General Surgery Study Guide 2023 PDF

Gen Surg Study Guide 2023 Molly Jo e General Surgery Study Guide HERNIAS What? Abnormal protrusion of tissue/organs through muscle/connective tissue ->Internal: protrudes through defect in peritoneal cavi...

Gen Surg Study Guide 2023 Molly Jo e General Surgery Study Guide HERNIAS What? Abnormal protrusion of tissue/organs through muscle/connective tissue ->Internal: protrudes through defect in peritoneal cavity (mesenteric defect —> diaphragmatic hernia) ->External: protrudes through layers of abdominal wall (internal/femoral/umbilical hernia) ->Reducible: can return contents to place of origin ->Irreducible: contents can’t be returned (aka incarcerated) ->Strangulated: incarcerated hernia + vascular compromise; SURGICAL EMERGENCY (extreme pain, tenderness, erythema of overlying skin) ->Obstructed: hernia causes bowel obstruction -> Sx ->Richters: incarcerated hernia involving part of bowel wall (so no obstruction) **DOES NOT require US for Dx** Who? increased risk with chronic increased abdominal pressures (obesity, ascites, peritoneal dialysis, VP shunt, pregnancy, constipation, prostatism, chronic cough, COPD, repeated heavy lifting) Where? Abdominal wall most common (5% of people), especially at sites where the aponeurosis and fascia aren’t covered by striated muscle (inguinal (75%), femoral, umbilical, linea alba, semilunar line, sites of previous incisions) Groin Hernias: ->Hasselbach’s triangle: in posterior wall of inguinal canal; borders = lateral border of rectus (medial), inguinal ligament (inferior), inferior epigastric vessels (superiolateral) ->Inguinal Canal: short, internal and external ring; converts spermatic cord/round ligament from internal abdo->ext abdo; roof=int oblique&TA, oor=inguinal lig, ant wall=ext oblique aponeurosis, posterior wall=transversalis fascia ff fl  Gen Surg Study Guide 2023 Molly Jo e ->Femoral Canal: external iliac artery out of pelvis and down thigh (becomes femoral artery); borders = inguinal lig (ant) Cooper’s lig (post) lacunar (med) femoral vein (lat) Indirect Inguinal Hernia (congenital) - most common in males What: Abdominal contents protrude through internal/super cial inguinal ring (medial to epigastric vessels) into inguinal canal (conveys spermatic cord/round ligament) Etiology: 1-3% of children, 25% of preemies; M>F Common Presentation: intermittent bulge in groin, possible extension to scrotum/labia -> Communicating hydrocele: intermittent scrotal/labial swelling w/o groin bulge -> Non-communicating hydrocele: tense, nontender bluish scrotal swelling, doesn’t uctuate in size Tx: must be repaired (high ligation of sac)— risk of incarceration; same repair for communicating hydrocele but can be delayed (non-communicating, self-resolves by 1y) Direct Inguinal Hernia (acquired) - most common in males What: Abdominal contents penetrate directly through wall of inguinal canal, through Hesselbach’s triangle (lateral to epigastric vessels) Common presentation: lifting heavy —> pain, popping sensation —> lump in groin (painful w/ stooling, exertion) Tx: expectant if high anesthetic risk/ asymptomatic; if symptomatic — tissue/ mesh repairs (can be done open or laparoscopically); mesh repair = gold standard Femoral Hernia - more common in females What: protrusion of intestinal loop through weakened abdominal wall of lower abdomen below inguinal ligament (near thigh) Common presentation: intermittent painful lump in groin, no obvious onset Tx: higher risk of incarceration than direct inguinal hernia; tissue/mesh repair, open vs laparoscopic Ventral Hernias: Umbilical Hernia What: most common pediatric hernia; through umbilical ring at linea alba Common presentation: outie belly button