Surgical shorts Flashcards
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.
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
What is the triad of a thyroid storm?
Hyperthermia + fast AF + pulmonary oedema
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
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
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
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
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.
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
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)
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.
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.
What are the borders of the inguinal canal?
Floor = inguinal ligament Anterior = External oblique Posterior = Transversalis fascia Roof = Internal oblique and Conjoint tendon
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.
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.
Scrotal lump DDx:
Get above it? - No
Inguino-scrotal hernia
Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - No
Transilluminable - Yes
Hydrocoele
Scrotal lump DDx:
Get above it? - Yes
Testis separately palpable - No
Transilluminable - No
Tumour
Orchitis
Haematocoele
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
