Surgery
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| Appendicitis: Pathophysiology | hyperplasia (kids); fecalith (adults); also neoplasm, parasite
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| Appendicitis prevalence | 7% general (mostly teens); 20% mortality in elderly
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| Appendicitis: most common (first) sx | anorexia
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| Appendicitis: complications | Wound infxn; Dehiscence; Bowel obstruction; Peritoneal abscess; Stump appendicitis
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| Appendicitis: pt mgmt | Laparoscopic appendectomy; after 24-48 hr (prob ruptured): percutaneous drainage & Abx; interval appy after 4 wks
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| Gold standard for dx appendicitis | CT (>7 mm & >2mm thick = appy)
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| Imaging used for appy in kids: | US
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| Cholecystectomy: performed for: | cholelithiasis, cholecystitis, gallstone pancreatitis, GB cancer
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| Gall stones: Etiology related to: | increasing conc of cholesterol (chol stones: 80%) or bile salts (pigments stones: 15%)
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| Gall stones: 4 Fs | female, fertile, fat, forty
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| Cholecystectomy: prevalence | US: 10-20% of popn develop gallstones; 60-80% of pts w/ gallstones never develop sx
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| Gall stones: sx | Abd pain, jaundice, fever
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| Gall stones: dx imaging | US best; plain films only 15%; CT; HIDA (dye)
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| Cholecystitis = | stone in neck (cystic duct); GB cannot drain
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| Cholangitis = | obstr GB as well as fr L/R ducts (common bile duct cannot drain)
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| Gall stone Pancreatitis = | obstr ampulla; have obstruction of pancreas: both Panc duct and common bile duct (can be surg emergency)
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| Procedure of choice for GB dz | Laparoscopic Cholecystectomy
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| Cholecystectomy: complications | Common bile duct injury (often w/ lap); retained stones (ERCP); Bile leak; Hemorrhage; abscess, bowel injury, wound infection
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| Abd hernia defn | protrusion of extraperitoneal fat, peritoneum, omentum, bowel, or other viscera thru a defect in transversalis fascia
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| Abd wall anatomy (in order): | Skin; SubQ Tissue; Ext Oblique Fascia; Cremasteric Fibers; Spermatic Cord; Transversus Abdominus Aponeurosis; Transversalis Fascia; Preperitoneal Tissue; Peritoneum
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| Hesselbach triangle | rectus sheath, Inf epigastric vessels, Inguinal lig
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| Direct inguinal hernia: | From gradual weakening of transversalis fascia. Directly thru inguinal triangle (do not occur in infants). Defect is medial to internal ring & inside Hesselbach triangle.
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| Indirect inguinal hernia: | Congenital. Abd viscera pass thru internal ring within a patent processus vaginalis
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| Femoral hernia: | more common in elderly women; can become incarc / strangulated (repair early); medial to vessels, inferior to inguinal ligament
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| Epigastric hernia: | occur thru midline defects in fascia in upper abdomen
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| Sliding hernia: | a viscus forms an integral part of the wall
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| Incisional hernia: | recurrent by definition
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| Spigelian hernia: | lateral to rectus sheath
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| Grynfeltt’s/Petit’s hernia: | posterior hernias (lumbosacral area)
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| Internal hernia: | Rare; typically occurs thru openings in mesentery or ligaments within the peritoneum; usu strangulated (repair early)
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| Umbilical hernia: | Usuallycongenital. Also PG, obese, ascites
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| Hernia: imaging useful in obese pt | CT
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| Hernia: Incarceration | inability to reduce hernia contents
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| Hernia: Strangulation | compromise of intestinal vascular supply; secondary to incarceration
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| Open hernia repair: most common complications | wound related / infxn; testicular; urinary
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| Hernia post-op recurrence by type: | recurrent (5-35%); direct (4-10%); indirect, femoral (each 1-7%)
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| Purpose of onlay prosthetic mesh | when repair causes undue tension; bridges gap btw margins of hernia aperture
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| Laparoscopic vs open hernia repair | More expensive; longer op time; higher risk of rare serious comp; dec postop pain / numbness; quicker time back to work; equivalent recurrence
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| Bassini surg for: | direct / indirect inguinal
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| Coopers surg for: | direct, lg indirect, recurrent
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| Surg: femoral hernia | inguinal canal approach; open preperitoneal; or lap
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| Surg: incisional hernia | usu open
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| Type I hiatal hernia | Sliding hernia: GI junction is above hiatus of diaphragm. Most common type
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| Type II hiatal hernia | Paraesophageal or rolling hernia. GE junction remains intra-abdominal; stomach's fundus herniates
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| Mackler triad | Vomiting, lower chest pain, cervical subcutaneous emphysema; sx of esophageal perforation
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| Hamman sign | Crunching sound caused by heart beating against air-filled mediastinum; sx of esophageal perforation
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| Acalculous acute cholecystitis requires: | emergent surgery
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| Appendicitis clinical exam | RLQ pain with LLQ palpation (Rovsing sx), thigh extension (psoas sx), lateral hip rotation (obturator sx)
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| Dx studies for femoral hernia | US or CT. FNA bx ONLY IF fem hernia is excluded (otherwise risk bowel perf/abscess)
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| Hernia: direct vs indirect | Direct: through external inguinal ring / Hesselbach triangle. Indirect: through internal inguinal ring to inguinal canal (most common)
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| Direct inguinal hernia: | directly thru inguinal triangle (do not occur in infants)
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| Indirect inguinal hernia: | abd viscera pass thru internal ring within a patent processus vaginalis
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