fl ff fi  Gen Surg Study Guide 2023 Molly Jo e Tx: most close spontaneously, low risk of incarceration; teach parents to monitor and palpate defect, if persists past age 3-5, primary tissue repair (for peds, adults repair with mesh) Epigastric Hernia What: tiny defect in preperitoneal fat, 20% of cases have multiple (so small that bowel/ contents cannot poke through) Common presentation: small, painless lump in upper abdomen Tx: repair if symptomatic or cosmetic concerns Spigelian Hernia What: hernia sac dissects interparietal, along semilunaris (often below arcuate line) Presentation: vague lower abdominal wall pain (for months); v. rare…CT if suspicious Incisional Hernia What: hernia at the site of a previous surgical incision Risk factors: high tension wound closure, steroid use, wound infections Presentation: progressively worsening midline abdominal pain Tx: repair ACUTE ABDOMEN Acute Appendicitis Hx: Epigastric/periumbilical pain migrating to RLQ (8-12h), nausea, vomiting, anorexia, diarrhea Physical: RLQ tenderness +/- rebound and guarding — Rovsing’s sign = palpation of LLQ —> RLQ pain, pain at McBurney’s point, int. Rotation of R hip (obturator’s sign), posts sign (pain on hip extension); di use peritonitis, fever (suspect perf in context of fever and pain that improved before worsening) Ix: Fever (high fever may be sign of perf.); elevated WBCs; NOTE THIS IS PRIMARILY A CLINICAL DX!!! Alvarado Score: predicts likelihood of appendicitis; 7 appendicitis likely (if all 3 highlighted criteria present, 90% chance of appendicitis (before US) US: diameter >6mm, non-compressible, hyperaemia, appendicolith, periappendiceal fat stranding, free uid, collection/phlegmon/abscess CT: diameter >10mm, non lling, appendicolith, periappendiceal fat stranding, free uid, collection/phlegmon/abscess Tx: abx (ancef/ agyl), appendectomy (most common — even if you get in there and things look ne, still take it out if presentation is consistent), IR drainage fl ff fi fl fl fi ff  Gen Surg Study Guide 2023 Molly Jo e Small Bowel Obstruction Hx: crampy, colicky abdominal pain, N/V, obstipation (if complete); increased bowel sounds Causes: extramural, intramural (stricture), intraluminal (polyp, tumor, intussusception, FB) ->Most common: adhesion, hernia, Crohn’s, cancer ->other: stricture, CF, gallstones, intussusception, FB Ix: full panel (normal in early dz.), AXR (chest, supine, upright-air uid levels, paucity of gas in colon, ladder pattern of plica; rule out free air under diaphragm); if vomiting, expect hypokalemic hypochloremic metabolic alkalosis Optional Ix: - Upper GI series: double contrast study with barium, then gas pills to distend stomach; assesses stomach, esophagus, duodenum - Small bowel follow through: single contrast study, follows UGS, assesses ENTIRE small bowel Tx: NG decompression, IVF (for all); if virgin abdomen, concern for ischemia, non resolving pathology, failure to resolve with conservative management, refer for Sx Pseudoobstruction: ->Acute: most commonly caused by toxic megacolon (consider in colitis), paralytic ileus (late disturbance, post-op, opioids, bedridden), retroperitoneal hemorrhage ->Chronic: scleroderma, neurologic dz. involving enteric/central/peripheral NS AAA Hx: acute onset abdominal and back pain, associated with hypovolemic shock and generally unstable vitals Ix: CTA Tx: uid/blood product resus, repair (open vs endovascular) Perforated Ulcer Hx: acute onset severe generalized abdominal pain; Most commonly gastroduodenal ulcers; risk factors include NSAIDs, EtOH, COPD, PUD, diverticular disease Ix: CXR (will show free air under the diaphragm if perforated), CT can be helpful for surgical planning Tx: abx, IVF, surgery (Graham