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Surgery Firm Mushkies Flashcards

1
Q

What are the pre-operative checks?

A

OP CHECS

  1. Operative fitness: cardiorespiratory comorbidities
  2. Pills
  3. Consent
  4. History: Medical (MI, Asthma, HTN, Jaundice) + Anaesthetic (DVT, anaphylaxis)
  5. Ease of Intubation: neck arthritis, dentures, loose teeth
  6. Clexane: DVT Prophylaxis
  7. Site: correct and marked
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2
Q

What is the crossmatch quantities for gastrectomy

A

4 units

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3
Q

Prophylactic Abx is used for which surgeries?

A 
GI surgery (20% post-op infection if elective) 
Joint replacement
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4
Q

DVT prophylaxis protocol for low, medium, and high risk

A

Low risk = early mobilisation
Medium risk = early mobilisation + TEDS + 20mg clexane
High risk = early mobilisation + TEDS + 40mg clexane + intermittent compression boots perioperatively

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5
Q

What is the crossmatch quantity for AAA?

A

6 units

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6
Q

What are the ASA grades? x6

A

ASA I = a normal healthy patient
ASA II = a patient with mild systemic disease
ASA III = a patient with severe systemic disease
ASA IV = a patient with severe systemic disease that is a constant threat to life
ASA V = a moribund patient that is not expected to survive without the operation
ASA VI = a declared brain-dead patient whose organs are being removed for donor purposes

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7
Q

Post-operative complications due to diabetes? x4

A

Increased risk of infection
NBM –> increased risk of hypo
Stress hormone release –> insulin antagonism
IHD and PVD

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8
Q

T1DM pre-operative management? x4

A

Put pt first on list and inform surgeon + anaesthetist
? Stop long acting insulin the night before
Omit AM insulin if surgery is in morning
Start sliding scale insulin
Continue until tolerating food

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9
Q

What T1DM post-surgical glucose levels are you aiming for?

A

7-11mM

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10
Q

Is an insulin sliding scale necessary for minor operations for pts with T1DM?

A

May not be necessary, if in doubt liaise w/ specialist nurse

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11
Q

T2DM pre-operative management?

A

If glucose control poor (fasting >10mM) –> Tx as T1DM
Omit oral hypoglycaemics on AM of surgery
Resume oral hypoglycaemics with meal

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12
Q

Post-operative complications due to steroids? x3

A
  1. Poor wound healing
  2. Infection
  3. Addisonian Crisis
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13
Q

What are patients with obstructive jaundice at increased risk of post-operatively?

A

Renal failure

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14
Q

Pre-op management of jaundice x5

A
  1. Avoid morphine
  2. Check clotting and consider pre-op Vit K
  3. Give 1L NS pre-op (unless CCF)
  4. Urinary Catheter
  5. ABx : Cef and Met
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15
Q

Intra-operative management of jaundice x2

A

Hourly Urine Output monitoring

Normal saline titrated to output

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16
Q

Post-operative management of jaundice x 2

A

Intensive monitoring of fluid status

Consider CVP + Frusemide if poor output despite NS

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17
Q

What anaesthesia should you avoid on anticoagulated patients?

A

Epidural, spinal, and regional blocks

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18
Q

Should you stop aspirin/clopidogrel before surgery?

A

Continue usually If risk of bleeding is high - stop 7d before surgery

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19
Q

Risks of COPD and surgery? x3

A
  1. Basal atelectasis
  2. Aspiration
  3. Pneumonia
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20
Q

What are the aims of anaesthesia?

A 
HAAM
Hypnosis 
Analgesia 
Amnesia 
Muscle relaxation (paralysis)
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21
Q

What are the 7As of pre-medication?

A

Anxiolytics and Amnesia = Temazepam
Analgesics = Paracetamol, NSAIDS, opioids
Anti-emetics = Ondansetron 4mg/Metoclopramide 10mg Antacids = Lanzoprazole
Anti-sialogue = glycopyrolate
Antibiotics

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22
Q

What agent is used for anaesthetic induction?

A

Propofol

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23
Q

What agent is used for muscle relaxation?

A 
Depolarising = suxamethonium 
Non-depolarising = atracurium/vecuronium
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24
Q

What agent is used for anaesthetic maintenance?

A

Enflurane/Desflurane

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25
Q

What chemical compound are enflurane/desflurane?

A

Halogenated ethers

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26
Q

What are complications of anaesthesia? x6

A
  1. Propofol induction = cardiorespiratory depression
  2. Intubation = oropharyngeal injury, oesophageal intubation
  3. Loss of pain sensation = urinary retention, pressure necrosis, nerve palsies
  4. Loss of muscle power = corneal abrasion, no cough (atelectasis + pneumonia)
  5. Malignant hyperthermia
  6. Anaphylaxis
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27
Q

What is malignant hyperthermia?

A
  1. Rare complication prompted by halothane or suxamethonium
  2. AD inheritance
  3. Characterised by rapid rise in temperature and masseter spasm
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28
Q

What is the management of malignant hyperthermia?

A

Dantrolene and active cooling

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29
Q

What are some possible triggers of surgical anaphylaxis?

A
  1. Antibiotics
  2. Colloid
  3. Neuromuscular blockers e.g. vecuronium
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30
Q

Spinal Anaesthesia Agents

A 
Little Boys Prefer Toys 
Lidocaine
Bupivucaine 
Procaine
Tetracaine
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31
Q

Where not to use LA with adrenaline

A

Ears, nose, fingers, toes and penis

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32
Q

How does carcinoid syndrome present?

A

FIVE HT
Flushing (paroxysmal, upper body, wheals)
Intestinal (diarrhoea)
Valve fibrosis (tricuspid regurg and pulmonary stenosis) Wheeze (bronchoconstriction)
Hepatic involvement (bypassed 1st pass metabolism) Tryptophan deficiency –> Pellagra (3D’s)

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33
Q

What are the symptoms of Pellagra?

A

Dementia
Diarrhoea
Dermatitis

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34
Q

Symptomatic treatment of carcinoid syndrome?

A

Octreotide or loperamide

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35
Q

What is the commonest surgical emergency?

A

Acute appendicitis

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36
Q

What is the most common cause of acute appendicitis?

A

Obstruction of appendix by a faecolith

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37
Q

What is Murphy’s triad?

A

Triad of Appendicitis Presentation

Pain, Anorexia+Nausea+Vomiting, Fever

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38
Q

Signs associated with acute appendicitis?

A
  1. Rovsing’s sign = LIF pressure –> more pain in RIF
  2. Psoas sign = Pain on extending hip (retrocaecal appendix)
  3. Cope sign = Flexion+internal rotation of R hip –> pain (appendix lying close to obturator internus)
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39
Q

How to classify UC vs. Crohns

A
  1. Macroscopic = Location, Distribution, Strictures

2. Microscopic = Inflammation, Ulceration, Fibrosis, Granulomas, Pseudopolyps

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40
Q

Extra-abdominal manifestations of IBD?

A 
Skin 
Eyes 
Joints 
HPB 
Other
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41
Q

Skin changes in IBD?

A

Clubbing
Erythema Nodosum
Pyoderma Gangrenosum

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42
Q

Eye changes in IBD?

A

Iritis
Conjunctivitis
Episcleritis
Scleritis

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43
Q

Joint changes in IBD?

A

Arthritis (non-deforming, asymmetrical)
Sacroiliitis
Ankylosing Spondylitis

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44
Q

HPB changes in IBD?

A

PSC + Cholangiocarcinoma (UC)
Gallstones (Crohn’s)
Fatty Liver

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45
Q

‘Other’ changes in IBD?

A

Amyloidosis

Oxalate renal stones

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46
Q

Complications of UC? x4

A
  1. Toxic megacolon (perforation)
  2. Bleeding
  3. Malignancy (Colorectal cancer, cholangiocarcinoma)
  4. Strictures (Obstruction)
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47
Q

Complications of Crohn’s DIsease? x4

A
  1. Fistulae
  2. Strictures (obstruction)
  3. Abscesses (abdominal, anorectal)
  4. Malabsorption (Fat, B12, Vit D, Protein)
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48
Q

What complications can occur as a result of malabsorption in Crohns disease?

A

Fat = steatorrhoea, gallstones
B12= megaloblastic anaemia
Vit D = osteomalacia
Protein = oedema

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49
Q

Parameter for toxic megacolon?

A

Megacolon >6cm on AXR

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50
Q

What criteria is used for grading UC severity?

