Surgery 8 Flashcards
What are the benefits of Hickman lines over PICC lines?
PICC lines are not suitable for all medications
PICC lines block more easily
PICC lines may cause clots in your arm
What are the features of Leriche syndrome?
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
NOTE: caused by aorto-iliac insufficiency
List some complications of TURP.
IMMEDIATE: TURP syndrome, haemorrhage
EARLY: haemorrhage, infection, clot retention (requires bladder irrigation with 3-way catheter)
LATE: retrograde ejaculation, erectile dysfunction, incontinence, urethral stricture, recurrence
What are the advantages and disadvantages of suprapubic catheterisation?
ADVANTAGES: reduced risk of UTI, reduced risk of stricture formation, patient preference, maintain sexual function
DISADVANTAGES: more complex, risk of serious complications (viscus perforation, haemorrhage, malignancy seeding)
NOTE: contraindicated if suspected bladder cancer, undiagnosed haematuria or previous lower abdominal surgery (adhesions)
What are the main types of testicular tumour?
Seminomatous (50%)
Non-Seminomatous: teratoma is most common
Yolk sac tumour (most common in children)
Leydig or Sertoli cell tumour (may produce oestrogens)
Lymphoma (NHL is most common testicular mass in > 60 yrs)
Outline the surgical management of inguinal hernias.
Open surgery: Lichtenstein tension-free mesh, Shouldice suture repair
Laparoscopic: TEP or TAPP repair
TEP: totally extraperitoneal (peritoneum not incised)
TAPP: transabdominal pre-peritoneal (peritoneum incised)
NOTE: laparoscopic is better for bilateral hernias, no mesh needed in children
List some conditions that cause lipomas.
Dercum’s disease - multiple painful lipomas, peripheral neuropathy, obesity
Familial multiple lipomatosis
Madelung’s disease (multiple symmetric lipomatosis - mainly causes symmetrical lipomas on shoulders)
Bannayan-Zonana syndrome
What is a cholesteatoma?
In-growing stratified squamous epithelium of the ear drum within the middle ear
Leads to chronic foul discharge, hearing loss, facial nerve damage and vertigo
Can lead to deafness, meningitis and brain abscess
What are the borders of the femoral canal?
Medial: lacunar ligament
Lateral: femoral vein
Anterior: inguinal ligament
Posterior: pectineal ligament
NOTE: contains fat and Cloquet’s node (femoral nerve, artery and vein are lateral to the femoral canal)
What are the indications for immediate CT head scan (within 1 hour) in patients who have had a head injury?
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
Post-traumatic seizure.
Focal neurological deficit.
More than 1 episode of vomiting
List some causes of shoulder pain with or without reduced range of motion.
Rotator cuff tear/tendonitis Subacromial bursitis Adhesive capsulitis (frozen shoulder) Synovitis Osteoarthritis Dislocation Fracture of the humeral head Referred pain from the diaphragm
Which operations are likely to require a loop colostomy?
RUQ: defunctioning transverse colostomy to cover a distal anastomosis (RARE)
LIF: apex of sigmoid exteriorised without resection for inoperable colorectal cancer that is likely to obstruct
List some differentials for midline neck masses.
Thyroid isthmus mass
Inclusion dermoid cyst
Thyroglossal cyst
What is a dermoid cyst?
Epidermal-lined cyst deep in the skin
Congenital (inclusion cyst) - forms along lines of skin fusion (e.g. midline neck, lateral eyebrows)
Acquired/implantation cyst - often secondary to piercing
What does the McMurray test look for?
Meniscal tears
EPONYMOUS OPERATIONS: pyloric stenosis
Ramstedt pyloromyotomy - longitudinal incision through muscularis propria at pylorus
What is the main indication for abdomino-perineal resection?
Tumours lying within 4-5 cm of the anal verge
List some complications of mechanical ventilation.
Pneumothorax
Fluid retention
Ventilator-induced lung injury
Ventilator-associated pneumonia
Outline the management of Dupuytren’s contractures.
Non-Surgical: physiotherapy, steroid injections, allopurinol
Surgical: fasciotomy, partial fasciectomy (Z-plasty), arthrodesis
List some complications of carpal tunnel decompression surgery.
Hypertrophic and keloid scars
Scar tenderness
Nerve injury (palmar cutaneous branch of median nerve, motor branch to thenar muscles)
Failure to relieve symptoms
What causes winging of the scapula?
Serratus anterior weakness
May be due to long thoracic nerve injury, upper brachial plexus injury and muscular dystrophy (fascio-scapulo-humeral)
Outline the surgical management of extracapulsar neck of femur fractures.
ORIF with dynamic hip screw
What are the different types of external fixation?
Monoplanar
Multiplanar
What are the advantages and disadvantages of minimal access surgery?
ADVANTAGES - reduced post-op pain - reduced risk of wound infection - faster recovery - reduced hospital stay - better cosmetically DISADVANTAGES - reduced tactile feedback - old skills may be lost - complications (e.g. bleeding) may be harder to manage - expensive
What are the main approaches to preventing problems with fracture union?
Optimise physiology: treat/prevent infection, bone graft, ensure adequate blood supply, bone morphogenetic protein
Optimise mechanics: external fixation, internal fixation
List some complications of surgical management of NOF fractures.
