Surgery E2 random questions pt 2

What are the 9 layers of the abdominal wall?**

1. skin

2. subcutaneous tissue

3. superficial fascia

4. external oblique

5. internal oblique

6. transversus abdominis

7. transversalis fascia

8. preperitoneal adipose

9. peritoneum

what are the 3 main branches of the aorta that supply the GI tract organs?**

1. celiac a. → supplies foregut

2. superior mesenteric a. → supplies midgut

3. inferior mesenteric a. → supplies hindgut

What is the MC type of hernia?

inguinal

which structures form Hesselbach's triangle?***

Medial → rectus abdominus

lateral → inferior epigastric

inferior → inguinal ligament

what structures lay in the inguinal canal?***

male → spermatic cord

female → round ligament of uterus

damage to which nerve could result in persistent testicular pain?

ilioinguinal nerve**

what is the difference between direct and indirect inguinal hernias?***

indirect = through internal inguinal ring

direct = through transversalis fascia in hasselbach's triangle

which open hernia repair (herniorrhaphy) is tension-free?***

lichtenstein →no sutures or mesh

which hernias require emergent surgery?

incarcerated and strangulated

strangulated is more emergent

what are the types of ventral hernias?***

1. umbilical →common in kids

2. incisional →MC in obese/infection/smokers

3. spigelian →lateral edge of rectus muscle

4. obturator →passes through obturator foramen and muscles (elderly female)

which laparoscopic hernia repair approach is used for bilateral, large, and recurring hernias?**

transabdominal preperitoneal procedure (TAPP)

omphalocele or gastroschisis: covered by membrane?

omphalocele

gastroschisis is NOT covered

what is the procedure to treat acute peptic ulcer disease?

billroth procedure

which arteries are involved in acute peptic ulcer disease?***

gastric ulcer → erodes gastric and splenic vessels

duodenal ulcer → erodes gastroduodenal artery

what is the MCC of pneumoperitoneum?

perforated ulcer

pneumoperitoneum = free air in diaphragm

what criteria is used to evaluation pancreatitis?

ranson criteria

what is the MCC of SBO?***

adhesions from surgery

what are the complications of laparoscopic appendectomy?***

- post op infection

- intraabd abscess

- recurrence if remnants remain

if a child <3 has bilious emesis and abd distention, it is __________ until proven otherwise?

volvulus → r/o with stat upper GI series

which dx shows up as coffee/kidney bean on abd XR and birds beak on contrast enema***

volvulus

what is the surgical management of volvulus?***

sigmoid = proctosigmoidectomy w/o anastomosis and temporary colostomy (Hartmanns)

cecum - right hemicolectomy with ileocolic anastomosis

which organ is most frequently injured in blunt abd trauma?

spleen

what is the mainstay for eval of splenic rupture?

stat CT abd pelvis

what are the clinical features of splenic rupture?

seatbelt and kehr sign

hypovolemic shock and LUQ tenderness

lower rib fx

which vaccines should be given after splenectomy?***

pnuemovax

h. influenza

meningiditis

what is the TOC for hemodynamically stable pt with splenic rupture?

non-op management and monitoring***

what is the gold standard for choledocholithiasis?***

ERCP

how do you eval for pancreatic cancer?***

- inc. alk phosphatase

- inc. direct bilirubin

- CT abd

- ERCP→ determines obstruction, can do bx at same time

which dx shows string of pearls air fluid levels on abd XR?***

SBO → also see thickened dilated loops of bowel "stack of coins"

what are the clinical features of pancreatic cancer?***

- courvosier's sign→ jaundice and poalpable nontender GB

- cullen's sign

- obstructive jaundice

- weight loss and deep abd pain

- pruritis with jaundice

what is the treatment for pancreatic cancer?***

whipple → for pancreatic HEAD

distal pancreatectomy with splenectomy for tumors in tail/body → these tumors are usually fatal :(

can't do whipple if cancer involves hepatic artery

what is the MC congenital abnormality of the small intestine?**

meckel's diverticulum → MCC of GI bleeding in children

painless rectal bleeding

what is the most sensitive eval for meckel's diverticulum?

Meckel radionuclide scan (Tch-99)

what is the tx for Meckel's diverticulum?***

Meckel's diverticulectomy

which IBD is transmural and has cobblestone appearance and skip lesions?

crohns

which IBD is friable and restricted to the mucosa and submucosa?

