Exam 2 study guide

Question 1

1) What is the most common type of hernia in males & females (R>L)? Explain
2) What causes most cases?

Answer 1

1) Intra-abdominal contents protrude at internal inguinal ring
-Lateral to inferior epigastric vessels
2) Congenital

Question 2

Direct inguinal hernia:
1) What is it?
2) What makes up the boundaries of this area?
3) What causes it?

Answer 2

1) Intra-abdominal contents protrude through Hesselbach’s triangle
2) Inferior: inguinal ligament
Lateral: inferior epigastric vessels
Medial: rectus abdominis
3) Weakness/defect in the transversalis fascia (floor of the triangle)

Question 3

1) What is the Tx for hernias in adults?
2) What if minimally or asymptomatic?

Answer 3

1) Hernias do not regress in adults & usually eventually require surgical repair
2) Observation, esp if: Elderly, sedentary patients
-Patients with high morbidity for operation
-Pregnant females

Question 4

How do you Tx the following hernia scenarios?:
1) Symptomatic
2) Acutely incarcerated
3) Chronically incarcerated

Answer 4

1) Req elective surgical repair (if pt can tolerate surgery)
2) May require urgent or emergent surgery (usually laparoscopic)
3) 1st attempt nonoperative reduction but will need surgical repair eventually
Repair may be deferred/delayed if mass reduces & no strangulation

Question 5

1) How do you Tx strangulated hernias?
2) What may be req during hernia surgery to eval for intestinal viability?

Answer 5

1) IVF, broad-spectrum IV abx, +/- NGT, consult surgery for emergent repair
2) Abdominal exploration (laparoscopy)

Question 6

1) What is the goal of surgical hernia Tx?
2) When should you use open vs laparoscopic surgery?

Answer 6

1) Goal is to restore structures to previous anatomic position & minimize recurrence
2) Open: can be with local anesthesia, tissue repair can be repaired, best for recurrent hernia after laparoscopic or hernias after surgery
Lap: bilat hernias, recurrent hernia after open hernia

Question 7

Hernia Tx:
1) Outpt or inpt?
2) What type of anesthesia?
3) What should you do for direct hernias?
4) When should pts return to work?

Answer 7

1) Usually outpatient procedure
2) General, spinal, or local anesthesia; local is adequate for most patients (open)
-General or spinal for recurrent hernias bc Local does not readily diffuse scar tissue
3) Look for indirect and cord lipomas
4) Sedentary: few days
Heavy laborer: up to 4-6weeks

Question 8

Differentiate Bassini repair and Shouldice repair

Answer 8

1) Traditional autologous tissue repair method
5-20% recurrence
2) 0.6% recurrence
Not widely used outside of specialty surgery centers (more extensive dissection required)

Question 9

1) What is POC for femoral hernias?
2) Descr Lichtenstein repair

Answer 9

1) McVay (Cooper’s ligament) repair: POC for femoral hernias
2) Tension-free mesh repair allowing for early return to activities
Low complication and recurrence rates
Best and MC open repair

Question 10

Descr the basic steps of open hernia repair

Answer 10

Skin incision
Dissection through skin, SQ fat, Camper’s & Scarpa’s fascia to external oblique aponeurosis
Below inguinal ligament medially, the deep fascia of thigh opened to expose femoral canal & check for concomitant femoral hernia
Safeguard ilioinguinal nerve (lying under aponeurosis) and other nerves and vessels
Indirect hernia exposed, separated from cord by dividing cremaster muscle
Mesh placed on floor of inguinal canal
Contents replaced into peritoneal cavity
Inguinal canal floor repaired (direct hernia)

Question 11

1) When is laparoscopic repair preferred?
2) List the 3 methods of laparoscopic repair

Answer 11

1) Bilateral & recurrent hernias
Less postop pain, fewer postop activity restrictions, earlier return to work
2) ALL use mesh:
Transabdominal Preperitoneal (TAPP) repair
Total Extraperitoneal (TEP) repair
Intraperitoneal Onlay Mesh (IPOM) repair

Question 12

What are the basic steps of laparoscopic hernia repair?

