Surgery Flashcards
head injury
who needs a CT head immediately (within 1 hour)?
GCS <13 on initial assessment
GCS <15 at 2-hours post injury
suspected open or depressed skull fracture
any sign of basal skull fracture (battle’s, panda eyes, haemotympanum, CSF leak from nose or ear)
post-traumatic seizure
focal neurology
>1 episode of vomiting
head injury
who needs a CT urgently (within 8 hours)?
LoC or amnesia plus
- >65 y/o
- bleeding or clotting disorders, on warfarin
- dangerous mechanism of injury
- pedestrian or cycle hit by vehicle, occupant ejected from vehicle, fall from height >1m or 5 steps
- >30 mins retrograde amnesia of events before the injury
what surgey is recommended for sigmoid CRC?
sigmoid colectomy or anterior resection
what surgery is recommended for anorectal cancer without involvement or the sphincters?
anterior resection with defunctioning loop ileostomy
what surgery is recommended for caecal CRC?
right hemicolectomy
what are the components of the modified glasgow score for pancreatitis?
PaO2 (<8 kPa)
age (>55 years)
neutrophilia (>15 x10 ^9)
calcium (<2 mmol/L)
renal function (Ur >16 mmol/L)
Enzymes (LDH >600; AST >200)
Albumin (<32 g/L)
Sugar (>10 mmol/L)
what surgery is recommended for anorectal cancer affecting the anal verge/sphincters?
abdominoperineal (AP) resection, end colostomy and closure of the anus
what portion of the bowel is resected in Hartmann’s procedure?
rectosigmoid colon
what signs on abdominal exam would suggest a retrocaecal appendix?
how is this performed?
psoas or cope’s sign positive
psoas - pain on extension of the right hip
Cope’s - pain on flexion and internal rotation of the right hip
(idicates proximity to obturator internus)
what are the predisposing factors for ischaemic colitis?
A fib
older age
smoking, hypertension, diabetes
cocaine use in younger patients
other causes of emboli (endocarditis)
what are the borders of the inguinal canal?
anterior - external oblique
posterior - transversalis fascia
inferior - inguinal ligament mostly, bordered by the lacunar ligament medially
superior - aponeurosis of the arcing fibres of the internal oblique and transverus abdominis
what is the deep ring?
a triangular hiatus in the transversalis fascia through which the spermatic cord and the ilioinguinal nerve enter the inguinal canal
it is located 1 cm superiolaterally to the midpoint of the inguinal ligament
what is the superficial ring?
a divergence of the fibres (crura) of the external oblique aponeurosis about 1 cm superiorlateral to the pubic tubercle
an inguinal hernia will most likely present through the superficial ring
what is the relevance of the artery of Adamkiewicz?
supplies the lumbar and sacral cord
aortic surgery - occlusion/damage during surgery (AAA repair, bronchial embolisation for haemoptysis) leads to compromised supply to the cord.
clinical findings:
anterior spinal artery syndrome: motor > sensory neurological defecit of the lower limbs, urinary and faecal incontinence
how do you classify fibroadenoma of the breast?
juvenile - early in adolesence
common
giant - >4 cm
how is management of fibroadenoma decided? what are the options?
small (<3 cm) - watchful waiting
large (>4 cm) - core needle Bx to exclude phyllodes tumour
what are the ratios of ductal adenocarcinoma versus other types of breast CA?
80% ductal adenocarcinoma
20% - mucinous, lobular or medullary adenocarcinoma
what is Bowen’s disease?
squamous cell carcinoma in situ; nipple as the primary site of disease.
signs are eczema-like changes to the periareolar skin
in breast CA, what does peau d’orange suggest?
it is lymphoedema of the skin, indicating local lymph node involvement or locally aggresive tumour
what is the assessment of a breast lump?
triple assessment:
- assessment and history by surgeon
- USS/mammography/MRI breast
- core needle biopsy or fine needle aspiration cytology
what are the common sites of metastasis for breast CA?
liver, bone and lungs
what is the mangement of breast CA?
medical (adjuvant, prevent systemic relapse)
-
endocrine
- ER +ve patients - tamoxifen (premenopause) or letrozole (postmenopause)
- HER +ve patients - herceptin
- chemotherapy (high risk features)
-
palliative (metastatic disease)
- endocrine, chemotherapy and radiotherapy given to control symptoms and prolong life
surgical (non-metastatic disease)
- wide local excision
- adjuvant radiotherapy to remaining breast
- simple mastectomy
- reconstruction: prosthesis, transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi myocutaneous flap; nipple reconstruction; contralateral alteration
- regional lymph node dissection
- axillary node sampling (min 4 nodes)
- axilary node clearance
- sentinel node biopsy
what is the rate of recurrence in WLE (breast conserving surgery) for non-metastatic ductal adenocarcinoma?
