Surgical shorts Flashcards by Adam Sullivan

Explain the difference between a Modified Hartmann’s and an Anterior Resection

A Modified Hartmann’s involves resection of a portion of colon + end colostomy + oversewed rectal stump. Later there can be a reversal of Hartmann’s to formed a delayed anastomosis.

An anterior resection also involves resection of a portion of colon. (Typically the term was limited to just rectum but now can be used for most descending colon). However, there is an immediate formation of an immediate anastomosis. Sometimes to protect this anastamosis a defunctioning loop ileostomy is formed. This can be reversed after 6 weeks.

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What are the complications of thyroidectomy?

Acute but rare

haemorrhage
thyroid storm

Damage to local structures

recurrent laryngeal nerve palsy -> hoarse voice
hypoparathyroidism

Late but common

Hypothyroidism
Recurrent hyperthyroidism

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What is the triad of a thyroid storm?

Hyperthermia + fast AF + pulmonary oedema

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How do you avoid damage to the recurrent laryngeal nerve in a thyroidectomy?

Remain anterior to the pre-tracheal fascia that separates it from the thyroid and parathyroid

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What are the causes of cervical lymphadenopathy?

LIST

Lymphoma and Leukaemia
Infection
Sarcoid
Tumours - breast, bronchus and stomach.

Infections

Bacterial - tonsillitis, TB
Viral - EBV, HIV
Protozoa - Toxo

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Complications of a stoma

FOUL SHITS

Fluid loss - haemorrhage and high output
Odour
Ulceration of the skin
Leakage

Stenosis and stricture
Herniation and prolapse
Ischaemia
Terminal ileum loss - bile salt and B12
Sexual and psychological

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Breast Ca risk factors

Bleeding - early menarche (55)
Oestrogen (OCP, HRT)
Age of first child (>35y increases risk)
Breastfeeding protective
Other breast disease
FHx breast disease

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What is the difference between an incarcerated and a strangulated hernia?

An incarcerated is irreducible, sometimes with a loss of cough impulse.

A strangulated hernia has an occlusion of the vascular supply leading to infarction with subsequent peritonitis and abscess formation.

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What are the borders of the femoral triangle?

SAIL

Medial = sartorius
Lateral = adductor longus
Base = inguinal ligament

Roof = skin and fascia
Floor = iliopsoas + pectineus + adductor longus

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What are the borders of the femoral ring?

The femoral ring is the opening to the femoral canal which is the medial compartment of the femoral sheath.

Anterior = inguinal ligament
Posterior = Pectineus
Medial = Lacunar ligament
Lateral = Femoral vein (within middle compartment of femoral sheath)

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What is a Richter’s hernia?

This is where only part of the bowel herniates through a narrow orifice.

This can allow for strangulation without obstruction.

Common in narrow orifices - femoral hernia.

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What is the difference anatomically between an inguinal and femoral hernia?

An inguinal hernia is superior and medial to the pubic tubercle whilst a femoral hernia is inferior and lateral.

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What are the borders of the inguinal canal?

Floor = inguinal ligament
Anterior = External oblique
Posterior = Transversalis fascia
Roof = Internal oblique and Conjoint tendon

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What structure has a defect in both an epigastric and paraumbilical hernia

Linea alba.

In an epigastric hernia this defect can be anywhere from the xiphisternum to the umbilicus.

In a paraumbilical hernia this defect is just above or below the umbilicus.

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What is the difference and relevant of the mid-point of the inguinal canal and the mid-inguinal point?

Mid-point of the inguinal canal is between ASIS and pubic tubercle and marks the deep inguinal ring.

Mid-inguinal point is between the ASIS and pubic symphysis and marks the femoral artery.

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Scrotal lump DDx:

Get above it? - No

Inguino-scrotal hernia

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Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - No
Transilluminable - Yes

Hydrocoele

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Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - No
Transilluminable - No

Tumour
Orchitis
Haematocoele

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Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - Yes
Transilluminable - Yes

Epididymal cyst

Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - Yes
Transilluminable - No

Varicoele
Spermatocoele
Sperm granuloma
Epididymitis

Definition of a hydrocoele

Accumulation of fluid within the tunica vaginalis

Definition of varicocoele

Dilated veins of the pampiniform plexus

Grey-Turner sign indicates what and what are the common causes?

