Surgery Firm Mushkies Flashcards
1
Q
What are the pre-operative checks?
A
OP CHECS
- Operative fitness: cardiorespiratory comorbidities
- Pills
- Consent
- History: Medical (MI, Asthma, HTN, Jaundice) + Anaesthetic (DVT, anaphylaxis)
- Ease of Intubation: neck arthritis, dentures, loose teeth
- Clexane: DVT Prophylaxis
- Site: correct and marked
2
Q
What is the crossmatch quantities for gastrectomy
A
4 units
3
Q
Prophylactic Abx is used for which surgeries?
A
GI surgery (20% post-op infection if elective) Joint replacement
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
5
Q
What is the crossmatch quantity for AAA?
A
6 units
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
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
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
9
Q
What T1DM post-surgical glucose levels are you aiming for?
A
7-11mM
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
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
12
Q
Post-operative complications due to steroids? x3
A
- Poor wound healing
- Infection
- Addisonian Crisis
13
Q
What are patients with obstructive jaundice at increased risk of post-operatively?
A
Renal failure
14
Q
Pre-op management of jaundice x5
A
- Avoid morphine
- Check clotting and consider pre-op Vit K
- Give 1L NS pre-op (unless CCF)
- Urinary Catheter
- ABx : Cef and Met
15
Q
Intra-operative management of jaundice x2
A
Hourly Urine Output monitoring
Normal saline titrated to output
16
Q
Post-operative management of jaundice x 2
A
Intensive monitoring of fluid status
Consider CVP + Frusemide if poor output despite NS
17
Q
What anaesthesia should you avoid on anticoagulated patients?
A
Epidural, spinal, and regional blocks
18
Q
Should you stop aspirin/clopidogrel before surgery?
A
Continue usually If risk of bleeding is high - stop 7d before surgery
19
Q
Risks of COPD and surgery? x3
A
- Basal atelectasis
- Aspiration
- Pneumonia
20
Q
What are the aims of anaesthesia?
A
HAAM Hypnosis Analgesia Amnesia Muscle relaxation (paralysis)
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
22
Q
What agent is used for anaesthetic induction?
A
Propofol
23
Q
What agent is used for muscle relaxation?
A
Depolarising = suxamethonium Non-depolarising = atracurium/vecuronium
24
Q
What agent is used for anaesthetic maintenance?
A
Enflurane/Desflurane
25
What chemical compound are enflurane/desflurane?
Halogenated ethers
26
What are complications of anaesthesia? x6
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
27
What is malignant hyperthermia?
1. Rare complication prompted by halothane or suxamethonium
2. AD inheritance
3. Characterised by rapid rise in temperature and masseter spasm
28
What is the management of malignant hyperthermia?
Dantrolene and active cooling
29
What are some possible triggers of surgical anaphylaxis?
1. Antibiotics
2. Colloid
3. Neuromuscular blockers e.g. vecuronium
30
Spinal Anaesthesia Agents
```
Little Boys Prefer Toys
Lidocaine
Bupivucaine
Procaine
Tetracaine
```
31
Where not to use LA with adrenaline
Ears, nose, fingers, toes and penis
32
How does carcinoid syndrome present?
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)
33
What are the symptoms of Pellagra?
Dementia
Diarrhoea
Dermatitis
34
Symptomatic treatment of carcinoid syndrome?
Octreotide or loperamide
35
What is the commonest surgical emergency?
Acute appendicitis
36
What is the most common cause of acute appendicitis?
Obstruction of appendix by a faecolith
37
What is Murphy's triad?
Triad of Appendicitis Presentation
| Pain, Anorexia+Nausea+Vomiting, Fever
38
Signs associated with acute appendicitis?
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)
39
How to classify UC vs. Crohns
1. Macroscopic = Location, Distribution, Strictures
| 2. Microscopic = Inflammation, Ulceration, Fibrosis, Granulomas, Pseudopolyps
40
Extra-abdominal manifestations of IBD?
```
Skin
Eyes
Joints
HPB
Other
```
41
Skin changes in IBD?
Clubbing
Erythema Nodosum
Pyoderma Gangrenosum
42
Eye changes in IBD?
Iritis
Conjunctivitis
Episcleritis
Scleritis
43
Joint changes in IBD?
Arthritis (non-deforming, asymmetrical)
Sacroiliitis
Ankylosing Spondylitis
44
HPB changes in IBD?
PSC + Cholangiocarcinoma (UC)
Gallstones (Crohn's)
Fatty Liver
45
'Other' changes in IBD?
Amyloidosis
| Oxalate renal stones
46
Complications of UC? x4
1. Toxic megacolon (perforation)
2. Bleeding
3. Malignancy (Colorectal cancer, cholangiocarcinoma)
4. Strictures (Obstruction)
47
Complications of Crohn's DIsease? x4
1. Fistulae
2. Strictures (obstruction)
3. Abscesses (abdominal, anorectal)
4. Malabsorption (Fat, B12, Vit D, Protein)
48
What complications can occur as a result of malabsorption in Crohns disease?
Fat = steatorrhoea, gallstones
B12= megaloblastic anaemia
Vit D = osteomalacia
Protein = oedema
49
Parameter for toxic megacolon?
Megacolon >6cm on AXR
50
What criteria is used for grading UC severity?
Truelove and Witts criteria
51
What is the law of 2s for Meckel's diverticulum? x5
```
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
```
52
Difference between a true and false diverticulum?
```
True = composed of complete wall e.g. Meckel's
False = composed of mucosa only (pharyngeal, colonic)
```
53
What is Saint's triad?
