Surgery Flashcards
Which women should be offered radiotherapy after a mastectomy?
- Women with T3 or T4 graded cancers
- Those with 4+ nodes affected
NB: All women receiving a wide-local excision should receive it
What do you need to tell women taking the contraceptive pill before having major surgery?
If it contains oestrogen stop 4 weeks before
If they forget, give thromboprophylaxis
If progesterone-only it can be continued
1st and 2nd line treatmenr for neuropathic pain
1st: amitriptyline (SNRI) or pregabalin (acts on GABA system)
2nd: amitriptyline and pregabalin
How large would a ductal carcinoma in situ (in the breast) have to be for a woman to receive a mastectomy rather than a wide local excision?
4cm
Borders of the femoral canal?
Posterior- pectineus muscle
Anterior- inguinal ligament
Lateral- femoral vein
Medial- lacunar ligament
Borders of the inguinal canal
The deep inguinal ring is found at the mid point between the ASIS and pubic tubercle
Anterior- external oblique aponeurosis + internal oblique
Posterior- transversalis fascia
Roof- transversalis fascia, internal oblique
Floor- inguinal ligament and thickened medially by lacunar ligament
Things to ask about in a breast lump history?
PC- obesity
PMH- previous breast cancer
Obs- nulliparity, 1st pregnancy over 30 years, no breastfeeding
Gynae- early menarche, late menopause
DHx- HRT, the Pill
FHX- relatives (unilateral, bilateral, degree of closeness, any men, BRCA+)
What might microcalcification on mammography indicate?
Ductal carcinoma in situ- unifocal or widespread
Types of breast cancer
Invasive ductal 70%
Invasive lobular 15%
Medullary cancers 5% (aggressive looking, BRCA1, good prognosis)
Colloid 2%
Which features of a breast tumour’s expressed receptors are associated with good or bad prognosis?
Oestrogen +ve good prognosis
HER2 +ve poor prognosis (aggressive disease)
Risks of axillary radiotherapy for treatment of +ve lymph nodes in breast cancer
Brachial plexoplexy- weakness, sensation change, pain
Lymphoedema
Pneumonitis
Rib fractures
Pericarditis
Outline the management of stage 1-2 breast cancer?
Surgery- wide local excision or mastectomy
Radiotherapy- for any WLE
Chemotherapy- post surgery (Adjuvant) improves survival
Hormonal- tamoxifen (pre-menopausal) or anastrozole (aromatase inhibitor) or GnRH analogues
Outline the management of stage 3-4 breast cancer.
(Stage 3- tumour fixed to muscle, not chest wall, skin involvement
Stage 4- distant mets, chest wall fixation)
IHx: CXR, CT or PET CT or MRI, bone scan, liver USS, LFTs, Ca+
Hormonal: tamoxifen
Chemotherapy:
Monoclonal: trastuzumab HER2 targeting
Describe the inclusion criteria of the breast cancer screening programme
2 view mammography every 3 years
If aged 47-73
Why are aromatase inhibitors only indicated for menopausal women with breast cancer?
They prevent conversion of testosterone and it’s precursor into oestrogen, which is the only way menopausal women gain oestrogen, however in the premenopausal woman the ovaries have alternative pathways to produce oestrogen.
What does the triple assessment of a breast lump entail?
Clinical exam
Radiology- USS if under 35 years, + mammography if over 35 years
Histology- fine needle aspiration or core biopsy
What is a fibroadenoma and how is it managed?
Solid tumours of collagenous mesenchyme which are firm, smooth and mobile.
May increase in size during pregnancy + regress after menopause.
IHx: reassure, if in doubt USS ± fine needle aspiration
How is a simple breast cyst diagnosed?
Suspicion confirmed with aspiration- if clear fluid is withdrawn with no residual mass, it may be considered a simple cyst.
Enlargement of the cyst may cause pain
The cyst is derived from the terminal duct lobular unit, which fills with fluid is the efferent ductule becomes blocked
What kind of imaging is needed for triple assessment of the breast of a woman who has had implants
MRI
In patients with acute urinary retention, what medication can be given alongside catheterisation?
alpha 1a-blockers like Tamulosin
Relaxation of these receptors in the bladder neck and in the smooth muscle of the urethra enable passage of urine
How may chronic and acute urine retention be distinguished?
