Surgery: General

What are the 9 layers of the abd? (superficial to deep)

skin → SQ tissue → superficial fascia → external obliques → internal obliques → transversus abdominis → transversalis fascia → preperitoneal fat → peritoneum

What is above/below the arcuate line?

above: rectus sheath runs posterior to rectus abdominis

below: no rectus sheath present

What are the two layers of the peritoneum?

Parietal: lines cavity wall

Visceral: lines the organs

What organs are within the intraperitoneal cavity?

stomach, SI, liver, gallbladder, tail of the pancreas, spleen, transverse colon

What covers the abdominal contents?

greater omentum

What connects the digestive organs?

mesentery

What organs are located in the retroperitoneal cavity?

SADPUCKER: suprarenal gland (adrenals), aorta & IVC, duodenum, pancreas, ureters, colon, kidneys, esophagus, rectum

What part of the GI tract makes up the foregut?

mouth to Ampulla of Vater

What part of the GI tract makes up the midgut?

Ampulla of Vater to proximal transverse colon

What part of the GI tract makes up the hindgut?

proximal transverse colon to the dentate line of the anal canal

What supplies blood to the abdomen?

Superior epigastric artery: central abd wall above the umbilicus

Inferior epigastric artery: abd wall below umbilicus

What branch of the aorta supplies the foregut?

Celiac artery

What branch of the aorta supplies the midgut?

Superior mesenteric artery

What branch of the aorta supplies the hindgut?

Inferior mesenteric artery

What are the branches of the celiac artery?

left gastric, common hepatic, splenic

What are the branches of the superior mesenteric artery?

Inferior pancreaticduodenal (head of pancreas, part of duodenum)

middle colic (proximal 2/3 transverse colon)

right colic (ascending colon)

ileocolic (ileum, appendix, cecum)

What does the Inferior mesenteric artery supply?

left third of the transverse colon, descending colon, sigmoid colon, rectum

What makes up the portal venous system?

superior mesenteric vein, inferior mesenteric vein, splenic vein

What are the indications for a laparotomy?

Emergent: acute/uncontrollable GI bleed, blunt/penetrating abd injury, bowel perforation

Elective: large organ resection or transplant

Where is the incision for a laparotomy usually done?

midline incision along linea alba

What is a laparotomy?

large incision made through abd wall to gain access to the peritoneal cavity

What is laparoscopic surgery?

minimally invasive surgery that involves insufflation of the abd and placement of ports/trocars to perform surgery

What are the benefits of laparoscopic surgery?

dec peri-op pain, wound healing time, ileus; faster recovery, shorter hospital stays, improved cosmesis

What is used to insufflate or expand the abd during laparoscopic surgery (pneumoperitoneum)?

CO2 (~4L)

What are the hemodynamic effects of a pneumoperitoneum seen during laparoscopic surgery?

dec venous return (preload) & CO, inc MAP, tachycardia or bradycardia, hypercarbia, mycoardial suppression, may induce arrhythmias, embolism (rare)

When are trocars placed in laparoscopic surgery?

after pneumoperitoneum is achieved

What is daVinci surgery?

robotic surgery

What procedures is the DaVinci surgical system designed to perform?

MV repair, bypass, colectomy, repair rectal prolapse, splenectomy, cholecystectomy, bowel resection, hysterectomy, oophorectomy, tumor resection, prostatectomy, nephrectomy

What are the 4 walls that border the inguinal canal?

anterior: external oblique aponeurosis

posterior: transversalis fascia

roof: internal olique and transversus abdominus

floor: inguinal ligament

What does the inguinal canal contain?

spermatic cord (M), round ligament (F), ilioinguinal nerve, genital branch of genitofemoral nerve

What type makes up the majority of abdominal hernias?

Inguinal hernias

*more common in males

What is a direct inguinal hernia?

passes directly through the transversalis fascia

What is an indirect inguinal hernia?

*MC groin hernia

passes through the internal inguinal ring

What is a pantaloon hernia?

both direct and indirect hernia simultaneously

Which hernia is more common in females?