Hiatus Hernia
Cholelithiasis
Diverticular Disease
54
What is the grading system for perforated diverticulitis?
Hinchey Grading
55
What is a Hartmann's procedure?
Surgical resection of the rectosigmoid colon with the formation of an anorectal stump and formation of an end colostomy
56
Complications of Diverticular Disease?
```
Perforation
Haemorrhage
Abscess
Fistulae
Strictures
```
57
What are the 3 types of bowel obstruction?
Simple
Closed Loop
Strangulated
58
What is a simple bowel obstruction?
1 obstructing point + no vascular compromise
| May be partial or complete
59
What is a closed loop bowel obstruction?
Bowel is obstructed at 2 points
60
What is a strangulated bowel obstruction?
Bowel has a compromised blood supply
61
Commonest causes of small bowel obstruction?
Adhesions = 60%
| Hernias
62
Commonest causes of large bowel obstruction?
Colorectal Neoplasia = 60%
Diverticular Stricture = 20%
Volvulus = 5%
63
How do you classify causes of bowel obstruction?
Mechanical and Non-Mechanical
64
What are the non-Mechanical Causes of Bowel Obstruction (Paralytic Ileus)?
```
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
```
65
What are the Mechanical Causes of Bowel Obstruction?
Intraluminal
Intramural
Extramural
66
What are the Intraluminal causes of bowel obstruction?
Impacted matter (faeces, worms, bezoars)
Intussusception
Gallstones
67
What are the Intramural causes of bowel obstruction?
1. Benign Stricture = IBD, Surgery, Ischaemic colitis, Diverticulitis, Radiotherapy
2. Neoplasia
3. Congenital Atresia
68
What are the Extramural causes of bowel obstruction?
1. Hernia
2. Adhesions
3. Volvulus (Sigmoid, Caecal, Gastric)
4. Extrinsic Compression (Pseudocyst, Abscess, Haematoma, Tumour, Congenital bands)
69
Presentation of Bowel Obstruction?
DAVe
Distension
Abdominal Pain
Vomiting
70
Emergency management of bowel obstruction?
"Drip and Suck"
NBM + NGT
IV Fluids
Catheterise
71
What is the most common type of volvulus?
Sigmoid volvulus
72
Classification of colonic adenomas?
Tubular
Villous
Tubulovillous
73
Difference in the main presentation of L vs. R colorectal carcinoma?
```
L = altered bowel habit
R = Anaemia
```
74
Aetiology of colorectal carcinoma?
```
Doesnt it feel so grizzly
Diet
IBD
Familial = FAP, HNPCC, Peutz-Jeghers
Smoking
Genetics
```
75
What are protective for colorectal carcinoma?
NSAIDs/Aspirin
76
Locations of colorectal carcinoma?
```
Rectum = 35%
Sigmoid = 25%
Caecum and Ascending Colon = 20%
Transverse = 10%
Descending = 5%
```
77
Spread of colorectal carcinoma?
Local
Lymphatic
Blood
Transcoelomic
78
Mutation responsible for FAP?
APC gene on 5q21
| Autosomal Dominant
79
Features of Gardner's syndrome?
TODE
Thyroid tumours
Osteomas of the mandible, skull and long bones
Dental abnormalities = supernumary teeth
Epidermal cysts
80
What is the 3-2-1 rule for HNPCC?
≥3 family members over 2 generations with 1 <50y/o
81
Mutation responsible for Peutz-Jeghers Syndrome?
STK11 mutation
| Autosomal Dominant
82
Features of Peutz-Jeghers Syndrome?
3 M's
Mucocutaneous hyperpigmentation
Multiple GI hamartomatous polyps
Malignancy risk = colorectal, pancreas, breast, lung, ovaries, uterus
83
What are the types of GI polyp?
1. Inflammatory pseudopolyps
2. Hyperplastic polyps
3. Hamartomatous
4. Neoplastic (tubular/villous/tubulovillous adenomas)
84
What are gallstones composed of?
1. Phospholipids (lecithin)
2. Bile pigments
3. Cholesterol
85
Aetiology of gallstones?
1. Lithogenic bile: Admirand's triangle
2. Gallbladder hypomotility = pregnancy, OCP, TPN, fasting
3. Biliary sepsis
86
What are the different types of gallstone?
Mixed stones = 75%
Cholesterol stones = 20%
Pigment stones = 5%
87
What makes up pigment stones?
Calcium bilirubinate
88
How do you classify the complications of gallstones?
1. In the Gallbladder
2. In the Common Bile Duct
3. In the Gut
89
What are the gallbladder complications of gallstones?
1. Biliary colic
2. Acute cholecystitis +/- empyema
3. Chronic cholecystitis
4. Mucocele
5. Carcinoma
6. Mirizzi Syndrome
90
What are the CBD complications of gallstones?
Obstructive Jaundice
Pancreatitis
Cholangitis
91
What is the gut complication of gallstones?
Gallstone ileus
92
What is Mirizzi syndrome?
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
93
What is the pathogenesis of biliary colic?
Gallbladder spasm against a stone impacted in the neck of the gallbladder (Hartmann's pouch)
94
What are the US findings of biliary colic?
1. Stones = acoustic shadow
2. Dilated ducts = >6mm
3. Inflamed gallbladder = wall oedema
95
What is the pathogenesis of acute cholecystitis?
1. Stone or sludge impaction in Hartmann's pouch --> chemical and or bacterial inflammation
2. 5% are acalculous = sepsis, burns, DM
96
What are some signs of acute cholecystitis?
1. Murphy's sign
2. Palpable phlegmon (mass of adherent omentum and bowel)
3. Boas' sign (hyperaesthesia below the right scapula)
97
What are the characteristic features of chronic cholecystitis?