A

Truelove and Witts criteria

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51
Q

What is the law of 2s for Meckel’s diverticulum? x5

A 
2 inches long 
2ft from ileocaecal valve on antimesenteric border 
2% of population 
2% symptomatic 
2 tissue types = gastric or pancreatic 
2:1 male predominance 
<2 y/o children
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52
Q

Difference between a true and false diverticulum?

A 
True = composed of complete wall e.g. Meckel's 
False = composed of mucosa only (pharyngeal, colonic)
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53
Q

What is Saint’s triad?

A

Hiatus Hernia
Cholelithiasis
Diverticular Disease

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54
Q

What is the grading system for perforated diverticulitis?

A

Hinchey Grading

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55
Q

What is a Hartmann’s procedure?

A

Surgical resection of the rectosigmoid colon with the formation of an anorectal stump and formation of an end colostomy

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56
Q

Complications of Diverticular Disease?

A 
Perforation 
Haemorrhage
Abscess
Fistulae 
Strictures
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57
Q

What are the 3 types of bowel obstruction?

A

Simple
Closed Loop
Strangulated

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58
Q

What is a simple bowel obstruction?

A

1 obstructing point + no vascular compromise

May be partial or complete

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59
Q

What is a closed loop bowel obstruction?

A

Bowel is obstructed at 2 points

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60
Q

What is a strangulated bowel obstruction?

A

Bowel has a compromised blood supply

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61
Q

Commonest causes of small bowel obstruction?

A

Adhesions = 60%

Hernias

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62
Q

Commonest causes of large bowel obstruction?

A

Colorectal Neoplasia = 60%
Diverticular Stricture = 20%
Volvulus = 5%

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63
Q

How do you classify causes of bowel obstruction?

A

Mechanical and Non-Mechanical

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64
Q

What are the non-Mechanical Causes of Bowel Obstruction (Paralytic Ileus)?

A 
5Ps, 2Ms
Post-op 
Peritonitis 
Pancreatitis/any localised inflammation 
Poisons/Drugs e.g. Anti-ACh (TCAs) 
Psuedo-obstruction 
Metabolic (Low K, Na, Mg and Uraemia)
Mesenteric ischaemia
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65
Q

What are the Mechanical Causes of Bowel Obstruction?

A

Intraluminal
Intramural
Extramural

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66
Q

What are the Intraluminal causes of bowel obstruction?

A

Impacted matter (faeces, worms, bezoars)
Intussusception
Gallstones

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67
Q

What are the Intramural causes of bowel obstruction?

A
  1. Benign Stricture = IBD, Surgery, Ischaemic colitis, Diverticulitis, Radiotherapy
  2. Neoplasia
  3. Congenital Atresia
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68
Q

What are the Extramural causes of bowel obstruction?

A
  1. Hernia
  2. Adhesions
  3. Volvulus (Sigmoid, Caecal, Gastric)
  4. Extrinsic Compression (Pseudocyst, Abscess, Haematoma, Tumour, Congenital bands)
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69
Q

Presentation of Bowel Obstruction?

A

DAVe
Distension
Abdominal Pain
Vomiting

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70
Q

Emergency management of bowel obstruction?

A

“Drip and Suck”
NBM + NGT
IV Fluids
Catheterise

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71
Q

What is the most common type of volvulus?

A

Sigmoid volvulus

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72
Q

Classification of colonic adenomas?

A

Tubular
Villous
Tubulovillous

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73
Q

Difference in the main presentation of L vs. R colorectal carcinoma?

A 
L = altered bowel habit 
R = Anaemia
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74
Q

Aetiology of colorectal carcinoma?

A 
Doesnt it feel so grizzly
Diet 
IBD 
Familial = FAP, HNPCC, Peutz-Jeghers 
Smoking 
Genetics
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75
Q

What are protective for colorectal carcinoma?

A

NSAIDs/Aspirin

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76
Q

Locations of colorectal carcinoma?

A 
Rectum = 35%
Sigmoid = 25%
Caecum and Ascending Colon = 20%
Transverse = 10% 
Descending = 5%
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77
Q

Spread of colorectal carcinoma?

A

Local
Lymphatic
Blood
Transcoelomic

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78
Q

Mutation responsible for FAP?

A

APC gene on 5q21

Autosomal Dominant

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79
Q

Features of Gardner’s syndrome?

A

TODE
Thyroid tumours
Osteomas of the mandible, skull and long bones
Dental abnormalities = supernumary teeth
Epidermal cysts

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80
Q

What is the 3-2-1 rule for HNPCC?

A

≥3 family members over 2 generations with 1 <50y/o

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81
Q

Mutation responsible for Peutz-Jeghers Syndrome?

A

STK11 mutation

Autosomal Dominant

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82
Q

Features of Peutz-Jeghers Syndrome?

A

3 M’s
Mucocutaneous hyperpigmentation
Multiple GI hamartomatous polyps
Malignancy risk = colorectal, pancreas, breast, lung, ovaries, uterus

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83
Q

What are the types of GI polyp?

A
  1. Inflammatory pseudopolyps
  2. Hyperplastic polyps
  3. Hamartomatous
  4. Neoplastic (tubular/villous/tubulovillous adenomas)
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84
Q

What are gallstones composed of?

A
  1. Phospholipids (lecithin)
  2. Bile pigments
  3. Cholesterol
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85
Q

Aetiology of gallstones?

A
  1. Lithogenic bile: Admirand’s triangle
  2. Gallbladder hypomotility = pregnancy, OCP, TPN, fasting
  3. Biliary sepsis
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86
Q

What are the different types of gallstone?

A

Mixed stones = 75%
Cholesterol stones = 20%
Pigment stones = 5%

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87
Q

What makes up pigment stones?

A

Calcium bilirubinate

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88
Q

How do you classify the complications of gallstones?

A
  1. In the Gallbladder
  2. In the Common Bile Duct
  3. In the Gut
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89
Q

What are the gallbladder complications of gallstones?

A
  1. Biliary colic
  2. Acute cholecystitis +/- empyema
  3. Chronic cholecystitis
  4. Mucocele
  5. Carcinoma
  6. Mirizzi Syndrome
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90
Q

What are the CBD complications of gallstones?

A

Obstructive Jaundice
Pancreatitis
Cholangitis

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91
Q

What is the gut complication of gallstones?

A

Gallstone ileus

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92
Q

What is Mirizzi syndrome?

A

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder

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93
Q

What is the pathogenesis of biliary colic?

A

Gallbladder spasm against a stone impacted in the neck of the gallbladder (Hartmann’s pouch)

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94
Q

What are the US findings of biliary colic?

A
  1. Stones = acoustic shadow
  2. Dilated ducts = >6mm
  3. Inflamed gallbladder = wall oedema
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95
Q

What is the pathogenesis of acute cholecystitis?

A
  1. Stone or sludge impaction in Hartmann’s pouch –> chemical and or bacterial inflammation
  2. 5% are acalculous = sepsis, burns, DM
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96
Q

What are some signs of acute cholecystitis?

A
  1. Murphy’s sign
  2. Palpable phlegmon (mass of adherent omentum and bowel)
  3. Boas’ sign (hyperaesthesia below the right scapula)
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97
Q

What are the characteristic features of chronic cholecystitis?

A

Flatulent dyspepsia exacerbated by fatty foods

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98
Q

What are 4 rarer gallstone diseases?

A 
2Ms and 2Gs
Mucocele 
Mirizzi's syndrome 
Gallbladder carcinoma 
Gallstone Ileus
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99
Q

What is a mucocele?

A

When the neck of the gallbladder is blocked by a stone but the contents remain sterile

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100
Q

What are some features of gallbladder carcinoma?

A

Rare
Associated w/ gallstones and gallbladder polyps Calcification of gallbladder –> porcelain gallbladder Incidental Ca found in 0.5-1% of lap choles

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101
Q

What is a gallstone ileus?

A
  1. When a large stone (>2.5cm) erodes from the gallbladder to the duodenum
  2. Via a cholecysto-duodenal fistula secondary to chronic inflammation
  3. May impact in the distal ileum, leading to obstruction
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102
Q

What is Rigler’s triad?

A

Combination of AXR findings in gallstone ileus

  1. Small bowel obstruction
  2. Pneumobilia
  3. Gallstone outside the gallbladder
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103
Q

What is Bouveret’s syndrome?

A

Duodenal obstruction due to a gallstone ileus

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104
Q

What are the causes of obstructive jaundice?

