paralysis)
What are indications for splenectomy?
Traumatic rupture
Haem: hereditary spherocytosis, thalassaemia, sickle cell, ITP, TTP
Malignancy: lymphoma, lymphoproliferative disorders
Cysts/abscess
Feltys syndrome
Gaucher’s disease
Splenic vein thrombosis
What are the different categories of haemorrhoids?
First degree: bleeding no prolapse
Second: spontaneously reducible
Third: manual reduction required
Fourth: irreducible
What is the mainstay of treatment for haemorrhoids?
Rubber band ligation
What are complications of band ligation for haemorrhoids?
Band slippage Ulcer Urinary retention Anal pain Haemorrhage Infection
What is the most effective way of treating haemorrhoids?
Open haemorrhoidectomy
What are complications of open haemorrhoidectomy?
Pain Bleeding Urinary retention Anal stenosis Skin tags Incontinence
What are different categories of peri anal fistulae?
Type 1: intersphincteric
Type 2: transsphincteric
Type 3: extrasphincteric
What are the aims of treatment for peri anal fistula?
Close fistula
Maintain continence
What is a fistula seton?
Surgical thread left in fistula to keep it open, allowing it to drain and help it heal
Used in high and complex fistulas
What is the difference between acute and chronic fissures?
Acute <6 weeks
What drugs are used for chronic anal fissure?
GTN cream
Diltiazem
Botox
Why do you not do a sphinceterotomy in women for anal fissure?
Shorter anal sphincter
Occult obstetric sphincter damage
What are causes of pruritis ani?
Anal disease Skin disease: psoriasis, eczema, thrush Threadworms Allergy Skin irritation: soaps, perfumes Sweating
What is APER?
Abdomino perineal excision of rectum
Used for anal/low rectal cancers
What parts does a hernia consist of?
Neck
Sac
Where is the femoral canal?
Most medial structure in the femoral triangle
What are the boundaries of the femoral triangle?
Inguinal ligament
Sartorius
Adductor longus
What are the boundaries of the femoral canal?
Anterior: inguinal ligament
Posterior: pectineal ligament
Laterally: femoral vein
Medial: lacunar ligament
What are features of a saphena varix?
Soft and compressible
Disappears on lying down
Exhibits expansile cough impulse
Demonstrates fluid thrill
Where can a hydrocoele occur in a female?
Canal of nuck
What are indications for surgery in crohns?
Complications: abscess, perf, fistula, obstruction, bleeding
Failure of medical management
Intolerance of medical therapy
Neoplasia
What is the string sign of Kantor?
Crohns: incomplete filling of intestinal lumen due to irritability and spasm associated with severe ulceration
How many anastamoses are there in whipples procedure?
3
Which AAA are considered high risk of rupture?
5.5cm or above
Rapidly enlarging >1cm/year
Symptomatic
What is buergers test and buergers angle?
Angle: angle at which the foot goes pale when elevated in patient with PVD
Test: when leg goes pale, hang foot over edge of bed, if goes hyperaemic, buergers positive
What classification system can be used for venous disease?
CEAP classification
What are surgical treatments for varicose veins?
Endovenous treatment: endothermal ablation, foam sclerotherapy
Open vein surgery
What is the definition of an aneurysm?
Vessel dilated to >2.5 times normal size
Who gets AAA screening?
Men aged 65
USS
What is the difference between an empyema and an abscess?
Empyema: collection of pus in already existing cavity eg pleural space
Abscess: collection of pus inside newly formed cavity