Flatulent dyspepsia exacerbated by fatty foods
98
What are 4 rarer gallstone diseases?
```
2Ms and 2Gs
Mucocele
Mirizzi's syndrome
Gallbladder carcinoma
Gallstone Ileus
```
99
What is a mucocele?
When the neck of the gallbladder is blocked by a stone but the contents remain sterile
100
What are some features of gallbladder carcinoma?
Rare
Associated w/ gallstones and gallbladder polyps Calcification of gallbladder --> porcelain gallbladder Incidental Ca found in 0.5-1% of lap choles
101
What is a gallstone ileus?
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
102
What is Rigler's triad?
Combination of AXR findings in gallstone ileus
1. Small bowel obstruction
2. Pneumobilia
3. Gallstone outside the gallbladder
103
What is Bouveret's syndrome?
Duodenal obstruction due to a gallstone ileus
104
What are the causes of obstructive jaundice?
```
1/3rd = stones
1/3rd = carcinoma of the head of the pancreas
1/3rd = Other
```
105
What are the 1/3rd 'other' causes of obstructive jaundice?
1. Lymph nodes at Porta Hepatis = TB, Ca
2. Inflammatory = PBC, PSC
3. Drugs = OCP, sulfonylureas, flucloxacillin
4. Neoplastic = Cholangiocarcinoma
5. Mirizzi's syndrome
106
What is Charcot's triad of ascending cholangitis?
Charcot's triad = Rigors, RUQ pain, jaundice
107
What is Reynold's pentad of ascending cholangitis?
Charcot's triad + shock + confusion
108
What is the management of ascending cholangitis?
1. Cef and Met
2. ERCP
3. Open or laparoscopic stone removal with T tube drain
109
What are the risk factors for pancreatic carcinoma?
```
SINED
Smoking
Inflammation = chronic pancreatitis
Nutrition = high fat diet
EtOH
Diabetes Mellitus
```
110
What is the pathology of pancreatic carcinoma?
1. 90% are ductal adenocarcinomas
2. Present late, metastasise early
3. 60% head, 25% body, 15% tail
111
What is Trousseau's sign of malignancy?
Migratory thrombophlebitis most commonly due to adenocarcinomas of the lung and pancreas, and gliomas
112
What is Courvoisier's Law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones
113
What is a Whipple's procedure?
A pancreaticoduodenectomy performed to remove malignancy from the head of the pancreas
114
What are the causes of acute pancreatitis?
```
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
```
115
What are some eponymous signs of acute pancreatitis?
1. Grey Turner's sign = flank ecchymosis
| 2. Cullen's sign = periumbilical ecchymosis
116
What is the Modified Glasgow Criteria?
1. For assessing the severity and predicting mortality of acute pancreatitis
2. Valid for EtOH and Gallstones
117
What are the components of the Modified Glasgow Criteria?
```
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
```
118
What is Ranson's criteria?
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)
119
Causes of mesenteric ischaemia?
1. Arterial = Thrombotic 35%, Embolic 35%
2. Non-occlusive (20%) = Splanchnic vasoconstriction 2° to shock
3. Venous Thrombosis = 5%
4. Other = Trauma, Vasculitis, Strangulation
120
Cause of chronic small bowel ischaemia?
Atheroma + Low flow state (e.g. LVF)
121
Cause of chronic large bowel ischaemia?
Low flow in IMA territory
122
Most common/important causes of lower GI bleed?
Malignancy
Diverticulitis
Rectal = haemorrhoids/fissure
123
'Other' causes of lower GI bleeding?
IIPLA (sound blood makes when it hits toilet)
Infection = CHESS
Inflammation = IBD
Polyps
Large upper GI bleed
Angio = dysplasia, ischaemic colitis, HHT
124
What are the CHESS organisms?
```
Campylobacter
Haemorrhagic E. coli
Entaemoeba Histolytica
Shigella
Salmonella
```
125
What is angiodysplasia?
Submucosal AV malformations
70-90% occur in right colon
Can affect anywhere in GIT
126
What is the treatment for angiodysplasia?
Embolisation
Endoscopic laser electrocoagulation
Resection
127
How do you classify the complications of acute pancreatitis?
1. Early (systemic)
| 2. Late (Local) >1wk
128
What are the early (systemic) complications of acute pancreatitis?
1. Respiratory = ARDS, pleural effusion
2. Renal failure
3. Shock = hypovolaemic or septic
4. DIC
5. Metabolic = hypocalcaemia, hyperglycaemia, metabolic acidosis
129
What are the late (local) complications of acute pancreatitis?
1. Pancreatic necrosis/infection/abscess
2. Bleeding e.g. from splenic artery (may require embolisation)
3. Thrombosis
4. Fistula formation = pancreato-cutaneous (skin breakdown)
130
Where might a pancreatic abscess form, and how do you treat it?
May form in a pseudocyst or in the pancreas itself Treated with open or percutaneous drainage
131
What is a pancreatic pseudocyst? How often does it occur?
A collection of pancreatic fluid in the lesser sac surrounded by granulation tissue Occur in 20% with pancreatitis (esp. due to EtOH)
132
What are the causes of chronic pancreatitis?
AGATS
Alcohol (70%)
Genetic (CF/HH)
Autoimmune (Lymphoplasmacytic sclerosing pancreatitis, raised IgG4)
Raised triglycerides
Structural (obstruction by tumour, pancreas divisum)
133
What are the complications of chronic pancreatitis?