Femoral hernia

What are the types of ventral hernias?

Incisional & umbilical

What causes a congenital inguinal hernia?

patent processus vaginalis

What are RF for an inguinal hernia?

smoking, obesity, heavy lifting, CTD

What makes up the Hesselbach’s triangle?

medial: rectus abdominis

inferior: inguinal ligament

lateral: inferior epigastric vessels

Which hernia travels through the internal inguinal ring lateral to the epigastric vessels?

indirect hernia

*may extend into the scrotum

Which hernia travels through the Hesselbach’s triangle medial to the inferior epigastric vessels?

direct hernia

Which hernia travels beneath the inguinal ligament down the femoral canal medial to the femoral vessels?

femoral hernia

*more common on the right

What are sx of an incarcerated hernia?

firm, painful, swollen, cannot be reduced (EMERGENCY)

What are sx of a strangulated hernia?

firm, painful, swollen, mass w/ overlying skin discoloration, presence of vascular compromise, ischemia (EMERGENCY)

What is the tx for hernias?

open repair (herniorrhaphy)

Which type of hernia repair is “tension free” because the posterior wall is not sutured but reinforced w/ mesh to cover the fasical defect and prevent recurrent hernias?

Lichtenstein repair

Which type of hernia repair is a mesh free approach that sutures the conjoined tendon to Cooper’s ligaments?

McVay repair

Which type of hernia repair is a 4 layer repair that creates upper and lower flaps that are overlapped w/ 2 layers of sutures and sutures the conjoined tendon to the inguinal ligament in overlapping layers?

Shouldice repair

Which type of hernia repair sutures the transversalis fascia and conjoined tendon to the inguinal ligament?

Bassini repair

Which type of hernia repair uses polypropylene plug shaped as a cone that is deployed into the internal ring after reduction of the hernia sac?

Plug-and-Patch repair

Which type of hernia repair sutures an anterior oval polypropylene mesh above the conjoined tendon and posterior mesh in the preperitoneal space using the overlay and underlay technique?

Prolene Hernia System (PHS) repair

What are the two types of laparoscopic hernia repair?

Transabdominal preperitoneal procedure (TAPP)

Total extraperitoneal procedure (TEP)

What are complications of inguinal hernia repairs?

vascular injury, injury to spermatic cord, nerve injury, injury to surrounding structures, seroma/hematoma, infection, pain

What inc risk of incisional hernia?

obesity, wound infection, smoking

What is a Spigelian hernia?

rare, >50 yo, occur at lateral edge of rectus at semilunar line, below level of umbilicus

What is an Obturator hernia?

passes thru obturator foramen btwn pectineus & obturator m.

*MC in females, elderly, right side

What is a Richter hernia?

rare, protrusion of the anti-mesenteric bowel

What is a Bochdalek diaphragmatic hernia?

defect in the posterolateral diaphragm

What is a Morgagni diaphragmatic hernia?

defect in the anterior retro-sternal diaphragm

What is a hiatal diaphragmatic hernia?

defect at the esophageal hiatus where part of the stomach herniates through

*paraesophageal vs sliding

What is an Amyand hernia?

appendix herniates

What is a Littre hernia?

Meckels diverticulum in an inguinal hernia

What is an Omphalocele?

rare congenital abd wall defect where abdominal contents protrude through the umbilicus covered by peritoneum

*assoc w/ Beckwith-Weidemann, Trisomy 13, 18, 21

What is the tx for an omphalocele?

surgical repair w/ closure of skin and fascia

What is Gastroschisis?

paraumbilical abd wall defect where bowel contents protrude through, no membranous covering

*rarely associated w/ genetic conditions

How is an Omphalocele or Gastroschisis detected?

detected on prenatal US, elevated AFP

What is the tx for Gastroschisis?

primary surgical repair vs delayed closure (requires use of silo bag to gradually reduce bowel back into abd)

What is diastasis recti?

wide linea alba that results in separation of rectus muscles, no fascial weakness or true defect. NO surgery necessary

What are non surgical causes of acute abdomen?

endocrine/metabolic abnormalities, hematologic (SS crisis), toxin

What are the features of acute abd?

immediate onset or progressively worsening pain, N/V/D, appears ill, mod/severe distress, abd VS

What is visceral pain?

vague, crampy, poorly localized, result of smooth muscle stretch or ischemia

What is parietal pain?

sharper, better localized, corresponds to the segmental nerve roots innervating the peritoneum

What is referred pain?

pain perceived at a site distant from the source of stimulus

What is needed for pre-op stabilization before acute abd pts can go to surgery?

