surgery Flashcards
drugs linked to acute pancreatitis
sodium valproate, steroids, thiazides, and azathioprine
scoring system to diagnosing acute appendicitis
Alvarado
what incision is used for an appendectomy
classical giridron incision perpendicular to the imaginary line between the umbilicus and anterior illiac spine and centred over Mc burney’s point
common Lanz incisions 2 cm medial to the ASIS better cosmetic outcome
what should the surgeon look for while he is doing an appendix
Meckels diverticulum
what is the rule of 2s
2% of the population may contain 2 types of ectopic cells (pancreatic and gastric) 2 ft (within) of the illeocecal valve 2 inches long symptomatic by 2 years
interval appendectomy
surgeons remove the appendix after successful conservative treatment to prevent reoccurrence (only 10-35% have reoccurrence)
relationship between appendectomy and IBD
protective against UC
risk of chron’s increased during first few years after procedure
sudden onset of pain in the LIF
more likely to be either a perforation of a viscus or a haemorrhage
or torsion
sharp pain in the LIF
heamorrhage, perforation, torsion
medications to look out for in the drug history of a women with LIF pain?
steroids can mask the symptoms the patient is more deteriorated then she seems
antibiotics = pseudomembranous colitis caused by C. Diff
hinchey’s classification
- pericolic or mesenteric abcess
- walled off pelvic abcess
- generalised purulent peritonitis (5% mortality)
- generalised faecal peritonitis (35% mort)
assessment of peritoneal contamination guide to suitability for primary anastomosis
what are some red flag signs of constipation?
absolute constipation not able to pass flatus
rectal bleeding or tenesmus or intermittant mucous diarrhoea
sig. weight loss, night sweats, or iron def anaemia
past medical history of UC or colonic polyps
severe persistent constipation
signs of hypothyroidism
loss of hair brittle hair dry skin puffy eyes malar flush
where is Vichows node?
left supraclavicular fossa
what electrolyte abnormalities can cause constipation?
hypokalaemia and hypercalcaemia
what are the markers of colorectal carcinoma?
CEA, CA 19-9 CA125
lack specificity
CA125 more specific for ovarian CA
use to monitor and detect relapse in patients with confirmed GI cancer
what is the normal MCV value?
76-96 fL
what is the management of a sigmoid volvulus?
drip and suck nil by mouth and no tube placed
removal of the obstruction by sigmiodoscope with a long soft flatus tube to untwist and decompress the bowel or surgery if this procedure in unsuccessful.
DUKES CRITERIA
A no spread to the muscularis propria
B tumour invading beyond the muscularis propria
C tumour to lymph nodes
D tumour mets to other organs
how does the DUKES criteria influence clinical management? A
A 90% survival at 5 years
offered surgical removal with associated blood supply adipose tissue and lymph vessels
radiotherapy if the tumour is at the rectum
DUKE criteria clinical management B and C
30-40% survival at 5 years
surgical removal of tumour plus multi drug adjuvant chemotherapy
if rectal will get radiotherapy
DUKE criteria D clinical management
5-10% survival largely palliative resection of the tumour and larger mets chemotherapy stenting of the tumour and palliative radiotherapy
What are the indication for TURP?
transurethral resection of the prostate is undertaken after the patient has a trial without catheter and fails to urinate with the alpha blocker and 5 alpha redactase
OPD with other TWOC can’t urinate then a TURP is indicated
OR if the creatinine was raised on presentation would go straight to TURP
How do you differentiate between a direct and an indirect hernia surgically?
Direct hernias have their origin medial to the deep inferior artery
indirect hernias have their origin lateral to the deep inferior artery.
How would you manage a indirect reducible inguinal hernia?
elective surgical repair.
what has the highest risk of strangulation femoral or inguinal hernias?
femoral because their is a smaller opening to get through.
What is your differential for a groin lump inferior and lateral to the pubic tubercle?
Either a femoral hernia or a staphena varix
how do you manage a direct hernia?
They are less likely to strangulate so you can treat conservatively
lifestyle like losing weight
surgical repair.
causes of inguinal lymphadenopathy - infective systemic
HIV
Tuberculous
causes of inguinal lymphadenopathy local infectious
non specific lymphadenopathy from the groin or lower limb infection or sexually transmitted disease.
causes of lymphadenopathy neoplastic systemic
lymphoma
leukemia
neoplastic local causes of lymphadenopthy
mets from primary limb external genitalia or perianal region
what are the contents of the inguinal canal?
