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Final Year Defintions > Surgical > Flashcards

Surgical Flashcards

1
Q

Is the long saphenous vein medial or lateral?

A

Medial

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2
Q

Aneurysm

A

Dilatation of a blood vessel

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3
Q

Describe the potential presentation of an aneurysm

A

asymptomatic or symptomatic (pressure symptoms, rupture symptoms, thrombosis or embolisation - distal ischaemia)

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4
Q

Indications for aneurysm repair

A

symptoms or large asymptomatic aneurysms (>5.5 cm) or increasing by >1cm per year

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5
Q

Signs of peripheral vascular disease

A 
Cold peripheries
Marbled skin
Trophic changes
Venous guttering
Arterial ulcers 
Gangrene 
Prolonged CRT
Beurger Test positive 
Weak / absent distal pulses
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6
Q

Venous Guttering

A

Test for peripheral vascular disease - lift leg up, veins empty and when return flat, it takes time to refil

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7
Q

Acute limb ischaemia

A

critical limb ischaemia, onset within 24 hours, without intervention the limb will be lost

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8
Q

Surface marking for femoral pulse

A

Mid inguinal point

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9
Q

Location of the peripheral pulses: femoral, popliteal, posterior tibial

A

Femoral pulse - mid inguinal point is the surface marking for the femoral pulse

Popliteal pulse - first examine flat then leg bent, if you can feel it flat then it is likely to be aneurysmic

Posterior tibial artery - a third of the way between the medial malleolus and the distal point of the calcaneous

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10
Q

Risk factors for varicose veins

A

family history, pregnancy, smoking, previous DVT, obesity, age, reduced mobility

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11
Q

6 Ps of acute limb ischaemia

A 
Pain
Pallor
Paraesthesia
Paralysis 
Pulseless
Perishingly cold
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12
Q

Signs of irreversible limb ischaemia

A

Mottling
Muscle tenderness
Motor or sensory loss
Major necrosis

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13
Q

Signs of chronic limb ischaemia

A

Claudication
Rest pain
Ulceration
Necrosis

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14
Q

Most common site of venous ulceration

A

Gator reign - posterior aspect of lower limb

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15
Q

Virchow’s Triad

A

stasis, hypercoaguability, endothelial injury

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16
Q

CT colonoscopy - definition and indication

A

Air inserted into the colon and then a CT scan is performed.

It is used for patients who are not fit for colonoscopy.

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17
Q

Transpyloric plane

A

Line that separates epigastric and umbilical areas

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18
Q

Semi lunaris line

A

Line that separates the flanks from the umbilical

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19
Q

Hockey stick scar (what was the surgery?)

A

Renal transplant

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20
Q

Midline laparotomy (what was the surgery?)

A

Open abdominal surgery (eg: resection)

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21
Q

Grid iron (what was the surgery?)

A

Open appendicectomy

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22
Q

Location of port scars

A

Umbilical (camera) plus at least two more for triangulation of instruments

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23
Q

Cockers (describe this scar + what was the surgery?)

A

Oblique scar on the R side extending from the hypochondrium to the epigastrium

Open cholecystectomy or liver lobectomy

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24
Q

Ileostomy - what are the features?

A

Small bowel, right sided, spouted (due to irritant contents as it is acidic and contains enzymes), liquid contents of a yellow or green colour

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25
Q

Colostomy - what are the features?

A

Large bowel, left sided, flush to skin

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26
Q

Urostomy - what are the features?

A

Urine, aka ileal conduit, usually following cystectomy, spouted

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27
Q

What are the 3 types of stomas?

A

Urostomy, Ileostomy, Colostomy

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28
Q

Super-sphincteric fistula

A

Fistula that goes above the sphincter, loops around it and back down below dentate line

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29
Q

Stoma rod (or bridge)

A

Rodsplaced as a ‘bridge’ to support the loopstomawhile the mucocutaneous junction heals in order to prevent retraction (placed during formation of stoma and removed prior to discharge)

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30
Q

Stress ulcer - pathophysiology

A

Physiological stress (specifically hypotension) causing an ulcer

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31
Q

Rockall score

A

Upper GI bleeding risk and severity score

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32
Q

AIN

A

Anal Intraepithelial Neoplasia, like CIN. Graded 1-3. Caused by HR HPV strains 16 and 18

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33
Q

Spigellian hernia

A

Hernia on semi-lunars lines

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34
Q

Grey Turner Sign

A

A sign of reptroperitoneal haemorrhage, flank bruising, usually a sign of severe pancreatitis but can be a sign of rupture aneurysm

