Surgery Flashcards
Sclerotherapy
Varicose vein treatment
Inject superficial vein lumen with sclerosing substance (hypertonic saline, detergent solutions ie. sodium tetradecyl sulfate and corrosive agents ie. glycerin) which reacts with vascular endothelium and seals the vein leading to its permanent collapse
Up to ___ deg angulation is acceptable in fifth metacarpal fractures
40
Up to ___ deg angulation is acceptable in second metacarpal fractures
10
Up to ___ deg angulation is acceptable in third metacarpal fracutres
20
Boxer’s fracture
Acute angulation of neck of 5th metacarpal into palm
Ulnar gutter x 4-6wks
Major predictors of increased perioperative CV risk
Unstable coronary syndromes
Acute or recent MI with evidence of important ischemic risk by clinical symptoms or noninvasive study
Unstable or severe angina
Decompensated HF
Significant arrhythmias
High grade AV block
Symptomatic ventricular arrhythmias with underlying heart disease
Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
Treatment of tension pneumothorax
Needle thoracostomy at 2nd ICS mid clavicular line
then chest tube in 5th ICS anterior axillary line
Treatment of hemothorax
Tube thoracostomy
Most common neoplasm found in ventricular system of brain, esp in children
Ependymomas
2 most commonly injured knee structures
Medial collateral ligament
Anterior cruciate ligament
Open pneumothorax treatment
Air tight dressing sealed on 3 sides (allows air to escape during expiratory phase but seals itself during inspiratory)
Chest tube
Surgery
Incarcerated hernia
Can’t be reduced
Strangulated hernia
Vascular supply of bowel is compromised
Internal hernia
Sac protrudes through fascial defect within abdo cavity or diaphragm
Richter’s hernia
Only part of bowel wall is affected
Can lead to strangulation of that part –> gangrene –> perforation
Spigelian hernia
AKA lateral ventral hernia
Sac protrudes through defect in linea semilunaris
Littre’s hernia
Involves meckel’s diverticulum
Most common type of inguinal hernia
Indirect
Investigation of choice to dx Meckel’s diverticula in children
Technetium-99m pertechnetate scan
Radionuclide binds to plasma protein and accumulates in functional gastric mucosa –> focus of increased activity often mid abdo or in RLQ
Pyloric stenosis
2-8wks of age
1st born male
Non-bilious vomiting PPP
Palpable olive, visible gastric peristalsis
Volume depleted - hypoK, hypoCl, metabolic alkalosis
Intussusception
3mo to 3yrs of age
Adenovirus, rotavirus, mostly idiopathic
Some have lead points (meckel’s, polyp, tumour)
10% recurrence
Pneumotosis intenstinalis on AXR
Necrotizing enterocolitis
Bleeding meckel’s diverticulum is typically painless vs painful
Painless
Gastroschisis
Tissues exposed outside of abdo wall
Omphalocele
Tissues covered outside of abdo wall
Risks a/w succinylcholine
Malignant hyperthermia
Hyperkalemia
Malignant hyperthermia
Genetic dz Auto dominant with reduced penetrance Mutations with ryanodine receptor Chromosome 19 Pts with diseases (central core disease, minicore myopathy, King-denborough syndrome) that affect chromo 19 are at high risk of developing MH if exposed to triggering agents
Postcholecystectomy syndrome
Persistent abdo pain, dyspepsia after chole
Caused by changes in bile flow due to loss of reservoir function in gallbladder
Can lead to: continuous increase of bile flow into upper GI tract leading to esophagitis and gastritis or related to lower GI tract where diarrhea and colicky lower abdo pain may result
Fothergill sign
Mass does not change in shape or cross midline with rectus sheath flexon, suggests rectus sheath hematoma
Epidural hematoma
Lenticular shaped bleed on NCCT
Most often caused by severe trauma rupturing middle meningeal artery
Admit, serial CTs if stable (<30mL, <15mm thick, minimal midline shift, GCS < 8, no focal deficit)
Otherwise, urgent craniotomy to evacuate clot
Subdural hemorrhage