```
Chronic Pancreatitis Does Painful Stuff
Carcinoma
Pancreatic swelling --> biliary obstruction
Diabetes Mellitus
Pseudocyst
Splenic vein thrombosis --> splenomegaly
```
134
What are some pancreatic endocrine neoplasias?
1. Insulinoma
2. Gastrinoma (Zollinger-Ellinson)
3. Glucagonoma
4. VIPoma
5. Somatostatinoma
135
What are some pancreatic malformations? x3
1. Ectopic pancreas (Meckel's diverticulum, small bowel)
2. Pancreas divisum
3. Annular pancreas
136
What is pancreas divisum?
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
137
What is a cholangiocarcinoma and where does it typically occur?
A rare bile duct adenocarcinoma
| Typically occurs at the confluence of the right and left hepatic ducts (called 'Klatskin' tumours)
138
What are some risk factors for cholangiocarcinomas?
1. UC
2. PSC
3. Hep B/C
4. Choledocholithiasis
5. Choledochal cysts
6. Lynch 2
7. Flukes
139
What is the pathophysiology of a hydatid cyst?
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
140
What are 3 key anatomical features of the rectum?
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
141
What are the key anatomical features of the anal canal?
4cm long
| From the levator ani muscle to the anal verge
142
What are the features of the upper 2/3rds of the anal canal?
1. Columnar epithelium
2. Insensate
3. Supplied by the superior rectal artery and vein
4. Lympathic Drainage to the internal iliac nodes
143
What are the features of the lower 1/3rd of the anal canal?
1. Squamous epithelium
2. Sensate
3. Supplied by middle and inferior rectal arteries and veins
4. lymphatic drainage to the superficial inguinal nodes
144
What is the dentate line?
The squamomucosal junction
145
What is the white line?
Where the anal canal becomes true skin
146
What are features of the internal anal sphincter?
1. Thickening of the rectal smooth muscle
| 2. Involuntary control
147
What are features of the external anal sphincter?
1. Three rings of skeletal muscle = deep, superficial, subcutaneous
2. Voluntary control
148
What is the anorectal ring?
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
149
What demarcates the junction between the anal canal and the rectum?
The anorectal ring
150
What are haemorrhoids?
Disrupted and dilated anal cushions
151
What is an anal cushion?
Masses of spongy vascular tissue positioned at 3, 7 and 11 O'clock
152
What causes haemorrhoids?
1. Constipation with prolonged straining
| 2. Venous congestion = pregnancy, abdominal tumour, portal HTN
153
What is the classification for haemorrhoids?
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
What are the symptoms of haemorrhoids?
1. Fresh painless PR bleeding
2. Pruritis ani
3. Lump in perianal area
4. Severe pain = thrombosis
155
What is the management for thrombosed haemorrhoids?
```
Conservative = Ice packs
Medical = Analgesia, Topical lignocaine jelly, Stool softeners
Surgical = Haemorrhoidectomy is not usually necessaryPain usually resolves in 2-3 weeks
```
156
Retroperitoneal organs
```
SAD PUCKER
Suprarenal (adrenal) glands
Aorta/IVC
Duodenum (2nd and 3rd part)
Pancreas (except tail)
Ureters
Colon (ascending and descending)
Kidneys
Oesophagus
Rectum
```
157
Abdominal wall muscles
```
TIRE
Transversus Abdominis
Internal Oblique
Rectus Abdominis
External Oblique
```
158
Initial Management of All Surgical Emergencies?
```
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
DDx for a groin lump
```
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
Diaphragm apertures: spinal levels
Aortic Hiatus = T12
Oesophagus = T10
Vena Cava = T8
161
Length of Parts of Duodenum
1st part = 2 inches
2nd part = 3 inches
3rd part = 4 inches
4th part = 1 inch
162
Descending Abdominal Aorta Branches
```
Prostitutes Cause Sagging Swollen Red Testicles Living In Sin
Phrenic
Coeliac
Superior mesenteric
Suprarenal
Renal
Testicular
Lumbars
Inferior mesenteric
Sacral
```
163
What is an anal fissure?
A tear of the squamous epithelial lining in the lower anal canal
164
Causes of an anal fissure?
1. Passage of hard stool
2. Crohns
3. Herpes
4. Anal cancer
165
Management of anal fissure?
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
What is an anal fistula?
An abnormal connection between the anorectal canal and the skin
167
Pathogenesis of anal fistula?
1. Usually secondary to perianal sepsis
| 2. Associations = Crohns, Diverticular disease, Rectal Ca, Immunosuppression
168
Classification of anal fistula?
```
High = cross sphincter muscles above dentate line
Low = cross sphincter muscles below dentate line
```
169
What is a sinus?
A blind ended tract, lined by epithelial or granulation tissue, which opens onto an epithelial surface
170
What is a pilonidal sinus?
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
What are risk factors for a pilonidal sinus?
1. Males
2. Hirsute
3. Asians/Mediterranean/Middle East
4. Overweight
5. Occupation with lots of sitting
172
Management of a pilonidal sinus?
1. Conservative = hygeine advice, shave/remove hair from affected area
2. Surgical = incision and drainage of abscess, elective sinus excision
173
What is a rectal prolapse?
Protrusion of rectal tissue through the anal canal
174
What is the classification of anal prolapse?
Type I = Mucosal prolapse
| Type II = Full thickness prolapse
175
What is a hernia?
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
176
What is Maydl's hernia?
A herniating double loop of bowel
| The strangulated portion may reside as a single loop inside the abdomen
177
What is Littre's hernia?
Hernial sac containing a strangulated Meckel's diverticulum
178
What is Amyand's hernia?