A 
1/3rd = stones 
1/3rd = carcinoma of the head of the pancreas 
1/3rd = Other
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105
Q

What are the 1/3rd ‘other’ causes of obstructive jaundice?

A
  1. Lymph nodes at Porta Hepatis = TB, Ca
  2. Inflammatory = PBC, PSC
  3. Drugs = OCP, sulfonylureas, flucloxacillin
  4. Neoplastic = Cholangiocarcinoma
  5. Mirizzi’s syndrome
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106
Q

What is Charcot’s triad of ascending cholangitis?

A

Charcot’s triad = Rigors, RUQ pain, jaundice

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107
Q

What is Reynold’s pentad of ascending cholangitis?

A

Charcot’s triad + shock + confusion

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108
Q

What is the management of ascending cholangitis?

A
  1. Cef and Met
  2. ERCP
  3. Open or laparoscopic stone removal with T tube drain
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109
Q

What are the risk factors for pancreatic carcinoma?

A 
SINED
Smoking 
Inflammation = chronic pancreatitis 
Nutrition = high fat diet 
EtOH
Diabetes Mellitus
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110
Q

What is the pathology of pancreatic carcinoma?

A
  1. 90% are ductal adenocarcinomas
  2. Present late, metastasise early
  3. 60% head, 25% body, 15% tail
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111
Q

What is Trousseau’s sign of malignancy?

A

Migratory thrombophlebitis most commonly due to adenocarcinomas of the lung and pancreas, and gliomas

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112
Q

What is Courvoisier’s Law?

A

In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones

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113
Q

What is a Whipple’s procedure?

A

A pancreaticoduodenectomy performed to remove malignancy from the head of the pancreas

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114
Q

What are the causes of acute pancreatitis?

A 
I GET SMASHED 
Idiopathic 
Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps + Coxsackie B 
Autoimmune e.g. PAN 
Scorpion venom = Trinidadian scorpion (Tityus trinitatis)
Hyperlipidaemia, Hypercalcaemia, Hypothermia 
ERCP = 5% risk 
Drugs e.g. thiazides, azathioprine
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115
Q

What are some eponymous signs of acute pancreatitis?

A
  1. Grey Turner’s sign = flank ecchymosis

2. Cullen’s sign = periumbilical ecchymosis

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116
Q

What is the Modified Glasgow Criteria?

A
  1. For assessing the severity and predicting mortality of acute pancreatitis
  2. Valid for EtOH and Gallstones
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117
Q

What are the components of the Modified Glasgow Criteria?

A 
PANCREAS
PaO2 <8kPaAge >55y/o
Neutrophils >15x10^9/L
Ca <2mM
Renal function = U>16mM
Enzymes LDH>600IU/L, AST>200IU/L
Albumin <32g/L
Sugar>10mM
Score: 1 = mild, 2 = moderate, 3 = severe
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118
Q

What is Ranson’s criteria?

A
  1. For assessing the severity and predicting mortality of acute pancreatitis
  2. Only valid for EtOH and can only be fully applied after 48hrs
  3. GALAW (admission) and CHOBBS (48hrs)
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119
Q

Causes of mesenteric ischaemia?

A
  1. Arterial = Thrombotic 35%, Embolic 35%
  2. Non-occlusive (20%) = Splanchnic vasoconstriction 2° to shock
  3. Venous Thrombosis = 5%
  4. Other = Trauma, Vasculitis, Strangulation
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120
Q

Cause of chronic small bowel ischaemia?

A

Atheroma + Low flow state (e.g. LVF)

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121
Q

Cause of chronic large bowel ischaemia?

A

Low flow in IMA territory

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122
Q

Most common/important causes of lower GI bleed?

A

Malignancy
Diverticulitis
Rectal = haemorrhoids/fissure

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123
Q

‘Other’ causes of lower GI bleeding?

A

IIPLA (sound blood makes when it hits toilet)
Infection = CHESS
Inflammation = IBD
Polyps
Large upper GI bleed
Angio = dysplasia, ischaemic colitis, HHT

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124
Q

What are the CHESS organisms?

A 
Campylobacter 
Haemorrhagic E. coli 
Entaemoeba Histolytica 
Shigella 
Salmonella
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125
Q

What is angiodysplasia?

A

Submucosal AV malformations
70-90% occur in right colon
Can affect anywhere in GIT

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126
Q

What is the treatment for angiodysplasia?

A

Embolisation
Endoscopic laser electrocoagulation
Resection

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127
Q

How do you classify the complications of acute pancreatitis?

A
  1. Early (systemic)

2. Late (Local) >1wk

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128
Q

What are the early (systemic) complications of acute pancreatitis?

A
  1. Respiratory = ARDS, pleural effusion
  2. Renal failure
  3. Shock = hypovolaemic or septic
  4. DIC
  5. Metabolic = hypocalcaemia, hyperglycaemia, metabolic acidosis
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129
Q

What are the late (local) complications of acute pancreatitis?

A
  1. Pancreatic necrosis/infection/abscess
  2. Bleeding e.g. from splenic artery (may require embolisation)
  3. Thrombosis
  4. Fistula formation = pancreato-cutaneous (skin breakdown)
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130
Q

Where might a pancreatic abscess form, and how do you treat it?

A

May form in a pseudocyst or in the pancreas itself Treated with open or percutaneous drainage

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131
Q

What is a pancreatic pseudocyst? How often does it occur?

A

A collection of pancreatic fluid in the lesser sac surrounded by granulation tissue Occur in 20% with pancreatitis (esp. due to EtOH)

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132
Q

What are the causes of chronic pancreatitis?

A

AGATS
Alcohol (70%)
Genetic (CF/HH)
Autoimmune (Lymphoplasmacytic sclerosing pancreatitis, raised IgG4)
Raised triglycerides
Structural (obstruction by tumour, pancreas divisum)

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133
Q

What are the complications of chronic pancreatitis?

A 
Chronic Pancreatitis Does Painful Stuff 
Carcinoma 
Pancreatic swelling --> biliary obstruction 
Diabetes Mellitus 
Pseudocyst 
Splenic vein thrombosis --> splenomegaly
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134
Q

What are some pancreatic endocrine neoplasias?

A
  1. Insulinoma
  2. Gastrinoma (Zollinger-Ellinson)
  3. Glucagonoma
  4. VIPoma
  5. Somatostatinoma
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135
Q

What are some pancreatic malformations? x3

A
  1. Ectopic pancreas (Meckel’s diverticulum, small bowel)
  2. Pancreas divisum
  3. Annular pancreas
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136
Q

What is pancreas divisum?

A
  1. Failure of fusion of the dorsal and ventral buds leading to the bulk of the pancreas draining through a smaller accessory duct
  2. Usually asymptomatic
  3. May lead to chronic pancreatitis
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137
Q

What is a cholangiocarcinoma and where does it typically occur?

A

A rare bile duct adenocarcinoma

Typically occurs at the confluence of the right and left hepatic ducts (called ‘Klatskin’ tumours)

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138
Q

What are some risk factors for cholangiocarcinomas?

A
  1. UC
  2. PSC
  3. Hep B/C
  4. Choledocholithiasis
  5. Choledochal cysts
  6. Lynch 2
  7. Flukes
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139
Q

What is the pathophysiology of a hydatid cyst?

A

A zoonotic infection by Echinococcus granulosus Occurs in sheep-rearing communities The parasite penetrates the portal system and infects the liver, leading to a calcified cyst

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140
Q

What are 3 key anatomical features of the rectum?

A
  1. 12cm long
  2. From the sacral promontory to the levator ani muscle
  3. The 3 tenia coli fuse around the rectum to form a continuous muscle layer
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141
Q

What are the key anatomical features of the anal canal?

A

4cm long

From the levator ani muscle to the anal verge

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142
Q

What are the features of the upper 2/3rds of the anal canal?

A
  1. Columnar epithelium
  2. Insensate
  3. Supplied by the superior rectal artery and vein
  4. Lympathic Drainage to the internal iliac nodes
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143
Q

What are the features of the lower 1/3rd of the anal canal?

A
  1. Squamous epithelium
  2. Sensate
  3. Supplied by middle and inferior rectal arteries and veins
  4. lymphatic drainage to the superficial inguinal nodes
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144
Q

What is the dentate line?

A

The squamomucosal junction

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145
Q

What is the white line?

A

Where the anal canal becomes true skin

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146
Q

What are features of the internal anal sphincter?

A
  1. Thickening of the rectal smooth muscle

2. Involuntary control

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147
Q

What are features of the external anal sphincter?

