Thank you for purchasing this e-book. To receive special offers and news about our latest products, sign up below.
Sign Up Or visit LWW.com
ADVANCED SURGICAL RECALL Fourth Edition “‘SCUT’............ Forgive me for this; I HATE this word. Ward work is patient care. It’s the work of Angels and Saints. It is a privilege to do. It’s fun. It is necessary to the care of patients. If you call this patient care scut, you (and your protégés) won’t do it. If you call an admission a ‘hit,’ you won’t take care of them. Your language defines your feelings. Your feelings determine what you have energy for. I get energy from getting a patient a cup of coffee, drawing their blood well, and closing their skin in a nice manner ............ as much energy as I get from transplanting their hearts and lungs, and bypassing their vessels. I can’t do what I don’t have energy for.” —Curt Tribble, M.D.
ADVANCED SURGICAL RECALL Fourth Edition Recall Series Editor and Senior Editor Lorne H. Blackbourne, M.D., F.A.C.S. Acute Care Surgery, Trauma, Burn, Surgical Critical Care San Antonio, Texas
Advisor Curtis G. Tribble, M.D. Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery Medical Director of Transplantation University of Mississippi
Acquisitions Editor: Tari Broderick Product Manager: Lauren Pecarich Marketing Manager: Joy Fisher Williams Manufacturing Manager: Margie Orzech Design Coordinator: Terry Mallon Art Director: Jennifer Clements Compositor: Aptara, Inc. Fourth Edition Copyright © 2015 Wolters Kluwer Copyright © 2015, 2008, 2004, 1997 Lippincott Williams & Wilkins, a Wolters Kluwer business. Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA
351 West Camden Street Baltimore, MD 21201
Printed in China All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at
[email protected], or via website at lww.com (products and services). 987654321 Library of Congress Cataloging-in-Publication Data ISBN: 978-1-4511-1653-3 Available upon request
DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.
Dedication This book is dedicated to my father, Dr. Brian D. Blackbourne, M.D.
Editors and Contributors Contributors Will Cauthen, M.D. Chief Resident General Surgery University of Mississippi Medical Center Contributors to Previous Editions Gina Adrales, M.D. Joshua B. Alley, M.D. Stephen Bayne, M.D. Gauri Bedi, M.D. Robert Benjamin, M.D. Kyrie Bernstein, M.D. Oliver A.R. Binns, M.D. Shawn A. Birchenough, M.D. Joshua Bleier, M.D. Carol Bognar, M.D. Lee Butterfield, M.D. Sung W. Choi, M.D. Vernon L. Christenson, M.D. Jeffery Cope, M.D. Sagar Damle, M.D. Jennifer Deblasi, B.S. Soffer Dror, M.D. Matthew Edwards, M.D. Brian Ferris, M.D. Anne C. Fischer, M.D. Kirk J. Fleischer, M.D. Charity Forstmann, M.D. Cynthia Gingalewski, M.D. Thomas Gleason, M.D. Penelope A. Goode, M.D. Sharon Goyal, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Huntington Hapworth, M.D. Sean P. Hedican, M.D.
vi
Stanley “Duke” Herrel, M.D. Teofilo R. Lama, M.D. Jason Lamb, M.D. Scott London, M.D. Tananchai A. Lucktong, M.D. Jana B.A. MacLeod, M.D., M.S.C. F.R.C.S. (C) Peter Mattei, M.D. Addison May, M.D. Joseph R. McShannic, M.D. Nancy E. Morefield, M.D. Paul Mosca, M.D. Mark Mossey, M.D. David Musante, M.D. Mark J. Pidala, M.D. John Pilcher, M.D. Philip Pollice, M.D. Cherie D. Quesenberry, M.D. Naveen Reddy, M.D. Brian Romaneschi, M.D. Janice Ryu, M.D. Moises Salama, M.D. Robert E. Schmieg, Jr., M.D. Donald B. Schmit, M.D. Carl Schulman, M.D. Paul Shin, B.A. Kimberly Sinclair, M.S. John Sperling, M.D. Akin Tekin, M.D. Pierre Theodore, M.D. Steven D. Theis, M.D. Michael Tjarksen, M.D. Stephanie VanDuzer, M.D. Jeffry Watson, M.D. Mark Watts, M.D. Joseph Wells, M.D. David White, M.D. Kate Willcutts, M.D.