patch) Large Bowel Obstruction Hx: progressive abdominal distension and obstipation, sometimes associated with dementia/chronic constipation, colicky pain, N/V (later nding); open vs closed loop obstruction -> Open (10-20%) = iliocecal valve incompetent, gas can get back into small bowel (safer!) -> Closed (80-90%) = competent iliocecal valve, gas can’t get back into small bowel so increased pressures, extreme distension and risk of perf (pain over cecum is a sign) fl ff fi fl  Gen Surg Study Guide 2023 Molly Jo e Causes: extramural, intramural, intraluminal ->Most common: colorectal cancer, diverticulitis, volvulus ->Other: IBD, benign tumours, stool impaction, adhesions, endometriosis Ix: AXR (chest, upright, supine - look for air in small bowel to determine if open/closed, air uid level, proximal dilatation and distal decompression) Tx: NG decompression, IVF, surgery/stenting/colonoscopy Mesenteric Ischemia Hx: older patients (usually), severe generalized abdo pain (pain out of proportion), N/V; CAD, CHF, DM, sepsis, dehydration, AF, hypercoagulable states Causes: acute mesenteric artery embolus/thrombus, chronic mesenteric ischemia, mesenteric vein thrombosis, nonocclusive mesenteric ischemia Ix: CT=best, may also see thumbprinting on AXR, elevated lactate, WBCs, LFTs, Cr Tx: emergency surgery Gallstone Dz. V. Common, ~20% women and 5-10% men have stones, ~20% of these develop symptoms (~20% progress to more severe than biliary colic) - bile composed of bile salts, phospholipid and cholesterol; if composition altered, can get 1 of 3 types of stones: 1. Cholesterol stones 2. Pigmented stones 3. Mixed stones (most common) ->US=best way to see them since most are radiolucent Risk factors: female, obesity, age>40, multiparity, Indigenous Symptoms occur when ow of bile is obstructed Biliary Colic - stone in and out of cystic duct, pain as gall bladder contracts against obstructed cystic duct Hx: episodic post-prandial RUQ/epigastric pain (worse with fatty meals since they trigger GB contraction), colicky, resolution if late presentation, patient should be given abx and analgesia, f/u with surgeon for cholecystectomy at later date since ongoing in ammation can make Sx more challenging and decrease laparoscopic success; if lipase elevated, wait for it to normalize prior to chole ->if severe dz. but patient not healthy enough for surgery, can do percutaneous drain of GB ->if gas bubbles present, need URGENT Sx due to risk of perforation ->acalculus cholecystitis: consider in very ill/longterm NPO patients — caused by biliary stasis rather than stone Choledocholithiasis - stone in common bile duct; sometimes may make it into duodenum without complication, but sometimes can result in cholangitis/pancreatitis Hx: RUQ pain, pale stools, dark urine, jaundice Ix: elevated liver enzymes, elevated direct bili, cholelithiasis on US, CBD>4mm Choledocholithiasis + Cholangitis - infection of common bile duct resulting from obstruction (usually choledocholithiasis) Hx: RUQ pain, pale stools, dark urine, UNWELL — fever + jaundice + RUQ pain (Charcot’s triad); fever + jaundice + RUQ pain + hypotension + decreased LOC (Raynaud’s Pentad) Ix: elevated WBCs, liver enzymes, bili, US Tx: BSA (pip-taz), uid resuscitation, decompression of CBD (ERCP), cholecystectomy to prevent further incidence Gallstone Pancreatitis Hx: RUQ/epigastric pain + radiation to back; UNWELL Ix: elevated amylase and lipase Cholecystectomy - indicated in any patient with systematic gallstone dz. - Most often done laparoscopically; GB directed from fossa and removed - Be careful to identify and dissect arteries and cystic duct prior to clipping these structures to avoid potential for injury to CBD (which requires drain