40%, which is the reason that adjuvant radiotherapy is indicated on the remaining breast tissue
what are the guidelines for perioperative steroids in patients on long-term steroids already?
<10 mg pred, any procedure = no extra steroids needed
>10 mg pred, minor procedure = 25 mg iv hydrocortisone preoperatively and nothing after
>10 mg pred, intermediate procedure = 25 mg iv hydrocortisone preoperatively and 25 mg iv hydrocortisone q8 hours for 24 hours post-op
>10 mg pred, major procedure = 50 mg iv hydrocortisone preoperatively and 50 mg iv hydrocortisone q8 hours for 72 hours post-op
how do you classify post-operative fever?
Wind - POD 1-2 - pneumonia, asipration, pulmonary embolism; atelectasis
Water - POD 3-5 - UTI
Wound - POD 5-7 - infection (superficial or deep), dehiscence
(W)abscess - POD 5-7
(W)eins - POD 5+ - VTE
What did we do? - anytime - drugs or blood transfusions (NFTR or TRALI)
what is the anti-coagulation strategy for patients on warfarin due for elective/planned major surgery?
admit the patient 3-5 days before the operation and check the day before that INR < 1.5
what is the anti-coagulation strategy for patients on warfarin due for emergency major surgery?
stop warfarin, check INR q6-8 hours, give 2-3 mg vitamin K PO, request FFP +/- blood products be present during the procedure in case
liaise with haematology
what is the PIG strategy for managing diabetes perioperatively?
PIG = potassium, insulin, glucose
give 500 mL of 5% or 10% dextrose over 4-6 hours
add potassium and insulin titrated to to blood glucose and potassium levels
what are the considerations for surgery on patients who are jaundiced?
always best to try to relieve the jaundice with ERCP if possible before surgery. if you have to operate while the patient is jaundiced, the following should be taken into consideration:
- increased risk of bleeding from decreased absorption of factors II, VII, IX and X
- increased risk of infection - give prophylactic antibiotics
- risk of developing hepatorenal syndrome - give generous iv hydration
- opiate analgesia is more effective as it is not metabolised as efficiently
what are the common aetiological factors in true aneurysm formation?
- atherosclerosis
- infectious (mycotic)
- connective tissue disease (ED or Marfan’s)
what is the AAA screening programme?
what is the surveillance programme for a known AAA ?
when do we intervene?
one-off abdominal USS for men in UK over 65 years
scan q6 months between 4-5.4 cm
1% per year risk of rupture
surgical intervention is required if:
- AP diameter is >5.5 cm
- >0.5 cm dilation in 6 months
what are the options for AAA repair?
-
open
- striaght (aorta only)
- trousered/bifurcated (incl distal iliac aneurysms)
-
laparoscopic
- quicker recovery
-
endovascular (EVAR)
- pro: reduced early mortality (i.e. procedure is safer)
- cons: no long-term survival benefit, lifelong surveillance, high early re-intervention rate
what are the risks of aneurysm rupture based on size?
<4 cm = <0.5% per year
4-5.4 cm = 1% per year
>5.5 cm = 3% per year
worse if comorbid hypertension and >55 years old
what are the complications of emergency AAA repair?
- death in 50% of all cases
- coagulopathy, anaemia and hypotension (haemorrhage)
-
shock:
- MI
- renal failure
- lower limb ischaemia
- mesenteric ishaemia
-
reperfusion:
- abdominal compartment syndrome
what are the indications for amputation?
90% arterial disease
10% trauma
few cases of venous ulceration, tumour or deformity
‘dangerous, dead or damn nuisance’
- spreading gangrene, burns, tumours, sepsis
- unreconstructable arterial disease, necrosis
- neurpathic or deformed
what are the types of lower limb amputation?
- hip disarticulation
- AKA
- supracondylar AKA, Gritti-Stokes
- TKA (through the knee)
- BKA
- Symes (ankle)
- Transmetatarsal
- Ray
- digital
what procedure?
below the knee amputation
what procedure?
above the knee amputation
what procedure is this?
Ankle or Symes amputation
what procedure?