Inguinal hernia containing strangulated appendix
179
What is Richter's hernia?
1. Only part of circumference of bowel is within sac
2. Most commonly seen with femoral hernias
3. Can strangulate without obstructing
180
What is a pantaloon hernia?
A simultaneous direct and indirect hernia
181
What is a herniotomy?
Excision of hernial sac
182
What is herniorrhapy?
Suture repair of hernial defect
183
What is hernioplasty?
Mesh repair of hernial defect
184
What are the types of hernia? x11
```
Inguinal
Femoral
Incisional
Umbilical
Paraumbilical
Epigastric
Spigelian
Obturator
Lumbar
Sciatic
Gluteal
```
185
What are the causes of an inguinal hernia?
1. Congenital = Patent processus vaginalis
| 2. Acquired = Things which increase IAP
186
What are the acquired causes of inguinal hernias?
1. Chronic cough = COPD, asthma
2. Prostatism
3. Constipation
4. Heavy lifting
5. Previous incision/repair
6. Ascites/obesity
7. Appendicectomy
187
What are features of indirect hernias?
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
What are features of direct hernias?
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
What are the borders of Hesselbach's triangle?
1. Medially = Lateral border of rectus abdominis
2. Laterally = Inferior epigastric artery
3. Inferiorly = Base of the inguinal ligament
190
What are the complications of inguinal hernia repair?
1. Early = haematoma/seroma formation, intra-abdominal injury, infection, urinary retention
2. Late = recurrence, ischaemic orchitis, chronic groin pain/paraesthesia
191
What is a femoral hernia?
Protrusion of viscus through the femoral canal
| Commoner in women
192
What is the aetiology of a femoral hernia?
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
Features of a femoral hernia?
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
What are the surgical operations for femoral hernias?
```
Elective = Lockwood approach (low approach)
Emergency = McEvedy approach (high approach)
```
195
What percentage of surgical incisions develop an incisional hernia?
6%
196
What are risk factors for developing incisional hernias?
Pre-operative
Intra-operative
Post-operative
197
Pre-operative risk factors for incisional hernias?
1. Age
2. Obesity/malnutrition
3. Steroids
4. Chemo/Radiotherapy
5. Comorbidities = DM, CKD, Malignancy
198
Intra-operative risk factors for incisional hernias?
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
Post-operative risk factors for incisional hernias?
1. Infection
2. Haematoma
3. Raised IAP = Chronic cough, straining, post-op ileus
200
Features, Risk Factors and Management of Umbilical hernias?
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
Features, Risk Factors and Management of Paraumbilical hernias?
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
Features and Management of Epigastric hernias?
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
Features of spigelian hernia?
1. Hernia through linea semilunaris
2. Hernia lies between layers of abdominal wall
3. Palpable mass more likely to be colon cancer
204
Features of obturator hernia?
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
Features of lumbar hernia?
1. Middle aged M>F
2. Typically follow loin incisions
3. Herniates through superior/inferior lumbar triangles
206
Features of sciatic hernia?
1. Hernia through lesser sciatic foramen
| 2. Usually presents as SBO + gluteal mass
207
Features of gluteal hernia?
1. Hernia through greater sciatic foramen
| 2. Usually presents as SBO + gluteal mass
208
What are the advantages of minimal access surgery?
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
What are the disadvantages of minimal access surgery?
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
What are some common minimal access procedures?
Laparoscopic:
1. Cholecystectomy
2. Appendicectomy
3. Hernia repair
4. Colectomy
5. Fundoplication
211
Relative contraindications to minimal access surgery?
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
What is ERAS?
Enhanced Recovery After Surgery
1. Commonly employed in colorectal and orthopaedic surgery
2. Has Pre-op, intra-op, and post-op strategies
213
What are the aims of ERAS?
1. Increase speed of recovery and return to function
| 2. Minimise adverse physiological responses to surgery e.g. hypercoagulability
214
Pre-op strategies of ERAS?
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
Intra-op strategies of ERAS?
REDUCING PHYSICAL STRESS
1. Short acting anaesthetic agents
2. Epidural use
3. Minimally invasive techniques
4. Avoid drains and NGTs where possible
216
Post-op strategies of ERAS?
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
How do you classify surgical complications?
Immediate (<24hrs)
Early (1d-1m)
Late (>1m)
218
What are the immediate surgical complications?
```
AASH
Anaesthetic complications
Atelectasis
Surgical trauma to local structures
Haemorrhage (Primary or reactive)
```
219
What are the early surgical complications?
```
WAVII SUPA
Wound infection and dehiscence
Atelectasis
VTE
Infection (7Cs)
Ileus
Secondary Haemorrhage
Urinary Retention
Pain
Antibiotic-associated colitis (AAC)
```
220
What are the late surgical complications?
```
SHANF
Scarring
Hernias
Adhesions
Neuropathy
Failure/Recurrence
```
221
What are possible causes of post-operative fever?
```
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
What are the early complications of colonic surgery?
```
3As, E, I
Antibiotic-associated colitis (AAC)
Anastomatic leak
Abdominal abscess
Enterocutaneous fistula
Ileus
```
223
What are the late complications of colonic surgery?
1. Adhesions --> Obstruction
| 2. Incisional hernias
224
What is the classification of operative haemorrhage?
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
What is the operative classification of a wound?
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
What is wound dehiscence preceded by?
Serosanguinous discharge from wound
227
How do you classify the risk factors for wound dehiscence?
Pre-operative
Operative
Post-operative
228
What are the pre-operative risk factors for wound dehiscence?