UC →microabscess in crypts of lieberkuhn → procedure of choice is proctocolectomy with ileal pouch anal anastomosis (IPAA)

what is the procedure of choice for UC?

proctolectomy with ileal pouch anal anastomosis

what is the tx for thrombosed hemorrhoids?

hemorrhoidectomy

what is the tx for internal incarcerated hemorrhoids?

immediate hemorrhoidectomy**

which type of hemorrhoid is above the dentate line?**

internal → painLESS

which hemorrhoids tend to thrombose?

external → painFUL

below dentate line***

what are the different classes of hemorrhoids?***

1 = no protrusion

2 = reduces spontaneously

3 = manual reduction necessary

4 = incarcerated→ need hemorrhoidectomy

what is the diff between perirectal and perianal abscesses?

perirectal → inflam of subQ tissue from obstructed crypt gland

perianal → inflam of superficial tissue

tx both with I&D :)

what is the indication for bariatric surgery?***

- BMI >40 or >35 with comorbidity

- unsuccessful weight loss

- mental health clearance

which type of hiatal hernia involves upward displacement of the GEJ causing the GE junction, LES, and part of the stomach to slide into the mediastinum?**

type 1 sliding →MC type

which type of hiatal hernia involves migration of part of the stomach into the mediastinum parallel to the esophagus?**

type 2 paraesophageal → part of the fundus herniates adjacent to the esophagus

which type of hiatal hernia involves both GEJ and part of the stomach migrating into the mediastinum?**

type 3 (both sliding and paraesophageal)

in which type of hiatal hernia do the stomach and other organs herniate into the chest?

type 4

what is the MC complaint of pts with hiatal hernia?

heartburn

what are the surgical options for tx of hiatal hernias?

1. Nissen fundoplication (360)

2. partial fundoplication

3. hill repair

4. belsey

what are the surgical options for GERD?

Nissen fundoplication →360 degree wrap

partial fundoplication (dor and toupet)

what is the gold standard procedure for GERD?

laparoscopic nissen fundoplication

what is a common complication of thyroid surgery?

recurrent laryngeal nerve injury*

injury of which nerve results in paralysis of ipsilateral vocal cord leading to hoarseness and weak voice?

recurrent laryngeal nerve

bilateral injury = speech loss and loss of airway control :(

barret's esophagus is a complication of which dx?

GERD

what are the risk factors for squamous cell esophageal cancer?

smoking, alcohol, poor diet

what are the risk factors for adenocarcinoma of the esophagus?

barretts, GERD, obesity, smoking

what is the TOC for esophageal cancer?***

chemo followed by *En Bloc esophagectomy* → requires J-tube for life after surgery

chagas dz is an etiology for which dx?

achalasia ***→failure of LES to relax

dysphagia

regurg of UNDIGESTED food

chest pain

heartburn

what is the gold standard for dx of achalasia?

esophageal manometry**

what does barium swallow in achalasia look like?***

birds beak

what is the first line tx for achalasia?

CCBs and PDEIs

what is the surgical management for achalasia?***

laparoscopic heller myotomy with partial fundoplication (to prevent GERD)

what is a Zenker's diverticulum?

diverticulum in the hypopharynx d/t dysfunction of the cricopharyngeal muscle in Killian's triangle

how would you manage diverticulitis with a large abscess or perforation?***

large abscess → IR drainage

perf/free air→ hartmann procedure

what is the diff between boerhaave's and mallory weiss tear?

boerhaaves = complete perofation

mallory weiss tear = longitudial tear

tx both w stent palcement, debridement/drainage

what are the risk factors for thyroid nodules?**

- increasing age

- female

- iron deficiency

- hx of thyroid radiation

what is the MC type of thyroid cancer?*

Papillary carcinoma → good prognosis

assoc. with radiation exposure

which type of thyroid cancer has the worst prognosis?*

anaplastic

which type of thyroid cancer is seen as part of MEN 2A or 2B?

medullary thyroid → autosomal dominant inheritance

what is the classification system for thyroid nodules?

bethesda

3/4 = FNA q 6-12 months or scan

5/6 = surgery for sure

what are the labs for primary hyperparathyroidism?**

excess PTH → inc. Ca++ and dec. PO4

what are the labs for secondary hyperparathyroidism?**

seen w renal dz or vit D deficiency → inc. PO4, dec Ca+, PTH stimulation

what are the labs for hyperthyroidism?*

Low TSH, high T3 and T4

opposite for hypo

what sx is commonly seen with pituitary adenoma?***

bilateral hemianopsia

other sx depend on the hormone secreted

what is the medical management of prolactinoma?

cabergoline or bromocriptine

what is the surgery management for pituitary adenomas?***

transsphenoidal resection → indicated for MACROadenomas (>10mm)

what are the post op complications of parathyroidectomy?***

- perioral numbness/paresthesia

- carpopedal spasm

- seizures

- Chvosteck's sign →tap on facial nerve

what will pts s/p parathyroidectomy need to supplement?***

calcium

what med will pts s/p thyroidectomy need to be on for life?***

levothyroxine