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35
Q

Cullen Sign

A

A sign of intraperitomeal haemorrhage, umbilical bruising, usually a sign of severe pancreatitis

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36
Q

Charcot Triad

A

Triad of ascending cholangitis: fever, RUQ pain, jaundice

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37
Q

Riggler’s Sign

A

air on both sides on both bowel wall, seen on AXR, sign of perforation

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38
Q

PCT - definition and indication

A

percutaneous trans hepatic cholangiogram, going through the liver to access the gallbladder and CBD to remove a stone that you cannot get on ERCP

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39
Q

Biliary colic

A

gallstones with pain in the absence of inflammation and fever

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40
Q

Coffee bean sign

A

AXR appearance of volvulus

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41
Q

Transcoelomic spread

A

intra-peritoneal spread of abdominal cancers (commonly colonic and ovarian).
Often presents with malignant ascites

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42
Q

Kruckenburg tumour

A

Secondary ovarian tumour - primary usually in the bowel or stomach. Spread by transcoelomic spread.
Often bilateral.

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43
Q

What sign on AXR is suggestive of Gallstone Ileus

A

Gas in the biliary tree

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44
Q

What does Courvossier Law say?

A

Painless jaundice with a palpable gallbladder is UNLIKELY to be gallstones

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45
Q

What kind of tumour has a necrotic and haemorrhagic centre?

A

Teratoma

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46
Q

What are the three features of a hernia?

A

Soft
Compressible
Cough impulse

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47
Q

How do you tell the difference between a direct and indirect hernia?

A

Indirect - will go to the testis

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48
Q

What is the Duke’s staging of CRC?

A

A - not invaded the wall
B - invaded the mucosa
C - LN involvement (C1 is regional lymph nodes, C2 is distant lymph nodes)
D - distant mets

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49
Q

Which LN does testicular cancer metastasise to? Why?

A

Para-aortic LN - because the testicles are embryologically intro abdominal organs which come down during development

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50
Q

Which lymph nodes does scrotal cancer metastasise to?

A

Inguinal

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51
Q

What is the difference between ascending cholangitis and cholecystitis?

A

Ascending cholangitis is inflammation of the tubes (biliary tree), cholecystitis is inflammation of the GB

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52
Q

Where anatomically is the mid inguinal point? What does it mark?

A

Half way between the ASIS and pubic symphisis.

Marks the deep (internal) ring and femoral artery.

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53
Q

Anatomically, what is the difference between a femoral and inguinal hernia?

A

Below and lateral to pubic tubercle is femoral hernia

Above and medial to pubic tubercle is inguinal hernia

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54
Q

On examination, how do you differentiate between direct and indirect inguinal hernias?

A

Cover deep ring (mid inguinal point), get patient to cough - if hernia appears it is DIRECT, if not it is INDIRECT (as this comes through the deep ring)

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55
Q

Define: synchronous and metachronous cancer risks

A

Synchronous - the risk a patient with one tumour has another simultaneously. It is 3%

Metachronous - the risk a patient who has had a tumour then goes on to have another later. It is 5%

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56
Q

Define: primary intention

A

most surgical wounds
excision and closure - edges are approcimated and closed with sutures or stables
Minimal scarring

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57
Q

Define: secondary intention

A

Wound left open
Granulation from bottom up
Usually occurs when approximation cannot be done

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58
Q

Define: wound dehiscence

A

Surgical complication where there is rupture along the line of the wound

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59
Q

List some of the risk factors for poor wound healing

A

Local - limited moisture, mechanical factors, ischaemia, foreign body, oedema, infection

Systemic - metabolic, drugs, tissue health, underling health

60
Q

Define: hernia

A

protrusion of a viscous through a defect in its walls out of it’s normal position

61
Q

Complications of a hernia

A

Incarceration
Strangulation
Bowel obstruction

62
Q

Define: incarceration (cf hernias)

A

An irreducible hernia, can be painful - high risk of strangulation

63
Q

Define: strangulated (cf hernias)

A

Confinement of the bowel within the hernia interrupting blood supply
This is painful
Surgical emergency

64
Q

Define: incisional hernia

A

Extrusion of the peritoneum and abdominal contents through a weak scar on the abdominal wall, representing a partial wound dehiscence where the skin remains in tact

65
Q

List some of the risk factors for incisional hernias

A

Pre-op - raised intra-abdominal pressure (eg: COPD), age, immunocompromise

Operative - poor closure of the wound, size of wound, drains

Post-op - haematoma, infection, early mobilisation

66
Q

What is the difference between an indirect and direct inguinal hernia?