Chronic- may drain >1.5L
In acute can go up to 1L but unlikely to be more than that
Need an urgent renal US incase backup of fluid and pressure has caused hydronephrosis
In the histology of prostate hyperplasia which zone enlarges compared to in prostate malignancy?
Hyperplasia- the inner transitional zone
Carcinoma- peripheral zone
Lower urinary tract symptoms to ask about
Irritative: nocturia, frequency, urgency
Obstructive: poor flow, hesitancy, post-micturition dribbling
Incontinence- can be a sign of acute-on-chronic with overflow
3 investigations to rule out prostate cancer in someone with lower urinary tract symptoms?
PSA (before PR)
Transrectal USS
± biopsy
Also PR obviously
Conservative management of benign prostatic hyperplasia
Lifestyle: avoid caffeine + alcohol, void twice in a row, bladder training (hold on for longer)
Rx: a1A blockers- tamulosin, alfuzosin, doxazosin, terazosin
5a-reductase inhibitors- finasteride to reduce testosterone’s conversion to dihydrotestosterone
SEs of benign prostatic hyperplasia drugs?
a1A-blockers
Low BP, dizziness, ejaculatory failure (SHOOT), dry mouth
5a-reductase
Lower libido, impotence from less dihydrotestosterone
Surgical options for benign prostatic hyperplasia?
> Transurethral resection of prostate- 14% risk of impotence
> Transurethral incision of the prostate- for smaller prostates, some cuts reduce urethral pressure as the tissue can spring apart
> Transurethral laser-induced prostatectomy
> Retropubic prostatectomy- open op for very large prostate
Why do U+Es need to be checked after a transurethral rection of prostate?
The water used can be absorbed leading to hyponatraemia, fits and low temperature
What complications may arise following insertion of a catheter for chronic urinary retention?
Hyperkalaemia
Metabolic acidosis (from Na+ and HCO3- loss, see below)
Post-obstructive diuresis (provide resus fluids, matching output)
Sodium and bicarbonate losing nephropathy- replace
Infection- MC and S
Why would a patient get faeculent vomiting?
Where there is colonic fistula with the proximal gut or potentially ileal obstruction
Can recognise it by the smell on the breath
How can ileus be differentiated from mechanical bowel obstruction?
There may be vomiting, nausea and anorexia in both but there is no pain in ileus, and bowel sounds are not present
What are the three types of mechanical bowel obstruction?
- Simple- one obstructing point, no vascular compromise
- Closed loop- obstruction at two points forming a grossly distended bowel at risk of perforation (sigmoid volvulus, competent ileocaecal valve)
- Strangulated- sharper, more constant and localised pain
Management of bowel obstruction
Drip and suck
Bloods- inc amylase
AXR, erect CXR
Catheter
Surgery for closed loops (like sigmoid volvulus) or strangulation
Management of sigmoid volvulus causing bowel obstruction
Sigmoidoscopy with insertion of a flatus tube
Occasionally may need sigmoid colectomy
How distended does the large bowel need to get for you to worry about urgent decompression?
12cm should be getting urgent surgery
What is Ogilvie’s syndrome (acute colonic pseudo-obstruction) and how is it managed?
Mechanical GI obstruction, so bowel is active (not ileus) where no obstruction can be found (on CT or otherwise). Occurs after cardiac events and surgery, thought to be related to too much parasympathetic
Rx: Neostigmine (anti-cholinesterase, which may increase parasympathetic output)
What is the definition of a fistula?
Abnormal connection between epithelial surfaces
What prevents fistulae spontaneously closing?
Presence of: Malignant tissue Distal obstruction Foreign body Chronic inflammation Muco-cutaneous junction (stoma)
What is thought to be the cause of a fistulo-in-ano (fistula between skin and anal canal)
Blockage of deep intramuscular gland ducts leads to build up of secretions and then an abscess forms, which discharges by forming a fistula tract
How does Goodsall’s rule describe the path of a fistula track around the anus?