Crescent shaped bleed Rupture of vessels that bridge subarachnoid space Serial CTs if stable/improving Craniotomy if clinically symptomatic More likely to present subacute/chronic
Peptic stricture
Endstage of chronic reflux esophagitis
Often a/w hiatal hernias
Heartburn, dysphagia, odynophagia, food impaction, weight loss, chest pain
Progressive with solids then liquids
Achalasia
Failure of peristalsis of esophagus and LES failure
Rare
Simultaneous difficulty in swallowing solids and liquids
Risk factors a/w colonic volvulus
Chronic constipation Advancing age (usually 70-80yo) Institutionalized pts with neuropsych d/o Use of psychotropic drugs High fiber diet
Most common cause of fever first 48h post-op
Atelectasis
Biliary atresia
Conjugated bilirubinemia
Shrunken gallbladder on U/S
Biopsy that reveals portal fibrosis and bile duct proliferation
Tx for biliary atresia
Kasai proecdure (most successful procedure is Roux-en-Y hepatoportojejunostomy done before 60d of age) Ursodeoxycholic acid may be useful to promote bile flow in patent extrahepatic biliary system (done AFTER kasai procedure) Liver transplant is definitive tx
Top 3 causes of SBO
From most common to least
- Adhesions
- Bulge (hernias)
- Cancer
Triad of findings in AXR for SBO
- Dilated small bowel (>3cm)
- Air fluid levels on upright
- Scare air in colon
Imaging sign of ischemic bowel
Pneumatosis intestinalis (free air in bowel wall)
Inguinal hernia anatomy
MDs don’t LIe
Medial to the inferior epigastric artery = Firect inguinal hernia
Lateral to the inferior epigastric artery = Indirect inguinal hernia
Borders of Hesselbach’s Triangle
Lateral: Inferior epigastric artery
Inferior: Inguinal ligament
Medial: Lateral margin of rectus sheath
Direct inguinal hernias protrude through this triangle
Post-op complications from hernia repair
Recurrence
Scrotal hematoma (painful swelling from compromised venous return of testes)
Nerve entrapment - ilioinguinal N –> numbness of inner thigh or lateral scrotum; genital branch of genitofemoral N –> in spermatoc cord
Stenosis of femoral vein –> acute leg selling
Ischemic colitis
Hernia most likely to become strangulated
Femoral
Most common hernia in women secondary to pregnancy
Femoral
Crohn’s disease surgery options
Resection and anatomosis
Stricutroplasty
UC surgery options
Proctocolectomy and ileal pouch-anal anatomosis
Proctocolectomy with permanent end ileostomy
Hartmann procedure
Proctosigmoidectomy - resection of rectosigmoid colon with closure of anorectal stump and formation of an end colostomy
Anastomosis in ~3mo
Top causes of LBO in order
Cancer
Diverticulitis
Volvulus
Ogilvie’s syndrome
Acute pseudo-obstruction
Distention of colon without mechanical obstruction in distal colon
Usually conservative mgmt only
Outpt treatment of LBO
Clear fluids
Ancef + Flagyl 7-10d
Most common non-neoplastic polyp
Hyperplastic
Malignant potential of polyps
Villous (sessile) > tubulovillous > tubular (pedunculated)
Familial adenomatous polyposis
Auto dominant
colorectal adenomas –> virtually 100% lifetime risk of colon CA
If no polyposis found: annual flex sig from puberty to age 50, then routine screening
Tx: Sx indicated by 17-20yo, total proctocolecotmy with ileostomy or total colectomy with ielorectal anastomosis + chemo
Hereditary non-polyposis colorectal Cancer
AKA Lynch syndrome
Auto dominant
R>L
HNPCC I
Hereditary site-specific colon CA
HNPCC II
Cancer family syndrome - high rates of colon, endometrial, ovarian, hepatobiliary, small bowel CA
Amsterdam Criteria to dx hereditary non-polyposis colorectal CA
- 3 or more relatives with verified Lynch syndrome associated cancers and 1 must be 1st degree relative of other 2
- 2 or more generations involved
- FAP excluded
Angiodysplasia most common location
Right colon of pts >60yo
Volvulus types in order of frequency
Sigmoid > cecum > transverse colon > splenic flexure
UC vs CD for more likely to cause toxic megacolon?