1. Age
2. Smoking
3. Obesity/malnutrition/cachexia
4. Comorbidities = BM, chronic cough, Ca
5. Steroids
6. Chemo/radio
229
What are the operative risk factors for wound dehiscence?
1. Length and orientation of incision
2. Closure technique: follow Jenkin's rule
3. Suture material
230
What are the post-operative risk factors for wound dehiscence?
1. Infection
2. Haematoma/seroma formation
3. Raised IAP e.g. prolonged ileus --> distension
231
What is Jenkin's rule?
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
What is the management of wound dehiscence?
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
What are the borders of the inguinal canal?
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
What are the borders of the femoral canal?
1. Medially = lacunar ligament
2. Laterally = femoral vein
3. Anteriorly = inguinal ligament
4. Posteriorly = Pectineal ligament of Cooper
235
What are the contents of the femoral canal?
Fat and Cloquet's node
236
What are the contents of the inguinal canal in males?
Spermatic Cord + Ilioinguinal nerve
237
What are the contents of the inguinal canal in females?
Round ligament + Iiioinguinal nerve + Genital branch of genitofemoral nerve
238
What are the contents of the spermatic cord?
3 layers of fascia
3 Arteries + 3 Veins
2 Nerves
3 Other things
239
What is the operative distinction between indirect and direct hernias?
```
Indirect = arise lateral to inferior epigastric vessels
Direct = arise medial to inguinal ligament, through Hesselbach's triangle
```
240
What are the borders of Hesselbach's triangle?
```
Medially = Lateral border of rectus abdominis
Laterally = Inferior epigastric artery
Inferiorly = Inguinal ligament
```
241
What are the approaches to operating on Inguinal hernias?
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
What must you always do when consenting pt for hernia repair?
Examine testes and document if any abnormalities
| Explain risk of testicular damage when consenting pt
243
What are the complications of hernia repair?
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
What is the definition for an incisional hernia?
Extrusion of peritoneum and abdominal contents throgh a previously acquired defect
245
What Hx might a pt with an incisional hernia present with?
1. Previous surgery
2. Post-op wound infection or other complications
3. Comorbidities e.g. chronic cough
4. Discomfort or episodes of obstruction
246
What Hx might a pt with an umbilical/paraumbilical hernia present with?
1. Predisposing factors: pregnancy, ascites, obesity
2. Pain
3. Previous repairs
4. Reducible
5. Episodes of obstruction or strangulation
247
What is gastroschisis?
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
What is exomphalos?
1. Protrusion of abdominal contents within a 3-layered sac
| 2. Commonly associated with other defects e.g. cardiac, anencephaly
249
What are the 4 key questions to ask whilst examining a scrotal lump?
APTT
1. Can you get above it?
2. Is it tender?
3. Is testis palpable separately?
4. Does it transilluminate?
250
What are causes of a tender testis?
1. Torted testis or hydatid of Morgagni
2. Epididymo-orchitis
3. Strangulated hernia
251
What are the causes of post-operative SOB?
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
What are the different types of healing?
Primary intention
Secondary intention
Tertiary Intention
253
What is healing by primary intention?
1. Most surgical wounds
2. Excision and closure (sutures/staples) with edges approximated
3. Minimises scarring
254
What is healing by secondary intention?
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
What is healing by tertiary intention?
1. Combination of primary and secondary intention
| 2. Purposely left open and closed at a later date
256
What are the three complications of a hernia?
1. Incarceration
2. Strangulation
3. Bowel Obstruction
257
What are causes of post-operative urinary retention?
1. Drugs = opioids, epidural/spinal, anti-AChm
2. Pain = sympathetic activation --> sphincter contraction
3. Psychogenic = hospital environment
258
What are some risk factors for post-operative urinary retention?
1. Male
2. Age
3. Neuropathy e.g. DM, EtOH
4. BPH
5. Surgery type e.g. hernia and anorectal
259
What is the management of post-operative urinary retention?
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
What are the specific complications for a cholecystectomy?
1. Conversion to open = 5%
2. CBD injury = 0.3%
3. Bile leak
4. Retained stones (needing ERCP)
5. Fat intolerance/loose stools
261
What are the specific complications for an appendicectomy?
1. Abscess formation
2. Fallopian tube trauma
3. Right hemicolectomy
262
What are the specific complications for anorectal surgery?
1. Anal incontinence + fissure + fistula
| 2. Stenosis
263
What is the specific complication for small bowel surgery?
Short gut syndrome
264
What is the average length of the small bowel?
6 metres (20 feet)
265
What is the average length of the large bowel?
1.5 metres (5 feet)
266
What is short gut syndrome?
A malabsorption disorder caused by <100-250cm of normally functioning small intestine
267
What are specific complications of a splenectomy?
1. Gastric dilatation secondary to gastric ileus
2. Thrombocytosis --> VTE
3. Infection = encapsulated organisms
268
What are specific complications of arterial surgery?
1. Thrombosis and embolisation
2. Anastomotic leak
3. Graft infection
269
What are specific complications of aortic surgery?
1. Gut ischaemia
2. Renal failure
3. Aorto-enteric fistula
4. Anterior spinal syndrome (paraplegia)
5. Emboli --> distal ischaemia (trash foot)
270
What are specific complications of breast surgery?
1. Arm lymphoedema
2. Skin necrosis
3. Seroma
271
What are specific complications of urological surgery?
1. Sepsis
| 2. Uroma = extravasation of urine
272
What are specific complications of prostatectomy?
PURE
1. Prostatitis
2. Urinary incontinence
3. Retrograde ejaculation
4. Erectile dysfunction
273
What are specific complications of a thyroidectomy?
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
What are specific complications of a fracture repair?