Goodsall’s rule:
Anterior opening- the track is in a straight line to the anus
Posterior opening- the internal opening is always at 6 o clock, so when excising, cut a track that goes posterior immediately, then curves round
Patient has bloody pus draining from a hole near their anus and pain on deification. What IHx what help determine if there is a fistula in ano there?
MRI
Endoanal US scan
Treatment of a fistula-in-ano?
Fistulotomy + excision
Or lay open the fistula if low (heals by second intention)
Causes of anal fistulas?
Inflammatory: Crohn’s disease, immunocompromise
Infectious: TB, perianal abscess (DM more common)
Structural: Diverticular disease, rectal carcinoma
What are haemorrhoids and what positions around the anus are they found in?
Dilated anal cushions (masses of spongy vascular tissue)
From lithotomy position- 3, 7 and 11 o clock
What’s the innervation of the anus?
Above the dentate line (squamomucosal junction) = visceral supply from inferior hypogastric plexus
Below dentate line- supplied by inferior rectal nerve (pudendal nerve branch) has somatic supply.
Differential of rectal bleeding- bright red blood coating stools, found on PR
Perianal haematoma
Anal fissure- incredibly painful (below dentate line)
Abscess
Tumour
In suspected haemorrhoids, what 3 questions would make you thing about more sinister causes?
Weight loss
Change in bowel habit
Tenesmus
How should you investigate internal + external suspected haemorrhoids?
Abdo exam + PR (internal ones won’t be palpable)
Proctoscopy- for internal
Sigmoidoscopy- identifies any pathology up to the rectosigmoidal junction
Management of haemorrhoids:
Conservative: fluid + fibre ± stool softener (docusate)
Non-operative: rubber band ligation, sclerosants (more occurrence), infra-red coagulation
Surgical: excisional haemorrhoidectomy, stapled haemorrhoidectomy (more reoccurrence)
Classification of haemorrhoids:
1st: remain in the rectum
2nd: prolapse through anus on defecation, spontaneously reduce
3rd: need digital reduction
4th: persistently prolapsed
Medical treatment only for 1st degree haemorrhoids, otherwise non-operative or surgical treatment
Definition of hernia
Protrusion of tissue or an organ through the wall of the cavity in which it is normally contained
How are inguinal and femoral hernias different?
Inguinal = commoner in males, Femoral in females
Inguinal is superior + medial to the pubic tubercle
Femoral is inferior + lateral to the pubic tubercle
Femoral= more likely to be strangulated due to rigidity of canal borders
Differential of a femoral hernia:
- Inguinal hernia (wrong place mate)
- Saphena varix (vein)
- Enlarged Cloquet’s node (lymph)
- Lipoma (fat)
- Femoral aneurysm (artery)
- Psoas abscess (infection)
What are the three different approaches to wound closure?
First intention- clean wound, all tissues are sewn up including skin
Second intention- dirty wound with large epithelial loss, wound is left open and granulation tissue forms to close the wound slowly
Third intention- wound is left open and then if found to be clean enough is sewed closed
Which form of IBD is associated with the formation of fistulas?
Crohns disease (not UC)
Risk factors for paraumbilical hernias?
Obesity
Ascites
What is a Spigelian hernia?
One that occurs through the linea semilunaris (lateral edge of the rectus sheath, runs parallel to the linea alba)
What is a Richter’s hernia?
A hernia of the bowel wall which does not involved the whole lumen of the bowel
What is a Maydl’s hernia?
When a double loop of bowel is herniating- one loop through and another
Becomes strangulated
What is a littre’s hernia?
Hernia of Meckel’s diverticulum
(Remnant of the yolk stalk, in 2% of people, 2 feet before the ileocaecal valve, 2 inches lng, 2 years for age of presentation)
Main difference between gastroschisis and exomphalos
In exomphalos the gut herniates through the umbilicus and surgical repair is less urgent as the bowel is covered by a 3-layer membrane of peritoneum, Wharton’s jelly and amnion.
In gastroschisis, the herniation is right of the umbilicus and only a thin peel covers the protruding bowel. URGENT surgery needed
What kind of inguinal hernias do male infants get?
Indirect hernias (from the patent procesus vaginalis)
What is the management of umbilical and inguinal hernia’s in infants?
