Surgery E2: Study Guide

What labs indicate prerenal azotemia?

urine Na < 20

FENa < 1%

What labs indicate post-renal dysfunction?

urine Na > 40

FENa > 4%

What labs indicate intrinsic renal dysfunction?

urine Na > 40

FENa > 1%

How do you calculate FENa?

[(urine Na x serum Cr) / (urine Cr x serum Na)] x 100

What are sx of testicular torsion?

acute testicular pain or swelling, absence of cremasteric reflex, testicle may be abnormal or lying transverse

What workup is needed for testicular torsion?

STAT scrotal US w/ doppler

STAT uro consult

What is the tx for testicular torsion?

immediate surgical detorsion & bilateral orchiopexy to the scrotum

*if done w/in < 6 hrs, 90-100% salvage rate

What is the tx for testicular torsion if the testis are nonviable?

orchiectomy

What are the complications of correcting testicular torsion?

loss of testis, infection, infertility, cosmetic deformity, loss or diminished exocrine/endocrine function

What is 1-stage Fowler-Stephens orchiopexy?

*laparoscopic

gonadal vessels are divided and the testis is dissected off a pedicle of the vas deferens to bring it down

What is 2-stage Fowler-Stephens orchiopexy?

*laparoscopic

clips placed to divide the gonadal vessels, dissection of the testis is deferred for 6 months allowing for optimal development of collaterals before proceeding w/ testicular relocation

What is 2-stage Shehata technique orchiopexy?

*laparoscopic

performed in 2 stages, has the benefit of relocating intraabdominal testis w/o sacrificing the main testicular vessels

What are potential complications of an orchiopexy?

testicular atrophy, testicular ascent

What are the benefits of orchiopexy?

reduce risk of infertility, corrects patent processus vaginalis (predisposes to hydrocele or hernia), allows for exam of testis (malignancy)

What are sx of an urethral injury?

blood at meatus, painful urination or inability to void, palpable bladder, swelling, hx trauma, uro surg, dyspareunia

What is the workup of an urethral injury?

retrograde urethrogram (gold standard)

*CT preferred if assessing intraabdominal (kidney, ureter, bladder)

What is the tx for an urethral injury?

cystoscopy w/ urethral repair

*leave in post-op foley until completely healed

What are the RF for prostate cancer?

AA, > 60 yo, + FHx in 1st degree relative

What are sx of prostate cancer?

asx early on, elevated PSA, BPH w/ LUTS; advanced → anemia, wt loss, bone pain

What workup is needed for prostate cancer?

prostate biopsy (gold standard) → use Gleason score

DRE, trend PSA, MRI prostate - assign PIRADS score (4-5 = sus)

What is Grade 1 (Gleason score < 6)?

well-formed gland; low risk of cancer

What is Grade 2 (Gleason 3+4=7)?

predominantly poorly-formed glands w/ lesser component of well-formed glands; intermediate risk of cancer

What is Grade 3 (Gleason 4+3=7)?

predominantly poorly formed glands; intermediate risk of cancer

*most prostate cancers fall into this group

What is Grade 4 (Gleason = 8)?

only poorly formed glands; high risk

What is Grade 5 (Gleason 9 or 10)?

lacks gland formation (or w/ necrosis); high risk

What are surgical tx options for prostate CA?

robotic or laparoscopic-assisted prostatectomy (radical prostatectomy) -offers definitive cure

TURP, open prostatectomy, TUNA

What are complications for prostate surgery?

hematuria post op, painful or difficult urination, infection, retrograde ejaculation, bleeding, impotence, incontinence

What muscles make up the breast?

Pectoralis major: lies beneath breast

Serratus anterior: lateral wall

Rectus abdominis: inferior border

External oblique: anterolateral wall

What provides blood supply to the breast?

anterior perforating intercostal arteries (60%)

lateral thoracic artery (30%)

posterior intercostal arteries (10%)

Where does the majority of breast lymph drain through?

axilla (75%), lymph drainage occurs first to a lower lymph node level and proceeds on to higher levels

What are the 4 nerves to be aware of during axillary dissection?

long thoracic, thoracodorsal, medial pectoral, lateral pectoral

What are the RF for breast cancer?

inc age, + FHx breast or ovarian CA, HRT, alcohol consumption, early menarche, late menopause, nulliparity, radiation exposure

What are sx of breast CA?

