Surgical Vivas Flashcards
What are the risk factors for incisional hernias?
What are the borders of the inguinal canal?
Classify into pre-operative, operative and post-operative:
Pre-operative risk factors : Age, immunocompromised (steroids, renal failure, diabetes), obesity, malignancy
Operative risk factors: Poor wound closure (too small bites or inappropriate suture material), placing drains through wounds, site, length of the wound.
Post-operative: Wound haematoma, wound infection, early mobilisation (premature?), post-operative atelectasis and chest infection.
Borders of the inguinal canal are:
- Superiorly the internal oblique and tranversus abdominis
- Inferiorly the inguinal and lacunar ligament
- Anteriorly an aponeurosis of internal and external oblique
- Posteriorly transversalis fascia and conjoint tendon
What are the borders of the femoral triangle?
What does it contain?
Borders of the femoral triangle are as follows:
- Superiorly by inguinal ligament
- Medially by adductor longus
- Laterally by sartorius
- Posteriorly by iliopsoas, pectineus and adductor longus
- Anteriorly by superficial fascia.
The femoral triangle contains the femoral nerve, artery and vein and the deep inguinal lymph nodes.
What are the general complications of abdominal surgery?
Classify into immediate, early and late:
Immediate: Neurovascular damage, damage to surrounding anatomical structures, bleeding, anaesthetic risks.
Early: DVT/PE, pain, respiratory complications (pulomnary oedema, PE, atelectasis - pneumonia), anaemia, wound dehiscence, sepsis/infection.
Late: DVT/PE, pain, adhesions (bowel obstruction/pain), failure of procedure.
List a few differentials for what a palpable mass on examination could be for each of the following areas.
Right upper quadrant:
Left upper quadrant:
Right lower quadrant:
Left lower quadrant:
Midline and lower abdomen:
Two or three answers for each region would suffice, this is just an exhaustive list to consider.
Right upper quadrant: Hepatomegaly, gallbladder, renal mass, colon cancer, small bowel obstruction/tumour, omental mass, retroperitoneal tumours
Left upper quadrant: Splenomegaly, left lobe of liver, gastric tumour/dilatation, renal mass, colon cancer, small bowel obstruction/tumour, omental mass. retroperitoneal tumours.
Right lower quadrant: Appendix, caecal cancer, Crohn’s mass, transplanted kidney, undescended testicle, iliac aneurysm, ovarian cyst/tumour, carcinoid tumour, psoas abcess, pelvic bone tumour, small bowel obstruction/tumour, omental mass, lympadenopathy, hernia.
Left lower quadrant: Diverticular mass, sigmoid cancer, faeces, transplanted kidney, undescended testicle, iliac aneurysm, ovarian cyst/tumour, psoas abcess, pelvic bone tumour, small bowel obstruction/tumour, omental mass, lympadenopathy, hernia.
Midline and lower abdomen: Bladder (urinary retention/tumour), uterus (pregnant, fibroids, tumour), omental mass (metastasis)
What is shown in the picture?
How would you describe a similar finding in a surgical short?
Complications of a stoma?
There is a stoma, not spouted and flush to the skin, located in the left lower quadrant/left iliac fossa. It is pink in colour, active, (producing reasonably well formed stool). On closer inspection, it does not appear herniated or retracted and there appears to be only one lumen.
This would be consistent with a colostomy.
The potential indications for this could include sigmoid cancer and diverticulitis, or less commonly inflammatory bowel disease.
Peripheral evidence for sigmoid cancer would include cachexia as evidenced by muscle wasting of the temporalis and triceps, peripheral sensory neuropathy, radiotherapy tattoos and/or PortaCath.
Complications of a stoma?
Local – parastomal hernia, dermititis, strangulation or necrosis of stoma, blockage of stoma, infection.
Systemic – High output stomas – dehydration, sepsis,
What are some causes and risk factors of Carpal Tunnel Syndrome?
Do you know of any special tests to diagnose Carpal Tunnel Syndrome?
What nerve is affected in Carpal Tunnel Syndrome and what muscles does it innervate? How would you test for power in these muscles?
Carpal tunnel syndrome is a common condition that affects a wide population with a range of causes and risk factors such as pregnancy, diabetes, arthritis of the wrist, obesity, hypothyroidism, acromegaly and cardiac failure.
Special tests to diagnose carpal tunnel syndrome include:
Tinnel’s sign: Tingling sensation after tapping on the affected wrist indicates carpal tunnel syndrome.
Phalen’s test: Maximal flexion of the wrist for one minute may cause symptoms
Motor assessment: Power of the muscles supplied by the median nerve may be weakened.
The nerve which is affected in carpal tunnel syndrome is the median nerve, which innervates:
- Lateral two lumbricals (difficult to test)
- Opponens Pollicis (Ask the patient to make a ring with their thumb and little finger and don’t let you pull them apart)
- Abductor pollicis brevis(Ask patient to turn hands over and lift their thumb towards the ceiling against resistance)
- Flexor pollicis brevis (Not an independent muscle (innervation varies))
What are the common clinical features of Achalasia?
What would you expect to see on barium swallow in Achalasia?
What other investigations would you do in a patient with suspected Achalasia?
What is the management of a patient with Achalasia?
What are the two main options for breast reconstruction post-mastectomy?
What are the advantages and disadvantages of both?
What are the types of myocutaneous flaps?
The two main options for breast reconstruction surgery is an implant or a myocutaneous flap.
The advantages of an implant is that it’s a simpler and quicker surgery, which can be done at the same time as a mastectomy (primary breast reconstruction) or at a delayed time. The disadvantages of an implant is that the cosmetic result is not as good - lies higher than other breast, and it requires plenty of available skin. Late complications of breast reconstruction with an implant are capsular contracture, implant leakage and infection requiring removal.
Conversely the advantages of a myocutaneous flap are that they can be used if little remaining skin or muscle, they achieve a good cosmetic result and they can be either primary (with mastectomy op) or delayed as well. The disadvantages are increased blood loss and operation time and subsequent complications for both of those, and the rectus muscle cannot be used if the patient has had previous abdominal surgery. The late complications of breast reconstruction with a myocutaneous flap are flap necrosis and infection.
There are three types of myocutaneous flaps:
- latissimus dorsi myocutaneous flap is a a surgery where the lat dorsi is mobilised and tunneled medially creating a neo breast, and is often augmented with an implant. It is pedicled by skin fat, muscle and blood supply which is via the thoracodorsal artery via the subscapular artery.
- Transverse rectus abdominis myocutaneous (TRAM) flap where the inferior epigastric artery is pedicled (may be free and attached to internal thoracic artery). This is contraindicated in patients who have poor circulation, are smokers, obese, patients with peripheral vascular disease and diabetes mellitus. The benefits of a TRAM flap reconstruction are that there is no implant necessary and it combines with a “tummy tuck”. Disadvantages of a TRAM flap is an increased risk of abdominal hernia.
- deep inferior epigastric perforator (DIEP) flap, this is an evolution of the TRAM flap which spares the rectus leading to reduced pain and decreased risk of herniation. However, it isn’t possible in patients with small perforators.