Editors and Contributors vii
Jonathan Winograd, M.D. Jim Soo Yoo, M.D. Stephen Yung, M.D. Amer Ziauddin, M.D.
Sara S. Kim Resident Department of Surgery University of North Carolina
Developmental Contributor Patricia Blackbourne Kingsbury, Texas
Tad Kim, M.D. Resident Division of Cardiothoracic Surgery University of Mississippi Medical Center Peter Vezeridis, M.D. Orthopedic surgery Boston, MA
Editor Jon D. Simmons, M.D. Assistant Professor Associate Residency Director Department of Surgery Division of Trauma, Acute Care Surgery, Burn, & Surgical Critical Care University of South Alabama Editors, Previous Editions Oliver A.R. Binns, M.D. Anikar Chhabra, M.D. Kirk J. Fleischer, M.D. Tananchai A. Lucktong, M.D. Damle Sagar Joseph Wells, M.D. Associate Editors Louis R. Pizano MD MBA FACS Associate Professor of Surgery and Anesthesia Chief, division of Burns Director, Trauma/ Surgical Critical Care Fellowship Program University of Miami Brian J. Eastridge MD FACS Trauma Surgery University of Texas San Antonio, Texas
Associate Editors, Previous Editions Fouad M. Abbas, M.D. Tekin Akin, M.D. Robert Benjamin, M.D. Kyle D. Bickel, M.D. Duke E. Cameron, M.D. H. Ballantine Carter, M.D. Bruce Crookes, M.D. Martin A. Goins, III, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Richard F. Heitmiller, M.D. David Holt, M.D. Billy Johnson, M.D. Brian Jones, M.D. Scott Langenburg, M.D Teofilo Lama, M.D. Jana Macleod, M.D. John Minasi, M.D. Stanley L. Minken, M.D. Michael A. Mont, M.D. Marcia Moore, M.D. Paul J. Mosca, M.D., Ph.D Charles N. Paidas, M.D. John Pilcher, M.D. Moises Salama, M.D.
viii Editors and Contributors
Donald Schmit, M.D. Carl Schulman, M.D. Dror Soffer, M.D. R. Scott Stuart, M.D. Rafael Tamargo, M.D. Curtis G. Tribble, M.D. Reid Tribble, M.D. Craig A. Vander Kolk, M.D. Kate Willcutts, M.D. Leslie Wong, M.D. Jeffrey Young, M.D.
International Editor Gwinyai Masukume, MB ChB(UZ), Dip Obst(SA) Department of Obstetrics and Gynaecology Mpilo Central Hospital Bulawayo Zimbabwe
Foreword Advanced Surgical Recall is a study aid for students and residents who have progressed past their introductory experiences in the discipline of surgery. In actuality, this group includes surgical residents, senior medical students, and even junior medical students who have progressed past the usual introductory materials. This book should also serve as a source of questions for teachers of surgery, particularly for the venerable activity of teaching rounds. The best teachers usually are those individuals who have thought the most about how they themselves learned. The editors of Advanced Surgical Recall clearly are teachers who have given an enormous amount of thought to learning and teaching. They have used the principles of the Socratic method and of their own self-education techniques to develop this collection of questions. These editors have a special knack for writing and editing these types of questions and study aids; through their impressive medical and surgical educational trajectories, they have won teaching awards and created a plethora of study aids. This collection of questions and answers is useful to students of surgery, not only because it will help them learn the answers they need to know, but also because it will help them remember the questions. Knowing the right questions is, in my opinion, more important than knowing the answers, at least in real life. After all, the answers will change over time. The questions are timeless. Curtis G. Tribble, M.D. Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery Medical Director of Transplantation University of Mississippi
ix
Preface ADVANCED SURGICAL RECALL Fourth ed. is written as the natural extension of SURGICAL RECALL. It is intended primarily for surgical residents, but advanced students will also find it can give them an extra competitive edge. In addition to the previous features, this new edition includes a Rapid Fire Review for the ABSITE. Lorne H. Blackbourne, M.D., F.A.C.S. Acute Care Surgery, Trauma, Burn and Surgical Critical Care San Antonio, Texas
x
Contents Editors and Contributors .................................................................................................. vi Foreword ............................................................................................................................... ix Preface .................................................................................................................................... x
SECTION I OVERVIEW AND BACKGROUND SURGICAL INFORMATION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.