A

Direct - weak point in abdominal wall (Hesselbach’s traingle) - medial to inferior epigastric vessels

Indirect - patent processus vagnalis, lateral to inferior epigastric vessels, protrudes through deep ring

67
Q

Clinically, how do you differentiate between direct and indirect hernias

A

Reduce hernia and put pressure at the deep ring - if the hernia protrudes it is direct, if it stays reduced it is indirect

68
Q

Define: fistula

A

An abnormal connection between two epithelial surfaces

69
Q

List some causes of fistulae

A

Malignancy
Diverticular disease
Crohn’s
Abscess

70
Q

Outline the management of a fistula (HINT: think SNAP)

A

Sepsis = ABC approach
Nutrition
Anatomy = imaging
Planning = operative

71
Q

Define: sinus

A

Blind ending tract between a epithelial surface and a cavity lined with granulation tissue

72
Q

What are the 4 features of bowel obstuction

A

Pain
Distention
Vomiting
Absolute constipation

73
Q

Which procedures are considered high risk and required DVT prophylaxis?

A 
Orthopaedic surgery
Major general, urological or gynaecological surgery
Neurological surgery
Cardiac surgery
Major vascular surgery
74
Q

Outline what is involved in DVT prophylaxis

A

Conservative measures - optimise hydration, early mobilisation

Mechanical measures - TED stockings

Pharmacological measures - fondaparinux / LMWH

75
Q

List some of the findings in chronic venous disease (HINT: think HAS LEGS)

A 
Haemosiderin deposition
Atrophie blanche
Swelling
Lipodermatosclerosis (inverted champagne bottle leg) 
Eczema
Gaiter ulcers
Starts
76
Q

How does LMWH work?

A

Inhibition of thrombin (therefore mediates inhibition of factor Xa)

77
Q

How does warfarin work?

A

Inhibition of vitamin K (therefore prevents the formation of Vit K-dependent factors: 2, 7, 9, 10)

78
Q

How does fondaparinux work?

A

Activation of anti-thrombin (therefore mediates inhibition of factor Xa)

79
Q

What are the vitamin K dependent factors?

A

2, 7, 9 , 10

80
Q

Outline the fontaine classification for chronic limb ischaemia (i.e. the stages)

A

Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - ischaemic rest pain
Stage 4 - ulceration / gangrene

81
Q

What is a normal ABPI?

A

1 - 1.2

82
Q

What ABPI measurement is suggestive of critical limb ischaemia

A

<0.5

83
Q

What is Leriche’s Syndrome?

A

Triad of arterial disease symptoms in MEN - buttock claudication, ED and absent femoral pulses

Caused by aortoiliac occlusive disease (secondary to atheroscelrosis)

84
Q

With chronic limb ischaemia - which vessel is affected if the patient presents with buttock pain?

A

Iliac disease (internal or common)

85
Q

In chronic limb ischaemia - which vessel is affect if the patient presents with calf pain?

A

Superficial femoral disease

86
Q

What is the difference between intermittent and spinal claudication?

A

Intermittent claudication is due to arterial disease - there is vascular insufficiency causing claudication pain in the calf and/or buttock. Pain is normally eased by rest.

Spinal claudication is due to nerve disease - there is nerve compression causing claudication pan in the whole leg. Pain is of a burning nature. It is normally eased by sitting forward.

87
Q

What are the indications for bypass grafting in chronic limb ischaemia?

A

Short claudication distance
Rest pain
Sx interfering with QOL

88
Q

Which anticoagulation is used in the following types of bypass grafts:

(a) Synthetic
(b) Autologous

A

(a) aspirin

(b) warfarin

89
Q

Generally speaking when is a synthetic graft used over an autologous graft for bypass?

A

Above the inguinal ligament

90
Q

What are the two classifications of bypass graft?

A

Anatomical (eg: aorto-bifemoral bypass)

Extra-anatomical (eg: axillofemoral, femoral-femoral)

91
Q

List the indications for amputation (HINT: think “4Ds”)

A

Dead - PVD
Dangerous - sepsis, malignancy
Damaged - trauma, burns, frostbite
Damned nuisance - pain / neurological damage

92
Q

Describe the presentation of acute limb ischaemia (HINT: think “6 Ps”)

A 
Pale
Pulselessness 
Perishingly cold
Pain
Paraestehsia
Paralysis
93
Q

What is the difference in presentation in acute limb ischaemia caused by thrombosis or embolism?