Answer 12

Entry into peritoneal cavity or preperitoneal space: camera & instruments ports
TAPP into intraperitoneal space
TEP into preperitoneal space
Access to hernia location
Indirect hernias mobilized & dissected away from cord structures
Direct hernias isolated from transversalis fascia
Mesh placement to reinforce pelvic floor (in preperitoneal space)
Re-secure peritoneal flap (in TAPP repair only)

Question 13

Descr high risk features/ PE of acute abd

Answer 13

1) Pain characteristics: sudden onset, maximal at onset, pain then vomiting, constant pain <2 days in duration
2) Tense or rigid abdomen, involuntary guarding, signs of shock
>65yo, immunocompromised, alcoholism, CVD, major comorbidities, prior surgeries or recent GI instrumentation, early pregnancy

Question 14

Concerns for life-threatening causes of abdominal pain on H&P incl?

Answer 14

Unstable vital signs
Signs of peritonitis on exam
Concern that pain is due to life-threatening condition
Concern for infection on initial exam

Question 15

Descr potential character of acut abd pain

Answer 15

Sharp, superficial, constant pain due to peritoneal irritation: typical of perforated ulcer or a ruptured appendix, ovarian cyst, or ectopic pregnancy)
Pain out of proportion: raise concern for mesenteric ischemia

Question 16

What are some indications for urgent operation of acute abd?

Answer 16

Guardian or rigidity
Increasing severe localized tenderness
Tense or progressive distention
Tender abd or rectal mass w. High fever or hypotension
Rectal bleeding w/ shock or acidosis
Abd findings & septicemia (high fever, rising leuks, AMS, glucose intolerance in DM pt)
Bleeding (unexplained shock, falling hct)
Suspected ischemia (acidosis, fever, tachycardia)
Deterioration on conservative tx

Question 17

What are some radiologic findings that may indicate urgent surgery for acute abd?

Answer 17

Pneumoperitoneum
Gross or progressive bowel distension
Free extravasation of contrast media
Space-occupying lesion on scan + fever
Mesenteric occlusion of angiography

Question 18

What are 2 ways to surgically consult for acute abd?

Answer 18

Laparotomy (ex lap)
Laparoscopy

Question 19

Acute cholecystitis:
1) What is it?
2) Dx?

Answer 19

1) Persistent obstruction of bile flow from gallbladder (calculous)
Also in very ill pts or pts on TPN with biliary stasis (acalculous)
2) RUQ U/S (first test of choice; may be only test required)
then HIDA if more information required

Question 20

Acute cholecystitis :
1) Definitive Tx?
2) Mainstays of therapy?
3) Timing & approach to biliary decompression depends on

Answer 20

1) Laparoscopic cholecystectomy within 24-72 hours of admission for most pts with symptoms + supportive care
2) IVF, abx, biliary decompression
3) Establishing diagnosis
Length of disease at presentation
Pt’s pre-existing health to undergo surgery

Question 21

Acute cholecystitis: What are the 3 main Tx options?

Answer 21

Urgent laparoscopic cholecystectomy
Percutaneous cholecystostomy (if pt not good surgical candidate)
Abx +/- Interval cholecystectomy

Question 22

What is a complication of acute cholecystitis?

Answer 22

Persistent cystic duct obstruction may lead to perforation or necrosis
Life-threatening surgical emergency

Question 23

Umbilical hernia:
1) What is it?
2) Tx?

Answer 23

1) Protrusion of intra-abdominal contents through umbilical ring
Mostly omentum or peritoneal fat but possibly bowel
Steadily increases in size over time
2) Surgical repair (elective OR emergent if bowel involvement):
Contents reduced or excised
Open recommended
Mesh to reinforce repair
Deferred until >4yo in kids

Question 24

Hepatic hemangioma:
1) What is it?
2) Cause?
3) S/Sxs?

Answer 24

1) MC benign hepatic tumor
Mass of blood vessel cells
2) Thought to be congenital vascular malformations
3) Most small, solitary & asymptomatic
Abdominal pain or discomfort possible with lesions >10 cm

Question 25

Hepatic hemangioma: 1) Dx? 2) Tx?

