Surgical abdomen Flashcards

Question 1

Q

CLD Hand signs (6)

Answer

A

clubbing
leukonychia
Terry’s nails
- white ground glass nail
- loss of lunula
- pink tips
Palmer erythmea
dupuytron’s contracture
asterexis

Question 2

Q

Abdominal causes of clubbing

(4)

Answer

A

Cirrhosis: esp with PBC
IBD
Coeliac
GI lymphoma

Question 3

Q

What are spider naevi?
Where are they?
How many = pathological?
What are you differential diagnosis?

Answer

A

Central arteriole with radiating vessls (fill fom the centre-telangiectasia fill from the edge!)
found in the distribution of the SVC
>4= abnormal
differential diagnosis: CLD, OCP, Pregnancy

Question 4

Q

Inguinal hernia

Examination; set up/inspection/palpation/ausc/special/complete

Answer

A

Set up:

Expose from umbilisu to knees
begin with pt STANDING!

Inspection:

look for any masses in groins
- sie, site, features of inflammation (strangulation), ask pt to cough
look for scars:
- previous hernia op, appendicectomy (risk factor for direct hernia!)

Palpation:

check if in pain
palpated mass for cough impulse
Define anatomy (relationship to PT)
- above (and medial); inguinal hernia
- below (and lateral): femoral hernia
Does mass extend into scrotum:
- inguinoscrotal hernia; more likely to indirect

auscultate:

bowel sounds: hernia may lack bowel sounds if only contains fat/omentum

REPEAT INSPECTION AND PALPATION with pt SUPINE!

Direct vs indirect hernia test

complete:

Examine external genitalia: incidental lumps, testes
contralateral groin
examine abdomen
- evidence of increased IAP: masses, ascites
- Other hernias: paraumbilical, umbilical

Question 5

Q

Test for direct vs indirect hernia

Answer

A

ask pt to reduce hernia
place 2 fingers over deep ring (mid pt of inf lig (1.5 cm above fem pulse)) and ask pt to cough
- hernia controlled=indirect
- not controlled= direct

not accurate test: definitive determination in theatre!

Question 6

Q

Groin lump differential! (10)

Answer

A

Skin: sebaceous cyst, psoas abscess
Fat: lipoma
CT: fibroma
Nerves: neuroma of femoral nerve
Lymphatics: LN
Veins: sphena varix
Arteries: femoral artery aneurysm
Inguinal canal: inguinal hernia, hydrocele or lipoma of cord
femoral canal: femoral hernia
Testes: undescended testis

Question 7

Q

4 distinguishing features of an inguinal hernia

Answer

A

Above and medial to PT
cough impulse
Reducible
bowel sounds

Question 8

Q

Hx Qs for inguinal hernia

Answer

A

predisposing factors: cough, straining, lifting
pain
reducible
episodes of obstruction or strangulation
previous repairs

Question 9

Q

Management of inguinal hernia

(conservative, surgical)

Answer

A

Conservative:

Manage RFs e.g. constipation, cough
weight loss
elastic corset or truss

Surgical:

Open: lichtenstein tension free mesh
lap: TEP or TAPP mesh

TEP= Totally ExtraPeritoneal

TAPP=TransAbdominal PrePeritoneal (TAPP)

Question 10

Q

Inguinal hernias

definition; general

classification (2 types)

Answer

A

Protrusion of a viscus or part of a viscus into an abnormal position through a defect in its containing cavity

Indirect: 80%:
- commoner in young due to congenital patent processus vaginalis
- emerge through deep ring
- same 3 coverings as cord
- descents into scrotum
- can strangulate
Direct: 20%
- commoner in elderly
- aquired: weak posterior wall of canal
- emerges through hasselbach’s triangle
- can acquire internal and external spermatic fascia
- rarely descends into scrotum
- rarely strangulates

Question 11

Q

Inginal canal antomy

MALT

superior/anterior/lower/posterior

Answer

A

superior wall (roof): Muscles
- internal oblique M
- Transferse abdominus M
Anterior wall: Aponeuroses
- A of external oblique
- A of internal oblique
Lower wall (floor): Ligaments
- Inguinal L
- Lacunar L
Posterior wall: Ts
- Transfersalis fascia
- conjoint Tendon

Question 12

Q

Femoral canal anatomy

med/late/ant/post

and contents

Answer

A

Med: lacunar ligament

Lat: femoral vein

Ant: inguinal ligament

Posterior: pectineal ligament (of cooper)

Contents: fat and cloquet’s node

Question 13

Q

Contents of inguinal canal (MF!)