A

Thrombotic ischaemia - gradual onset over hours/days with less severe disease due to the presence of collateral (i.e. usually presents as incomplete ischaemia). There will be a history of caludication

Embolic ischaemia - sudden onset with profound ischaemia (i.e. usually presents as complete ischaemia). There is be no past history of claudication. Patient likely to have AF.

94
Q

What is the main management of thrombotic acute limb ischaemia?

A

Thrombolysis and bypass surgery

95
Q

What is the main management of embolic acute limb ischaemia?

A

Enbolectomy and warfarin WITHIN 6 HOURS - amputation may be required

96
Q

Define: an aneurysm

A

abnormal dilation of a blood vessel >50% of its normal diameter

97
Q

What is the difference between a true and false aneurysm?

A

A true aneurysm involves all layers of the vessel wall

A false aneurysm is a collection of blood around a vessel wall that communicates with the lumen

98
Q

Define: dissection

A

Dilation of a blood vessel caused by blood splaying the media forming a channel within the vessel wall

99
Q

List some causes of an aneurysm

A

Congenital (eg: PCKD, Marfan’s, Ehlers-Danlos)

Acquired - atheroscelrosis, trauma, inflammation (eg: HSP), infection (eg: syphillis)

100
Q

List the complications of aneurysm rupture

A

Rupture
Thrombosis
Distal embolisation
Fistula

101
Q

List some common sites of aneurysm formation

A

Popliteal aneurysm
Abdominal aortic aneurysm
Cerebral (eg: berry aneurysm)

102
Q

Where are most abdominal aortic aneurysms?

A

infra-renal

103
Q

At what size should AAA be actively managed?

A

> 5.5cm

104
Q

What is the management for small (<5.5 cm), unruptured AAAs?

A

US monitoring - yearly if <4cm, 3 monthly if 4 - 5.5 cm

105
Q

When should you operate on a AAA?

A

> 5.5 cm
Growing >1cm/year
Symptomatic
Complications

106
Q

What is the AAA screening programme?

A

One-off USS in men aged >65 years

107
Q

Describe the presentation of an aortic dissecton

A

Sudden onset tearing pain radiating through back

108
Q

What is an important sign of an aortic dissection?

A

unequal BP in both arms

109
Q

Name the two types of aortic dissection

A

Type A - proximal (more common)

Type B - distal

110
Q

List some RFs for AAA

A 
Male
>65 year old
Smoking
FH
HTN
111
Q

Define the following terms:

(a) gangrene
(b) wet gangrene
(c) dry gangrene
(d) pregangrene
(e) fournier’s gangrene
(f) meleney’s gangrene
(g) gas gangrene

A

(a) gangrene - tissue death due to poor vascular supply
(b) wet gangrene - tissue death + infection
(c) dry gangrene - tissue death
(d) pregangrene - tissue on the bring of gangrene (i.e. critical vascular supply)
(e) fournier’s gangrene - perineal gangrene
(f) meleney’s gangrene - post-op ulceration
(g) gas gangrene - clostrigium perfringes myositis

112
Q

What is a varicose vein?

A

tortuous dilated vein of the SUPERFICIAL venous system of the lower limb (most commonly)

113
Q

Why do varicose veins occur?

A

Due to valve incompetence:

1) back flow of blood from the deep to superficial system
2) increased pressure in the superficial venous system
3) varicosities

114
Q

What are the most common sites of valve incompetence in the lower limb leading to varicosities?

A

Sapheno-femoral junction
Sapheno-popliteal junction
Perofrators

115
Q

List some of the RFs for primary (idiopathic) varicose veins

A 
Prolonged standing 
Pregnancy
Obesity
OCP
FH
116
Q

What is Klippel-Trenaunay-Webber syndrome

A

Triad of - port wine stain, varicose veins and limb hypertrophy

It is a secondary cause of varicose veins

117
Q

What is the CEAP classification?

A

Classification system of varicose veins (from C0-C6) to determine whether or not a patient should be referred for vascular surgery

It stands for - 
Clinical signs
Eitiology
Anatomy
Pathophysiology
118
Q

What are the indications for surgical management of varicose veins?

A

SFJ incompetence
Major perforator involvement
Symptomatic varicose veins

119
Q

What is an ulcer?