Retroperitoneal haemorrhage.

Acute haemorrhagic pancreatitis
leaking AAA
Ruptured ectopic pregnancy

Management of an acute oculogyric crisis?

STOP offending agent - e.g. post-op prochlorperazine

IV procyclidine (anti-cholinergic)

Consider BDZs

Specific operative complication of (damage to local structure): Breast cancer surgery with axillary dissection.

Lymphoedema of the arm

Specific operative complication of (damage to local structure): Panproctocolectomy

Damage to the pre-sacral plexus Men: erectile impotence Women: Reduced vaginal lubrication and anorgasmia

Specific operative complication of (damage to local structure): Thyroidectomy

Recurrent laryngeal nerve - hoarse voice Parathyroids - hypoparathyroidism - hypoCa

Specific operative complication of (damage to local structure): Total hip replacement

Damage to sciatic nerve

Specific operative complication of (damage to local structure): Femoral-popliteal bypass

Damage to femoral nerve

Specific operative complication of (damage to local structure): Removal of parotid tumour

Damage to facial nerve

Specific operative complication of (damage to local structure): Branchial cyst excision

Damage to accessory and hypoglossal nerves

Laporoscopic cholecystectomy

Biliary peritonitis.

Definition of a stoma

An abnormal communication between an internal viscera and the external environment

Defition of a hernia

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

What are the risk factors for an incisional hernia?

Pre-op - Co-morbidites - DM, CKD - Drugs - steroids - Obese Operative - Incision site - midline - Closure technique - Drains through wounds Post-op - ↑ intra-abdominal pressure: cough, - infection - haematoma

2 hours after a football game in which a 34 year old man was struck with a ball in the groin, he is brought to hospital with a swelling in the scrotum that has not resolved with application of an ice pack. O/E there is a small scar in the right groin, the left testis is lying slightly higher than the R. The testicular adnexae are firm but non-tender. These findings are suggestive of: ``` Torsion of hydatid of Morgagni Epididymo-orchitis Seminoma Teratoma Scrotal haematoma ```

Seminoma Testicular tumours are often found incidentially after minor trauma to the scrotum, the mass is often mistakenly attributed to the trauma. Torsion is often heralded by pain and rarely a blue spot. The scar in the groin points to perhaps a previous surgery for undescended testis which is associated with testicular tumour. Seminomas are more common in those over 30 than teratomas.

Adjuvant chemotherapy agent for Duke C colorectal Ca

5-FU Reduces mortality by 25%

Indications for a mastectomy over a WLE

Pt preference Multi-focal disease (often lobular) Large lump over a large area (>4cm) Nipple involvement

What are the features of an acute pancreatitis on AXR?

NB. Often normal. Loss of psoas shadow - due to retroperitoneal fluid. Sentinel loop - segment of gas-filled proximal jejunum.

Complications of TURP

TUR syndrome: fluid overload + dilutional hyponatremia + glycine toxicity. Urethral stricture Retrograde ejaculation Perforation of prostate

Grading of diverticulitis and assoc management

Hinchey grading 1) Small abscess limited to colon 2) Large abscess extending into pelvis 3) Purulent peritonitis 4) Faecal perionitis Mx Resus: admit, NBM, fluids, abx Hinchey 1 + 2: mainly supportive Hinchey 3: Wash-out Hinchey 4: Hartmann's

Jenkin's Rule

Suture length = 4x incision length

Important anatomical landmark to locate in Laparoscopic cholecystectomy?

Identify Calot's Triangle: 1) Superior = inferior liver edge 2) Medial = Common Hepatic Duct 3) Hypotenuse = Cystic duct + GB Identify Cystic duct and cystic artery (within Calot's triangle) and clip them.

4 anatomical locations of oesophageal narrowing

1) Junction w/ pharynx at level of the cricoid 2) Posterior to aortic arch 3) Posterior to L main bronchus 4) Lower oesophageal junction

Surface anatomy of the renal pelvis

L1 on left, slightly lower on right

Cushing reflex

HTN + Bradycardia + irregular breathing