U/L spontaneous nipple discharge, noncyclic pain, firm fixed mass, complex findings on imaging, Peau d’orange

What is lobular carcinoma in situ (LCIS)?

RF for development of breast cancer, conforms to the outline of the normal lobule w/ expanded and filled acini

What is ductal carcinoma in situ (DCIS)?

pre-invasive form of ductal CA

What is infiltrating ductal carcinoma?

90% of invasive breast CA, tends to grow as a cohesive mass and appears as discrete abnormalities on mammogram

*Paget’s: skin involvement

What is infiltrating lobular carcinoma?

10% of breast CA, difficult to detect, tends to grow in a single file nature

What is tubular carcinoma?

usually low grade lesions, account for 1-2% breast CA

What is the workup for breast CA?

mammogram -MC screening

US -good at assessing size and consistency of lumps; used for guided needle biopsy

MRI -sensitive at describing abnormalities

Which BI-RADS risk score:

incomplete; needs additional imaging

0

Which BI-RADS risk score:

negative; symmetrical and no masses or suspicious calcifications

1

Which BI-RADS risk score:

benign; 0% probability of malignancy

2

Which BI-RADS risk score:

probably benign; < 2% probability of malignancy

3

Which BI-RADS risk score:

suspicious; 2-95% probability of malignancy

4

Which BI-RADS risk score:

high suggestive of malignancy

5

Which BI-RADS risk score:

known biopsy proven malignancy

6

What are MRIs good for ?

dense breasts, scar tissue, implants; used for local staging for DCIS and lobular cancer

*sensitivity & specificity may be greater than that of a mammogram

How is breast CA diagnosed?

fine needle aspiration FNA, core needle biopsy, stereotactic biopsy, US guided biopsy, excisional biopsy

How is breast CA staged?

TNM

What is a lumpectomy?

excision of breast lump w/ a surrounding rim of normal breast tissue

What is a simple mastectomy?

removes breast tissue, nipple, areola, and skin, but not all of the lymph nodes

What is a modified radical mastectomy?

affected breast is removed as well as part of the axillary lymph system (levels 1 & 2), underlying muscle is preserved

What is a radical mastectomy?

affected breast, all lymphatic drainage and underlying pectoral muscles are removed

What are indications for a lumpectomy?

equivocal patho on biopsy, category 3 or 4 mass, DCIS or invasive breast CA that is amenable to breast conserving therapy based on the size

What lumpectomy incision is ideal for central lumps?

periareolar

What lumpectomy incision is ideal for peripheral lumps?

curvilinear

What are complications of a lumpectomy?

hematoma, infection, poor cosmesis, re-excision

What is a skin sparing mastectomy?

breast tissue, nipple and areola only removed

What is a nipple-sparing mastectomy?

option for early stage > 2cm away from nipple/areola

What are indications for a mastectomy?

advanced malignant tumors, Paget’s disease of the breast, multifocal or multicentric disease w/ chest wall involvement, inflammatory breast CA, hx lumpectomy w/ + margins, prophylactic for BRCA1, BRCA2, p53 carriers

What incision is used for a radical mastectomy?

elliptical

What are complications of a mastectomy?

seroma, hematoma, wound infection, skin flap breakdown or necrosis, lymphedema

What can be done intraoperatively to identify involved lymph nodes and help stage cancer?

lymphatic mapping and sentinel node biopsy

What nerve can be injured during axillary dissection resulting in weakening or paralysis of the serratus anterior mm?

long thoracic nerve → “winged” scapula, limited ability to lift arm above head, scapula “pops” out when pt pushes against resistance

Breast surgery can cause an obstruction of lymph flow. What are sx of the resulting lymphedema?

usually progresses distal → proximal, pigmentation changes, ulceration, fibrosis → thick rough skin

What is the secondary lymphedema?

from surgical removal of lymph nodes or from lymphatic destruction by radiation

What is the tx for lymphedema?

external pneumatic devices, elastic garments, exercise, diuretics, massage

What is the follow up protocol after tx of breast CA?

B/L mammograms 6 mos post completion of RT following lumpectomy; then yearly

C/L mammograms yearly after modified radical mastectomy

serial exams every 3-6 mos x 3 yrs, then annually

Which type of free flaps removes tissue from the lower abd to use for breast reconstruction?