A

An interruption in the continuity of an epithelial surface

120
Q

List some causes of ulcers

A 
Venous
Arterial
Neuropathic
Traumatic
Systemic disease
Neoplastic
121
Q

Where are venous ulcers most commonly found?

A

Gaiter area - near the medial malleolus

122
Q

Describe a venous ulcer

A

Painless, sloping, shallow ulcer
Usually in gaiter’s areas
May be associated with other signs of chronic venous disease (i.e. HAS LEGS)

123
Q

List some of the risk factors for venous ulcer development

A

Venous insufficiency
Varicosities
DVT
Obesity

124
Q

List some of the risk factors for arterial ulcer development

A

Vasculopaths - obesity, smoking, alcohol XS, hyperlipidaemia, hypercholesterolaemia, ischaemic heart disease, previous MI, previous TIA

125
Q

Describe an arterial ulcer

A

Painful, deep, punched out ulcer

Occur at pressure points (eg: heal, between toes)

126
Q

List the major risk factor for neuropathic ulcers?

A

Diabetes Mellitus

127
Q

Describe a neuropathic ulcer

A

Painless
Insensate skin surrounding ulcer
Good peripheral pulses
Associated joint deformities (Charcot Joints)

128
Q

What is a Charcot joint?

A

A neuropathic joint - long-standing peripheral neuropathy where joint has been subject to lots of trauma

129
Q

What is lymphoedema?

A

Collection of interstitial fluid due to blockage or absence of lymphatics

130
Q

List some secondary causes of lymphoedema?

A

Fibrosis (post-radiotherapy)
Infiltration (malignancy)
Infection (TB)
Trauma (blockage of lymphatics)

131
Q

Where does breast cancer metastasise to?

A

Bone
Brain
Lung
Liver

132
Q

List some risk factors for breast cancer

A

Gender - female
Family history - assoc. w/ BRCA
Oestrogen exposure - nulliparity, early menarche, late menopause, first child >35, obesity, HRT > 5yrs, COCP
Age

133
Q

Outline the breast cancer screening programme

A

All women from ages 50-70 have 3-yearly mammography

134
Q

What is triple assessment?

A

Assessment for breast cancer - made up of three components:

1) History and clinical examination
2) Imaging
3) Pathology

135
Q

What form of imaging is used in triple assessment? Why does it change depending on the patient’s age?

A

< 35 years = USS
> 35 years = mammography + USS if lump found

Change due to difference in breast tissue density (younger women have more dense breast tissue)

136
Q

What form of pathology is used in triple assessment?

A

Solid lump - biopsy

Cystic lump - FNA

137
Q

List some features of a malignant breast lump

A 
Irregular, nodular surface 
Poorly defined edge
hard 
Painless 
Fixation 
Nipple involvement 
\+/- skin involvement
138
Q

List the important aspects of pre-op checks (HINT: think OP CHECS)

A

Operative fitness - cardiorespiratory fitness
Pills

Consent
History - relevant past medical and surgical history (inc. any previous anaesthesia complications)
Ease of intubation 
Clexane - DVT prophylaxis if required
Site - marked
139
Q

How long prior to elective surgery should a patient be NBM?

A

> 6 hours for solid foods

>2 hours for clear liquids

140
Q

List some general post-op complications

A 
Haemorrhage
Infection
Urinary retention
Atelectasis
Wound dehiscence
141
Q

List some causes of post-op pyrexia (HINT: split depending on time of onset)

A

Early - w/in 5 days

  • Blood transfusion
  • Physiological (SIRS)
  • Atelectasis (pulm lobe collapse)
  • Infection
  • Drug reaction

Delayed - >5 days

  • Pneumonia
  • VTE
  • Wound infection
  • Anastomotic leak
  • Collection
142
Q

What is refeeding syndrome?

A

Life threatening metabolic complication of feeding (via any route) following prolonged period of starvation

143
Q

List some of the risk factors for refeeding syndrome?

A

Malignancy
Anorexia nervosa
Alcoholism
GI surgery

144
Q

What biochemical findings would you expect to see with refeeding syndrome?

A

Low potassium, magnesium and phosphate

145
Q

How do you treat refeeding syndrome?

A

1) Identify at risk patients prior to feeding
2) Get dietician input
3) ABC approach - esp with certain life threatening complications
4) Phosphate supplementation (IV or PO)
5) Rx any complications

Final Year Defintions (13 decks)

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