Surgical Flashcards
1
Q
Is the long saphenous vein medial or lateral?
A
Medial
2
Q
Aneurysm
A
Dilatation of a blood vessel
3
Q
Describe the potential presentation of an aneurysm
A
asymptomatic or symptomatic (pressure symptoms, rupture symptoms, thrombosis or embolisation - distal ischaemia)
4
Q
Indications for aneurysm repair
A
symptoms or large asymptomatic aneurysms (>5.5 cm) or increasing by >1cm per year
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
6
Q
Venous Guttering
A
Test for peripheral vascular disease - lift leg up, veins empty and when return flat, it takes time to refil
7
Q
Acute limb ischaemia
A
critical limb ischaemia, onset within 24 hours, without intervention the limb will be lost
8
Q
Surface marking for femoral pulse
A
Mid inguinal point
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
10
Q
Risk factors for varicose veins
A
family history, pregnancy, smoking, previous DVT, obesity, age, reduced mobility
11
Q
6 Ps of acute limb ischaemia
A
Pain Pallor Paraesthesia Paralysis Pulseless Perishingly cold
12
Q
Signs of irreversible limb ischaemia
A
Mottling
Muscle tenderness
Motor or sensory loss
Major necrosis
13
Q
Signs of chronic limb ischaemia
A
Claudication
Rest pain
Ulceration
Necrosis
14
Q
Most common site of venous ulceration
A
Gator reign - posterior aspect of lower limb
15
Q
Virchow’s Triad
A
stasis, hypercoaguability, endothelial injury
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.
17
Q
Transpyloric plane
A
Line that separates epigastric and umbilical areas
18
Q
Semi lunaris line
A
Line that separates the flanks from the umbilical
19
Q
Hockey stick scar (what was the surgery?)
A
Renal transplant
20
Q
Midline laparotomy (what was the surgery?)
A
Open abdominal surgery (eg: resection)
21
Q
Grid iron (what was the surgery?)
A
Open appendicectomy
22
Q
Location of port scars
A
Umbilical (camera) plus at least two more for triangulation of instruments
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
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
25
Colostomy - what are the features?
Large bowel, left sided, flush to skin
26
Urostomy - what are the features?
Urine, aka ileal conduit, usually following cystectomy, spouted
27
What are the 3 types of stomas?
Urostomy, Ileostomy, Colostomy
28
Super-sphincteric fistula
Fistula that goes above the sphincter, loops around it and back down below dentate line
29
Stoma rod (or bridge)
Rods placed as a 'bridge' to support the loop stoma while the mucocutaneous junction heals in order to prevent retraction (placed during formation of stoma and removed prior to discharge)
30
Stress ulcer - pathophysiology
Physiological stress (specifically hypotension) causing an ulcer
31
Rockall score
Upper GI bleeding risk and severity score
32
AIN
Anal Intraepithelial Neoplasia, like CIN. Graded 1-3. Caused by HR HPV strains 16 and 18
33
Spigellian hernia
Hernia on semi-lunars lines
34
Grey Turner Sign
A sign of reptroperitoneal haemorrhage, flank bruising, usually a sign of severe pancreatitis but can be a sign of rupture aneurysm
35
Cullen Sign
A sign of intraperitomeal haemorrhage, umbilical bruising, usually a sign of severe pancreatitis
36
Charcot Triad
Triad of ascending cholangitis: fever, RUQ pain, jaundice
37
Riggler’s Sign
air on both sides on both bowel wall, seen on AXR, sign of perforation
38
PCT - definition and indication
percutaneous trans hepatic cholangiogram, going through the liver to access the gallbladder and CBD to remove a stone that you cannot get on ERCP
39
Biliary colic
gallstones with pain in the absence of inflammation and fever
40
Coffee bean sign
AXR appearance of volvulus
41
Transcoelomic spread
intra-peritoneal spread of abdominal cancers (commonly colonic and ovarian).
