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GI Surgery 1

Surgery

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