Introduction .................................................................................................. 1 Review of Surgical Acronyms and Memory Aids ...................................14 Surgical Syndromes .....................................................................................26 Surgical Most Commons.............................................................................27 Surgical Percentages ...................................................................................30 Surgical History ............................................................................................32 Surgical Instruments ...................................................................................36 Sutures and Stitching..................................................................................53 Surgical Knot Tying......................................................................................61 Incisions .........................................................................................................64 Surgical Positions .........................................................................................66 Surgical Speak ..............................................................................................69 Preoperative 201 ..........................................................................................70 Advanced Procedures .................................................................................72 Surgical Operations You Should Know ....................................................85 Cell Biology and Cytokines ..................................................................... 108 Wounds ....................................................................................................... 115 Drains and Tubes....................................................................................... 118 Surgical Anatomy...................................................................................... 123 Surgical Respiratory Care ........................................................................ 138 Renal Facts.................................................................................................. 144 Fluids and Electrolytes ............................................................................. 154 Surgery by the Numbers and Surgical Formulae ............................... 157 Blood and Blood Products ...................................................................... 162 Surgical Hemostasis ................................................................................. 173 Surgical Medications ................................................................................ 175 Complications ............................................................................................ 180 Common On-Call Pages ........................................................................... 192 Surgical Nutrition...................................................................................... 198 Shock ........................................................................................................... 201 Surgical Infection ...................................................................................... 204 xi
xii Contents
32. 33. 34. 35. 36. 37.
Fever ............................................................................................................ 212 Surgical Prophylaxis ................................................................................. 213 Surgical Radiology .................................................................................... 215 Anesthesia .................................................................................................. 223 Surgical Ulcers ........................................................................................... 235 Surgical Oncology..................................................................................... 237
SECTION II GENERAL SURGERY 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67.
GI Hormones and Physiology ................................................................. 243 Acute Abdomen and Referred Pain....................................................... 251 Hernias ........................................................................................................ 256 Laparoscopy ............................................................................................... 259 Trauma ........................................................................................................ 262 Burns ........................................................................................................... 287 Upper GI Bleeding .................................................................................... 297 The Stomach .............................................................................................. 299 Bariatric Surgery ....................................................................................... 304 Ostomies ..................................................................................................... 306 Small Intestine ........................................................................................... 310 The Appendix ............................................................................................ 316 Carcinoid Tumors ...................................................................................... 319 Fistulas ........................................................................................................ 323 Colon and Rectum .................................................................................... 324 The Anus ..................................................................................................... 330 Lower GI Bleeding..................................................................................... 333 Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis ....................................................................................... 335 Liver ............................................................................................................. 338 Portal Hypertension ................................................................................. 345 Biliary Tract................................................................................................. 350 Pancreas ...................................................................................................... 364 The Breast ................................................................................................... 370 Endocrine ................................................................................................... 379 Thyroid Gland ............................................................................................ 390 Parathyroid................................................................................................. 399 Spleen.......................................................................................................... 402 Surgically Correctable Hypertension .................................................... 406 Soft Tissue Sarcomas and Lymphomas ................................................ 409 Skin Lesions................................................................................................ 416
Contents xiii
68. Melanoma................................................................................................... 417 69. Surgical Intensive Care ............................................................................ 420
SECTION III SUBSPECIALTY SURGERY 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82.