Often presents with malignant ascites
42
Kruckenburg tumour
Secondary ovarian tumour - primary usually in the bowel or stomach. Spread by transcoelomic spread.
Often bilateral.
43
What sign on AXR is suggestive of Gallstone Ileus
Gas in the biliary tree
44
What does Courvossier Law say?
Painless jaundice with a palpable gallbladder is UNLIKELY to be gallstones
45
What kind of tumour has a necrotic and haemorrhagic centre?
Teratoma
46
What are the three features of a hernia?
Soft
Compressible
Cough impulse
47
How do you tell the difference between a direct and indirect hernia?
Indirect - will go to the testis
48
What is the Duke’s staging of CRC?
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
49
Which LN does testicular cancer metastasise to? Why?
Para-aortic LN - because the testicles are embryologically intro abdominal organs which come down during development
50
Which lymph nodes does scrotal cancer metastasise to?
Inguinal
51
What is the difference between ascending cholangitis and cholecystitis?
Ascending cholangitis is inflammation of the tubes (biliary tree), cholecystitis is inflammation of the GB
52
Where anatomically is the mid inguinal point? What does it mark?
Half way between the ASIS and pubic symphisis.
| Marks the deep (internal) ring and femoral artery.
53
Anatomically, what is the difference between a femoral and inguinal hernia?
Below and lateral to pubic tubercle is femoral hernia
| Above and medial to pubic tubercle is inguinal hernia
54
On examination, how do you differentiate between direct and indirect inguinal hernias?
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)
55
Define: synchronous and metachronous cancer risks
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%
56
Define: primary intention
most surgical wounds
excision and closure - edges are approcimated and closed with sutures or stables
Minimal scarring
57
Define: secondary intention
Wound left open
Granulation from bottom up
Usually occurs when approximation cannot be done
58
Define: wound dehiscence
Surgical complication where there is rupture along the line of the wound
59
List some of the risk factors for poor wound healing
Local - limited moisture, mechanical factors, ischaemia, foreign body, oedema, infection
Systemic - metabolic, drugs, tissue health, underling health
60
Define: hernia
protrusion of a viscous through a defect in its walls out of it's normal position
61
Complications of a hernia
Incarceration
Strangulation
Bowel obstruction
62
Define: incarceration (cf hernias)
An irreducible hernia, can be painful - high risk of strangulation
63
Define: strangulated (cf hernias)
Confinement of the bowel within the hernia interrupting blood supply
This is painful
Surgical emergency
64
Define: incisional hernia
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
List some of the risk factors for incisional hernias
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
What is the difference between an indirect and direct inguinal hernia?
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
Clinically, how do you differentiate between direct and indirect hernias
Reduce hernia and put pressure at the deep ring - if the hernia protrudes it is direct, if it stays reduced it is indirect
68
Define: fistula
An abnormal connection between two epithelial surfaces
69
List some causes of fistulae
Malignancy
Diverticular disease
Crohn's
Abscess
70
Outline the management of a fistula (HINT: think SNAP)
Sepsis = ABC approach
Nutrition
Anatomy = imaging
Planning = operative
71
Define: sinus
Blind ending tract between a epithelial surface and a cavity lined with granulation tissue
72
What are the 4 features of bowel obstuction
Pain
Distention
Vomiting
Absolute constipation
73
Which procedures are considered high risk and required DVT prophylaxis?
```
Orthopaedic surgery
Major general, urological or gynaecological surgery
Neurological surgery
Cardiac surgery
Major vascular surgery
```
74
Outline what is involved in DVT prophylaxis
Conservative measures - optimise hydration, early mobilisation
Mechanical measures - TED stockings
Pharmacological measures - fondaparinux / LMWH
75
List some of the findings in chronic venous disease (HINT: think HAS LEGS)
```
Haemosiderin deposition
Atrophie blanche
Swelling
Lipodermatosclerosis (inverted champagne bottle leg)
Eczema
Gaiter ulcers
Starts
```
76
How does LMWH work?
Inhibition of thrombin (therefore mediates inhibition of factor Xa)
77
How does warfarin work?