A
  1. Three rings of skeletal muscle = deep, superficial, subcutaneous
  2. Voluntary control
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148
Q

What is the anorectal ring?

A
  1. The deep segment of the external sphincter which is continuous with the puborectalis muscle (part of levator ani)
  2. Palpable on PR 5cm from the anus
  3. Must be preserved to maintain continence
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149
Q

What demarcates the junction between the anal canal and the rectum?

A

The anorectal ring

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150
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions

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151
Q

What is an anal cushion?

A

Masses of spongy vascular tissue positioned at 3, 7 and 11 O’clock

152
Q

What causes haemorrhoids?

A
  1. Constipation with prolonged straining

2. Venous congestion = pregnancy, abdominal tumour, portal HTN

153
Q

What is the classification for haemorrhoids?

A

1st degree = never prolapse
2nd degree = prolapse on defecation but spontaneously reduce
3rd degree = prolapse on defecation but require digital reduction
4th degree = remain permanently prolapsed

154
Q

What are the symptoms of haemorrhoids?

A
  1. Fresh painless PR bleeding
  2. Pruritis ani
  3. Lump in perianal area
  4. Severe pain = thrombosis
155
Q

What is the management for thrombosed haemorrhoids?

A 
Conservative = Ice packs 
Medical = Analgesia, Topical lignocaine jelly, Stool softeners
Surgical = Haemorrhoidectomy is not usually necessaryPain usually resolves in 2-3 weeks
156
Q

Retroperitoneal organs

A 
SAD PUCKER 
Suprarenal (adrenal) glands 
Aorta/IVC
Duodenum (2nd and 3rd part) 
Pancreas (except tail) 
Ureters 
Colon (ascending and descending) 
Kidneys 
Oesophagus 
Rectum
157
Q

Abdominal wall muscles

A 
TIRE 
Transversus Abdominis
Internal Oblique 
Rectus Abdominis 
External Oblique
158
Q

Initial Management of All Surgical Emergencies?

A 
4A's, 2C's, 2N's
ABC assessment 
Analgesia e.g. morphine 
Anti-emetic 
Aggressive fluid replacement (IV fluids and e-) 
CVP line may be needed
Catheter
NBM 
NG Tube
159
Q

DDx for a groin lump

A 
Some Surgeons like to manage various hernias 
Spermatic cord (lipoma/hydrocoele)
Skin (sebaceous cyst) 
Lymph nodes
Testicle (ectopic, undescended) 
Muscle (psoas abscess) 
Vascular (femoral artery aneurysm, saphena varyx) 
Hernias (inguinal, femoral)
160
Q

Diaphragm apertures: spinal levels

A

Aortic Hiatus = T12
Oesophagus = T10
Vena Cava = T8

161
Q

Length of Parts of Duodenum

A

1st part = 2 inches
2nd part = 3 inches
3rd part = 4 inches
4th part = 1 inch

162
Q

Descending Abdominal Aorta Branches

A 
Prostitutes Cause Sagging Swollen Red Testicles Living In Sin 
Phrenic 
Coeliac 
Superior mesenteric 
Suprarenal 
Renal
Testicular 
Lumbars 
Inferior mesenteric 
Sacral
163
Q

What is an anal fissure?

A

A tear of the squamous epithelial lining in the lower anal canal

164
Q

Causes of an anal fissure?

A
  1. Passage of hard stool
  2. Crohns
  3. Herpes
  4. Anal cancer
165
Q

Management of anal fissure?

A
  1. Conservative = soaks in warm bath, toileting advice, dietary advice (increase fibre and fluids)
  2. Medical = laxatives (lactulose + fybogel), topical (lignocaine, GTN ointment, diltiazem cream), EUA + botulinum injection
  3. Surgical = Lateral partial sphincterotomy
166
Q

What is an anal fistula?

A

An abnormal connection between the anorectal canal and the skin

167
Q

Pathogenesis of anal fistula?

A
  1. Usually secondary to perianal sepsis

2. Associations = Crohns, Diverticular disease, Rectal Ca, Immunosuppression

168
Q

Classification of anal fistula?

A 
High = cross sphincter muscles above dentate line 
Low = cross sphincter muscles below dentate line
169
Q

What is a sinus?

A

A blind ended tract, lined by epithelial or granulation tissue, which opens onto an epithelial surface

170
Q

What is a pilonidal sinus?

A

The obstruction of natal cleft hair follicles approximately 6cm above the anus, leading to ingrowing of hair that excites an inflammatory foreign body reaction, leading to an epithelialised sinus

171
Q

What are risk factors for a pilonidal sinus?

A
  1. Males
  2. Hirsute
  3. Asians/Mediterranean/Middle East
  4. Overweight
  5. Occupation with lots of sitting
172
Q

Management of a pilonidal sinus?

A
  1. Conservative = hygeine advice, shave/remove hair from affected area
  2. Surgical = incision and drainage of abscess, elective sinus excision
173
Q

What is a rectal prolapse?

A

Protrusion of rectal tissue through the anal canal

174
Q

What is the classification of anal prolapse?

A

Type I = Mucosal prolapse

Type II = Full thickness prolapse

175
Q

What is a hernia?

A

Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position

176
Q

What is Maydl’s hernia?

A

A herniating double loop of bowel

The strangulated portion may reside as a single loop inside the abdomen

177
Q

What is Littre’s hernia?

A

Hernial sac containing a strangulated Meckel’s diverticulum

178
Q

What is Amyand’s hernia?

A

Inguinal hernia containing strangulated appendix

179
Q

What is Richter’s hernia?

A
  1. Only part of circumference of bowel is within sac
  2. Most commonly seen with femoral hernias
  3. Can strangulate without obstructing
180
Q

What is a pantaloon hernia?

A

A simultaneous direct and indirect hernia

181
Q

What is a herniotomy?

A

Excision of hernial sac

182
Q

What is herniorrhapy?

A

Suture repair of hernial defect

183
Q

What is hernioplasty?

A

Mesh repair of hernial defect

184
Q

What are the types of hernia? x11

A 
Inguinal
Femoral
Incisional 
Umbilical 
Paraumbilical 
Epigastric 
Spigelian 
Obturator 
Lumbar 
Sciatic 
Gluteal
185
Q

What are the causes of an inguinal hernia?

A
  1. Congenital = Patent processus vaginalis

2. Acquired = Things which increase IAP

186
Q

What are the acquired causes of inguinal hernias?

A
  1. Chronic cough = COPD, asthma
  2. Prostatism
  3. Constipation
  4. Heavy lifting
  5. Previous incision/repair
  6. Ascites/obesity
  7. Appendicectomy
187
Q

What are features of indirect hernias?

A
  1. 80%
  2. Commoner in young
  3. Congenital patent processus vaginalis
  4. Emerge through deep ring
  5. Same 3 coverings as cord and descend into the scrotum
  6. Can strangulate
188
Q

What are features of direct hernias?

A
  1. 20%
  2. Commoner in elderly
  3. Acquired
  4. Emerge through Hesselbach’s triangle
  5. Can acquire internal and external spermatic fascia
  6. Rarely descend into scrotum
  7. Rarely strangulate
189
Q

What are the borders of Hesselbach’s triangle?

A
  1. Medially = Lateral border of rectus abdominis
  2. Laterally = Inferior epigastric artery
  3. Inferiorly = Base of the inguinal ligament
190
Q

What are the complications of inguinal hernia repair?

A
  1. Early = haematoma/seroma formation, intra-abdominal injury, infection, urinary retention
  2. Late = recurrence, ischaemic orchitis, chronic groin pain/paraesthesia
191
Q

What is a femoral hernia?

A

Protrusion of viscus through the femoral canal

Commoner in women

192
Q

What is the aetiology of a femoral hernia?

A
  1. Acquired = raised intra-abdominal pressure

2. Congenital = femoral canal is larger in females due to shape of pelvis and changes in its configuration after birth

193
Q

Features of a femoral hernia?

A
  1. Neck is inferior and lateral to the pubic tubercle
  2. Cough impulse
  3. Often irreducible due to tight borders
  4. Commonly presents with obstruction or strangulation
  5. 50% risk of strangulation within 1 month
194
Q

What are the surgical operations for femoral hernias?

A 
Elective = Lockwood approach (low approach)
Emergency = McEvedy approach (high approach)
195
Q

What percentage of surgical incisions develop an incisional hernia?

196
Q

What are risk factors for developing incisional hernias?

A

Pre-operative
Intra-operative
Post-operative

197
Q

Pre-operative risk factors for incisional hernias?