placement and repair - can cause cirrhosis requiring liver transplant) - May need to convert to open procedure if anatomy unclear, or if bleeding/ contamination that can’t be controlled laparoscopically Diverticulitis What: outpouching of intestine becomes in amed/infected Signs/Symptoms: LGIB, LLQ pain, constipation, diarrhea, nausea/vomiting, fever Ix: CT, scope Tx: ↑ bre, change medications, clear uids + abx, NPO/IVF/IV abx, Sx (if severe with peritonitis/perf — surgical drainage and diverting colostomy —> colonic reanastomosis) fi ff fl fl fl fl  Gen Surg Study Guide 2023 Molly Jo e INFLAMMATORY BOWEL DISEASE Crohn’s What: in ammation of all layers of bowel wall Signs/Symptoms: large volume, watery, non-bloody diarrhea; fever = common, 25% have RLQ mass; colicky post-prandial pain Endoscopy: skip lesions; may be rectum-sparing; aphthous ulcers, “cobblestoning,” non-caseating granulomas Tx: STOP SMOKING, anti-diarrheals; induction of Tx with steroids, maintain with biologics; Sx for management but IS NOT CURATIVE Complications: abscess, perianal dz., stulas, obstuction Ulcerative Colitis What: in ammation of mucosal layer Signs/Symptoms: frequent, bloody & mucousy small volume diarrhea, urgency/ tenesmus is common; pain pre-defecation Endoscopy: starts in rectum, progresses proximally (continuous); will see retraction and loss of haustra Tx: 5-ASAs ( rst line), steroids—>immunosuppressive Tx (2nd line), curative colectomy Complications: megacolon, perforation, strictures ANORECTAL Hemorrhoids >50% symptomatic at some point in their lives, incidence increases with age; rarely painful What? Vascular cushions, act as plug (help with continence) and may help protect the anal canal during defecation — PART OF NORMAL ANATOMY Risk factors for symptomatic/enlarged: predisposition (personal/familial), ↑intra-abdo pressure (pregnancy, chronic straining, consitpation, heavy-lifting) Hx: anal swelling/itching, protrusion of tissue with BM (sometimes require manual reduction), bleeding (drip/squirts), ache/discharge, hygiene issues Physical: normal DRE, will be able to visualize external on inspection Tx: bre, metamucil, avoidance of sitting/straining on toilet for prolonged periods ->for refractory hemorrhoids: rubber band ligation (sclerotherapy), surgical hemorrhoidectomy Thrombosed External Hemorrhoid Symptoms: swelling/excruciating pain around anus, inability to sit comfortably, recurrent episodes Treatment: bre, metamucil, avoidance of sitting/straining on toilet for prolonged periods, SITZ BATHS, NSAIDs ->refer for formal excision if recurrent Anal Fissure fi ff fl fl fi fi fi  Gen Surg Study Guide 2023 Molly Jo e What: almost always midline; hard stool/diarrhea + dry skin —> tear in anoderm below dentate line —> irritation and spasm of internal anal sphincter —> ↓blood ow +ischemia - chronic if >2-3months Hx: pain with/after BM, streaks of blood, sphincter tightness/spasm Medical Tx: Sitz baths, increased bre, diltiazam 2% cream, stool softeners, NSAIDs prn Chronic Anal Fissure Triad: sentinel tag, hypertrophic anal papilla, exposed bres of internal sphincter Tx: i. Sitz baths, increased bre, diltiazam 2% cream ii. botox injections iii. Sx: lateral internal sphincterotomy (LIS), anoplasty Anorectal Abscess Hx: increasing perianal pain, non-relenting, unable to sit, soft tender lump; NO PREVIOUS EPISODES Tx: I&D ->post-drainage: Sitz bath, gauze dressing, healing in 2-6wks (no abx unless systemically unwell) Anorectal Abscess and Fistula Obstructed/infected anal gland —> stula ->requires I&D Fistula in Ano Will not resolve unless surgery; management includes: stulotomy, staged stula repair, stula plug, advancement ap, seton Pilonidal Disease What: chronic infection of