Inhibition of vitamin K (therefore prevents the formation of Vit K-dependent factors: 2, 7, 9, 10)
78
How does fondaparinux work?
Activation of anti-thrombin (therefore mediates inhibition of factor Xa)
79
What are the vitamin K dependent factors?
2, 7, 9 , 10
80
Outline the fontaine classification for chronic limb ischaemia (i.e. the stages)
Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - ischaemic rest pain
Stage 4 - ulceration / gangrene
81
What is a normal ABPI?
1 - 1.2
82
What ABPI measurement is suggestive of critical limb ischaemia
<0.5
83
What is Leriche’s Syndrome?
Triad of arterial disease symptoms in MEN - buttock claudication, ED and absent femoral pulses
Caused by aortoiliac occlusive disease (secondary to atheroscelrosis)
84
With chronic limb ischaemia - which vessel is affected if the patient presents with buttock pain?
Iliac disease (internal or common)
85
In chronic limb ischaemia - which vessel is affect if the patient presents with calf pain?
Superficial femoral disease
86
What is the difference between intermittent and spinal claudication?
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
What are the indications for bypass grafting in chronic limb ischaemia?
Short claudication distance
Rest pain
Sx interfering with QOL
88
Which anticoagulation is used in the following types of bypass grafts:
(a) Synthetic
(b) Autologous
(a) aspirin
| (b) warfarin
89
Generally speaking when is a synthetic graft used over an autologous graft for bypass?
Above the inguinal ligament
90
What are the two classifications of bypass graft?
Anatomical (eg: aorto-bifemoral bypass)
| Extra-anatomical (eg: axillofemoral, femoral-femoral)
91
List the indications for amputation (HINT: think "4Ds")
Dead - PVD
Dangerous - sepsis, malignancy
Damaged - trauma, burns, frostbite
Damned nuisance - pain / neurological damage
92
Describe the presentation of acute limb ischaemia (HINT: think "6 Ps")
```
Pale
Pulselessness
Perishingly cold
Pain
Paraestehsia
Paralysis
```
93
What is the difference in presentation in acute limb ischaemia caused by thrombosis or embolism?
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
What is the main management of thrombotic acute limb ischaemia?
Thrombolysis and bypass surgery
95
What is the main management of embolic acute limb ischaemia?
Enbolectomy and warfarin WITHIN 6 HOURS - amputation may be required
96
Define: an aneurysm
abnormal dilation of a blood vessel >50% of its normal diameter
97
What is the difference between a true and false aneurysm?
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
Define: dissection
Dilation of a blood vessel caused by blood splaying the media forming a channel within the vessel wall
99
List some causes of an aneurysm
Congenital (eg: PCKD, Marfan's, Ehlers-Danlos)
| Acquired - atheroscelrosis, trauma, inflammation (eg: HSP), infection (eg: syphillis)
100
List the complications of aneurysm rupture
Rupture
Thrombosis
Distal embolisation
Fistula
101
List some common sites of aneurysm formation
Popliteal aneurysm
Abdominal aortic aneurysm
Cerebral (eg: berry aneurysm)
102
Where are most abdominal aortic aneurysms?
infra-renal
103
At what size should AAA be actively managed?
>5.5cm
104
What is the management for small (<5.5 cm), unruptured AAAs?
US monitoring - yearly if <4cm, 3 monthly if 4 - 5.5 cm
105
When should you operate on a AAA?
>5.5 cm
Growing >1cm/year
Symptomatic
Complications
106
What is the AAA screening programme?
One-off USS in men aged >65 years
107
Describe the presentation of an aortic dissecton
Sudden onset tearing pain radiating through back
108
What is an important sign of an aortic dissection?
unequal BP in both arms
109
Name the two types of aortic dissection
Type A - proximal (more common)
| Type B - distal
110
List some RFs for AAA
```
Male
>65 year old
Smoking
FH
HTN
```
111
# 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) 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
What is a varicose vein?
tortuous dilated vein of the SUPERFICIAL venous system of the lower limb (most commonly)
113
Why do varicose veins occur?