1. Mal/non-union
2. Osteomyelitis
3. Avascular necrosis
4. Compartment syndrome
275
What are specific complications of a hip replacement?
1. Deep infection
2. VTE
3. Dislocation
4. Nerve injury: sciatic/GN
5. Leg length discrepancy
276
What are specific complications of cardiothoracic surgery?
1. Pneumo/haemothorax
| 2. Infection: mediastenitis, empyema
277
What is the epidemiology of DVTs?
They occur in 25-50% of surgical patients without thromboprophylaxis
278
What are the risk factors for a DVT?
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
What are some signs of a DVT?
1. Calf warmth, erythema, tenderness, swelling
2. Mild pyrexia
3. Pitting oedema
280
When is the peak incidence of DVTs after surgery?
5-10 days
281
What percentage of DVTs below the knee are asymptomatic?
65%
282
What are 2 differentials for a DVT?
1. Cellulitis
| 2. Ruptured Baker's cyst
283
What is the scoring system for a DVT?
Wells' Score
284
What is the management for a DVT?
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
What is the duration of anticoagulation after a DVT?
1. Below knee = 6-12 weeks
2. Above knee = 3-6 months
3. On-going cause = indefinite
286
How can one prevent DVTs?
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
What is cellulitis?
Acute infection of the subcutaneous connective tissue
288
What are the most common causes of post-op cellulitis
1. Beta-haemolytic streps
| 2. Staph aureus
289
What are causes of post-operative reduced urine output?
1. Pre-renal = hypovolaemia
2. Renal = NSAIDs, gentamicin
3. Post-renal (commonest) = acute urinary retention, blocked/malsited catheter
290
What are common causes of post-operative N&V?
1. Emetic drugs e.g. opioids
2. Obstruction
3. Ileus
291
What are the causes of post-operative hypotension?
CHOD
1. Cardiogenic = MI, fluid overload
2. Hypovolaemia = inadequate replacement of fluid losses, haemorrhage
3. Obstructive = PE
4. Distributive = sepsis, neurogenic shock
292
What are the causes of post-operative hypertension?
1. Previous HTN
2. Urinary retention
3. Pain
293
What is the fluid composition of the human body?
60% of humans is water (if 70kg --> 42kg)
2/3rd intracellular
1/3rd extracellular
294
What is the composition of extracellular fluid in the body?
Interstitial
Plasma
Transcellular
295
What is Starling's hypothesis?
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
What is osmotic pressure?
The ability of solute to attract water
297
What is oncotic pressure?
A form of osmotic pressure exerted by proteins
298
What is hydrostatic pressure?
Pressure exerted by a fluid at equilibrium due to the force of gravity
299
Fluid balance: what are the fluid inputs?
```
Water = 1500ml
Food = 1000ml
Metabolism = 300ml
Total = 2800ml = 40ml/kg/day
```
300
Fluid balance: what are the fluid outputs?
Urine = 1500ml
Insensible (lungs + sweating) = 1000ml
Stool = 300ml
Total = 2800ml = 40ml/kg/day
301
What is the minimum urine output?
0.5ml/kg/h = 30ml/h
302
What is the minimum Na requirement?
1.5-2mmol/kg/d = 100mmol/d
303
What is the minimum K requirement?
1mmol/kg/d = 60mM/d
304
What is the daily fluid regimen to meet requirements?
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
How much extra fluid should you give someone with a fever?
An extra 500ml for each °C increase
306
What does CVP monitoring show?
Indicates RV preload, and depends on both venous return and cardiac output
307
What causes a raised CVP?
1. Increased circulating volume
| 2. Reduced CO (heart failure)
308
What causes a low CVP?
1. Reduced circulating volume
309
What is normal CVP?
5-10cm H20
310
How do you interpret CVP values?
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
What is a fun mushkie to interpret CVP values without using a fluid challenge?
Passive leg raising may be more useful than fluid challenge in determining response to fluids - a sustained raised in CVP suggests heart failure
312
What are examples of crystalloid solutions?
1. Normal Saline
2. Dextrose-Saline
3. Hartmann's/Ringer's lactate
313
What are the contents, pH, and uses for normal saline?
1. Contents = 0.9% NaCl (9g/L), 154mmol NaCl
2. pH = 5.5
3. Use = normal daily fluid requirements + replace losses
314
What are the contents and uses for 5% dextrose?
1. Contents = 50g dextrose/L
| 2. Use = normal daily fluid requirements
315
What are the contents and uses for Dextrose-Saline?
1. Contents = 4% dextrose (40g/L) + 0.18% NaCl (31mM NaCl)
| 2. Use = normal daily fluid requirements
316
What are the contents of Hartmann's/Ringer's Lactate?
1. Na = 131mM
2. Cl = 111mM
3. K = 5mM
4. Ca = 2.2mM
5. Lactate/HCO3- = 29mM
317
What are the uses for Hartmann's/Ringer's Lactate?
1. Resuscitation in trauma pts
| 2. Parkland's formula(for burns) = 4 x weight x %burn = mL in first 24hrs
318
What is the pH of Hartmann's solution?
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
What is colloid?
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
How do you classify the types of colloid?
1. Natural = albumin, blood
| 2. Synthetic = gelofusin, volplex, haemaccel, voluven
321
What are the uses for colloid?
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
What are problems associated with using colloid?
1. Anaphylaxis
2. Volume overload
3. Can interfere with cross-matching therefore take blood for cross-matching before using
323
How can you assess fluid status by examinations?
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
What is PCWP?
Pulmonary capillary wedge pressure, an indirect measure of LA pressure
325
What is the composition of ileal fluid coming out of an ileostomy?