Answer

A

M: spermatic cord + ilioinguinal N

F: Round lig + gen branch of genitofemoral N + ilioingional N

Question 14

Q

Contents of spermatic cord

Answer

A

3 layers of fascia
- External spermatic F
- Cremater musle and F
- Internal spermatic F
3 arteries + 3 veins
- Testicular A + Pampiniform plexus of testicular V
- Cremateric A and V
- Artery to vas deferens
2 nerves:
- genital branch of genitofemoral N
- Autonomic N
2 others:
- Vas deferens
- lymph vesels

Question 15

Q

Intra-operative distinction of indirect and direct inguinal hernia

Answer

A

indirect: arise lateral to inf. epigastic vessels
direct: arise medical to inf. epigastric vessels through hasselbach’s triange: (RI?P)
- Med: Rectus abdominis muscle
- Lat: Inferior epigastric artery
- Inf: poupart’s ligamen (inguinal lig)

Question 16

Q

Inguinal hernia surgical approaches:

open and lap

Answer

A

open and lap; lap if bilateral/recurrent!

nb mention risk of testicular damage when consenting pt

open:

open can be done under LA or GA: day case
RCS recoments the lichtenstein tension free mesh repair
- less recurrence cf to older shouldice repair

IN CHILDREN: simple ligation and division of the patent processus suffices: no mesh req

Lap:

2 main techniques:
- Total ExtraPeritoneal
- TransAbdominal Pre-Peritoneal
Better for bilateral hernias

Question 17

Q

Complications of surgical inguinal hernia repair

Early/late

management for optimal post-op recovery

Answer

A

Early:
- Urinary retention
- Haematoma/seroma formation 10%
- Infection
- Intra-abdominal injury (lap!)
Late:
- recurrence <2%
- ischaemic orchitis 0.5%; 2ndary thrombosis of pampiniform plexus
- chronic groin pain/paraesthesia 5%
Post op recovery
- pee pre leaving; retention
- avoid constipation: lactulose
- Early mobilisation
- painful; good analgesia
- keep area clean and dry: wash carefully (can bathe immediately)
- work in 1-2wks
  - heavy lifting >6wks)

Question 18

Q

Femoral hernia

general

Answer

A

Commoner in Females; wider femoral canal
middle ages and elderly
neck is inferior and lateral to PT
high risk of obstruction and strangulation

Question 19

Q

Femoral hernia

management

elective and emergency

Answer

A

50% risk of strangulation within 1 mnth -> URGENT surgery

Elective: lockwood low approach
- low incision over hernia with herniotomy and herniorrhaphy (suture inguinal ligament to pectineal ligament)
Emergency: Mc Evedy high approach
- high approach in inguinal region to allow insprection and resection of non-viable bowel
- then herniotomy and herniorrhaphy

Question 20

Q

Incisional hernia

Examination (inspection, palpation, ausc)

Answer

A

Examination

inspection:
- pt may be overweight
- describe scars and drain sites
- any evidence of inflammation
- ask pt to lift head off bed and cough
palpation:
- any tenderness?
- feel for presence of detect
- ask pt to cough while feeling for an impulse
- is the defect present along the whole legth of the scar?
  - sie of defect relates to risk of strangulation
- If a lump is present, can it be reduced
auscultate: for bowel sounds

Question 21

Q

Incisional hernia

Important history questions

Answer

A

previous surgery
post op wound infection or other complications
co-morbidities-> increased risk e.g. chronic cough
discomfort or episodes of obstruction

Question 22

Q

Incisional hernia:

definition

Answer

A

Extrusion of peritoneum and abdominal contents through a previously acquired defect

Question 23

Q

Incisional hernias:

Complications

Answer

A

Intestinal obstruction

irreducible

strangulation

pain/discomfort

Question 24

Q

Incisional hernia

RF:

PreOp/Intra-op/postOp

Answer

A

Pre-Op:
- increase age
- comorbidities: DM, renal failure
- drugs: steroids, chemo, radio
- Obesity or malnutrition
- malignancy
Intra-Op:
- surgical technique/skill (major factor)
  - too small suture bites
  - inapropriate suture material
- incisional type e.g. midline
- placing drains through wounds
Post-Op:
- increased IAP: chronic cough, straining, post-op ileus
- infection
- Haematoma

Question 25

Q

Management of incisional hernia

conservcative/surgical

Answer

A

Surgery is not appropriate for all pt

must ba;ance risk of op and recurrence with risk of obstruction/strangulation and pt cjoice

usually broad neced therefore low risk of strangulation

Conservative:

manage RF eg, constipation, cough
weight loss
elasticated coset or truss

surgical:

pre-op
- optimise cardioresp function
- encourage weight loss
nylon mesh repair: open or lap