Inguinal hernias need surgical repair, within days to weeks
Umbilical hernias should close themselves (due to defect in the transversalis fascia)- not an omphalocele
Difference between indirect and direct inguinal hernias:
- Direct go through abdominal wall, indirect go through deep inguinal ring
- Direct is medial to inferior epigastric vessel, indirect is lateral
- Clinically on reduction of the hernia and occlusion at the deep inguinal ring, a cough will lead to re-protrusion in a direct hernia (theoretically)
Contents of the inguinal canal:
3 fascial layers:
External spermatic fascia (from ext oblique)
Cremasteric (from internal oblique + transverses abdominus)
Internal spermatic fascia (from transversalis fascia)
3 nerves:
Sympathetics, genitofemoral nerve branch, ilioinguinal nerve
1 Artery, pampiniform plexus + vas deferenes + lymphatics
What is the difference between a sliding and rolling hiatus hernia?
Sliding: gastro-oesophageal junction slides up into the chest. Often reflux.
Rolling: gastro-oestrophageal junction remains in abdomen, with a bulge of stomach herniating into the chest. Reflux less common as sphincter remains intact
Best diagnostic test for a hiatus hernia?
Barium swallow
In cases of reflux, upper GI endoscopy can determine if there is oesophagitis of the mucosa but not reliably exclude hiatus hernia.
Indications for surgery in someone with a hiatus hernia?
30% of those over 50 have a hiatus hernia, so medical therapy for reflux is recommended foremost: antacids, alginates, PPI
Indication: intractable symptoms with medical management
Complications of oesophagitis- Barrett’s oesophagus, ulcers, benign strictures, iron-deficiency anaemia
When examining a lump what things should be mentioned?
3S, 3C, 4T:
Site, size, shape
Colour, contour, consistency
Tethered, temperature, tender, transilluminable
What are dermoid cysts?
Slow-growing benign subcutaneous nodules forming where squamous epithelial cells get caught in deeper tissue
In congenital cases, they will form along the midline, often in the neck.
In ovarian cysts, these are better known as teratomal cysts
Rx: surgical excision
What is the cause of vulval warts?
Human papillomavirus (HPV) mostly 6+11
Treatment of vulval warts?
If in a post-menopausal woman, always biopsy
Otherwise: diathermy, cryocautery or laser
Treatment of common warts?
Salicylic acid
Cryotherapy
How are plantar warts treated?
Plantar warts = large confluent Rx-resistant warts
Occlusive plaster and combination therapy
Ie
Salicyclic acid + podophyllotoxin (topoisomerase inhibitor)
What are the malignant and pre-malignant forms of skin moles?
Actinic keratoses > SCC in situ (Bowen’s disease) > SCC
Lentigo maligna > malignant melanoma
Basal cell carcinoma (rodent ulcer)
At what age should testicles ideally be fixed if they have failed to descend in an infant?
1 year
Reduces infertility and risk of neoplasm and torsion
(Malignancy risk still higher than normal, but easier to identify if testis are descended)
What is the management for suspected testicular torsion?
Surgery within 6 hours
Gain consent for orchidectomy (incase necrotic) and bilateral fixation.
Can do Doppler USS if uncertain of diagnosis to demonstrate lack of blood flow to testes
Patient has severe pain in the testis, and it appears tender, hot and swollen. What is the differential?
Testicular torsion- testis may lie high and transversely
Epididymo-orchitis (+ dysuria, gradual onset of pain)
Torsion of testicular appendage (less pain, blue nodule)
Doppler USS can differentiate
Causes of epididymo-orchitis:
Dysuria, fever, tender swelling
NET MuCh
Neisseria gonorrhoea E Coli TB Mumps Chlamydia
Rx of chlamydia
Doxycycline 100mg BD
Rx of gonorrhoea (neisseria)
Ceftriaxone 500mg IM STAT
Often Azithromycin also for chlamydia as it’s an atypical
First line investigations for suspected renal stones?