```
Na = 130mM
Cl = 110mM
K = 10mM
HCO3 = 30mM
```
326
What is normal output for an ileostomy, and what is high output
```
Normal = 10-15ml/kg/d = 700ml/d
High = >1L/d
```
327
What can you do if there is reduced urine output post-op?
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
What are 2 anthropometric measures of nutrition?
Skin-fold thickness and arm circumference
329
What are the daily nutritional requirements/kg/24hr?
```
Calories = 20-40kcal
Carb = 2g
Fat = 3g
Protein = 0.5-1g
Nitrogen = 0.2-0.4g
```
330
What are ways to deliver enteral nutrition?
PO
NGT
Gastrostomy
Jejunostomy
331
What are 4 different types of feeds?
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
What are complications of NGT and enteral feeding in general?
1. NGT = nasal trauma, malposition/tube blockage
| 2. Feeding = feed intolerance --> diarrhoea, electrolyte imbalance, aspiration, refeeding syndrome
333
What are indications for non-PO enteral feeding?
1. Catabolic = sepsis/burns/major surgery
2. Coma/ITU
3. Malnutrition
4. Dysphagia = stricture, stroke
334
What are the indications for parenteral nutrition?
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
How is parenteral nutrition delivered?
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
What are the typical contents of parenteral nutrition?
2000kcal = 50%fat, 50% carb
10-14g nitrogen
Vitamins, minerals and trace elements
337
How can you classify the complications associated with TPN?
1. Line-related
| 2. Feed-related
338
What are the line-related complications of TPN?
1. Pneumothorax/haemothorax
2. Cardiac arrhythmia
3. Line sepsis
4. Central venous thrombosis --> PE or SVCO
339
What are the feed-related complications of TPN?
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
What is refeeding syndrome?
A life threatening complication of refeeding via any route after a prolonged period of starvation, due to low potassium, magnesium and phosphate
341
What is the pathophysiology of refeeding syndrome?
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
What are the complications of refeeding syndrome?
1. Rhabdomyolysis
2. Respiratory insufficiency
3. Arrhythmias
4. Shock
5. Seizures
343
What patients are at-risk of refeeding syndrome?
1. Malignancy
2. Anorexia Nervosa
3. Alcoholism
4. GI surgery
5. Starvation
344
What questions must be asked in the history as part of a secondary survey?
```
AMPLE
Allergies
Medication
PMH
Last ate/drunk
Events
```
345
What investigations are done as part of the secondary survey?
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
How do you assess C-spine radiographs?
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
What is 'clearing the cervical spine?'
Process of determining if cervical spine injuries exist
348
What are the NEXUS criteria?
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
How can you estimate the circulating blood volume?
7% body mass
350
What are the causes of neurogenic shock?
1. Spinal anaesthesia
2. Hypoglycaemia
3. Cord injury above T5
4. Closed head injuries
351
How does neurogenic shock present?
Hypotension, bradycardia and warm extremities
352
How do you manage neurogenic shock?
1. Vasopressors = vasopressin and NA
| 2. Atropine = reverse the bradycardia
353
What is spinal shock?
Acute spinal cord transection leading to loss of all voluntary and reflex activity below the level of injury
354
How does spinal shock present?
1. Hypotonic paralysis
2. Arreflexia
3. Loss of sensation
4. Urinary retention
355
What are the differentials for life-threatening chest injuries?
```
ATOMIC
Airway obstruction
Tension pneumothorax
Open pneumothorax (sucking)
Massive haemothorax
Intercostal disruption and pulmonary contusion
Cardiac Tamponade
```
356
What is a massive haemothorax?
Accumulation of >1.5L of blood in the chest cavity, usually caused by disruption of hilar vessels
357
Inguinoscrotal hernia more likely to be?
Indirect hernia
358
Test for direct vs. indirect hernia?
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
4 distinguishing features of an inguinal hernia?
1. Above and medial to pubic tubercle
2. Cough impulse
3. Reducible
4. Bowel sounds
360
Completion of abdo exam?
1. DRE
2. External genitalia
3. Hernial Orifices
4. Dipstick the urine
5. Look at observation chart
361
3 DDx of spider naevi?
1. CLD
2. OCP
3. Pregnancy
362
Spider naevus vs. telangiectasia?
1. Spider naevus = fill from centre
| 2. Telangiectasia = fill from edge
363
Post-op recovery after surgery?
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
Mx of incisional hernias?
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
Normal bilirubin?
3-17uM
366
Visible jaundice bilirubin?
50uM (3 x ULN)
367
Dilated duct diameter on US?
>6mm
368
Imaging of post-hepatic jaundice?
1. US
2. ERCP
3. MRCP
4. Jaundice
369
Causes of post-op jaundice?
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
Calot's triangle borders?
1. Superior = inferior edge of liver
2. Medial = common hepatic duct
3. Inferior = cystic duct
371
Contents of Calot's triangle?
1. Cystic artery
2. Lund's node
3. +/- aberrant RHA
372
How to confirm absence of stones in CBD during surgery?
Operative cholangiogram
373
Causes of jaundice after cholecystectomy?
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
What to do if appendix is macroscopically normal?
1. Remove anyways = 20% have microscopic inflammation and avoids appendicitis in the future
2. Search for other cause = Meckel's, gynae pathology
375
Complications of open appendicectomy?
1. Abscess formation
| 2. Right hemicolectomy (e.g. for carcinoid, caecal necrosis)
376
Commonest appendix positions?
1. Retrocaecal = 65%
2. Pelvic = 30%
3. Subcaecal = 3%
4. Ante-ileal = 2%