Question 26

Q

umbilical and paraumbilical

inspection/palpation

Answer

A

inspection:
- pt may be overweight
- ask pt to lift head off bed and to cough
- note any associated skin damage e.g. ulceration
- note any overlying scars: may indicate recurrence
Palpation:
- any tenderness
- feel for presence of defect
- try to assess sie
- ask pt to cough while feeling for an impulse
- if a lump is present, ask pt to reduce it

Question 27

Q

umbilical an paraumbilical hernia

history

Answer

A

Predisposing factors: pregnancy, ascites, obesity
pain
reducible
episodes of obstruction or strangulation
previous repairs

Question 28

Q

Paraumbilical hernia pathogenesis and RF

Answer

A

acquired defect in linea alba just above or below the umbilicus
commoner in obese, middle aged pts
neck is commonly narrow
prone to befoming irreducible or strangulated
typically contain omentum

RF:

obesity
pregnancy
ascites
fibroids
bowel distension

Question 29

Q

Management of paraumbilical hernias

Answer

A

surgery advised: high risk of strangulation
Treat concurrent medical problems
May repait:
- mobilise sac and reduce contents
- double breast linea alba +/- sublay mesh

Question 30

Q

Umbilical hernia

pathogenesis

RF

Answer

A

congenital defect in umbilical scar (cicatrix)
typically congenital 3% of live births

RF:

afro-caribbean
trisomy 21
congenital hypothyroidism

recur in adults: pregnancy, ascites

Question 31

Q

Management of umbilical hernia

Answer

A

usually asymptomatic and resolves by 2-3 yrs
surgical repair advocated if no resolution by 3 yrs

Question 32

Q

2 other congenital defects in abdominal wall

Gastroschisis

Exomphalos

Answer

A

Gastroschisis:
- protrusion of abdo contents through defect in abdo wall to the right of the umbilicus
- not usually associated with other abnormalities
- promps surgical repair after fluid resuscitation
exomphalos:
- protrusion of abdo contents w/i in a 3 layered sac
- commonly associated with other defects:
  - cardiac
  - anencephaly

Question 33

Q

Epigastric hernia

Examination

(insprection.palpation.differential)

Answer

A

inspection:
- midline lump above the umbilicus when the pt coughs or lifts head from bed
- typically small: pea shaped
- assoc scars?
- Incisional hernia or previous repairs
Palpations:
- any pain
- feel for cough impulse
- establish sie of defect
Differential:
- incisional hernia: ?scar
- Divarification of recti: widening gap between recti muscles, not a hernia

Question 34

Q

Epigastric hernia

important history questions

Answer

A

History:

predisposing factors: pregnancy
obesity
symptoms
reducible
episodes of obstruction/strangulation
previous repair s

Question 35

Q

Epigastric hernia ke features and symptoms

Answer

A

features:
- abdnormal protrusion of abdominal contects through a defect in linea alba between xiphisternum and umbilicus
- usually contains extraperitoneal fat or omentum
- commoner in young (20s-50s)
symptoms:
- may be aSx
- may be confused for upper GI path
- pain: may inicreas after meals or exercise
- nause and early satiety
- Abdominal bloating

Question 36

Q

Management of

epigastric hernia

(conservative. surgical)

Answer

A

conservative:
- manage RF e.g. constipation, cough
- weight loss
surgical:
- reduce hernial contents and excise sac
- suture or mesh repair
  *

Question 37

Q

Examination of scrotal lump

set up/infpection/palpation (4Qs!)

?pathway?

Answer

A

set up: best to examine pt standing (won’t miss varicocele)

Inspection:

skin: scar, erythema, blue tinge, ulcers
groid lumps or scars
ask pt to cough

Palpation:

Can you get above it? can’t get above an inguinoscrtal hernia
is it tender?
- torted testis or hydatic of morgagni
- epididymo-orchitis
- strangulated hernia
is it palpable seperately?
- No:
  - tumour
  - orchitis
  - hydrocele
- Yes:
  - Varicocele
  - spermatocele/epididymal cyst
does it transluminate?
- No:
  - tumour
  - testis
  - varicocele
  - spermatocele
- Yes:
  - hydrocele
  - epididymal cyst

Question 38

Q

Hydrocele

Examination

(inspection.palpation)

Answer

A

Inspection:
- swollen scrotum
palpation:
- can get above it
- cannot feel testis seperately
- Firm/tense
- Transluminates

Question 39

Q

Hydrocele

History Qs

Answer

A

duration
pain, discomfort, other symptoms
previous testicular masses or infections
recent trauma
treatment so far
co-morbidities e.g. HF

