Surgery Flashcards
What is Balanitis (BXO), how does it present and what is its DDx?
Balanitis xerotica obliterans = keratinisation of the tip of the foreskin causing scaring and the prepuce remains non-retractile
Peak incidence 9-11y
S+S = irritation, dysuria, haematuria, local infection, prepuce will appear as a white/fibrotic/scarred preputial tip
DDx = Phimosis, balanitis, buried penis, zoon plasma cell balanitis
Mx = circumcision
What is Cryptorchidism, how does it present and what is its DDx?
Failure of testicular descent into the scrotum
- True undescended testis = testis absent from scrotum but lies along the line of testicular descent
- Ectopic testis = testis found away from the normal path of decent
- Ascending testis = testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum
Hormonal causes such as androgen insensitivity syndrome or disorder of sex development must also be excluded.
S+S = not palpable in scrotum
DDx = normal retractile testis, true undescended testis , ectopic testis, absent testis, bilaterally impalpable testes
Mx = wait 6m (can migrate), if not orchidopexy
What is congenital diaphragmatic hernia, how does it present and what is its DDx?
Congenital birth defect = opening in the diaphragm allowing herniation of abdo contents into the thorax (typically L sided) - leading to impaired lung devel
S+S = diff resus at birth, resp distress, bowel sounds in hemithorax, apex/heart sounds on R side, diminished air entry, cyanosis
Ix = x-ray (bowel in thorax)
Mx = thoracoabdominal incision, close incision/patch
DDx = bronchopulmonary sequestration, congenital cystic adenomatoid malformation, bronchogenic cysts, and enteric cysts
What is a hydrocele, how does it present and what is its DDx?
Abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis and/or along the spermatic cord
Processus vaginalis patent at birth allowing only fluid from the peritoneal cavity to pass down
S+S = painless swelling of one or both testicles
DDx = Spermatocele, varicocele, haematocele, inguinal hernia (bowel), testicular tumours
What is malrotation, how does it present and what is its DDx?
Absent attachment of the SI mesentery can cause mid-gut rotation or obstruction in the third-part of the duodenum by fibrotic bands
S+S = bilious vomiting, PR bleeding
DDx = Bowel Obstruction in the Newborn, congenital band, intestinal Volvulus, necrotizing enterocolitis, neonatal Sepsis, paediatric duodenal atresia
What is necrotising enterocolitis, how does it present and what is its DDx?
Typically occurs in 2-3w of life in low birth weight premature, after enteral feeds
Bowel ischemia (last place to be perfused - low end-diastolic flow then low perforation and poor devel), inflam, necrosis, potentially finally perforation
RF = prematurity, low birth weight/IUGR, formula feed, ibuprofen, PDA, Abx >10d, gastroschisis, sepsis, umbilical lines
S+S = poor feeding, distended tender abdo, decreased activity, blood in the stool, bilious vomiting, change in stool patterns, palpable bowel loops
Ix = AXR (pneumotosis intestinalis - gas in the bowel wall)
DDx = sepsis, anal fissure, infectious enterocolitis, Hirschsprung disease
What is a Trachea-oesophageal fistula, how does it present and what is its DDx?
Congenital birth defect
Connection between the oesophagus and the trachea
S+S = copious salivation associated with choking, coughing, vomiting, and cyanosis coincident with the onset of feeding
- if oesophageal atresia present = polyhydramnios, vomiting post feed, cyanotic ep, drooling
DDx = laryngo-tracheoesophageal cleft, oesophageal webs, oesophageal stricture, oesophageal diverticulum, tubular oesophageal duplications, congenital short oesophagus, and tracheal agenesis/atresia
What is the aetiology and pathophysiology of Pyloric stenosis?
Aetiology = unknown
Path = progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction
More common in boys
Hypochloremic, hypokalemic metabolic alkalosis, with paradoxical aciduria
How does pyloric stenosis present?
4-6 weeks of age
- projectile non-bilious vomiting after every feed
- Haematemesis
- Weight loss and dehydration
- Visible peristalsis
- Palpable olive-sized pyloric mass
Outline how pyloric stenosis should be investigated?
Test feed:
- NG tube in situ and the stomach aspirated
- Palpate for a pyloric mass and observe for visible peristalsis during
USS = hypertrophy of the pyloric muscle, with wall thickness >3mm, length >15mm and diameter >11mm
Dynamic scan - while swallowing
Describe the Mx of pyloric stenosis
Correct fluid or electrolyte abnormalities
Ramstedt’s pyloromyotomy (incision is made in the longitudinal and circular muscles of the pylorus)
Babies can resume feeding after 6h, although there may be some residual vomiting
What is the pathophysiology and aetiology of an acute appendicitis?