Avascular necrosis of femoral head (if displaced fracture)
Non/malunion
Infection
Osteoarthritis
What does pain on straight leg raise suggest?
Lumbosacral nerve root irritation
NOTE: Lesague sign is worsening pain on dorsiflexion of the foot
Which ducts connect the submandibular and parotid glands to the oral cavity?
Submandibular - submandibular duct (Wharton’s duct) - adjacent to frenulum
Parotid - parotid duct (Stensen’s duct) - opposite 2nd maxillary molar
Which operations are likely to require an end ileostomy?
Permanent: panproctocolectomy (e.g. UC)
Temporary: total colectomy with later ileal pouch-anal anastomosis (e.g. FAP)
EPONYMOUS OPERATIONS: Achalasia
Heller’s cardiomyotomy - longitudinal incision through muscularis propria at lower oesophageal sphincter
What are some major contraindications for using a nasopharyngeal tube?
Facial injuries
Basal skull fracture (Raccoon eyes, Battle sign, haemotympanum, CSF rhinorrhoea/otorrhoea)
Which surgical treatment options are considered in UC patients?
Subtotal colectomy with end ileostomy +/- mucus fistula (can be followed with ileorectal anastamosis, IPAA or permanent end ileostomy)
Proctocolectomy and end ileostomy
Describe Buerger’s test.
Lift both legs to 45 degrees and observe for pallor and venous guttering
The angle at which the foot goes white is Buerger’s angle
When the foot blanches, swing the legs over the side of the bed and let them hang
The ischaemic foot will go brick red (reactive hyperaemia)
NOTE: this indicated significant peripheral arterial disease
What is thoracic outlet syndrome?
Venous - upper limb DVT and swelling
Arterial - Raynaud’s, claudication, embolisation
Neurological - pain, radiculopathy
NOTE: caused by compression between the 1st rib, clavicle and scalenus anterior. It is investigated using MRI, Duplex and nerve conduction studies
List some indications for using a larngeal mask airway.
Non-definitive airway for short day-case surgery
Emergency situations if unable to insert ET tube
List some causes of gynaecomastia.
Drugs (spironolactone, digoxin, ranitidine, verapamil, captopril, anabolic steroids)
Physiological (puberty)
Hypogonadism (hyperprolactinaemia, renal failure, testicular atrophy, Klinefelter’s)
Increased oestrogens (sex cord stromal tumours, lung cancer, chronic liver disease, thyrotoxicosis)
Which classification system is used for diverticulitis?
Hinchey Grading 1 = small confined pericolic abscess 2 = large abscesses extending into the pelvis 3 = purulent peritonitis 4 = faecal peritonitis
NOTE: 1-2 rarely require surgery, 3 requires at least on table washout, 4 requires Hartmann’s
Which classification system is used for pelvic fractures?
Young and Burgess classification Lateral compression (ipsilateral pubic ramus fracture) AP compress (open book fracture) Vertical shear (inherently unstable)
NOTE: complications include haemorrhage, urethral injury and bladder injury
What is Goodsall’s law?
If the external opening of an anal fistula is posterior to the transverse anal line, it will follow a curvilinear path opening in the posterior midline of the anal canal
If it is anterior to the transverse anal line, it will have a radial fistulous tract.
What is the difference between an open and a closed surgical drain?
Open: fluid collects into dressing or stoma bag (e.g. corrugated rubber, plastic sheets)
Closed: tube is attached to a container (e.g. chest drain)
What are the contents of the inguinal canal in males?
Spermatic cord
Ilioinguinal nerve
Outline the staging of prostate cancer.
Stage 1 and 2 - can’t be palpated on DRE
Stage 3 - can palpate on DRE
Stage 4 - metastasised
List some indications for bypass grafting in chronic limb ischaemia.
Very short claudication distance
Symptoms greatly affecting patient
Rest pain
What is the main purpose of a CT urogram?
Pick up filling defects
NOTE: it takes a control film, then another image 5 mins after contrast administration and the final one at 15 mins after contrast
List some causes of a persistent hoarse voice.
Nodules Polyps Reinke's oedema Granuloma Laryngeal cancer
Which classification system is used for fractures of the growth plate?
Salter-Harris classification
1 - Straight across growth plate
2 - Above the growth plate (diaphyseal side)
3 - Lower than growth plate (epiphyseal side)
4 - Through the growth plate
5 - crush
NOTE: 2 is most common and 5 has the worst prognosis
Outline the management of incisional hernias.
Surgery not always necessary as hernias are usually broad-necked and low risk of strangulation
Manage risk factors (e.g. treat cough, weight loss)
Surgery: nylon mesh repair
List some indications for central venous catheters.
Central venous pressure measurement (for fluid balance)
Drug administration (amiodarone, mannitol, potassium)
Total parenteral nutrition
How can direct and indirect inguinal hernias be distinguished on examination?
Reduce the hernia
Place 2 fingers over the deep inguinal ring (midpoint of inguinal ligament)
Ask patient to cough (hernia pops out if it is direct)
NOTE: ultrasound can be used to identify hernias
What is the main indication for a urostomy?
Total cystectomy