Spiral non-contrast CT
(Superior to IV urography)
Need to exclude a ruptured AAA
Conservative management of ureteral stones? (Urolithiasis)
Assess likelihood of spontaneous stone passage:
If under 5mm, single stone, no evidence of complications (hydronephrosis) and low down, likely to spontaneously pass
NSAIDs + IV fluids if vomiting
(Opioids if NSAIDs CI)
> 5mm or pain unresolving- nifedipine or tamulosin (a-blocker)
1 cm requires urological input
Interventional management of renal stones?
Under 1cm- extracorporeal shockwave lithotripsy
or ureteroscopy
Large or multiple stones- percutaneous nephrolithotomy (keyhole)
What indications are there for urgent stone removal in nephrolithiasis?
Systemic demise:
If infected AND obstructed
Urosepsis
Intractable pain or vomiting
Kidney demise:
Impending acute kidney injury
Single kidney working
Bilateral obstructing stones
= percutaneous nephrostomy or stent
What prevention can be given for patients who have suffered calcium-based kidney stones?
Diet: Maintain normal calcium intake (low Ca cause increased oxalate excretion)
Rx: thiazide for calcium stones
Pyridoxine for oxalate stones
Preventative treatment for urate and cystine stones?
Allopurinol for urate stones
Sodium bicarbonate (urine alkinalinization) for urate or cystine stones
D-penicillamine for cystine stones
Who gets cystine stones?
Those with cystinuria- an autosomal recessive defect in reabsorbing the amino acid cystine from the PCT
Rx: High fluid intake
Urinary alkalinization- sodium bicarbonate
D-Penacillamine (forms a more soluble precipitate)
Given with pyridoxine to prevent vit B6 deficiency
3 features of Dent’s disease?
Proteinuria
Hypercalciuria
Nephrocalcinosis
= form alot of stones
Medical causes of abdominal pain?
MI KEY to PNEU where POOR THEOry may LEAD
MI Ketoacidosis Pneumonia Porphyria Lead poisoning
What are the borders of Hesselbach’s triangle and why is it significant?
Base- inguinal ligament
Lateral- inferior epigastric artery
Medial- rectus sheath
Where direct inguinal hernias occur
Indications for end colostomies:
Can’t tell from examination whether it’s temporary or permanent :
- Abdominoperitoneal resection (no anus)- permenant
- Hartmann’s- for resting the bowel in diverticulus or diverting if obstruction, temporary (may be mucous fistula)
Indications for loop colostomy:
2 lumens, flush with skin:
To protect distal anastomoses- for example after an anterior resection (proximal colon is anastomosed to the top of the anal canal)
Indications for loop ileostomies:
2 lumens, spouted, often RIF:
To protect distal anastomoses
Indications for end ileostomy?
Panproctolectomy- for ulcerative colitis or familial adenomatous polyposis
Indications for urostomy?
1 lumen, RIF, may have a catheter:
New bladder conduit formed with a fragment of ileum, ureters are attached
Complications of stomas:
Early:
Haemorrhage, high output (loss of K_)
Stoma ischaemia or obstruction (from adhesions)
Stoma retraction
Late:
Obstruction, stenosis, stoma intussusception, stoma prolapse
Dermatitis, parasternal hernia, fistulae
Psychological and adjustment difficulties
Indications for surgical amputation of a leg?
Irreversible ischaemia (necrosis) Refractory ulceration Loss of function such that it is not neeeded Extensive rhabdomyolysis
When is an ultrasound not going to be able to pick up a suspected DVT?
What should be used instead?
In veins above the common femoral vein, better to use CT venography for IVC and iliac vein thromboses.
A patient with cancer develops a DVT, how should it be managed differently to a person who gets a DVT for a different reason?
LMWH instead of Warfarin for the duration of the anti-coagulation
Anticoagulate for 6 months rather than 3 month norm for a provoked DVT
Imaging for a patient with a PE + renal impairment?
V/Q lung scan
Rather than CTPA scan, lower radiation also so may be preferred in a young patient
What are the different markers associated with different types of testicular tumours?
AFP- yolk sac (germ-cell, non-seminomatous)
BHCG- choriocarcinoma*, syncytiotrophoblast (germ cell, non-seminomatous)
Choriocarcinoma also known as malignant trophoblastic teratoma
Which histological types of breast cancer have a good or bad prognosis?
Bad: no specific type (ductal)
Good: tubular, mucinous + lobular