Inflam of the appendix
Aetiology =
- Faecolith = stony mass of faeces
- Lymphoid hyperplasia
- Impacted stool
- Caecal tumour
How does an acute appendicitis present?
- Abdominal pain = initially dull peri-umbilical localising to the RIF (sharp), aggravated by movement
- Vomiting
- Anorexia
- Nausea
- Diarrhoea
- Constipation
- Tachycardia
- Tachypnoeic
- Pyrexia
- Rebound tenderness
- Percussion pain over McBurney’s point
- Guarding = if perforated
Rovsing’s sign: RIF fossa pain on palpation of the LIF
Psoas sign: RIF pain with flexion of the right hip (inflamed appendix abutting psoas major muscle in a retrocaecal position)
How should a suspected acute appendicitis be investigated?
Urinalysis = exclude UTI, renal, urological cause
Pregnancy test
Routine bloods = FBC, CRP
Pelvic exam in females of reproductive age = gynaecological pathology
Trans-abdominal US = most useful in children (less abdo fat)
CT scan = used in older pts
How should an acute appendicitis be managed?
Abx = in uncomplicated cases
Laparoscopic appendicectomy = appendix sent to histopathology
Describe the pathophysiology of an inguinal hernia
Abdo contents enter the inguinal canal
DIRECT = bowel enters inguinal canal “directly” through a weakness in wall, Hesselbach’s triangle
INDIRECT = bowel enters the inguinal canal via the deep inguinal ring, patent processus vaginalis
How can you differentiate between an indirect and direct inguinal hernia?
Indirect hernias will be lateral to the inferior epigastric vessel
Direct hernias will be medial to the inferior epigastric vessels
How does an inguinal hernia present?
Lump in groin = will disappear with minimal pressure
Discomfort which can worsen with activity or standing
Incarcerated = painful, tender, erythematous
Strangulated = pain out of proportion to clinical signs
How should an inguinal hernia be investigated?
Exam = reduce hernia, place pressure over deep inguinal ring (mid-point of the inguinal ligament), before asking the patient to cough, protrusion = direct
Explorative surgery = definitive diagnosis
US = to exclude other pathology
How should an inguinal hernia be managed?
Surgical repair = open or laparoscopic
Outline the pathophysiology of testicular torsion
Twisting of spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle = surgical emergency
Rate of testicular viability decreases significantly after 6 hours from onset of symptoms
Twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle
Bell-clapper deformity (commonly adolescents) = attachment of tunica vaginalis to the testicle is inappropriately high, spermatic cord can rotate within it = intravaginal torsion
Extravaginal torsion (commonly neonates) = tunica vaginalis is not yet secured to the gubernaculum and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo torsion as a unit
What are the signs and symptoms of testicular torsion?
Sudden onset (may be related to trauma) of severe unilateral scrotal pain
Followed by inguinal and/or scrotal swelling
Nausea
Vomiting
Absence of cremasteric reflex
Abnormal testicular direction
Painful urination
Scrotal erythema
How should testicular torsion be investigated?
Surgical exploration
Scrotal exam = diff due to pain and scrotal oedema
TWIST scoring = testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1), high-riding testis (1)
Urinalysis = exclude UTI
Outline the management of testicular torsion
If Hx/exam strongly suggest testicular torsion, pt should go directly to surgery
Orchiopexy = testis is anchored to the scrotal wall
Orchietomy = if the testis is necrotic
Give a DDx for paediatric lumps of the neck
Ix if = >2w, >2cm, >2 regions affected
- Kawasaki Disease = unilateral, >15mm, painful nodes
- Viral infections (EBV, CMV)
- Bacterial infections (strep, staph)
- Malignancy (lymphoma, leukaemia)
- Juvenile chronic arthritis, SLE, atopic eczema
- Lipoma
- Dermoid cyst
- Sebaceous cyst
- Thyroid (moves on swallow)
- Branchial cyst
- TB
- Abscess
- Cystic hygroma
How long should children fast for prior to surgery?
Solids = 6h
Liquids = 2 h
Baby on breast milk = 4h
What is tongue tie (ankyloglossia)?
Unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue’s tip to the floor of the mouth
Congenital
Doesn’t effect speech but can effect feeding
Mx = watch and wait (may loosen over time, resolving), if not surgery
What is a thyroglossal cyst?
The thyroid gland is connected to the tongue during development via the thyroglossal duct
If the duct doesn’t close/atrophy, collects fluid, creates cyst (midline)
Painless unless infected (abscess)
Mx = sistrunks procedure (GA, remove cyst, thyroglossal tract, part of hyoid bone)
What is gastroschisis vs an omphalocoele?