Deep Inferior Epigastric Perforators (DIEP) -uses autologous tissue w/ perforators and blood vessels

Superficial Inferior Epigastric Artery (SIEA) -removes skin and fat

What are sx of fibroadenoma?

painless, unilateral, benign solid mass, highly mobile, firm-rubbery masses, typically shrink after menopause, MC 14-35 yo

What is the tx for fibroadenomas?

asx and small → observance and reassurance

lumpectomy or excisional biopsy, cryoablation

What are sx of phyllodes tumor?

unilateral, firm, enlarging, painless, may stretch overlying skin and show distension of veins, 1-45 cm, continuum benign → malignant, 40-50 yo

*high recurrence rate and metastatic potential

What are Phyllodes tumors linked to?

Li-Fraumeni syndrome

What is the workup for a Phyllodes tumor?

mammogram: round lobulated dense mass

US: hypoechoic, partially circumscribed mass w/ post enhancement, inc vacularity

MRI: lobulated mass w/ hyperintense fluid

What is the tx for Phyllodes tumor?

surgery → side local excision w/ > 1 cm margins

*large tumor = mastectomy

What is a Type 1 (sliding) hiatal hernia?

95% of cases; GEJ slides into the mediastinum; only significant when gastric acid is refluxed into the lower esophagus

What is a Type 2 (paraesophageal) hiatal hernia?

part of the stomach migrates into the mediastinum parallel to the esophagus; reflux is uncommon; fundus can become incarcerated

What is a type 3 (sliding & paraesophageal) hiatal hernia?

both GEJ and portion of the stomach have migrated into the mediastinum

What is a Type 4 hiatal hernia?

stomach and additional organs (bowel, spleen) herniate into the chest

What are RF for hiatal hernias?

elderly, elevated intra abdominal pressure, COPD, previous surgeries

How do hiatal hernias present?

typically present for GERD workup; heartburn is most common complaint; dysphagia, regurgitation

When is surgery indicated for hiatal hernias?

pts w/ severe esophageal injury, Barrett’s, persistent sx despite medical management, gastric volvus

What is Nissen fundoplication?

*for hiatal hernias

360 degree wrap of the fundus of the stomach to restore the LES/GEJ

What is Partial fundoplication (Dor and Toupet)?

*for hiatal hernias

anterior vs posterior wrap respectively

What is Hill repair?

*for hiatal hernias

restores GEJ w/ posterior anchoring to the median arcuate ligament

What is Belsey surgical method?

*for hiatal hernias

uses a thoracic approach

What test can detect moderate/severe esophagitis, strictures, hiatal hernias, and tumors?

Barium swallow

What is the gold standard for dx GERD?

24hr pH monitoring

What is the tx for Barrett’s esophagus?

radiofrequency ablation for low or high grade dysplasia; cryotherapy

When is surgery indicated for GERD?

failed medical management or wish to discontinue, underlying hiatal hernia

What are surgical options for GERD?

Laparoscopic Nissen fundoplication vs anterior approach; bariatric surgery

What are benefits of laparoscopic Nissen fundoplication?

85% of pts will have sx relief & healing of esophagitis, medical costs > costs w/in 10 yrs, pts may need to continue H2 blockers or PPI post op

What are complications of laparoscopic Nissen fundoplication?

secondary dysphagia, slipped wrap, recurrent heartburn, gastric distension, nausea → inability to tolerate PO

What are RF for squamous cell carcinoma?

smoking, alcohol consumption, diet low in fruits and vegetables, HPV

What are RF for adenocarcinoma?

Barrett’s esophagus, GERD, obesity, smoking

What are sx of esophageal CA?

dysphagia, anorexia, wt loss, odynophagia, constant mid-back or mic-chest pain, retrosternal discomfort, hoarseness

What workup needs to be done for esophageal CA?

barium swallow, CT/PET, endoscopic US (FNA suspicious lymph nodes)

What staging is used for esophageal CA?

TNM

What is the tx for esophageal CA?

chemo ± surgery (en bloc esophagectomy)

*< 20% 5 yr survival rate

What are sx of achalasia?

dysphagia and regurgitation of undigested food, CP, nocturnal cough, heartburn, wt loss