Ray amputation
what procedure?
digit amputation
what procedure?
transmetatarsal amputation
what are the complications of amputation?
operation: infection, stump non-healing
function: phantom limb pain, poor mobilisation
underlying disease: IHD, CVA, contralateral or ipsilateral progression of PVD leading to further amputation
what are the indications for carotid endarterectomy
symptoms and >70% stenosis
>50% stenosis wtih CVA/TIA and high ABCD2 score
new evidence - any patient with acute CVA/TIA
(re-stroke risk decreases from 18% to 3-5% with surgery)
technichal details of carotid endarterectomy
increasingly done under LA as allows assessment of contralateral carotid perfusion
can use a Pruitt/Javed shunt to protenct cerebral blood flow without intact circle of willis
use of transcranial Doppler to monitor MCA flow intra-operatively
what are the complications of carotid endarterectomy?
immediate: stroke (3-8%); cranial/superficial nerve palsy
- vagus nerve - hoarse voice
- hypoglossal - tongue deviates toward the side of the lesion
- glossopharyngeal - gag reflex, palatial movement
- greater auricular - ear numbness
- superficial cutaneous - local parasthesia
early: hypertension; wound haematoma, infection and poor healing
why do some claudicants have abnormally high ABPIs?
+/- comorbid diabetes
calcification of the lower limb arteries increases the pressure needed to compress them, giving a falsely elevated ankle pressure
what is post-thrombotic syndrome?
treatment?
leg symptoms following a DVT
- painful, heavy calves
- pruritis
- swelling
- varicose veins
- venous ulceration
treatment = graduated elasticated compression stockings
what are the complications of deep vein thrombosis?
- pulmonary embolus
- phlegmasia caerulea dolens (venous gangrene)
what are the complications of varicose veins?
- superficial thrombophlebitis
- swelling
- haemosiderin deposition
- bleeding
- venous eczema
- venous ulceration
- lipodermatosclerosis
what are the causes of Raynaud’s?
idiopathic
drug-induced (e.g. ergot derivatives)
occupational
thrombophilia
rheumatological (CREST)
thoracic outlet syndrome
haematological (cold agglutinins, AIHA)
what is the management of varicose veins?
conservative
- compression stockings
medical
- microlaser therapy for superficial, threading veins
- foam sclerotherapy for truncal and varicose veins
surgical (endovenous > stripping)
- vein stripping
- endavenous laser therapy
- radiofrequency ablation
- avlusion of distal varicosities (taking them out)
what is the treatment for venous ulceration?
check ABPI >0.8
wash the wound
debride (mechanical, surgical, autolytic, bio-surgical)
medication - pentoxifylline
compression bandages
- grade 4 if immobile
- grade 2 if mobile (more practical)
what is the management of peripheral vascular disease?
stop smoking and supervised, graded exercise programme
clopidogrel and statin (regardless of blood results)
severe, treat with surgery:
- angioplasty
- stenting
- bypass grafts
last resort - amputation
other (not recommended by NICE)
- naftidrofuryl oxalate: vasodilator
- cilostazol: PDE III inhibitor, vasodilator and antiplatelet
which are more dangerous, above the knee or below the knee DVTs?
above the knee - more likely to lead to pulmonary embolus
how would you manage symptomatic carotid artery stenosis, <50% stenosis on imaging?
optimise on medical management and observe
if still symptomatic then consider surgical intervention
define hernia
the protrusion of a viscous through a wall of the cavity containing it into an abnormal position
what are the boundaries of the femoral canal?
- anterior - inguinal ligament
- posterior - pectineal ligament/muscle, superior pubic ramus
- lateral - femoral vein
- medial - lacunar part of inguinal ligament
how do you treat an appendix mass?
appendix mass = inflammed appendix walled off by adhesions to the omentum
do not operate to remove the appendix when there is an abscess - operation is technically much more difficult
treat with IV antibiotics in hospital and observe. if the patient does not improve in a few days then there should be prompt referral for percutaneous drainage un radiological guidance to prevent a loculated abscess forming
what is the gold standard investigation of liver metastases?
gadolinium-enhanced liver MRI
what are the considerations for surgical treatment of CRC that has metastasised to the liver?
5-year survival rates can be improved from 5% to >30% if metastases are confined to a single liver lobe, and that lobe is resected
‘coffee bean sign’
sigmoid volvulus
where is the bowl is CRC most likely to develop?
- rectum (33%)
- sigmoid (25%)
- caecum and ascending
- transverse
- descending
in order of how long faecal matter in in contact with the mucosa
where is the most common site of complications from diverticular disease?
sigmoid colon
define volvulus
an acute condition where a loop of bowel becomes twisted on its mesentary, compromising its own blood supply.
complications include obstruction, ischaemia, perforation, bowel gangrene
who gets diverticular disease of the rectum?
nobody
diverticula = mucosal outpouchings between the taenia coli.
the taenia coli become fused at the level of the rectum so diverticula cannot form
bloody stool, perianal pain and loss of continence
what should be ruled out?
anal squamous cell carcinoma
loss of continence b/c 70% of patients have anal sphincter involvement at the time of diagnosis
associated with MSM b/c HPV infection is a risk factor
50% also have anal pain, only 25% have a palpable mass on DRE
what is the surgical procedure you would offer for fistula in ano?
examination under anaesthesia +/- proceed
have to examine first to decide if the fistula is :
- intersphincteric
*
how do you treat anal fissure?
remember, fissure = constipation always!!