Gastroschisis
- Failure of abdo wall to close = bowel outside
- Can have associated bowel atresia, absorption problems (dependent on parenteral nutrition)
- Mx = bowel in silo, held upright, gravity pushes bowel inside, 3-4d surgical closure of defect
Omphalocoele
- Persistent physiological gut herniation
- Surrounded by peritoneum
- Major (with liver), minor (just bowel)
- Prone to hypoglycaemia (check BM)
What factors can be used to differentiate testicular torsion from torted hydatid of Morgagni from epididymo-orchitis?
0-10mins, loss of cremasteric reflex = torsion
0-8hrs with worse pain after 1-2d, blue dot = torted hydatid of Morgagni
Dysuria first then pain + swelling after 2-3d, urine dip = epididymo-orchitis
What is the aetiology and pathophysiology of paediatric intussusception?
Segment of intestine “telescopes” inside of another, causing an intestinal obstruction (blockage) - most commonly ileum passing into the caecum through the ileocaecal value
Tends to happen between 3-18m
Causes typically unknown
Complication = venous obstruction, engorgement, bleeding, fluid loss, bowel perforation, peritonitis, gut necrosis
How does intussusception present?
Sudden onset crying, severe abdo pain, comes and goes, 2-3m
In between episodes, the child will look very pale, tired and floppy
After 12 hours or so the pain becomes more constant, and the child will usually go off food and may vomit (dehydration = lethargy, floppy, sunken fontanelle, fewer wet nappies)
A lump in the abdomen
Stool mixed with blood and mucus (sometimes referred to as “currant jelly” stool because of its appearance)
Outline how suspected intussusception should be investigated?
Palpation = swollen bowel
USS
AXR
Describe how diagnosed intussusception should be managed
Dehydration = fluids
NG tube = drain off the stomach and bowel contents, and vent any air that has built up
Intussusception = air enema
Unsuccessful = GA laparoscopic
Give a DDx for paediatric abdo pain
Intussusception Gastroenteritis Constipation UTI Appendicitis Abdominal migraine Lower lobe pneumonia Primary peritonitis - ascites from nephrotic syndrome/liver disease DKA Testicular pathology Ovarian pathology MSK Reflux Factitious Bowel Obstruction Food allergy Inguinal hernia
Give a DDx for paediatric intestinal obstruction
Meconium ileus Meconium plug Hirschsprung’s disease Oesophageal atresia Duodenal/jejunum/ileum atresia/stenosis Intussusception Imperforate anus Malrotation of the intestines with a volvulus Strangulated hernia
Outline Hirschsprung’s Disease
Ganglionic cells fail to develop in the myenteric and submucosal plexus in the large intestine = obstruction
S+S = delayed or failed passage of meconium within 48h of birth, distention, bilious vomiting, constipation
Ix = AXR, contrast enema, rectal suction biopsy
Mx = IV antibiotics, nasogastric tube insertion, bowel decompression, surgery resecting the aganglionic section (Swenson, Soave, and Duhamel pull-through procedures)
Outline paediatric malrotation and volvulus
Malrotation occurs when the intestine does not make the turns as it should
Malrotation causes the SI to twist around the SMA
S+S = vomiting bile, stomach pain, diarrhoea or constipation, bloody stools, distention, failure to thrive
Ix = AXR, CT, barium swallow/enema
Mx
- Symptomatic malrotation = Ladd’s procedure
- Volvulus = SI in an anticlockwise direction, caecum in L abdo, duodenum directed down R paravertebral gutte
Outline paediatric anorectal abnormalities
Types = cloacal malformation, imperforate anus, rectal atresia and stenosis, fistula
S+S = lack of stool, stool coming from the vagina, stool in the urine, urine coming from the anus, constipation
How does paediatric head injury present?
Scalp wound
LOC
Headache
Light-headedness
Confusion: disorientation, incoherent speech
N+V
Tinnitus
Seizures
Balance, coordination problems
Abnormal eye movements
Memory problems
Leaking of clear fluid from the ear or the nose
How should a head injury be Ix?
x3 vomiting = CT head and cervical spine imaging
Outline the Mx for a head injury?
A-E
GCS 8 or less, ensure there is early involvement of an anaesthetist or critical care physician to provide appropriate airway management
Manage pain effectively because it can lead to a rise in intracranial pressure (small dose IV morphine)
Discuss with a neurosurgeon if surgical abnormalities on imaging
What are the possible complications from a head injury?
Permanent changes in their personality
Decreased physical ability
Decreased cognition
Seizures
Hydrocephalus
List a DDx for head injury
Stroke Dementia Brain Metastasis Cerebral Aneurysms Hydrocephalus Prion-Related Diseases