Vascular Surgery ....................................................................................... 437 Pediatric Surgery....................................................................................... 469 Plastic Surgery ........................................................................................... 490 Hand Surgery ............................................................................................. 504 Otolaryngology Head and Neck Surgery ............................................. 528 Thoracic Surgery ....................................................................................... 548 Cardiovascular Surgery............................................................................ 582 Transplant Surgery ................................................................................... 640 Orthopedic Surgery.................................................................................. 649 Neurosurgery ............................................................................................. 699 Urology ....................................................................................................... 722 Ophthalmology ......................................................................................... 764 Obstetrics and Gynecology..................................................................... 775
SECTION IV RAPID FIRE POWER REVIEW 83. Rapid Fire Review for the American Board of Surgery In-Training Examination (ABSITE).......................................................... 789 Index .................................................................................................................................. 815
SECTION I Overview and Background Surgical Information
Chapter 1 Introduction HOW ADULTS LEARN Learning is accomplished through motivation, repetition, and association. Motivation must come from within; most medical students and residents are obviously motivated to learn. Repetition is obtained by reading, rereading, and studying information until it is mastered. Association is obtained by connecting information that has already been mastered to some new knowledge, such as remembering the anatomic order of the trauma neck zones 3, 2, and 1 in conjunction with the Le Fort fractures 3, 2, and 1.
HOW TO STUDY Always read about your patient’s disease as you are taking care of him or her. This habit serves two purposes: You will associate the information with that patient for life, and your increased knowledge will improve that patient’s quality of care.
USING THIS BOOK After completing the surgical basics in Surgical Recall, focus your attention on this book. Review the answers on the right until mastered. This book is designed to foster the acquisition of surgical information and will not help you gain experience in test taking; this skill can be learned from other books.
NURSES Treat nurses with respect and professional courtesy at all times; they often know more than you in any given situation. If your relationship is based on mutual respect, it is also less likely that they will call you at 3 AM asking for Tylenol.
SLEEP DEPRIVATION The best offense to combat sleep deprivation is to be in good physical shape and to be motivated. Staying up for 48 hr is no different than participating in an ultramarathon. Many residents find benefit from caffeine, orange juice, hot showers, brushing their teeth, doing push-ups, running steps, yelling, changing their socks, or listening to loud music. Try not to sit down, because sitting is conducive to falling asleep quickly. Studies have shown that in sleep deprivation physical abilities remain intact until extreme deprivation of sleep occurs. Tell yourself, “I am hardcore and I need no sleep!” 1
2 Section I / Overview and Background Surgical Information
INTERNSHIP The Perfect Intern Says only “Yes sir,” “No sir,” or “My fault, sir” and “Yes ma’am,” “No ma’am,” or “My fault, ma’am” Is always honest Is a team player Has a “can do” attitude Always brushes teeth before rounds Is the first to arrive and the last to leave clinic Is always clean Always makes the upper-level residents look good Teaches the students Does not scut the students too much Knows more about the patients than anyone else Is a physician, and not merely a scribe Is never late Never complains Is never hungry, thirsty, or tired Is always enthusiastic Follows the chain of command Some thoughts for interns to live by: “They can hurt you but they can’t stop the clock.” Internship only lasts for 12 months. “Never trust your brain.” Write everything down, do not trust anything to memory, and check off your chores when completed. “Load the boat.” Inform your superiors when a patient is not doing well or if you have any questions. That way, if your patient’s condition worsens (the proverbial sinking ship), you have loaded the ship with your superiors and they will go down with you. “Bad news does not age well.” Call right away (see above). “Never lie.” Honesty is the best policy.
LIVING WITH MISTAKES You will make mistakes, and many times these mistakes will harm your patients. Mistakes are forgivable if you are doing your absolute best. Do not make mistakes that result from laziness. There is a saying in surgery: “You cannot hurt yourself by getting out of bed.” After a mistake is made and you have determined that you were doing your absolute best, you must then forgive and remember. That is, forgive yourself for the mistake, but always remember the mistake and be sure to learn something from it.