ABCs, obtain IV, most need Abx, foley cath, bowel obstruction → NG tube, type and cross if needed

What is an acute peptic ulcer?

blood supply is compromised as ulcer erodes into muscles of stomach or duodenal wall → hemorrhage, perforation, peritonitis

What is the workup for an acute peptic ulcer?

CT w/ contrast, US if suspicious for free air

What is the surgical tx for an acute peptic ulcer?

Billroth procedure: gastric resection (part of stomach is removed and reconnected to intestine)

*I = gastrodudodenal

*II = gastrojejunal

What is pneumoperitoneum?

free air w/in abd cavity d/t trauma, neoplasm, perforation of an abd viscus (MCC = perforated ulcer)

What workup is needed for a pneumoperitoneum?

AP/upright abd XR: free air under diaphragm

STAT CT w/ contrast

What is the tx for a pneumoperitoneum?

emergent surgery (typically exploratory laparotomy)

What causes a majority of acute pancreatitis cases?

alcoholism and gallstone disease

What workup is needed for acute pancreatitis?

amylase, lipase, triglycerides, CT w/ contrast, APACHE II score for critically ill

What is the Ranson criteria?

assess mortality risk for acute pancreatitis based on # of criteria present at admission/during first 48 hrs

*7-11 = 100%

What is the tx for acute pancreatitis?

fluids, NSAIDs, surgery for severe cases w/ complications (abx, drainage of abscesses or cysts)

*comp: hemorrhage

What is the MC reason for urgent abd surgery?

acute appendicitis

What workup is needed for acute appendicitis?

peds: US appendix

adults: CT

What is the tx for acute appendicitis?

NPO, IVF, pain control, abs, laparoscopic appendectomy (may need open)

What is volvulus?

rotation of a segment of the colon causing a loop of bowel to twist around itself causing an obstruction

*sigmoid & cecum MC sites

What are sx of volvulus?

abd distension, pain, obstipation, vomiting, constipation, bloody stool, tachypnea, high pitched tinkling bowel sounds

What workup is needed for volvulus?

abd XR: coffee or kidney bean sign

contrast enema: birds beak (spot of rotation)

upper GI series, labs

What is the tx for volvulus?

NPO, IVFs

sigmoid: rectal tube for decompression, Surg - Hartmann procedure (proctosigmoidectomy w/o anastomosis & temp colostomy)

cecum: Surg- right hemicolectomy w/ ileocolic anastomosis

What is the most frequently injured organ in blunt abd trauma?

Spleen

What are sx of a splenic rupture?

hx of blunt trauma, seatbelt sign, pain, Kehr sign, hypovolemic shock, LUQ tenderness, lower rib fx

What workup is needed for splenic rupture?

US visualize free fluid

STAT CT: mainstay (grade 1-5)

What is the tx for a splenic rupture?

hemodynamically stable: close monitoring

unstable: exploratory laparotomy for splenic repair or splenectomy

*try to preserve > 50% of spleen

What are complications of splenic rupture?

Asplenia: inc risk of bacteremia, children > adults

Overwhelming post-splenectomy sepsis (OPSS): risk is highest 1st yr post-op, septic shock, DIC

What must be given to all asplenic pts post-splenectomy?

vaccinations: Pneumovax, H. influenza, N. meningitidis

Chandelier sign:

PID

Charcot’s sign:

choledocholithiasis

Courvoisier’s sign:

periampullary tumor