Fascia: 1. external spermatic fascia 2. cremasteric fascia 3. internal spermatic cord fascia arteries: gonadal artery cremasteric artery of the vas veins: testicular vein, cremasteric vein, vein of vas nerves: ilioinguinal nerve sympathetic supply from t10 and t11 genital branch of the genitofemoral nerve three other things: vas deferens lymphatic patient processes vaginalis
what are the boundaries of the Hesselback’s triangle
medially is the rectus sheath
inferiorly is the inguinal ligament
superiorly is the deep inferior artery
what is the significance of hesselbach’s triangle?
If the inguinal hernia arises from the triangle than it is direct if it arises lateral to the triangle it is indirect
What are the countries of the inguinal canal?
ant: skin superficial fascia, external oblique aponeurosis and internal oblique for the lateral third
post: conjoint tendon medially and transversalis fascia laterally
roof: arching fibres of the internal oblique and trans versus abdominis
floor: inguinal ligament
what are the boundaries of the femoral canal?
ant: inguinal ligament
posterior: pectineal and pectineus
medial: lacunar ligament
lateral: femoral vein
What are the general complications of any surgery?
haemorrhage infection thromboembolism anaesthetic complications death
what are the anaesthetic complications?
inadequate analgesia
respiratory depression
urinary retention
cardiac depression
What are the complications of hernial repair?
hernia reoccurrence
ischeamic orchitis/ testicular atrophy
bruising of the scrotum and penis
cutaneous anaesthesia or hyperaethesia
What is the mid inguinal point
the halfway point between the anterior illiac spine and the symphysis pubis. it represent the surface landmark of the femoral artery
What is the midpoint of the inguinal ligament?
the half-way point between the ASIS and the physis pubis. It represents the surface landmark of the surface landmark of the deep inguinal ring.
What is the direction of the nerve and vessels of the thigh.
Nerve Artery Vein lateral to medial
testicular mass what is your first line investigation
ultrasound scan of both testes sensitivity is close to 100%
If an ultrasound is highly suggestive of testicular malignancy what bloods should you order?
tumour markers: 1. ddx 2. monitoring treatment response 3. monitoring for relapse AFP, BHCG, LDH
What does the tumour marker a fetoprotein tell you?
50-70% teratomas but not normally expressed by seminomas
What does the tumour marker B HCG tell you?
40-60% teratomas express this and about 30% of seminomas
What does the tumour marker lactate dehydrogenase for Testicular ca?
less specific marker relseased during tissue breakdown thus present in a lot of ca. More commonly raised in seminomas.
what do you use radiologically for staging of testicular ca?
plain chest X-ray and CT scan of the chest abdomen and pelvis.
characteristic features of a epidermal cyst
- posterior and superior to the testes
- fluctuant and transilluminable
- it is possible to get above the swelling
what are the options for treatment of a varicocele
conservative: scrotal support with a jockstrap
non-conservative: embolisation, surgical ligation, or sclerotherapy
if you suspect a epididymitis-orchitis secondary to STI
urine dipstick culture and sensitivity
urethral swab and gentiourinary medicine screen
why is radical orchidectomy preformed via an inguinal incision rather than a scrotal incision?
removing the malignant testis via the scrotum would potentially risk seeding the malignant cells into the scrotum during the procedure. They have different lymphatic spreads
scrotum is the inguinal
testes is the para-aortic
does orchidoplexy reduce the cancer risk of undeceived or maldecended testes?
nom but it is easier to detect any changes therefore meaning quicker flagging of ca.
what are the most common types of testicular tumours
seminomas and teratomas
is varicoceles more common on the left or right
98% on left
What would you be considering as a cause of sudden left sided varicoele?
renal tumours as they invade the left renal vein and compromise the drainage of the left gonadal vein.
what pathogen is most likely to cause epididymitis-orchitis in patients less than 35?
STI chlamydia trachomatis and Neisseria Gonorrhoea
What pathogen is most likely to cause epididymo-orchitis in people over 35?
E.Coli most likely
pathogen in a young boy with swelling in the parotid and swollen testes?
mumps virus
What is idiopathic scrotal oedema
prepubertal boys 6-7
acute onset erythmatous oedematous scrotal swelling which is often bilateral… the child is most often not complaining of pain.
what are risk factors for hypercoagulable blood?
trauma, recent major surgery (3m), pregnancy, and post partum state (women increased risk of venous clot for 6 weeks), inflammatory bowel disease, active cancer, BMI greater than 30, oral combined pill, family history or medical history of DVT
what are risk factors for blood stasis?
bed rest greater than 3 days, or long haul travel
What can effect lymphatic drainage in the lower limb?
radiotherapy and surgery
What are the types of oesophageal ca?
squamous and adenocarcinoma most common
What is the pathology of oesophageal CA?
normal squamous epithelium in the distal esophagus replaced with glandular tissue (columnar)
This occurs with the condition known as Barrett’s esophagus
secondary to esophageal reflux disease. GORD