A
  1. Age
  2. Obesity/malnutrition
  3. Steroids
  4. Chemo/Radiotherapy
  5. Comorbidities = DM, CKD, Malignancy
198
Q

Intra-operative risk factors for incisional hernias?

A
  1. Surgical technique/skill e.g. too small suture bites/inappropriate suture material
  2. Incision type e.g. midline
  3. Placing drains through wounds
199
Q

Post-operative risk factors for incisional hernias?

A
  1. Infection
  2. Haematoma
  3. Raised IAP = Chronic cough, straining, post-op ileus
200
Q

Features, Risk Factors and Management of Umbilical hernias?

A
  1. Features = Congenital, 3% live births, defect in the umbilical scar
  2. Risk Factors = Afro-Caribbean, Trisomy 21, Congenital hypothyroidism
  3. Management = usually resolves by 2-3 years, surgical repair if no closure, can recur in adults (pregnancy/ascites)
201
Q

Features, Risk Factors and Management of Paraumbilical hernias?

A
  1. Features = acquired in middle aged obese men, defect through linea alba just above or below umbilicus, small defect –> strangulation (often omentum), typically contains omentum
  2. Risk factors = chronic cough, straining, obesity, pregnancy, ascites, fibroids, bowel distension
  3. Management = Mesh repair/Mayo (double-breast linea alba with sutures)
202
Q

Features and Management of Epigastric hernias?

A
  1. Features = Young M>F, pea-sized swelling caused by defect in linea alba between the xiphisternum and the umbilicus, usually contains omentum, can strangulate
  2. Management = Mesh/suture repair
203
Q

Features of spigelian hernia?

A
  1. Hernia through linea semilunaris
  2. Hernia lies between layers of abdominal wall
  3. Palpable mass more likely to be colon cancer
204
Q

Features of obturator hernia?

A
  1. Old aged F>M
  2. Sac protrudes through obturator foramen
  3. Pain on inner aspect of thigh or knee
  4. Frequently presents obstructed/strangulated
205
Q

Features of lumbar hernia?

A
  1. Middle aged M>F
  2. Typically follow loin incisions
  3. Herniates through superior/inferior lumbar triangles
206
Q

Features of sciatic hernia?

A
  1. Hernia through lesser sciatic foramen

2. Usually presents as SBO + gluteal mass

207
Q

Features of gluteal hernia?

A
  1. Hernia through greater sciatic foramen

2. Usually presents as SBO + gluteal mass

208
Q

What are the advantages of minimal access surgery?

A
  1. Smaller incisions –> less post op pain/risk of wound infection/hospital stay, faster post op recovery, better cosmesis
  2. May allow better visualisation and access e.g. diagnose and fix contralateral hernia in lap hernia repair
209
Q

What are the disadvantages of minimal access surgery?

A
  1. Reduced tactile feedback
  2. 2D view of 3D structures
  3. Technically challenging and old skills may be lost
  4. Haemorrhage harder to manager
  5. Different anatomy
210
Q

What are some common minimal access procedures?

A

Laparoscopic:

  1. Cholecystectomy
  2. Appendicectomy
  3. Hernia repair
  4. Colectomy
  5. Fundoplication
211
Q

Relative contraindications to minimal access surgery?

A
  1. Pneumoperitoneum may not be tolerated by patients with severe cardiorespiratory insufficiency (reduced venous return and diaphragm movement)
  2. Bleeding diatheses
  3. Multiple adhesions
  4. Shocked patients
212
Q

What is ERAS?

A

Enhanced Recovery After Surgery

  1. Commonly employed in colorectal and orthopaedic surgery
  2. Has Pre-op, intra-op, and post-op strategies
213
Q

What are the aims of ERAS?

A
  1. Increase speed of recovery and return to function

2. Minimise adverse physiological responses to surgery e.g. hypercoagulability

214
Q

Pre-op strategies of ERAS?

A

OPTIMISATION

  1. Aggressive physiological optimisation
  2. Smoking cessation ≥4wks before surgery
  3. Admission on day of surgery and avoidance of prolonged fast
  4. Carb loading prior to surgery
  5. Fully informed pt, encouraged to participate in recovery
215
Q

Intra-op strategies of ERAS?

A

REDUCING PHYSICAL STRESS

  1. Short acting anaesthetic agents
  2. Epidural use
  3. Minimally invasive techniques
  4. Avoid drains and NGTs where possible
216
Q

Post-op strategies of ERAS?

A

EARLY RETURN TO FUNCTION + MOBILISATION

  1. Aggressive Rx of pain and nausea
  2. Early mobilisation and physiotherapy
  3. Early resumption of oral intake
  4. Early discontinuation of IV fluids
  5. Remove drains and urinary catheters ASAP
217
Q

How do you classify surgical complications?

A

Immediate (<24hrs)
Early (1d-1m)
Late (>1m)

218
Q

What are the immediate surgical complications?

A 
AASH
Anaesthetic complications 
Atelectasis
Surgical trauma to local structures 
Haemorrhage (Primary or reactive)
219
Q

What are the early surgical complications?

A 
WAVII SUPA
Wound infection and dehiscence
Atelectasis 
VTE
Infection (7Cs)
Ileus
Secondary Haemorrhage
Urinary Retention 
Pain
Antibiotic-associated colitis (AAC)
220
Q

What are the late surgical complications?

A 
SHANF
Scarring 
Hernias
Adhesions
Neuropathy 
Failure/Recurrence
221
Q

What are possible causes of post-operative fever?

A 
8C's (Persistent, >38C, >24hrs post surgery)
Cut = infection/wound dehiscence 
Cannula = superficial thrombophlebitis 
Central Venous Line
Chest = pneumonia 
Collection = subphrenic, pelvis, anastomotic leak 
C.diff colitis 
Catheter 
Calves (DVT)
222
Q

What are the early complications of colonic surgery?

A 
3As, E, I
Antibiotic-associated colitis (AAC)
Anastomatic leak 
Abdominal abscess
Enterocutaneous fistula
Ileus
223
Q

What are the late complications of colonic surgery?

A
  1. Adhesions –> Obstruction

2. Incisional hernias

224
Q

What is the classification of operative haemorrhage?

A
  1. Primary = continuous bleeding starting during surgery
  2. Reactive = bleeding at the end of surgery or early post-op secondary to increasing CO and BP
  3. Secondary = bleeding >24hrs post-op, usually due to infection
225
Q

What is the operative classification of a wound?

A
  1. Clean = incise uninfected skin w/o opening viscus
  2. Clean/contaminated = intra-op breach of viscus (not colon)
  3. Contaminated = breach of viscus and spillage or opening of colon
  4. Dirty = site already contaminated = faeces, pus, trauma
226
Q

What is wound dehiscence preceded by?

A

Serosanguinous discharge from wound

227
Q

How do you classify the risk factors for wound dehiscence?

A

Pre-operative
Operative
Post-operative

228
Q

What are the pre-operative risk factors for wound dehiscence?

A
  1. Age
  2. Smoking
  3. Obesity/malnutrition/cachexia
  4. Comorbidities = BM, chronic cough, Ca
  5. Steroids
  6. Chemo/radio
229
Q

What are the operative risk factors for wound dehiscence?

A
  1. Length and orientation of incision
  2. Closure technique: follow Jenkin’s rule
  3. Suture material
230
Q

What are the post-operative risk factors for wound dehiscence?

A
  1. Infection
  2. Haematoma/seroma formation
  3. Raised IAP e.g. prolonged ileus –> distension
231
Q

What is Jenkin’s rule?

A

A rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge

232
Q

What is the management of wound dehiscence?

A
  1. Replace abdo contents and cover with sterile soaked gauze
  2. IV Abx: Cef and Met
  3. Opioid analgesia
  4. Call Senior and arrange theatre
  5. Repair in theatre = wash bowel, debride wound edges, close with deep non-absorbable sutures e.g. nylon
  6. May require VAC dressing or grafting
233
Q

What are the borders of the inguinal canal?

A
  1. Anterior = External oblique aponeurosis + internal oblique for lateral 3rd
  2. Posterior = Transversalis fascia + conjoint tendon for medial 3rd
  3. Floor = Inguinal ligament
  4. Roof = Arching fibres of transversus abdominis and internal oblique
234
Q

What are the borders of the femoral canal?

A
  1. Medially = lacunar ligament
  2. Laterally = femoral vein
  3. Anteriorly = inguinal ligament
  4. Posteriorly = Pectineal ligament of Cooper
235
Q

What are the contents of the femoral canal?