Question 40

Q

hydrocele

definition

Answer

A

accumulation of fluid within the tunica vaginalis

TV: remnant of the processus vaginalis that accompanied the testicle during its descent. forms one of the adult coverings of the testis

Question 41

Q

Anatomical classification of hydroceles

x4

Answer

A

vaginal: accumulation in the tunica vaginalis that doesn’t extend up the cord
congenital: proximal part of the processus has not obliterated and the sac communicates directly with the peritoneum
infantile: processus is obliterated at the deep ring but still extends up the cord
hydrocele of the cord: fluid accumulates around the ductus deferens. Can be hard to distinguish from inguinal hernia as it may extend proximal to the superficial ring. testicular tractin will pull it inferiorly (c.f. to inguinal hernia

Question 42

Q

Aeitiological classification of hydroceles (x2)

Answer

A

primary:
- caused by a patent processus vaginalis
- commonest type!
- young men, large, tense
secondary:
- vaginal type, can be caused by a variety of pathologies incl:
  - testicular tumours
  - epididymo-orchitis
  - trauma
  - torsion

Question 43

Q

Single investigation of hydrocele

Answer

A

US to exclude malignanacy!

Question 44

Q

Management of hydrocele

non-surgical and surgical

Answer

A

non-surgical:
- watch and wait (ensure no Ca)
- aspiration: symptom relief only as will accumulate
Surgical:
- lord’s repair: plication of tunical vaginalis
- jaboulay’s repair: eversion of sac

Question 45

Q

Epididymal cyst

exmination

(inspection.palpation)

Answer

A

inspection:
- normal appearing scrotum
palpation:
- can get above it
- seperate from testis: typically above and behind
- Firm
- Transiluminates: unless its a spermatocele

Question 46

Q

Epididymal cyst

history! and features

Answer

A

History:
- duration
- pain, discomfort, other Sx
- treatment so far
Features:
- retention cyst of tubule of the rete testis or epididymis
- often multiple
- may contain sperm: spermatocele (does not transluminate)
- generally aSx

Question 47

Q

Management of epididymal cyst

non-surgical

surgical

Answer

A

non-surgical:
- if the cyst isn’t troublesome it shouldn’t be removed due to risk of op damage and post-op fibrosis-> SUBFERTILITY
surgical:
- V large/painful cysts can be removed
- excision of entire epididymis may be indicated to prevent to recurrence of painful cysts

Question 48

Q

Varicolele

examination; inspection, palpation

Answer

A

Inspection:
- normal appearing scrotum
Palpation
- pt must be standing
- can get above mass
- seperate from testes
- feels like a bag of worms
- doesn’t transilluminate
- may have palpable cough impulse
- often disappear on lying

Question 49

Q

Varicocele

history and symptoms

Answer

A

History:
- duration
- pain, discomfort, other symptoms
- Treatment so far
symptoms:
- dragging sensation exacerbated by exertion
- subfertility; commonest surgically correctable cause

Question 50

Q

Varicocele pathophysiology

Answer

A

dilated veins of the pampiniform plexus
98% L sided, 50% bilateral
primary;
- occur in up to 15% of young men
- often around puberty
- anatomical cause ?nutcracker syndrome
secondary:
- varicoceles suddenly appearing in older men can be sinister
- retroperitoneal disease affecting the testicular V
  - e.g. genal cell carcinoma extending into L renal V
  - don’t disappear when pt lies down

Question 51

Q

Why do 98% of varicoceles occur on the left

Answer

A

Left testicular vein is more vertical where it joins the left renal vein cf to obliquity of R testicular V where it joins the IVC
LEft renal vein can be compressure by the colon
L testicular v is longer than R
left testicular V often lacks terminal valve to prevent backflow

Question 52

Q

Management of varicocele

non-surgical/surgical

Answer

A

non-surgical:
- scrotal support
- transfermoral radiological embolisation of testicular vein
surgical
- often advised as problem usually gets worse with age and can result in subfertility
- palomo-operation:
  - high approach with transferse incision slightly above and medial to ASIS
  - vein exposed and ligated
  - inguinal approach: ligation of veins in inguinal canal
- laparoscopic approach also possible

Question 53

Q

Testicular tumour

examination

(insp.palpation.completion)

differential

Answer

A

Inspection:
- Enlarged testis may be visible
Palpation:
- Can get above mass
- inseparable from testis
- hard irrgular nodular
- non-tender
- doesn’t transluminate
Completion
- examine contralateal scrotum
- abdo exam: hepatomegaly
- Chest exam: thoracic mets
- Examine for abdo lymphadenopathy
Differential:
- testicular tumour
- chronic infection-> scarring (orchitis, TB)
- chronic hydrocele (calcified)

