Surgery 6 Flashcards
List some causes of jaundice after cholecystectomy.
Gallstone retention Biliary sepsis Thermal injury Ligation of common hepatic or common bile duct Haemolysis after transfusion Halogenated anaesthetics
List some complications of joint prosthesis.
Cement reaction Deep infection Fracture Dislocation Loosening Failure
What is a major issue with the use of fine needle aspiration to investigate a thyroid lump?
Cannot distinguish between adenoma and follicular cancer
NOTE: before thyroid surgery, patients need to have their vocal cords assessed
What are the contents of the spermatic cord?
3 Fascia: external and internal spermatic fascia, and fascia or cremasteric muscle
3 Arteries: testicular artery, artery of the ductus deferens, cremasteric artery
2 Nerves: testicular nerves, nerve to cremaster
Pampiniform plexus
Vas deferens
Lymphatic vessels
Tunica vaginalis
What are the indications for an urgent CT head scan (within 8 hours) in patients who have had a head injury?
Age 65 years or older
Any history of bleeding or clotting disorders
Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
More than 30 minutes’ retrograde amnesia of events immediately before the head injury
List some indications for surgical treatment of CD.
ACUTE - obstruction secondary to stenosis - perforation - severe GI bleed CHRONIC - perianal disease (e.g. fistula, abscess) - failure of medical treatment - entero-cutaneous fistulae
What are the three main sites at which valvular incompetence occurs?
Saphenofemoral junction: 3 cm below and lateral to pubic tubercle
Saphenopopliteal junction: popliteal fossa
Perforators: draining the great saphenous vein (Cockett - 3 medial calf perforators; Hunter - 1 medial thigh perforator)
Define herniorrhaphy and herniotomy.
Herniotomy - ligation and excision of hernial sac
Herniorrhaphy - repair of abdominal wall defect
List some indications for using a circular bowel stapler.
Rectal anastomosis
Gastrectomy
Haemorrhoids
Rectal prolapse
List some features of chronic venous insufficiency.
Haemosiderosis Atrophie blanche Lipodermatosclerosis Venous eczema Venous ulcers
Which types of grafts can be used for bypass surgery in patients with peripheral vascular disease?
Saphenous vein graft (preferred for bypass below inguinal ligament)
Above IL: Dacron graft
Below IL: PTFE graft
NOTE: saphenous vein grafts are preferred for more distal operations because the risk of thrombosis is lower and the graft has better longevity
List some causes of smooth and irregular hepatomegaly.
Smooth: CCF, cirrhosis, lymphoreticular disease, Budd-Chiari syndrome, amyloidosis
Irregular: secondary mets, macronodular cirrhosis, polycystic disease, primary HCC
What is a post-phlebitic limb?
A limb which has features of chronic venous insufficiency due to previous deep vein thrombosis
What are the indications for carotid endarterectomy?
SYMPTOMATIC (ECST or NASCET guidelines) Usually > 70% stenosis Some recommend > 50% stenosis Perform within 2 weeks of presentation ASYMPTOMATIC: patients with stenosis >60% benefit
List some indications for using colloids.
Fluid challenge
Hypovolaemic shock
Burns
Complications: anaphylaxis, volume overload
What ABPI is required for the use of compression bandages?
ABPI > 0.8
NOTE: other treatment options include oral pentoxyfylline, topical antiseptics and split-thickness skin grafts
List some complications of varicose veins.
Itching (venous eczema)
Bleeding
Swelling
Skin changes (haemosiderin deposition, lipodermatosclerosis, venous ulcers)
How is thyroid cancer managed?
Total thyroidectomy
T4 to suppress TSH
With or without radioiodine
NOTE: thyroglobulin is used as a tumour marker (and calcitonin in medullar thyroid cancer)
What is the normal range for central venous pressure?
0-6 mm Hg
NOTE: fluid overload is associated with a high CVP
List some secondary causes of Raynaud’s phenomenon.
Blood: polycythaemia, cryoglobulinaemia, cold agglutinins
Arterial: atherosclerosis, thrombangiitis obliterans
Drugs: beta-blockers, OCP
Cervical rib: thoracic outlet obstruction
Autoimmune: SLE, RA, SS
What is Saint’s triad?
A condition in which diverticular disease, hiatus hernia and cholelithiasis occur at the same time
List some complications of using proctoscopes.
Haemorrhage
Perforation
List some differentials for exophthalmos.
Graves' disease Orbital cellulitis Trauma Masses (meningioma, glioma) Cavernous sinus thrombosis
Describe the national AAA screening programme.
Men aged 65 years offered a one-time ultrasound scan
What is a Fogarty embolectomy catheter used for?
Management of an acutely ischaemic limb
NOTE: insert into femoral artery at groin, pass catheter distal to embolus, inflate balloon and withdraw
List some complications of tracheostomy.
IMMEDIATE: haemorrhage, trauma, pneumothorax
EARLY: tracheal erosion, tube displacement/obstruction, surgical emphysema, aspiration pneumonia
LATE: tracheomalacia, tracheo-oesophageal fistula, tracheal stenosis
Describe the typical presentation of ACL injury.
Caused by deceleration and rotational movements Hear a pop Inability to continue activity Haemarthrosis within 4-6 hours Instability/giving way following injury
What are the two different types of prosthesis that can be used for hip arthoplasty?
Cemented (e.g. Thompson) - recommended by NICE, better in porous bone
Uncemented (e.g. Austin-Moore) - better for good quality bone (i.e. young patients)
Outline the measures taken to prevent DVT in orthopaedic patients.