skin and subQ in upper natal cleft related to debris and hair; most common ages 13-40 Tx: excision/debridement of chronically infected tissue, may require ap repair ->HIGH RECURRENCE RATE POSTOP COMPLICATIONS Fever Ddx: Onset Cause(s) 0-48h Atelectasis, soft tissue infection (clostridia, GAS) fi ff fi fl fi fi fi fi fl fl fi  Gen Surg Study Guide 2023 Molly Jo e POD 3 UTI, line infections, delirium tremens POD 3-5 Wound infection POD 5-10 Abscess, dehiscence POD 6-10 Drugs, DVT, PE Ix: repeat vitals, labs (including cultures), CXR, urinalysis/culture, gram stain wounds, culture drains, abx prn **Note on UTIs: send for C&S, in the meantime start on either Septra (1tab PO BID x3d) OR cipro (250mg PO BID x3d)** Abdominal Pain Worry about: i. Sepsis ii. Perforation iii. Anastomotic leak iv. Ischemic bowel Important to di erentiate between visceral and parietal pain Oliguria De nition: 6h Worry about: i. Hypovolemia ii. Out ow obstruction iii. Renal Dysfunction **Notes: - 5-10% of postop pts —> AKI; longer hospital stays, increase in mortality ->↓urine output = 1st clinical sign, IDs pt @risk - titrated intraoperative uid boluses improve postop outcomes - Fluid accumulation in critical pts —> ↑mortality, not renal function improvement - Liberal uids in pts undergoing bowel Sx —> ↑postop complications Approach: - Exclude reversible causes (obstruction, intra-abdo HTN) - Flush catheter or bladder scan - Assess volume status fi fl ff fl ff fl  Gen Surg Study Guide 2023 Molly Jo e - Vitals; tachy/hypotension - Maintain renal perfusion, minimize toxins Hypotension WORRY ABOUT SHOCK! 1. Cardiogenic Shock -> Extrinsic (tamponade) -> Intrinsic (CHF, MI) 2. Hemorrhagic Shock - low BP, tachycardia, pallor, diaphoresis - Low Hgb - Send stat blood work, type and screen, bolus uids, give PRBCs once available 3. Hypovolemic Shock 4. Distributive Shock Maintenance Calc. 4-2-1 Rule 4ml/kg/h x 1st 10kg 2ml/kg/h x 2nd 10kg 1ml/kg/h x rest ->Septic ->Neurogenic ->Anaphylactic **Note: if giving FFP, INR with correct by 0.1-0.2 with each unit FLUIDS Body Water - 50-70% of body weight - fat has less water than muscle: ↑fat results in ↓TBW; TBW ↓ with age - Avg female: 50% TBW - Avg male: 60% TBW Fluid Compartments 1. Intracellular (⅔) - K+, Mg2+, PO4-, proteins 2. Extracellular (⅔) - Na+, Cl-, HCO3- ->Intravascular (⅓) ->Interstitial (⅔) Fluid Replacement De cits fi ff fl  Gen Surg Study Guide 2023 Molly Jo e i. Hypovolemia (bleeding, vomiting, diarrhea/stoma losses, ↓intake) ii. Sepsis (fever, increased resp. rate, vasodilation, 3rd spacing ( ↑interstitial volume) Signs of uid de cit: anxiety, decreased mental status, dry mucous membranes, ↑HR, ↓BP, narrow pulse pressure, orthostatic changes, oliguria -Mild (15%): postural changes, narrow pulse pressure -Moderated (15-30%): tachycardia, oliguria, hypotension -Severe (30-40%): tachicardia, anuria, hypotension, ↓LOC What to replace with? Loss from: Replace with: Perspiration, evaporation, urinary output ————————-> CRYSTALLOID Acute blood loss/protein rich uid shifts ————————-> COLLOIDS/PROTEIN Bleeding ————————-> BLOOD Resus: Isotonic (NS/LR) Maintenance: D5W + 1/2NS + 20meqKCl/L — POD1 if NPO Gastric losses (NG): 1/2NS + 20meqKCl/L — with any NG tube Body Fluid Volume Primary Cation Primary Anion Gastric 2.5L Na Cl Pancreas 1L Na HCO3 Bile 1.5L Na Cl Small Bowel 3.5L Na Cl Diarrhea >1L Na Cl Sweat Na Cl 3rd Spacing: injured tissues and membranes leak uid into interstitial (aka 3rd) space post-op -> temporary inability of intravascular compartment to access whites uid ff fl fi fl fl fl  Gen Surg Study Guide 2023 Molly Jo e -> mobilized back via lymphatics by POD3 — corrects de cit and may cause temp uid OVERLOAD if over resuscitated ff fl fi