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
What are the most common sites of valve incompetence in the lower limb leading to varicosities?
Sapheno-femoral junction
Sapheno-popliteal junction
Perofrators
115
List some of the RFs for primary (idiopathic) varicose veins
```
Prolonged standing
Pregnancy
Obesity
OCP
FH
```
116
What is Klippel-Trenaunay-Webber syndrome
Triad of - port wine stain, varicose veins and limb hypertrophy
It is a secondary cause of varicose veins
117
What is the CEAP classification?
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
What are the indications for surgical management of varicose veins?
SFJ incompetence
Major perforator involvement
Symptomatic varicose veins
119
What is an ulcer?
An interruption in the continuity of an epithelial surface
120
List some causes of ulcers
```
Venous
Arterial
Neuropathic
Traumatic
Systemic disease
Neoplastic
```
121
Where are venous ulcers most commonly found?
Gaiter area - near the medial malleolus
122
Describe a venous ulcer
Painless, sloping, shallow ulcer
Usually in gaiter's areas
May be associated with other signs of chronic venous disease (i.e. HAS LEGS)
123
List some of the risk factors for venous ulcer development
Venous insufficiency
Varicosities
DVT
Obesity
124
List some of the risk factors for arterial ulcer development
Vasculopaths - obesity, smoking, alcohol XS, hyperlipidaemia, hypercholesterolaemia, ischaemic heart disease, previous MI, previous TIA
125
Describe an arterial ulcer
Painful, deep, punched out ulcer
| Occur at pressure points (eg: heal, between toes)
126
List the major risk factor for neuropathic ulcers?
Diabetes Mellitus
127
Describe a neuropathic ulcer
Painless
Insensate skin surrounding ulcer
Good peripheral pulses
Associated joint deformities (Charcot Joints)
128
What is a Charcot joint?
A neuropathic joint - long-standing peripheral neuropathy where joint has been subject to lots of trauma
129
What is lymphoedema?
Collection of interstitial fluid due to blockage or absence of lymphatics
130
List some secondary causes of lymphoedema?
Fibrosis (post-radiotherapy)
Infiltration (malignancy)
Infection (TB)
Trauma (blockage of lymphatics)
131
Where does breast cancer metastasise to?
Bone
Brain
Lung
Liver
132
List some risk factors for breast cancer
Gender - female
Family history - assoc. w/ BRCA
Oestrogen exposure - nulliparity, early menarche, late menopause, first child >35, obesity, HRT > 5yrs, COCP
Age
133
Outline the breast cancer screening programme
All women from ages 50-70 have 3-yearly mammography
134
What is triple assessment?
Assessment for breast cancer - made up of three components:
1) History and clinical examination
2) Imaging
3) Pathology
135
What form of imaging is used in triple assessment? Why does it change depending on the patient's age?
< 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
What form of pathology is used in triple assessment?
Solid lump - biopsy
Cystic lump - FNA
137
List some features of a malignant breast lump
```
Irregular, nodular surface
Poorly defined edge
hard
Painless
Fixation
Nipple involvement
+/- skin involvement
```
138
List the important aspects of pre-op checks (HINT: think OP CHECS)
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
How long prior to elective surgery should a patient be NBM?
>6 hours for solid foods
| >2 hours for clear liquids
140
List some general post-op complications
```
Haemorrhage
Infection
Urinary retention
Atelectasis
Wound dehiscence
```
141
List some causes of post-op pyrexia (HINT: split depending on time of onset)
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
What is refeeding syndrome?
Life threatening metabolic complication of feeding (via any route) following prolonged period of starvation
143
List some of the risk factors for refeeding syndrome?
Malignancy
Anorexia nervosa
Alcoholism
GI surgery
144
What biochemical findings would you expect to see with refeeding syndrome?
Low potassium, magnesium and phosphate
145
How do you treat refeeding syndrome?
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