Question 54

Q

Testicular tumour

history/presentation

Answer

A

History
- Pain, discomfort
- SOB: lung mets
- BAck pain: para-aortic node involvement
- haematospermia
- hydrocele
- Hx: tumour/infection
Presentation:
- commonest malignancy in men 15-45 yrs
- painless lump or dull ache in one testis in young man
- occasionally a history of trauma accompanying overlying mass
- 10% present with acutely painful testis
- haematospermia
- 2ndary hydrocele

Question 55

Q

Classification of testicular tumour

and table (age/markers/ early/lateMx)

Answer

A

95% are germ cell tumours
50% are pure cell populations:
- pure seminomatous: 50%
- non-seminomatous: teratoma is commones
Other types:
- yolk sack: commenest testicular tumour in children
- choriocarcinoma
- leydig or sertoli cell; may secrete oestrogens -> gynaecomastia
- lymphoma: NHL is commonest testicular mass >60yrs

Question 56

Q

Testicular tumour Investigations

Answer

A

Tumour markers AFP, bHCG, placental ALP
CxR: mets
US scrotum: diagnostic
CT abdomen: staging

Question 57

Q

Testicular tumour

Management

Seminoma/teratoma

Answer

A

all testicular tumours are treated with orchidectomy
groin incision with early clamping of spermatic cord to prevent seeding

seminoma

Early: DxT (radiotherapy) to para-aortic nodes
Late: DxT + combination chemo

Teratoma

early: observation
Late: combincation chemo:
- Bleomycin
- Etoposide
- cisPlatin

Question 58

Q

Nutcracker syndrome

Answer

A

a vascular compression disorder*
compression of the left renal vein between the superior mesenteric artery (SMA) and aorta*

Question 59

Q

Stomas

Examination

(inspection, palpation, completion)

Answer

A

Examination:

site
contents of bag
- solid stool
- semi-formed or liquid stool
- urine
Appearance:
- spout
- lumens
- rod
- mucosal health
scar: NO scars suggests clonoscopy assisted trephine colostomy

palpate:

palpate for parastomal hernia

complete:

remove bag to closely inspect and digitate stoma:
- no. of lumens
- health of mucosa and surounding skin
- strictures
- prolapse
Eclonoscopy assisted trephine colostomy examine perineum

Question 60

Q

Definition of a stoma

Answer

A

Artificial union between conduits or between a conduit and the outside

Question 61

Q

Stoma: history Qs

Answer

A

Surgery
output
pain
complications
psychosexual function

Question 62

Q

Indications for stomas

(x5)

Answer

A

Exteriorisation
- temporary: perforated or contaminated bowel e.g. hartmann’s
- permentant: e.g. AP resection
Diversion
- protection of distal anastomosis
  - contamination e.g. faecal peritonitis
  - anatomical e.g. ileorectal anastomosis
- acute crohn’s:
- urinary diversion following cystectomy
Decompression: bypass of distal obstructing lesion
Feeding: gastrostomy/jejunostomy
lavage e.g. appendicostomy

Question 63

Q

Distinction :

ileostomy vs colostomy

location/appearance, contents, examples (perm/temp)

Question 64

Q

Ileostomy/urostomy

2 types

(features/surgeries/indications)

Answer

A

located in RIF

Small bowel content is irritant therefore ileostomies = spouted

ileal pouch–anal anastomosis (IPAA)

Answer 64

A

Explanation of indications and complications

liaisn with stoma nurse to arrange siting

Siting:

done with pt standing up to ensure pt can see stoma
Avoid:
- bony prominences
- skin folds/creases
- waistline
- old wounds
- umbilicus
choose:
- site that is accessible to pt
- ideally below belt line for concealment
- w/i the rectus (reduce risk of hernia or prolapse

Answer 65

A

early:
- h’gge
- ischaemia
- high output (can lead to hypokalaemia)
  - loperamide +/- codeine to thicken output
- parastomal abscess
- stoma retraction
Delayed:
- parastomal hernia (on lat side)
- obstruction; adhesions or hernia through lat space around stoma
- dermatitis; ileostomy
- stoma prolapse
- stenosis or stricture
- fistulae
- psychosexual dysfunction

Answer 66

A

aim for normal diet
good skin care and cleanliness
psychosexual support

Answer 67

A

tracheostomy
gastrostomy
jejunostomy
ileostomy
caecostomy
colostomy
urostomy

Answer 68

A

fashioned following total cystectomy

ileal conduit: incontinent
- ureters attached to a portion of resected ileum which is exteriorised as a spouted stoma
- bowel continuity mainstained by primary anatomosis
- urine collected in bag
Indiana pouch: continent
- pouch created 2 ft of resected ascdemnding colon and portion of ileum which includes the ileosaecal valve
- ureters anastomosed to colonic end and ileal end exteriorised as spouted stoma
- ileocaecal valve prevents urinary leak from pouch
- Self catheterises to drain pouch