Answer 25

1) Freq incidental CT or MRI finding 2) Majority should be managed with observation (no surgery) significant symptoms or rare bleeding -> -Surgical tx >enucleation (MC): remove hemangioma w/out any removal of normal hepatic parenchyma or resection (lobectomy)

Question 26

Descr Post op incision care

Answer 26

1) Controlling bacterial contamination Debridement: Wound base preparation (bleeding, irrigation, surgical, enzymatic, biologic) May require serial debridement Drainage of purulence Frequent dressing changes wet to dry dressing- put on moist dressing, it drys & then remove it (can result in debridement in wound when removed) 2) Maintaining appropriate amount of moisture 3) Treating edema 4) Preventing further injury

Question 27

Obturator hernias: 1) What are they? 2) Pt? 3) S/Sxs? 4) Tx?

Answer 27

1) Defects through obturator canal 2) MC in elderly females 3) Howship-Romberg sign: pain down medial thigh with internal rotation of knee Crampy abdominal pain, symptoms of SBO Mass may be palpated on vaginal and/or rectal exam 4) Repaired surgically via transabdominal approach (high mortality rate)

Question 28

Femoral hernias: 1) What are they? 2) Pt? 3) Tx?

Answer 28

1) Acquired protrusion of intra-abdominal contents through femoral ring small empty space between the lacunar ligament medially and the femoral vein laterally 2) F>M 3) McVay (Cooper’s ligament) repair: POC

Question 29

Differentiate hypertrophic scars and keloids

Answer 29

1) Hypertrophic scar: remain in boundaries, regress spontaneously, rarely recur after surgical excision Excessive fibrotic tissue production MC in darker skin pts 2) Keloid: extend beyond boundaries, continue growth, commonly recur after excision, present minimum 1 yr (familial predisposition) Excessive fibrotic tissue production Also MC in darker skin pts

Question 30

Hemostasis: What is it? What occurs?

Answer 30

Not a phase, just the first step Platelet aggregation + Vasoconstriction initially Clot stabilization occurs within 10 minutes of injury

Question 31

Descr the Inflammatory phase (Days 0-4) after injury

Answer 31

-Vasodilation: Inflammatory cells to wound site -Edema, erythema, inflammation, pain -Neutrophils enable phagocytosis and allow for decontamination of wound

Question 32

Descr the Proliferative phase (weeks to months) after injury

Answer 32

Fibroblast migration (very active) Granulation tissue formation Neovascularization: angiogenesis & vasculogenesis Re-epithelialization (replace of damaged/loss epithelial tissue) ECM production Collagen production (gives the wound its strength) Wound contraction (decreases time of wound closure & reduces size of scar)

Question 33

Descr the Remodeling (maturation) phase (months to years) that happens once wound is closed

Answer 33

-Reorganizes collagen & increases cross-linking -Strength increases quickly over first 6-8 weeks -Force required to break a wound regardless of its dimension: (never goes to 100% strength) 3% at 1 week 20% at 3 weeks Peaks at 80% of its uninjured counterpart by 3 months

Question 34

Differentiate b/t the 2 main categories of wounds

Answer 34

Acute: normal physiology Chronic: impaired physiology (pressure ulcers, diabetic foot ulcers, gangrene, etc.)

Question 35

Differentiate b/t the 3 main intentions

Answer 35

1) Primary intention (staples, sutures) 2) Secondary intention (wound purposely left open, which will heal on its own, may have wound vac but no sutures or anything else) -Especially used if wounds are contaminated 3) Tertiary intention (aka, delayed primary closure/DPC) -Wound left open x 5 days, then closed like primary intention

Question 36

Most important factor in determining whether to close a wound is?

Answer 36

the level of contamination

Question 37

What are some potential complications of hernias/ repair?

Answer 37

Recurrence varies based on technique and surgeon experience -Mesh < tissue -Multiple causes (ie, tension, obesity) Seromas and hematomas common Testicular atrophy Neuralgia

Question 38

What are some potential complications of laparoscopic hernia repair?

Answer 38

Injury to surrounding structures during port placement Port site hernia Gas embolism Bowel obstruction secondary to adhesions

Question 39

Spigelian hernia: 1) What is it? 2) Tx?