A

Fat and Cloquet’s node

236
Q

What are the contents of the inguinal canal in males?

A

Spermatic Cord + Ilioinguinal nerve

237
Q

What are the contents of the inguinal canal in females?

A

Round ligament + Iiioinguinal nerve + Genital branch of genitofemoral nerve

238
Q

What are the contents of the spermatic cord?

A

3 layers of fascia
3 Arteries + 3 Veins
2 Nerves
3 Other things

239
Q

What is the operative distinction between indirect and direct hernias?

A 
Indirect = arise lateral to inferior epigastric vessels 
Direct = arise medial to inguinal ligament, through Hesselbach's triangle
240
Q

What are the borders of Hesselbach’s triangle?

A 
Medially = Lateral border of rectus abdominis 
Laterally = Inferior epigastric artery
Inferiorly = Inguinal ligament
241
Q

What are the approaches to operating on Inguinal hernias?

A
  1. Open –> Lichtenstein Tension Free Mesh Repair (recommended by RCS) or Shouldice repair
  2. Laparoscopic –> TEP (Totally ExtraPeritoneal) or TAPP (Trans Abdominal Pre-Peritoneal)
  3. Do laparoscopic if bilateral/recurrent
242
Q

What must you always do when consenting pt for hernia repair?

A

Examine testes and document if any abnormalities

Explain risk of testicular damage when consenting pt

243
Q

What are the complications of hernia repair?

A
  1. Early = urinary retention, haematoma/seroma formation (10%), infection (1%), intra-abdominal injury (lap)
  2. Late = Recurrence (<2%), Ischaemic orchitis (0.5%, secondary to thrombosis of pampiniform plexus), chronic groin pain/paraesthesia (5%)
244
Q

What is the definition for an incisional hernia?

A

Extrusion of peritoneum and abdominal contents throgh a previously acquired defect

245
Q

What Hx might a pt with an incisional hernia present with?

A
  1. Previous surgery
  2. Post-op wound infection or other complications
  3. Comorbidities e.g. chronic cough
  4. Discomfort or episodes of obstruction
246
Q

What Hx might a pt with an umbilical/paraumbilical hernia present with?

A
  1. Predisposing factors: pregnancy, ascites, obesity
  2. Pain
  3. Previous repairs
  4. Reducible
  5. Episodes of obstruction or strangulation
247
Q

What is gastroschisis?

A
  1. Protrusion of abdominal contents through defect in the abdominal wall to the right of the umbilicus –> prompt surgical repair after fluid resuscitation
  2. Not usually associated with other defects
248
Q

What is exomphalos?

A
  1. Protrusion of abdominal contents within a 3-layered sac

2. Commonly associated with other defects e.g. cardiac, anencephaly

249
Q

What are the 4 key questions to ask whilst examining a scrotal lump?

A

APTT

  1. Can you get above it?
  2. Is it tender?
  3. Is testis palpable separately?
  4. Does it transilluminate?
250
Q

What are causes of a tender testis?

A
  1. Torted testis or hydatid of Morgagni
  2. Epididymo-orchitis
  3. Strangulated hernia
251
Q

What are the causes of post-operative SOB?

A
  1. Lung related = PE/DVT, Pneumothorax
  2. Systemic = Infection (sepsis/LRTI), Respiratory Depression (Pain/Opiates)
  3. Exacerbation of pre-existing condition (COPD, HF/fluid overload)
252
Q

What are the different types of healing?

A

Primary intention
Secondary intention
Tertiary Intention

253
Q

What is healing by primary intention?

A
  1. Most surgical wounds
  2. Excision and closure (sutures/staples) with edges approximated
  3. Minimises scarring
254
Q

What is healing by secondary intention?

A
  1. Wound left open, granulation from bottom up
  2. Used when wound edges cannot be approximated e.g. pressure ulcers
  3. Can pack wound with gauze or use drainage system
  4. Broader scar, slower healing process
255
Q

What is healing by tertiary intention?

A
  1. Combination of primary and secondary intention

2. Purposely left open and closed at a later date

256
Q

What are the three complications of a hernia?

A
  1. Incarceration
  2. Strangulation
  3. Bowel Obstruction
257
Q

What are causes of post-operative urinary retention?

A
  1. Drugs = opioids, epidural/spinal, anti-AChm
  2. Pain = sympathetic activation –> sphincter contraction
  3. Psychogenic = hospital environment
258
Q

What are some risk factors for post-operative urinary retention?

A
  1. Male
  2. Age
  3. Neuropathy e.g. DM, EtOH
  4. BPH
  5. Surgery type e.g. hernia and anorectal
259
Q

What is the management of post-operative urinary retention?

A
  1. Conservative = privacy, ambulation, void to running taps, analgesia
  2. Catheter +/- gentamicin 2.5mg/kg IV stat
  3. TWOC = if failed, may be sent home with silicone catheter and urology output
260
Q

What are the specific complications for a cholecystectomy?

A
  1. Conversion to open = 5%
  2. CBD injury = 0.3%
  3. Bile leak
  4. Retained stones (needing ERCP)
  5. Fat intolerance/loose stools
261
Q

What are the specific complications for an appendicectomy?

A
  1. Abscess formation
  2. Fallopian tube trauma
  3. Right hemicolectomy
262
Q

What are the specific complications for anorectal surgery?

A
  1. Anal incontinence + fissure + fistula

2. Stenosis

263
Q

What is the specific complication for small bowel surgery?

A

Short gut syndrome

264
Q

What is the average length of the small bowel?

A

6 metres (20 feet)

265
Q

What is the average length of the large bowel?

A

1.5 metres (5 feet)

266
Q

What is short gut syndrome?

A

A malabsorption disorder caused by <100-250cm of normally functioning small intestine

267
Q

What are specific complications of a splenectomy?

A
  1. Gastric dilatation secondary to gastric ileus
  2. Thrombocytosis –> VTE
  3. Infection = encapsulated organisms
268
Q

What are specific complications of arterial surgery?

A
  1. Thrombosis and embolisation
  2. Anastomotic leak
  3. Graft infection
269
Q

What are specific complications of aortic surgery?

A
  1. Gut ischaemia
  2. Renal failure
  3. Aorto-enteric fistula
  4. Anterior spinal syndrome (paraplegia)
  5. Emboli –> distal ischaemia (trash foot)
270
Q

What are specific complications of breast surgery?

A
  1. Arm lymphoedema
  2. Skin necrosis
  3. Seroma
271
Q

What are specific complications of urological surgery?

A
  1. Sepsis

2. Uroma = extravasation of urine

272
Q

What are specific complications of prostatectomy?

A

PURE

  1. Prostatitis
  2. Urinary incontinence
  3. Retrograde ejaculation
  4. Erectile dysfunction
273
Q

What are specific complications of a thyroidectomy?

A
  1. Wound haematoma –> tracheal obstruction
  2. Recurrent laryngeal nerve trauma –> hoarse voice (transient in 1.5%, permanent in 0.5%, R commonest (as it is more medial)
  3. Hypoparathyroidism –> hypocalcaemia
  4. Hypothyroidism
  5. Thyroid storm
274
Q

What are specific complications of a fracture repair?

A
  1. Mal/non-union
  2. Osteomyelitis
  3. Avascular necrosis
  4. Compartment syndrome
275
Q

What are specific complications of a hip replacement?

A
  1. Deep infection
  2. VTE
  3. Dislocation
  4. Nerve injury: sciatic/GN
  5. Leg length discrepancy
276
Q

What are specific complications of cardiothoracic surgery?

A
  1. Pneumo/haemothorax

2. Infection: mediastenitis, empyema

277
Q

What is the epidemiology of DVTs?

A

They occur in 25-50% of surgical patients without thromboprophylaxis

278
Q

What are the risk factors for a DVT?

A

Virchow’s triad

  1. Stasis = surgery, immobility, obesity
  2. Hypercoagulability = dehydration, malignancy, age, surgery –> raised plts and fibrinogen
  3. Vessel wall damage = damage to veins + previous VTE
279
Q

What are some signs of a DVT?

A
  1. Calf warmth, erythema, tenderness, swelling
  2. Mild pyrexia
  3. Pitting oedema
280
Q

When is the peak incidence of DVTs after surgery?

281
Q

What percentage of DVTs below the knee are asymptomatic?

282
Q

What are 2 differentials for a DVT?

A
  1. Cellulitis

2. Ruptured Baker’s cyst

283
Q

What is the scoring system for a DVT?