Answer 69

A

Examination:
- describe anatomical location and orientation
- give correct technical name where possible
- Well healed or recently formed?
- incisional hernia; cough impulse?
- wait to be asked for suggested surgeries!:
  - use anatomical knowledge + NAVY to suggest
Look for:
- stoma and drain scars: bowel surgery
- vasc access scars: AAA, graft

Answer 70

A

Midline laparotomy
Aproach:
- skin
- camper’s fascia
- scarpa’s fascia
- linea alba
- transversalis fascia
- pre-peritoneal fat
- peritoneum
use:
- emergency:
  - perforated DU
  - trauma
  - ruptured AAA
  - hartmann’s
- elective:
  - colectomy
  - AAA
  - vasc bypass
Features:
- good:
  - good access
  - bloodless line
  - minimal nerve and muscle injury
- bad:
  - long midline scar
  - pain
closure:
- PDS blunt J shaped feature en mass
- jenkin’s rule
  - length of suture = 4x length of incision
  - 1 cm bite, 1cm apart

Answer 71

A

Right paramedian
use: not commonly used now as closure techniques have improved
location: 3cm lat to midline
aproach: rectus sheath opened and rectus displaced laterally slips back to cover the defect
bad: tme consuming

Answer 72

A

Kocher’s (subcostal)
R Open cholecystectomy, L Kocher’s used for splenectomy

Answer 73

A

Rooftop
Uses:
- hepatobilary surgery:
  - liver transplant
  - whipple’s; remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct
  - liver resection
- gastric surgery
disadvantage: longer to close than a midline as the incision is closed in 3 layers
adaptability: modified to a mercedes ben incision

Answer 74

A

pfannenstiel
use:
- gynae surgery
- lower UTI

Answer 75

A

Two
- McBurney’s: oblique
- Lan: Transverse
Anatomy:
- skin
- camper’s fascia
- scarpa’s fascia
- external oblique
- Internal oblique
- Transversus
- Transversalis fascia
- pre-peritoneal fat
- peritoneum
use: appendectomy
Two types: BOTH, follow langer’s lines
- Lan: favoured hidden in skin creases
risk: of injury to ilioinguinal and iliohypogastric nerves may predispose to inguinal hernia

Answer 76

A

Thoracoabdominal
Use: oesophagogastrectomy

Answer 77

A

Transverse muscle splitting
Right hemicolectomy
disadv: limited acces to midline incision
adv:
- reduced damage to rectus
- segmental nerve supply means the muscle can be cut transversely without weakening

Answer 78

A

Name; inguinal hernia incision
Use:
- Open inguinal hernia repair
- ORchidectomy
features: incision over the inguinal ligament follow’s langer’s lines
risk: high rates of chronic neuropathic pain

Answer 79

A

Name/aka: Mc Evedy-modified/aka half pfanenstiel
Use: emergency femoral hernia
Advantage: allows inspection of peritoneal cavity with easy confersion to laparotomy if necessary

Answer 80

A

Loin
Nephrectomy

Answer 81

A

Vasc access
Use:
- bypass
- embolectomy
- EVAR/TEVAR
- Stent insertion
- Fem endartectomy
- angioplasty

Answer 82

A

Right hemicolectomy

Features

Indication: tx in the cecum and proximal part of ascending colon
Scars:
- midline laparotomy
- Transverse muscle splitting
- Laparoscopic ports
Stoma: none
Anastomosis: ileocolic
Differential: midline laparotomy differential

Answer 83

A

Extended Right hemicolectomy

Features

Indication: tumours in the distal ascending colon or transverse colon
Scars:
- midline laparotomy
- laparoscopic ports
Stoma: none
Anastomosis: ileocolic
Differential: midline laparotomy differential

Answer 84

A

Left hemicolectomy

Features

Indication: tumours in the descending colon
Scars:
- midline laparotomy
- laparoscopic ports
Stoma: none
Anastomosis: colocolic
Differential: midline laparotomy differential

Answer 85

A

Hartmann’s procedure

Features

Indication: obstruction or perforation secondary to sigmoid tymour or diverticulitis
Description:
- emergency procedure
- sigmoid colectomy
- proximal bowel exteriorised as an end colostomy
- distal bowel oversewn to form a rectal stump
- MAY be reversed after 3-6mo (>50% of pts ARE NOT reversed)
Scars:
- midline laparotomy
- may have previous stoma acr in LIF if it has been reversed
Stoma: single lumen colostomy in LIF
Differential: APR!

