Abdominal Procedures

Question 1

Layers to get to the abdomen

Answer 1

1. Skin
2. SQ fat
3. Camper’s Fascia
4. Scarpa’s Fascia
5. Abdominal Wall Fascia
6. Pre-peritoneal Fat
7. Peritoneum

Question 2

Types of Incision used is dependent on?

Answer 2

Maximum exposure and location of patholog

Question 3

What types of incisions are there?

Answer 3

1. Midline (incision of indecision)
2. Kocher incision
3. Pfannelstiel
4. Clam Shell
5. Chevron
6. McBurney Incision
7. Paramedian

Question 4

If the pt has had a prior sx, what is important to take into account when choosing an incision?

Answer 4

1. Danger of adhesive dz
2. Possible bowel injury
3. Devascularizing skin (paramedian/midline)

Question 5

Define Extensile Exposure

Answer 5

Basically, you can start with a smaller incision that can become another one.
Ex. Midline can continue to a midline sternotomy, or the Kocher and be extended to a clam shell.

Question 6

This is a type of abdominal surgery that accesses the abdomen with small incisions and can insufflate the intraperitoneal cavity with CO2. They use a camera and specialized equipment for this.

Answer 6

Laparoscopy

Question 7

What are the advantages of a laparoscopy sx?

Answer 7

1. Minimal Access (Less scarring)
2. Decreased Pain
3. Shorter Hospitalization
4. Better Anatomic Visualization

Question 8

Disadvantages of a laparoscopy sx?

Answer 8

1. Carries same risks as open sx plussss gas embolism and pneumothorax
2. May require conversion to open sx
3. Poor visualization
4. No tactile sense

Question 9

CI for Laparoscopy?

Answer 9

1. Inability to withstand general anesthesia
2. Hypovolemic Shock
3. Heart Failure, Severe COPD cannot tolerate
4. Pneumoperitoneum
5. Intractable bleeding disorders
6. End stage Liver Dz

Question 10

Cholelithiasis Facts!

Answer 10

1. Present in 12% of Americans
2. 5 F’s
3. Most are asymptomatic (doesn’t indicate sx)
4. 70-80% of gall stones are cholesterol stones

Question 11

Biliary Colic

Answer 11

1. Symptomatic Gallstones
2. Impaction of gallstone at the GB neck
3. Intermittent RUQ pain-post prandially
4. +/- NV

**Indication for elective cholecystectomy

Question 12

Cholecystitis

Answer 12

1. Gall stone obstructing cystic duct causing inflammation and wall distention
2. Persistent RUQ pain, NV, Loss of Appetite
3. Gallstone on US
4. Murphy’s Sign
5. Wall thickening
6. Pericholecystic fluid with or without fever, WBC, elevated LFTs

**Indication for cholecystectomy

Question 13

Choledocoholithiasis

Answer 13

1. Obstructive Jaundice – GGT, Alk Phos, Total/Direct Bilirubin elevation
2. Intermittent RUQ pain
3. May resolve spontaneously, may require stone removal via ERCP or Sx

*** Patient should undergo elective cholecystectomy during the same hospitalization

Question 14

5 F’s

Answer 14

1. Fat (overweight)
2. Forty (age near or above 40)
3. Female
4. Fertile (premenopausal- increased estrogen is thought to increase cholesterol levels in bile and decrease gallbladder contractions)
5. Fair (gallstones more common in Caucasians)

Question 15

Ascending Cholangitis

Answer 15

1. Obstruction with bacterial stasis and inflammation
2. Charcot’s Triad (Fever, Jaundice, RUQ Pain)
3. Reynauld’s Pentad (Fever, Jaundice, RUQ Pain, Shock, Mental Status Change)
4. MEDICAL/SURGICAL EMERGENCY
5. Emergent fluids, foley catheter, abx, ICU admission
6. Endoscopic decompression

*If that fails, then sx extraction of stone, t-tube drainage of biliary system

Question 16

Biliary Pancreatitis

Answer 16

1. Occurs primarily in acute obstruction
2. Most often secondary to gallstones, but can be due to malignancy
3. Epigastric pain radiating to back, vomiting, elevated amylase/lipase
4. Initial medical management (NPO, IVF, NGT, Pain Control)
5. Stone extraction - ERCP
6. Cholecystectomy during same hospitalization once enzymes normalize