Answer 39

1) Protrusion of intra-abdominal contents through weakness in lateral border of the rectus sheath (linea semilunaris) 2) Surgical repair recommended due to high likelihood of incarceration or strangulation Recommend laparoscope/robotic repair Repair with mesh

Question 40

Diastasis recti: 1) What is it? Main cause? 2) S/Sxs? 3) Tx?

Answer 40

1) 2 rectus muscles are separated by an abnormal distance (>2 cm) Does NOT represent abdominal wall hernia (no fascial defect) Common in pregnancy 2) Obvious midline bulge on exam 3) 1st line: weight loss, core-strengthening exercises 2nd line: abdominoplasty with rectus abdominis plication w/ or w/out mesh (rare)

Question 41

Descr the role of Wound vac/ neg pressure wound therapy

Answer 41

Reduces edema Stimulates circulation Increases rate of granulation tissue formation Used on open (primarily) and even closed wounds including pressure ulcers & diabetic wounds

Question 42

Hepatic resection: 1) MC indications? 2) Other indications? 3) Explain this surgery

Answer 42

1) Primary & secondary malignant tumors and symptomatic benign tumors 2) Traumatic injury, infection/abscess, & liver donor transplantation 3) 75-80% removal -> expected that the remnant will regenerate (only if normal hepatic function)(& starts within 24hrs of surgery) Major hepatic resection defined as 3 or more segments

Question 43

Pre-op hepatic resection: 1) Relative contraindication? 2) What is risk factor for liver failure following major hepatic resection? 3) Explain Child-Pugh classification 4) Explain MELD score

Answer 43

1) Cirrhosis for partial hepatectomy (bc remaining cirrhotic liver won’t be able to regenerate like it’s supposed to) 2) Severe steatohepatitis 3) Ascites, encephalopathy, albumin, total bilirubin, prothrombin time Predicts mortality after hepatic resection in pts with cirrhosis 4) Bilirubin, Sr sodium, INR, Sr creatinine, dialysis Assesses liver function in pts undergoing resection (can also see who is higher risk & who should get transplant first)

Question 44

Descr preop before hepatic resection

Answer 44

Close monitoring for several post-op days Hemorrhage is the major concern in immediate post-op period Most pts without cirrhosis ready for discharge by POD 7 or 8 Increases in: Sr bilirubin, PT, ALT & AST Alkaline phosphatase initially normal then increases Sr albumin usually falls Some patients develop ascites Hypoglycemia NOT usually a problem

Question 45

What are some complications of hepatic resection?

Answer 45

1) Occur in up to 40% pts (most resolve without sequelae) 2) Liver-related (most frequent): perihepatic fluid collections (biloma), relative hepatic insufficiency, hepatic failure 3) Pulmonary: symptomatic pleural effusions or atelectasis, pneumonia (infrequent)

Question 46

Cirrhosis: 1) MC Tx? 2) Descr the role of surgery

Answer 46

1) Most frequently managed medically (underlying causes & complications) 2) Liver transplantation: -For complications of portal hypertension: tx of bleeding/non-bleeding varices & ascites -For diseases unrelated to underlying liver disease (cholecystitis, perforated viscus, abdominal wall hernias) -Severity of liver disease estimated by Child’s class or MELD score to quantify surgical risk -Consider preoperative eval for liver transplant prior to elective procedures (don’t want elective procedures to push them over the limit & negatively effect pt)

Question 47

1) Descr nonsurgical bleeding varices Tx 2) What is a mechanical way to stabilize?

Answer 47

1) Resuscitation & correction of coagulopathy -Antibiotic prophylaxis -Octreotide (reduces blood flow to the portal vein to stop bleed) -Interventional, nonsurgical: Endoscopic therapy (banding, ligation or sclerotherapy) or TIPS (salvage therapy of choice ) 2) Balloon tamponade

Question 48

Descr the 2 main operative emergency procedures for bleeding varices

Answer 48

1) Portosystemic surgical shunt (TIPS) & variceal ligation -Shunts reduce varices & risk of bleeding -Non-selective (all portal blood into systemic circulation) & selective (divert portion of portal blood into systemic circulation) -Complications: encephalopathy, difficult transplant, renal failure 2) Or Esophageal transection and re-anastomosis -Emergency measure to stop persistent bleeding -Not a definitive treatment

Question 49

Non-bleeding varices: 1) Main goal? 2) Prophylaxis? 3) Therapeutic Tx?