Chapter 1 / Introduction 3
Recovery Room Protocol Several things need to be done before you can take time to eat some food, so the acronym F.O.O.D.D. is helpful: Family: Talk to the patient’s family. Operative note: Write in the chart. Orders: Write postop orders. Dictate the procedure. Doctor: Call the primary/referring doctor.
DEALING WITH ACHES AND PAINS IN THE OR Many residents find that taking NSAIDs before and after long cases helps decrease muscle strains. Others do sit-ups to strengthen abdominal muscles and reduce backache, or use the OSHA back support belts. Support hose can lessen foot edema and the pain associated with venous lower extremity incompetence associated with long periods of standing.
AVOIDING MALPRACTICE Do the right thing. Talk to your patients and their families (never say “no comment” or “I can’t talk about it”). Be nice to your patients and their families. Honesty is the best policy. Document everything! Seek advice from mentor, colleagues, and lawyer. What should you do if you write the wrong word in a chart?
Put a line through the word, but make sure it is still legible, and then initial. Never blot out—it will look as though you are trying to hide something.
HIERARCHY AMONG SURGICAL RESIDENTS Suggestions and ideas regarding patient care should flow freely among all surgical residents (including interns), but the decisions follow a concrete chain of command.
ABBREVIATIONS AKA
Above the knee amputation
ALI
Acute lung injury
AMA
Against medical advice
4 Section I / Overview and Background Surgical Information
AMF YOYO
Adios my friend; you’re on your own
ARF
Acute renal failure
ASIS
Anterior superior iliac spine
ATFQ
Answer the first question
AVN
Avascular necrosis
BAL
Bronchoalveolar lavage
BAM
Bilateral augmentation mammoplasty
BCC
Basal cell carcinoma
BMI
Body mass index
BSO
Bilateral salpingo-oophorectomy
Bx
Biopsy
CMV
Cytomegalovirus
CRF
Chronic renal failure
CRNA
Certified Registered Nurse Anesthetist
DJD
Degenerative joint disease
DOE
Dyspnea on exertion
ELAP
Exploratory laparotomy
ER
Estrogen receptor
ESRD
End-stage renal disease
ETT
Endotracheal tube (a.k.a. ET)
FDP
Fibrin degradation product
FEV1
Forced expiratory volume in 1 sec
Chapter 1 / Introduction 5
FIDO
Forget it; drive on
FOS
Full of stool
FROM
Full range of motion
G1P1
Gravida (# of pregnancies), Para (# of children)
GI
Gastrointestinal
GIST
Gastrointestinal stromal tumor
GSW
Gunshot wound
hCG
Human chorionic gonadotropin
HNP
Herniated nucleus pulposus
HOB
Head of bed
HODAD
Hands of death and destruction
ICH
Intracranial hemorrhage
ICU
Intensive care unit
IDDM
Insulin-dependent diabetes mellitus
IM
Intramuscular
INR
International normalized ratio
IOC
Intraoperative cholangiogram
IVC
Inferior vena cava
KISS
Keep it simple, stupid
KVO
Keep vein open
LMD
Local medical doctor
LOS
Length of stay
6 Section I / Overview and Background Surgical Information
MAFAT
Mandatory anesthesia fooling around time
MAP
Mean arterial pressure
MCC
Motorcycle collision/crash
ME
Medical examiner
MODS
Multiple organ dysfunction syndrome
MOF
Multiple organ failure
MRA
Magnetic resonance angiography
MRCP
Magnetic resonance cholangiopancreatography
MRI
Magnetic resonance imaging
MRSA
Methicillin-resistant Staphylococcus aureus
MRSE
Methicillin-resistant Staphylococcus epidermidis
MVC
Motor vehicle collision/crash
PEA
Pulseless electrical activity
PFO
Patent foramen ovale
PFTs
Pulmonary function tests
pRBCs
Packed red blood cells
PSV
Pressure support ventilation
PVR
Pulmonary vascular resistance
QD
Once a day
RHIP
Rank has its privileges
RT
Respiratory therapist
Chapter 1 / Introduction 7
RTC
Return to clinic
SCIWORA
Spinal cord injury without radiographic abnormality
SDH
Subdural hematoma
SIMV
Synchronized intermittent mandatory ventilation
SIRS
Systemic inflammatory response syndrome
SVC
Superior vena cava
SVR
Systemic vascular resistance
SVT
Supraventricular tachycardia
TAH
Total abdominal hysterectomy
TAPP
Transabdominal preperitoneal (groin hernia repair)
TEPA
Totally extraperitoneal approach (groin hernia repair)
THE
Transhiatal esophagectomy