UC
1st degree hemorrhoids
Bleed but don’t prolapse
Tx: high fibre, sitz baths, steroid cream, parmoxine (Anusol), rubber band ligation, sclerotherapy, photocoagulation
2nd degree hemorrhoids
Bleed, prolapse with straining, spontaneous reduction
Tx: Rubber band ligation, photocoagulation
3rd degree hemorrhoids
Bleed, prolapse, requires manual reduction
Tx: Same as 2nd degree, may require close hemorrhoidectomy
4th degree hemorrhoids
Bleed, permanently prolapse, can’t be manually reduced
Tx: Closed hemorrhoidectomy
Tx for anal fissures
Stool softeners, increased fibre intake, sitz baths
Topical nitro or CCB
Lateral internal anal sphincterectomy (most effective) - NOT POSTERIOR (causes keyhole deformity)
Botox
Most common neoplasm of anal canal
SCC of anal canal
ABOVE dentate line
Most common benign hepatic tumour
Cavernous hemangioma
Most common malignant hepatic tumour
Metastases (colorectal)
Definitive mgmt of acute cholangitis
ERCP and sphincterotomy
Most common gallbladder cancer
Adenocarcinoma
Cholangiocarcinoma
Malignancy of extra or intrahepatic bile ducts
whipple procedure
pancreaticoduodenectomy
Remove: CBD, gallbladder, duodenum, head of pancreas, sometimes distal portion of stomach
Most clearly established risk factor for pancreatic CA
smoking
Most common location for pancreatic CA
Head of pancreas
Most useful serum marker of pancreatic CA
CA 19-9
Most common type of pancreatic CA
Ductal adenocarcinoma
Two greatest risk factors for breast CA
- Gender
2. Age
Most common type of breast CA Found in men and women
Invasive ductal carcinoma
Triple test for breast CA Dx
- Clinical breast exam
- Imaging (U/S <30yo, mammography + U/S if >30yo)
- Pathology (U/S or mammography guided core needle biopsy preferred over excisional)
Lobular carcinoma in situ vs ductal carcinoma in situ tx
DCIS needs lumpectomy with wide excision margins + radiation vs LCIS which does NOT need wide excision s
Paget’s disease of breast
Ductal carcinoma that invades nipple with scaling and eczematoid lesion
Tamoxifen
SERM
regular gyne f/u if on it for breast CA tx b/c of increased risk of endometrial CA
Most common sites of metastasis for breast CA
Bone > lungs > pleura > liver > brain
Best predictor of primary adrenal carcinoma
Size > 6cm
Pheochromocytoma investigation
24h urine epinephrine, norepinephrine, metanephrine, normetanephrine, vanillylmandelic acid
Cushing’s investigation
24h urine cortisol or 1mg O/N dexa suppression test
Treatment of adrenal gland tumours
Functional –> resect
Non-functional: >4cm –> resect, <4cm –> F/U imaging in 6-12mo, resect if >1cm enlargement
Vasoactive intestinal peptide secreting tumour
Commonly located in distal pancreas
Most are malignant when diagnosed
Severe watery diarrhea, dehydration, weakness, lyte imbalance
Dx: serum VIP, CT, U/S
Tx: Somatostatin analogues, surgical resection
Peds hydrocele
Most resolve spontaneously by 1 yr
Surgical repair if persist >2yr, painful, infection
Umbilical hernias
Repair if not spontaneously closed by age 5
Hirschprung’s disease rectal biopsy
Gold standard for dx
Look for aganglionosis and neural hypertrophy
Cryptorchidism
Most spontaneously descend by 6mo
Tx: hCG to stimulate T production (descent mediated by descendin which is created in response to testosterone)
Orchidopexy if undescended by age 6mo-2yr
No effect on malignant potential on testicle
Most common cause of bowel obstruction btwn 6-36mo
Intussusception
Peds inguinal hernias
ALL INDIRECT
Incarceration more common in female
Low birth weight and male sex increases risk
Dx: PHYSICAL EXAM (U/S only if uncertain by P/e)
Tx: manual reduction in ED and repair within few weeks if <1yr vs elective if >1yr
If incarcerated –> emergency repair
Metastatic disease from testicular cancer most likely to spread to ____ lymph nodes
Retroperitoneal/para-aortic
Metastatic disease from lung cancer most likely to spread to ____ lymph nodes
Mediastinal
Metastatic disease from small/large bowel CA most likely to spread to _____ lymph nodes
Mesenteric
Acute cholangitis treatment
Endoscopic sphincterectomy
3 most common causes of acute dyspnea in postoperative period
Laryngospasm (stridor) Bronchospasm Aspiration PNA (crackles/rhonchi in RLL)
Malignant hyperthermia treatment
Discontinue volatile agents and succinylcholine, hyperventilate Dantrolene IV Bicarb Coll patients if core temp >39 Manage hyperkalemia