TED stockings Hydration Minimise length of surgery Intermittent pneumatic compression devices LMWH (also DOACs) Early mobilisation Good analgesia Physiotherapy
List some complications of appendicectomy.
Abscess formation
Increased risk of hernia (injury to ilioinguinal nerve)
Adhesions
Bleeding
NOTE: at the operation, if the appendix looks macroscopically normal you remove it anyway (may have microscopic inflammation) and check for other causes (Meckel’s, gynaecological)
What are the advantages of tracheostomy over ET tubes?
Easier to wean patients No need for sedation Reduced discomfort Reduced risk of glottis trauma Reduced dead space (reduced work of breathing)
Which special tests can be used to elicit symptoms in patients with suspected carpal tunnel syndrome?
Phalen’s test (hands in prayer position)
Tinel’s sign (tapping over the median nerve)
Also look for wasting of thenar eminence and sensory loss over median nerve distribution
Which operations would require a Pfannenstiel incision?
Caesarean section
Gynaecological surgery
Lower urinary tract surgery
Extraction of excised organs (along with laparoscopic port sites)
List some risk factors of incisional hernias.
PRE-operative: age, diabetes, drugs (e.g. steroids), obesity, malnutrition
INTRA-operative: surgical skill, small suture bites, inappropriate suture choice, incision type
POST-operative: increased intra-abdominal pressure (e.g. cough), infection, haematoma
Which nerve roots are responsible for the following reflexes? Ankle Knee Triceps Biceps
Ankle: S1-S2
Knee: L3-L4
Biceps: C5-C6
Triceps: C7-C8
Which two types of incision are used for appendicectomy and how are they different?
McBurney’s: oblique
Lanz: transverse
NOTE: Lanz is favoured because it is hidden in a skin crease. Both follow Langer’s lines and carry a risk of injury to the ilioinguinal and iliohypogastric nerve (risk of inguinal hernia)
What are the main indications for amputation of a leg?
Dead (peripheral vascular disease, thrombangiitis obliterans)
Dangerous (sepsis, malignancy)
Damaged (trauma, burns, frostbite)
Damned nuisance (pain, neurological damage)
Define varus and valgus.
Varus: deformity characterised by displacement of the distal part towards the midline
Valgus: deformity characterised by the displacement of the distal part away from the midline
List some complications of Colles fracture.
Median nerve injury
Frozen shoulder
Tendon rupture (especially EPL)
Mal-/non-union
What is Calot’s triangle and what are its borders?
An anatomical space located at the porta hepatis that is dissected during a cholecystectomy
Superior: inferior edge of liver
Medial: common hepatic duct
Inferior: cystic duct
Contains: cystic artery, Calot’s node with or without aberrant hepatic artery
What are the advantages and disadvantages of the use of implants for breast reconstruction?
ADVANTAGES: simpler technique
DISADVANTAGES: worse cosmetic results, requires lots of available skin, risk of complications (capsular contracture, infection, implant leakage)
What is a branchial cyst?
A cyst found in the anterior triangle of the neck at the anterior border of SCM due to failure fusion of the 2nd or 3rd branchial arches
NOTE: it contains cholesterol crystals and can be medically treated with sclerotherapy or surgically excised
Outline the management of carpal tunnel syndrome.
NON-SURGICAL: treat underlying cause, wrist splints (hold it in extension), local steroid injections
SURGICAL: carpal tunnel decompression by dividing the flexor retinaculum
What are the general recommendations on how to prepare for surgery regarding oral intake?
Drink clear fluids until 2 hours before the operation
Do not consume solid fluids for 6 hours before the operation
NOTE: for emergency surgery, rapid sequence induction will be conducted
List some complications of hip arthroplasty.
IMMEDIATE: nerve injury (superior gluteal nerve, sciatic nerve), fracture, cement reaction
EARLY: DVT, deep infection, dislocation
LATE: loosening, leg length discrepancy, revision (most replacements last 10-15 years)
Where can the ulnar nerve be compressed?
Elbow: cubital tunnel
Wrist: Guyon’s canal
NOTE: other causes of ulnar nerve palsy include supracondylar fractures of the humerus and elbow dislocation
Outline the ASA classification system.
1 - normal healthy patient
2 - mild systemic disease (e.g. hypertension, smoker)
3 - severe systemic disease (poorly controlled diabetes, COPD, morbid obesity, end stage renal disease)
4 severe systemic disease that is a constant threat to life (recent MI, severe valve dysfunction, sever heart failure)
5 - moribund and not expected to survive without an operation (ruptured AAA)
6 - declared brain dead and organs are being removed for donor purposes
List some risk factors for wound infections.
PRE-OP: age, comorbidities (DM), pre-existing conditions (e.g. appendix perforation), colonisation (MRSA)
OPERATIVE: type of operation, duration, pre-operative antibiotics
POST-OP: contamination from staff
List some causes of unilateral leg swelling.
DVT
Trauma (e.g. compartment syndrome, muscle rupture)
Venous disease
Lymphoedema (Milroy syndrome, surgery, radiotherapy, TB, filariasis)
Malignancy (sarcoma)
What is the most common type of salivary gland neoplasm?
Pleomorphic adenoma (80% and usually in the parotid)
Others: adenolymphoma, mucoepidermoid tumour (MALIGNANT), adenoid cystic tumour (MALIGNANT)
NOTE: pleomorphic adenomas are treated with superficial parathyroidectomy