Answer 86

A

Abdomino-perineal resection (APR)

Features

Indication: rectal Ca <4-5cm from anal verge
Description:
- sigmoid rectum and mesorectal nodes removed via abdominal incision
- anus removed via perineal incision
Scars:
- midline laparotomy
- no anus
Stoma: single lumen colostomy in LIF
Differential: Hartmann’s procedure; look for patent anus

Answer 87

A

Anterior resection

Features

Indication: rectal Ca >4-5cm from anal verge
Description:
- excision of part of the rectum and sigmoid colon
- may be high or low depending on site of tumour
- - total mesorectal excision for tumours in the middle or lower 1/3
- rectal blood supply is poor!!:
  - THEREFORE colorectal anastomosis is convered by temporary loop ileostomy
Scars:
- midline laparotomy
- laparoscopic port scars
- stoma OR SCAR in RIF
Stoma: double lumen loop ileostomy in RIF
Differential:
- End ileostomy:
  - panproctocolectomy: UC, FAP
  - subtotal colectomy: acute severe UC
  - cystectomy + ileal conduit
- loop ileostomy:
  - Temporary diversion:
    - crohn’s
    - anterior resection; alows healing of colorectal anastomosis

Answer 88

A

Subtotal colectomy

Features

Indication: acute severe UC
Description:
- all colon excised except distal sigmoid and rectum
- temporary end ileostomy
- Rectosigmoid stump may be exteriorised as mucus fisula
- followed after 3mo by either:
  - completion protectomy + IPAA (ileal pouch anal anastomosis) or permenent end ileostomy
  - ileorectal anastomosis (IRA)
Scars:
- midline laparotomy
- laparoscopic port sites
Stoma: single lumen end ileostomy in RIF
Differential:
- end ileostomy:
  - panprotocolectomy: UC, FAP
  - subtotal colectomy: acute severe UC
  - cystectomy and ileal conduit
- Loop ileostomy
  - temporary diversion: anterior resection or crohn’s

Answer 89

A

Panproctocolectomy

Features

Indication: Uc or FAP
Description:
- all colon, rectum and anus removed
- permenant end ileostomy
Scars:
- midline laparotomy
- laparoscopic port sites
Stoma: single lumen end ileostomy in RIF
Differential:
- end ileostomy:
  - panprotocolectomy: UC, FAP
  - subtotal colectomy: acute severe UC
  - cystectomy and ileal conduit
- Loop ileostomy
  - temporary diversion: anterior resection or crohn’s

Answer 90

A

Inspection:
- Peripheral
  - Gen:
    - Malnutrition/wt loss
    - cushingoid (steroid yse)
  - Hands:
    - clubbing
    - leukonychia
    - Beau’s lines
  - eyes:
    - pale conjunctivae
    - iritis, episcleritis
  - Mouth:
    - aphthous ulcers
    - gingibal hypertrophy
  - legs:
    - erythema nodosmun
    - pyoderma gangrenosum
- Abdomen:
  - Scars:
    - mutple and ?atypical =crohn;s
    - healed stoma site
    - Healed drain sites
  - Stomas (or healed stoma sites)
  - Enerocutaneous fistulae
Palpation:
- Tenderness
- RIF mass!
- +/- hepatomegaly
completion:
- inepect perineum for perianal disease
- examine for extra-intestinal features
  - large joint monoarthritis
  - sacroileitis
  - bronchiectasis

Answer 91

A

Symptoms
- Wt. loss, fever, malaise
- Abdominal pain
- Diarrhoea, blood and/or mucus PR
Peri-anal disease: abscesses, fistulae
Extra-intestinal: EN, arthritis, iritis, gallstones, PSC
Therapy
- Admissions
- Medical therapy
- Operations

Answer 92

A

Bloods

FBC: ↓Hb, ↑WCC
U+E: dehydration, ↓K
LFTs: ↓ albumin, deranged LFTs
Clotting: ↑INR
↑ ESR, ↑ CRP: used to monitor activity

Stool

Culture + CDToxin: exclude infective causes
- Campy, Yersinia, Shigella, C. diff, TB
Faecal calprotectin

Imaging

AXR
- Toxic megacolon in UC
- Bowel obstruction 2O to strictures in Crohn’s
Contrast studies
- Ba or Gastrograffin enema in UC
- Small bowel follow–through in Crohn’s
MRI: perianal disease in Crohn’s