TLC
Triple lumen catheter
TPN
Total parenteral nutrition
TURB
Transurethral resection of bladder
Ucx
Urine culture
UNOS
United Network for Organ Sharing
VAP
Ventilatory-associated pneumonia
VRE
Vancomycin-resistant Enterococcus
WBAT
Weight bearing as tolerated
8 Section I / Overview and Background Surgical Information
WWDWWC
“Wound was dry when we closed”
y
Psychiatric (Greek letter psi)
mg
Microgram
ADVANCED GLOSSARY Antecolic
In front of the colon (anterior)
Bezoar
Undigested mass (“hair ball”)
Colloid
IV fluid with large molecules (e.g., albumin)
Colonized
Bacteria residing in the anatomic area but not causing infection, inflammation, signs, or symptoms
Demarcation
Line defining borders between two anatomically distinct entities (e.g., between viable and dead tissue)
Eschar
Thick dead skin seen after third-degree burns
Granulation
Wound with a surface made of “proud flesh” consisting of collagen/fibroblasts and without an epithelial cover
Montgomery straps
Straps affixed to a patient’s abdomen with tape; cloth straps are laced and tied after repeated wound changes, to avoid repeated taping of dressings
Pulsus paradoxus
Seen with cardiac tamponade; >10 mm Hg decrease in systolic blood pressure on inspiration
Pyrosis
Heartburn
Retrocolic
Behind the colon (posterior)
Seldinger technique
Placement of a tube over a previously placed wire (e.g., central line placement)
Chapter 1 / Introduction 9
Sterile
All microorganisms are killed
Sterile field
The prepped area of the patient, the drapes, and the instrument table: All items touching this area must be sterile
Strike through
Wound drainage penetrating (“striking through”) all layers of a wound dressing
Thrill
Palpable vibration of arterial turbulent flow
ADVANCED SIGNS Aaron’s sign
Pushing on McBurney’s point in patient with acute appendicitis results in epigastric pain!
Chandelier’s sign
Severe pain upon manual manipulation of the cervix on pelvic exam (patient “jumps for the chandelier”)
Claybrook’s sign
Pneumoperitoneum (ruptured hollow viscus) results in transmission of breath and heart sounds when abdomen is auscultated
Deep sulcus sign
Deep costophrenic angle in supine chest radiograph in patients with a pneumothorax
10 Section I / Overview and Background Surgical Information
Dunphy’s sign
Abdominal pain with coughing; sign of peritonitis
Jiffy Pop sign
Colostomy bag full of air!
Mannkopf ’s sign
Increase in heart rate upon pushing on a point of maximal abdominal tenderness (seen with real pain, not in malingering)
Ring sign
CSF and blood form rings when dropped on filter paper (or cloth), seen in CSF otorrhea and rhinorrhea
Soap bubble sign
Retroperitoneal air seen in severe pancreatitis
Ten horns sign
Pronounced tenderness upon manual tension applied to right spermatic cord, seen in acute appendicitis (think ten horns will make you go ten hut!)
MEDICAL STATS YOU NEED TO KNOW Define the following terms: Mean
The average value of all data points (e.g., 5, 10, 5, 20; 40/4 = 10 is the mean)
Mode
The most common numeric value of a set (e.g., in the set 2, 3, 4, 4, 4, 5, 6, 7; 4 is the mode)
Median
The middle value within the ordered set (e.g., 4, 4, 5, 6, 6; 5 is the median)
False-positive
A data point that is reported as positive but is really negative
False-negative
A data point that is reported as negative but is really positive
Distribution
A description of how the data look graphically (i.e., their shape)
Chapter 1 / Introduction 11
Describe some examples of common distributions. Normal distribution
A bell-shaped curve that is symmetrical around the middle
Skewed distribution
Not symmetrical, but slanted to the right or left
Bimodal distribution
Two graphical peaks of the distribution (i.e., two modes)
Define the following terms: Sensitivity
True-positives True-positives + false-negatives
Specificity
True-negatives True-negatives + false-positives
Blind study
The patient is blind to the clinical intervention
Double-blind study
The patient and the care providers are blind to the clinical intervention; (NOT two orthopods trying to read an ECG!)