- laxatives (treatment) & lidocaine gel (symptom control)
- diltiazem or GTN topical, 75% resolution in 8 weeks of therapy
- botox A injection
- surgical resection - risk of long-term incontinence
what is the differential for a mass in RIF?
- general - appendix mass/abscess, Crohn’s, caecal CRC
- urology - pelvic kidney, renal transplant
- gynae - ovarian cyst/tumour, fibroid
- vascular - iliac artery aneurysm
- infective - psoas abscess, iliocaecal TB granuloma
what is the significance of Dukes A CRC?
can be cured with resection only
what is the management of patients with small bowel obstruction likely 2ary to adhesions?
admit and trail non-operative management for 48 hours
drip & suck, bloods
then needs investigation +/- operative treatment
gastrograffin via NG tube, contemporaneous CT abdo
treatment & diagnosis
laparoscopic/open adhesiolysis
what are the different suture sizes used for?
10-0, 9-0: opthalmic and microvascular surgery
8-0, 7-0, 6-0: small vessels and facial plastic surgery
5-0, 4-0: large vessels and skin closure
3-0, 2-0: bowel repair and skin closure under tension
1-0: tendon and muscle repair in orthopaedics
what area of the prostate is enlarged in BPH?
in which area do cancers most commonly develop?
BPH - transitional zone
prostate CA - peripheral zone
what is the arterial supply to the prostate?
branches of the internal iliac artery
(middle rectal and inferior vesical)
which cancer affecting the kidney is associated with von Hippel-Lindau ?
which chromosome is the gene on?
renal cell carcinoma
chromosome 3
at what spinal level do the renal arteries branch from the abdominal aorta?
L1/L2
what are the layers surrounding the kidney?
kidney
fibrous capsule
peri-renal fat
gerota’s fascia
para-renal fat (part of the retroperitoneal fat)
what is the feature on USS abdo that indicates chronic pyelonephritis?
atrophic kidney
what is the inheritance pattern of poylcystic kidney disease?
are there kidney cysts evident at birth?
where else do you get cysts?
autosomal dominant on chromosome 16
yes
liver, breast, pancreas
what are the cardiovascular complication of ADPKD?
cerebrovascular aneurysm
mitral valve prolapse
aortic root dilitation
large and small artery dissection
in PVD, which vessels are likely to be occluded in a) thigh/buttock or b) calf pain?
a) aortoiliac
b) superficial femoral artery (most common)
what is the time frame you have to revascularise an acutely ischaemic limb before the tissue becomes gangrenous?
4-6 hours
options include embolectomy or thrombolysis (tPA)
what is the most common form of organ transplant in the UK?
kidney transplant
why is it better to transplant the kidney into the right iliac fossa versus the left iliac fossa?
easier access to the external iliac vein
how do you measure the function of a grafted kidney following transplant?
- measure serum Cr
- DTPA or Doppler US scan to assess perfusion
- embolism or thrombosis of the grafted vessels are a common reason for early graft failure
- percutaneous biopsy of the graft under US guidance if needed
- able to identify if the rejection is T cell mediated or humoral
otalgia made worse on superior elevation of the pinna
acute otitis externa
is there indication for myringotomy in acute otitis externa?
what is the treatment ?
no
Rx
- acidifying ear drops/steroids (neomycin)
- topical antibiotic ear drops (chloramphenicol)
- ear wax removal to aid contact of the medication with the ear canal
- impregnated ear wicks/gauze
- avoid swimming, ear buds, earphones
how do you treat mastoiditis?
this is a serious condition
risk of extension of the infection into the intracranial space
treat with
- high-dose IV antibiotics
- consider myringotomy and tympanostomy tube
- then consider simple or radical mastoidectomy
what is malignant otitis externa?
extension of otitis externa to include a portion of the temporal bone
more common in the immunosuppressed, diabetics and the elderly
features include otalgia worse at night, otorrhoea and granulation tissue at the bone-cartilage junction
can lead to meningitis, and in severe cases death
what is the staple drug treatment for meniere’s disease?
Betahistine
can give cyclizine to aid the nausea