Question 17

DDx for RLQ Pain

Answer 17

1. Colitis
2. Diverticulitis
3. Inguinal Hernia
4. UTI
5. Pyelonephritis
6. Ureteral Calculus
7. PID
8. Ectopic Preggo
9. Mesenteric Adenitis
10. APPENDICITIS

Question 18

Acute Appendicitis

Answer 18

1. NV, Anorexia
2. Pain starting centrally, moving to RLQ
3. Localizes at McBurney’s Point
4. Fever, mildly increased WBCs
5. CBC, UA, Pelvic/Rectal Exams
6. CT often performed but rarely necessary
7. Appendectomy – usually lap

Question 19

Perforated Appendicitis

Answer 19

1. Waxing/Waning course with sudden recovery
2. Re-emergence of symptoms/fever
3. CT scan for Dx, percutaneous drainage
4. At 6 weeks (1/ interval) appendectomy is performed

Question 20

Open Sx Appendectomy

Answer 20

1. McBurney/Lanz/Rocky Davis Incision
2. Identify the cecum
3. Deliver the appendix into the wound
4. Control mesoappendix, divide appendix control base - purse string suture

***Higher rate of local wound infection

Question 21

Laparoscopic Appendectomy

Answer 21

1. 3 ports (5 mm umbilicus, 5mm suprapubic, 10 mm LLQ)
2. Identify appendix separate from cecum
3. Lap Stapler to divis appendix and mesoappendix

***Higher rate of pelvic abscess

Question 22

DDx for LLQ Pain

Answer 22

1. Colitis
2. Appendicitis
3. Inguinal Hernia
4. UTI
5. Pyelonephriti
6. Ureteral Calculus
7. PID
8. Ectopic Preggo
9. DIVERTICULITIS

Question 23

Wth is the diverticula? Really doe?

Answer 23

Outpouching of weakened colon at site of vascular perforation. Typically the left (sigmoid) colon.

Commonly seen in older adults, but becoming more common in the young. When obstruction occurs, bacterial overgrowth can happen.

Question 24

So wth is diverticulitis then?

Answer 24

1. Presents with abdominal pain, bright red blood per rectum, fever, elevated WBC
2. May form contained abscess amenable to CT drainage which may or may not be followed by operation
3. May require urgent operation (sigmoid colectomy-Hartmann’s procedure)

Question 25

Crohn's Dz (Inflamm Bowel Dz)

Answer 25

1. May affect mouth to anus, but usually spares rectum 2. Presents with diarrhea, usually not bloody 3. Transmural inflamm dz with cobblestoning and ulcers 4. Dx with colonoscopy 5. Inc risk of cancer 6. Management is Medical (Anti inflamma, steroids) 7. Surgical management only for bowel obstruction unresponsive to med management or if perforated

Question 26

Ulcerative Colitis (Inflamm Bowel Dz)

Answer 26

1. Colonic Inflammation, involves rectum 2. Presents with diarrhea and red blood per rectum 3. Friable mucosal dz with pseudo polyps 4. Dx by colonoscopy with bx 5. Inc risk of cancer 6. Management is Surgical (total proctocolectomy with end ileostomy of ileal J-pouch)

Question 27

When are ileostomies/colostomies used?

Answer 27

In situations where anastomosis between segments of bowel is no feasible or is unsafe, such as 1. Contamination (trauma/perforation) 2. Concern regarding blood supply 3. Grossly dilated bowel (toxic megacolon, bowel obstruction) 4. When further operations on a segment of bowel are planned (imperforate anus)

Question 28

Post-op concerns of ileostomy or colostomy placement

Answer 28

- Ileostomy -- Fluid loss, inability to absorb B12, Vit ADEK - Colostomy -- Loss of capacity to reabsory -Both: Skin irritation, prolapse, parastomal hernia

Question 29

Closing the Abdomen

Answer 29

1. Count! Lap pads, instruments, malleable 2. Visual inspection 3. Tactile 4 quad search 4. Ensure good paralysis 5. Inform anesthetic team 6. ICU/Resp Therapy/Transport

Question 30

What sutures do you use for a Facial Closure?

Answer 30

1. Running Suture | 2. Interrupted suture

Question 31

What do you do for a Skin Closure?

Answer 31

1. None 2. Stapled 3. Suture (Interrupted, Running, Subcuticular)

Question 32

What are retention sutures, and can they be used internally, externally, or both?

Answer 32

Retention sutures - help! | Can be used in both situations

Question 33

What are other options in closing the abdomen?

Answer 33

1. Secure Drains 2. Ostomy Appliance 3. Abdominal Binder