Endoscopy

Ileocolonoscopy + regional biopsy
- Ix of choice
- Safe in acute disease
- Distinguish UC from Crohn’s
- Assess disease severity
Wireless capsule endoscopy

Answer 93

A

Truelove and Witts Criteria

Symptoms
- BMs >6 x /d
- Large PR bleed
Systemic Signs
- ↑ HR >90
- Pyrexia >37.8
Laboratory Values
- ↓ Hb <10.5g/dL
- ESR >30mm/Hr

Answer 94

A

Acute Severe

Megacolon: ≥6cm on AXR
Perforation: 30-40% mortality
Severe GI bleeding

Chronic

Medical Mx failure
Malignancy
Maturation failure in children

Answer 95

A

Acute Severe

Obstruction 2O to stenosis
Perforation
Severe GI bleeding

Chronic

Peri-anal disease: fistulae and abscesses
Intra-abdominal abscesses
Medical Mx failure: temporary defunction
Entero-cutaneous fistulae

Answer 96

A

Hepatobiliary

Fatty liver
Chronic hepatitis → cirrhosis
Gallstones
PSC (3% of UC) and cholangiocarcinoma

Answer 97

A

Principles

Curative intent
IPAA or IRA offer continence but suffer from ↑ BMs, pouchitis and risk of malignancy.

Subtotal colectomy c¯ end ileostomy ± mucus fistula

Operation of choice for acute severe colitis
All colon excised except distal sigmoid and rectum.
Rectosigmoid stump may be exteriorised as mucus fistula
Followed after ~3mo by either:
Completion proctectomy + IPAA or end ileostomy
Ileorectal anastomosis (IRA)

Proctocolectomy and permanent ileostomy

Rectum and anus excised c¯ all of colon
Only performed for pt. choice or when pt. is not suitable for restorative procedure
- ↑ age
- Impaired sphincter function

Restorative Proctocolectomy

Proctocolectomy or completion proctectomy
Construction of ileal reservoir which is anastomosed to anus
- Ileal pouch anal anastomosis (IPAA)
Usually covered by a diverting loop ileostomy
May check pouch anastomosis c¯ water soluble contrast

Answer 98

A

Principles

80% need ≥1 operation in their life
Never curative
Must be as conservative as possible: avoid short gut syndrome

Procedures

Ileocaecectomy
Drainage of intra-abdominal abscesses
Stricturoplasty
Colonic defunctioning for failed medical therapy
Occasionally a subtotal colectomy + permanent end ileostomy may be needed.

Answer 99

A

Inspection:
- Peripheral:
  - Cachexia
  - signs of CLD
  - look in sclera and at frenulum (of tongue): jaundice
  - Palpate for virchow’s node
- Abdo:
  - ascites
  - dilated abdo veins
  - umbilical/para-umbilical hernia
Palpation:
- hepatomegaly
- splenomegaly
- palpable gallbladder
Completion:
- check temp: obstruction complicated by infection
- dipstick urine: bilirubin, urobilinogen, hb

Answer 100

A

Post-hepatic:

Dark urine, pale stools
Itching
Stones: RUQ pain or biliary colic
Malignancy
- Wt. ↓ and ↓ appetite
- Change in bowel habit: esp. steatorrhoea
- Back pain

Hepatic

EtOH intake
Foreign travel: Hep A
Blood transfusions, IVDU, Sex: Hep B and C
Sore throat: EBV
Drug Hx: OCP, Abx, neuroleptics, OTCs

Pre-hepatic

Anaemia: tired, SOB, palpitations, ankle swelling
FH

Answer 101

A

Yellow discoloration of the skin and mucus membranes caused by the accumulation of bile pigments.

Normal BR = 3-17uM
Visible jaundice = 50uM (3 x ULN)
Very high levels usually have a hepatic cause

Answer 102

A

Urine:** ↑↑BR, no *urobilinogen
*Bloods**
LFTs: ↑cBR ↑↑↑ALP, ↑AST/ALT, ↑GGT
Clotting: ↑ INR
Auto-Abs: AMA, pANCA, ANA

Imaging

US
- Underlying hepatic disease
- Dilated ducts: >6mm
- Gallstones
- Pancreatic mass or lymphadenopathy
MRCP
ERCP
CT: staging tumour

Answer 103

A

*Pre-hepatic**: haemolysis after a transfusion
*Hepatic**
Halogenated anaesthetics
Sepsis
Intra- / post-operative hypotension

Post-hepatic: Biliary injury: e.g. in Lap Chole

Answer 104

A

Inspection
- Peripheral
  - Hands and Arms
    - Clubbing
    - AV fistula
  - Eyes
    - Pallor
    - Jaundice
  - Neck
    - LNs: e.g. Virchow’s node