A

Wells’ Score

284
Q

What is the management for a DVT?

A
  1. Therapeutic LMWH: enoxaparin 1.5mg/kg/24hr Subcut
  2. Start Warfarin using Tait model: 5mg OD for first 4d
  3. Stop LMWH when INR 2.5
285
Q

What is the duration of anticoagulation after a DVT?

A
  1. Below knee = 6-12 weeks
  2. Above knee = 3-6 months
  3. On-going cause = indefinite
286
Q

How can one prevent DVTs?

A
  1. Pre-operative = VTE risk assessment, TED stockings, aggressive optimisation, stop OCP 4wks pre-op
  2. Intra-operative = minimise surgery length, minimally invasive if possible, intermittent pneumatic compression boots
  3. Post-operative = LMWH, early mobilisation, analgesia, physio, adequate hydration
287
Q

What is cellulitis?

A

Acute infection of the subcutaneous connective tissue

288
Q

What are the most common causes of post-op cellulitis

A
  1. Beta-haemolytic streps

2. Staph aureus

289
Q

What are causes of post-operative reduced urine output?

A
  1. Pre-renal = hypovolaemia
  2. Renal = NSAIDs, gentamicin
  3. Post-renal (commonest) = acute urinary retention, blocked/malsited catheter
290
Q

What are common causes of post-operative N&V?

A
  1. Emetic drugs e.g. opioids
  2. Obstruction
  3. Ileus
291
Q

What are the causes of post-operative hypotension?

A

CHOD

  1. Cardiogenic = MI, fluid overload
  2. Hypovolaemia = inadequate replacement of fluid losses, haemorrhage
  3. Obstructive = PE
  4. Distributive = sepsis, neurogenic shock
292
Q

What are the causes of post-operative hypertension?

A
  1. Previous HTN
  2. Urinary retention
  3. Pain
293
Q

What is the fluid composition of the human body?

A

60% of humans is water (if 70kg –> 42kg)
2/3rd intracellular
1/3rd extracellular

294
Q

What is the composition of extracellular fluid in the body?

A

Interstitial
Plasma
Transcellular

295
Q

What is Starling’s hypothesis?

A

Fluid movement due to filtration across the wall of a capillary is dependent on the hydrostatic pressure gradient, the oncotic pressure gradient, and filtration coefficient (capillary permeability) across the capillary

296
Q

What is osmotic pressure?

A

The ability of solute to attract water

297
Q

What is oncotic pressure?

A

A form of osmotic pressure exerted by proteins

298
Q

What is hydrostatic pressure?

A

Pressure exerted by a fluid at equilibrium due to the force of gravity

299
Q

Fluid balance: what are the fluid inputs?

A 
Water = 1500ml
Food = 1000ml 
Metabolism = 300ml 
Total = 2800ml = 40ml/kg/day
300
Q

Fluid balance: what are the fluid outputs?

A

Urine = 1500ml
Insensible (lungs + sweating) = 1000ml
Stool = 300ml
Total = 2800ml = 40ml/kg/day

301
Q

What is the minimum urine output?

A

0.5ml/kg/h = 30ml/h

302
Q

What is the minimum Na requirement?

A

1.5-2mmol/kg/d = 100mmol/d

303
Q

What is the minimum K requirement?

A

1mmol/kg/d = 60mM/d

304
Q

What is the daily fluid regimen to meet requirements?

A
  1. 3L dex-sal w/ 20mM K+ in each bag
  2. 1L norm-sal + 2L dex-sal w/ 20mM K+ in each bag
  3. Each bag over 8h = 125mL/hr
  4. Replace other losses = D&V, NGT, drains, tachypnoea, high output stomas, fever
305
Q

How much extra fluid should you give someone with a fever?

A

An extra 500ml for each °C increase

306
Q

What does CVP monitoring show?

A

Indicates RV preload, and depends on both venous return and cardiac output

307
Q

What causes a raised CVP?

A
  1. Increased circulating volume

2. Reduced CO (heart failure)

308
Q

What causes a low CVP?

A
  1. Reduced circulating volume
309
Q

What is normal CVP?

A

5-10cm H20

310
Q

How do you interpret CVP values?

A

A single reading is not as useful as serial measurements before and after a fluid challenge

  1. Unchanged = hypovolaemia
  2. Rise that reverses after 30min = euvolaemic
  3. Sustained >5cm H20 = overload/failure
311
Q

What is a fun mushkie to interpret CVP values without using a fluid challenge?

A

Passive leg raising may be more useful than fluid challenge in determining response to fluids - a sustained raised in CVP suggests heart failure

312
Q

What are examples of crystalloid solutions?

A
  1. Normal Saline
  2. Dextrose-Saline
  3. Hartmann’s/Ringer’s lactate
313
Q

What are the contents, pH, and uses for normal saline?

A
  1. Contents = 0.9% NaCl (9g/L), 154mmol NaCl
  2. pH = 5.5
  3. Use = normal daily fluid requirements + replace losses
314
Q

What are the contents and uses for 5% dextrose?

A
  1. Contents = 50g dextrose/L

2. Use = normal daily fluid requirements

315
Q

What are the contents and uses for Dextrose-Saline?

A
  1. Contents = 4% dextrose (40g/L) + 0.18% NaCl (31mM NaCl)

2. Use = normal daily fluid requirements

316
Q

What are the contents of Hartmann’s/Ringer’s Lactate?

A
  1. Na = 131mM
  2. Cl = 111mM
  3. K = 5mM
  4. Ca = 2.2mM
  5. Lactate/HCO3- = 29mM
317
Q

What are the uses for Hartmann’s/Ringer’s Lactate?

A
  1. Resuscitation in trauma pts

2. Parkland’s formula(for burns) = 4 x weight x %burn = mL in first 24hrs

318
Q

What is the pH of Hartmann’s solution?

A
  1. pH = 6.5 but Hartmann’s is an alkalinising solution, as lactate is not an acid in itself but is a conjugate base
  2. Sodium lactate is metabolised in the liver to HCO3 as part of the cori cycle
319
Q

What is colloid?

A
  1. Solutions that contain large molecular weight molecules such as gelatin and dextrans.
  2. It preserves oncotic pressure therefore remains intravascular –> preferential increase in intravascular volume
320
Q

How do you classify the types of colloid?

A
  1. Natural = albumin, blood

2. Synthetic = gelofusin, volplex, haemaccel, voluven

321
Q

What are the uses for colloid?

A
  1. Fluid challenge: 250-500ml over 15-30 mins
  2. Hypovolaemic shock
  3. Mount Vernon Formula for burns: (weight x %burn)/2 = mL colloid per unit tume
322
Q

What are problems associated with using colloid?

A
  1. Anaphylaxis
  2. Volume overload
  3. Can interfere with cross-matching therefore take blood for cross-matching before using
323
Q

How can you assess fluid status by examinations?

A
  1. IV volume = CRT, HR, JVP, BP lying and standing
  2. Tissue perfusion = skin turgor, mucous membranes, oedema (ankle, pulmonary, ascites)
  3. End-organ = Consciousness, lactate, UO, raised U&Cr
324
Q

What is PCWP?

A

Pulmonary capillary wedge pressure, an indirect measure of LA pressure

325
Q

What is the composition of ileal fluid coming out of an ileostomy?

A 
Na = 130mM
Cl = 110mM
K = 10mM
HCO3 = 30mM
326
Q

What is normal output for an ileostomy, and what is high output

A 
Normal = 10-15ml/kg/d = 700ml/d
High = >1L/d
327
Q

What can you do if there is reduced urine output post-op?

A
  1. Suspect catheter problem = flush w/ 50ml and aspirate back
  2. Suspect pre-renal problem = fluid challenge (250-500ml colloid bolus over 15-30mins, look for CVP or UO response within minutes)
328
Q

What are 2 anthropometric measures of nutrition?

A

Skin-fold thickness and arm circumference

329
Q

What are the daily nutritional requirements/kg/24hr?

A 
Calories = 20-40kcal
Carb = 2g
Fat = 3g
Protein = 0.5-1g
Nitrogen = 0.2-0.4g
330
Q

What are ways to deliver enteral nutrition?

A

PO
NGT
Gastrostomy
Jejunostomy

331
Q

What are 4 different types of feeds?

A
  1. Oral supplements
  2. Polymeric = e.g. osmolite/jevity (intact proteins, starches and long term FAs)
  3. Disease-specific = e.g. fewer branched chains AAs in hepatic encephalopathy
  4. Elemental = simple AAs and oligo/monosaccharides - require minimal digestion and used if abnormal GIT e.g. in Crohn’s
332
Q

What are complications of NGT and enteral feeding in general?