Answer 49

1) To prevent bleeding. 2) Expectant management: endoscopic band ligation or sclerotherapy (high risk for bleed) beta blockers (low and high risk) 3) Beta blockers, endoscopic band ligation (both similarly effective in preventing rebleeding and reduce recurrence of varices) TIPS

Question 50

Non-bleeding varices: What are the 2 main surgical approaches?

Answer 50

Liver transplantation (relatively young pt with cirrhosis) Portosystemic shunts (if poor transplant candidate)

Question 51

Acites: 1) Cause? 2) Medical mgmt?

Answer 51

1) Results from increased formation of lymph, hypoalbuminemia, and salt and water retention of the kidneys 2) Diuretics (spironolactone initial tx) -Dietary sodium restriction (2g max) -Avoidance of excessive fluid intake

Question 52

Ascites: 1) Non-surgical interventions? 2) Surgery?

Answer 52

1) Paracentesis (should be performed before therapy started) TIPS 2) Liver transplantation portosystemic (portacaval) shunt

Question 53

Hepatic adenoma: 1) Pt? 2) Main cause? 3) Features?

Answer 53

1) Pt: young women of reproductive age 2) Most likely associated with OCP use 3) Some lesions have hemorrhage contrast-enhanced CT or MRI: appear hypervascular compared to surrounding liver parenchyma May enlarge with high levels of circulating hormones LFTs and AFP usually WNL

Question 54

Hepatic adenoma: 1) Tx? 2) Complications?

Answer 54

1) Observation with serial imaging (< 5 cm); surgical resection (> 5 cm) Avoid OCPs permanently 2) Rare progression to HCC (~5%)

Question 55

Liver mets: 1) MC malignant hepatic neoplasms are metastatic tumors from primary cancers of? 2) Main presentation?

Answer 55

1) MC malignant hepatic neoplasms are metastatic tumors from primary cancers of GI tract, breast, lung, GU system, ovary, & uterus 2) Often advanced at presentation (precluding surgery)

Question 56

Liver mets: 1) Dx? 2) Tx?

Answer 56

1) Contrast-enhanced helical CT of the C/A/P (triple phase): Best image of liver and extrahepatic spread -MRI may also be used (distinguishes benign from malignant) 2) Chemotherapy is only tx option for most patients (palliative) -Exception: metastatic colorectal cancer (~20% cure rate with hepatic resection)

Question 57

________________ should be done for pts with GB polyp(s) > 1 cm

Answer 57

Prophylactic cholecystectomy

Question 58

Gallstone ileus: 1) What is it? 2) Dx? 3) Tx?

Answer 58

1) Mechanical intestinal obstruction caused by a large gallstone lodged in the ileal lumen 2) CT: pneumobilia (pathognomonic) (presence of air within the biliary tree) 3) Emergency laparoscopy (or laparotomy) with removal of obstructing stone: -Proximal intestine inspected for 2nd stone -Gallbladder left undisturbed -Delayed elective cholecystectomy (once pt recovered and if chronic gallbladder symptoms; 30% patients) -Fistula closes spontaneously in most patients

Question 59

Descr MELD score

Answer 59

Bilirubin, Sr sodium, INR, Sr creatinine, dialysis Assesses liver function in pts undergoing resection (can also see who is higher risk & who should get transplant first)

Question 60

When should smoking be stopped?

Answer 60

Smoking (abstain 4-weeks prior & after surgery)

Question 61

Cystic duct leak: 1) What is it? 2) S/Sxs?

Answer 61

1) Complication of laparoscopic cholecystectomies Surgical clip slips off (inaccurately placed) -> biloma (collection of bile outside biliary system) 2) Abdominal pain, fever, +/- vomiting 3 days after procedure

Question 62

Cystic duct leak: 1) Dx? 2) Tx?

Answer 62

1) HIDA (identify biliary leak) or ERCP (identify leak, location, and allow for tx with CBD stent) 2) ERCP stenting of CBD & percutaneous drainage of biloma >90% leaks seal after CBD stenting without further surgery