A
  1. NGT = nasal trauma, malposition/tube blockage

2. Feeding = feed intolerance –> diarrhoea, electrolyte imbalance, aspiration, refeeding syndrome

333
Q

What are indications for non-PO enteral feeding?

A
  1. Catabolic = sepsis/burns/major surgery
  2. Coma/ITU
  3. Malnutrition
  4. Dysphagia = stricture, stroke
334
Q

What are the indications for parenteral nutrition?

A

The 7 S’s

  1. Short bowel syndrome
  2. Severe Crohn’s
  3. Severe malnutrition
  4. Severe pancreatitis
  5. Swallow = unable to
  6. High output fiStula
  7. Prolonged obstruction/ileuS (>7d)
335
Q

How is parenteral nutrition delivered?

A

It is delivered centrally as high osmolality is toxic to veins, and sterility is essential (use line only for PN)

  1. Short term = CV catheter
  2. Long term = Hickman or PICC line
336
Q

What are the typical contents of parenteral nutrition?

A

2000kcal = 50%fat, 50% carb
10-14g nitrogen
Vitamins, minerals and trace elements

337
Q

How can you classify the complications associated with TPN?

A
  1. Line-related

2. Feed-related

338
Q

What are the line-related complications of TPN?

A
  1. Pneumothorax/haemothorax
  2. Cardiac arrhythmia
  3. Line sepsis
  4. Central venous thrombosis –> PE or SVCO
339
Q

What are the feed-related complications of TPN?

A
  1. Villous atrophy of GIT
  2. E- disturbances = refeeding syndrome, hypercapnoea from excessive CO2 production
  3. Hyperglycaemia and reactive hypoglycaemia
  4. Line sepsis: increase risk with TPN
  5. Vitamin and mineral deficiencies
340
Q

What is refeeding syndrome?

A

A life threatening complication of refeeding via any route after a prolonged period of starvation, due to low potassium, magnesium and phosphate

341
Q

What is the pathophysiology of refeeding syndrome?

A
  1. Low carbs leads to a catabolic state with low insulin, fat and protein catabolism and depletion of intracellular phosphate
  2. Refeeding leads to a rise in insulin in response to carbs and an increased cellular phosphate uptake, leading to hypophosphateaemia
342
Q

What are the complications of refeeding syndrome?

A
  1. Rhabdomyolysis
  2. Respiratory insufficiency
  3. Arrhythmias
  4. Shock
  5. Seizures
343
Q

What patients are at-risk of refeeding syndrome?

A
  1. Malignancy
  2. Anorexia Nervosa
  3. Alcoholism
  4. GI surgery
  5. Starvation
344
Q

What questions must be asked in the history as part of a secondary survey?

A 
AMPLE
Allergies
Medication 
PMH 
Last ate/drunk 
Events
345
Q

What investigations are done as part of the secondary survey?

A
  1. Trauma series (C-spine lat + peg, CXR, pelvis)
  2. FAST scan (Focused Assessment with Sonography in Trauma)
  3. CT (when pt is stable)
346
Q

How do you assess C-spine radiographs?

A

VAABCS

  1. Views = Lateral, AP, open-mouth peg view
  2. Adequacy = must see C7-T1 junction, may need swimmer’s view with abducted arm
  3. Alignment = 4 lines (anterior vertebral bodies + anterior vertebral canal + posterior vertebral canal + tips of spinous processes
  4. Bones = shapes of bodies, laminae, processes
  5. Cartilage = IV discs should be equal height
  6. Soft tissue = width of soft tissue anterior to upper vertebrae should be 50% of vertebral width
347
Q

What is ‘clearing the cervical spine?’

A

Process of determining if cervical spine injuries exist

348
Q

What are the NEXUS criteria?

A

When an acute blunt force injury is present, a cervical spine is deemed to not need radiological imaging if all the following criteria are met: NSAID, None of:

  1. Neurological deficit
  2. Spinal tenderness in midline
  3. Altered consciousness
  4. Intoxication
  5. Distracting injury
349
Q

How can you estimate the circulating blood volume?

A

7% body mass

350
Q

What are the causes of neurogenic shock?

A
  1. Spinal anaesthesia
  2. Hypoglycaemia
  3. Cord injury above T5
  4. Closed head injuries
351
Q

How does neurogenic shock present?

A

Hypotension, bradycardia and warm extremities

352
Q

How do you manage neurogenic shock?

A
  1. Vasopressors = vasopressin and NA

2. Atropine = reverse the bradycardia

353
Q

What is spinal shock?

A

Acute spinal cord transection leading to loss of all voluntary and reflex activity below the level of injury

354
Q

How does spinal shock present?

A
  1. Hypotonic paralysis
  2. Arreflexia
  3. Loss of sensation
  4. Urinary retention
355
Q

What are the differentials for life-threatening chest injuries?

A 
ATOMIC
Airway obstruction 
Tension pneumothorax
Open pneumothorax (sucking) 
Massive haemothorax
Intercostal disruption and pulmonary contusion 
Cardiac Tamponade
356
Q

What is a massive haemothorax?

A

Accumulation of >1.5L of blood in the chest cavity, usually caused by disruption of hilar vessels

357
Q

Inguinoscrotal hernia more likely to be?

A

Indirect hernia

358
Q

Test for direct vs. indirect hernia?

A
  1. Ask pt to reduce hernia
  2. Place 2 fingers over deep ring and ask pt to cough
  3. Hernia controlled = indirect hernia, not controlled = direct
359
Q

4 distinguishing features of an inguinal hernia?

A
  1. Above and medial to pubic tubercle
  2. Cough impulse
  3. Reducible
  4. Bowel sounds
360
Q

Completion of abdo exam?

A
  1. DRE
  2. External genitalia
  3. Hernial Orifices
  4. Dipstick the urine
  5. Look at observation chart
361
Q

3 DDx of spider naevi?

A
  1. CLD
  2. OCP
  3. Pregnancy
362
Q

Spider naevus vs. telangiectasia?

A
  1. Spider naevus = fill from centre

2. Telangiectasia = fill from edge

363
Q

Post-op recovery after surgery?

A
  1. Pee before leaving
  2. Early mobilisation
  3. Good analgesia
  4. Prevent constipation = lactulose
  5. Can bathe immediately, but keep the area clean and dry
  6. Work in 1-2 weeks (6wks if heavy lifting)
364
Q

Mx of incisional hernias?

A
  1. Conservative = manage RFs, weight loss, elasticated corset/truss
  2. Surgical = pre-op, optimise cardiorespiratory function, encourage weight loss, nylon mesh repair (open or lap)
365
Q

Normal bilirubin?

366
Q

Visible jaundice bilirubin?

A

50uM (3 x ULN)

367
Q

Dilated duct diameter on US?

368
Q

Imaging of post-hepatic jaundice?

A
  1. US
  2. ERCP
  3. MRCP
  4. Jaundice
369
Q

Causes of post-op jaundice?

A
  1. Pre-hepatic = haemolysis after a transfusion
  2. Halogenated anaesthetics, sepsis, intra/post-op hypotension
  3. Post-hepatic = Biliary injury in e.g. lap chole
370
Q

Calot’s triangle borders?

A
  1. Superior = inferior edge of liver
  2. Medial = common hepatic duct
  3. Inferior = cystic duct
371
Q

Contents of Calot’s triangle?

A
  1. Cystic artery
  2. Lund’s node
  3. +/- aberrant RHA
372
Q

How to confirm absence of stones in CBD during surgery?

A

Operative cholangiogram

373
Q

Causes of jaundice after cholecystectomy?

A
  1. Pre-hepatic = haemolysis after transfusion
  2. Hepatic = halogenated anaesthetics
  3. Post-hepatics = gallstone retention, biliary sepsis, thermal injury (blunt dissection preferred), ligation of common hepatic or common bile duct
374
Q

What to do if appendix is macroscopically normal?

A
  1. Remove anyways = 20% have microscopic inflammation and avoids appendicitis in the future
  2. Search for other cause = Meckel’s, gynae pathology
375
Q

Complications of open appendicectomy?

A
  1. Abscess formation

2. Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

376
Q

Commonest appendix positions?

A
  1. Retrocaecal = 65%
  2. Pelvic = 30%
  3. Subcaecal = 3%
  4. Ante-ileal = 2%

Medicine and Surgery Mushkies (52 decks)

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