12 Section I / Overview and Background Surgical Information
What is the Hawthorne effect?
Improved outcomes in the control group due to increased medical staff vigilance during research
In statistical tests, what is the null hypothesis?
It is the hypothesis that states that there is no difference between the population value and the hypothesized value, or no difference among the groups being tested; the null hypothesis is often denoted H0
What is a type I error?
Rejecting the null hypothesis when it is true
What is a type II error?
Failing to reject the null hypothesis when it is not true
How is a paired t-test performed?
For each subject or pair of subjects, the difference is calculated for the two variables (e.g., weight before diet minus weight after diet); the difference is then analyzed using a one-sample t-test to determine whether or not the differences are equal to zero
When is the analysis of variance (ANOVA) method used?
When there are more than two groups to compare
Is it unusual to observe an effect with a placebo?
No, people often show an improvement with a placebo if they are blinded to the treatment
How is the incidence of a disease defined?
It is the number of new cases that occur during a specified amount of time divided by the number of people at risk of developing the disease at the beginning of the time interval
How is the prevalence of a disease defined?
It is the number of cases existing in a given population at a specific period of time (period prevalence) or at a particular moment in time (point prevalence)
What is the relative risk of a disease?
It is a measure of the relative amount of disease occurring in different populations
Chapter 1 / Introduction 13
How do you calculate relative risk?
Relative risk equals (incidence of disease in exposed group) divided by (incidence of disease in the unexposed group)
MEDICAL SPANISH Translate the following words and phrases: Hello
Hola (o la)
Good-bye
Adios
Please
Por favor
Sir
Senõr
Ma’am
Señora
You
Usted (respectful); Tu (familiar)
Speak
Hablas
English
Inglés
Where
Donde (dohn-day)
Is
Es; esta
Pain
Dolor (dough-lore)
Worse
Peor
Better
Mejor (mehor)
Nauseas
Mareado or náuseas
Where is the pain?
Donde esta el dolor?
Is the pain worse?
Es peor el dolor?
Is the pain better?
Es mejor el dolor?
Breathe deeply
Respiro profundo
14 Section I / Overview and Background Surgical Information
Cough
Tocé (toe say)
Does it hurt to breathe?
Le duele al respiro? (duele = doo-el-ay)
Does it hurt if I push here?
Le duele cuando aprieto aquí?
Where does it hurt?
Donde le duele?
Tetanus shot
Inyección de tétano
X-ray
Radiografía
Were you knocked out?
Estuvo inconsciente?
Neck
Cuello
Abdomen
Abdomen
Arm
Brazo
Rectum
Recto
Chest
Pecho
Head
Cabeza
Need an operation
Necesita una operación
Chapter 2 Review of Surgical Acronyms and Memory Aids Memory aid for sodium seen with SIADH?
SIADH = “Sodium Is Always Down Here” = Hyponatremia
Cause of SIADH?
Syndrome of Inappropriate AntiDiuretic Hormone (Think: Inappropriately Increased ADH)
Chapter 2 / Review of Surgical Acronyms and Memory Aids 15
Goodsall’s rule?
Think of a dog with an anterior straight nose and posterior curved tail
Grey Turner’s sign?
Think: TURNer’s = TURN side to site = flank
Symptoms triad for pheochromocytoma?
PHE ochromocytoma: Palpitations Headache Episodic diaphoresis
Leriche’s syndrome?
CIA = Claudication of buttocks, Impotence, Atrophy of buttocks
Gardner syndrome?
SOD = Sebaceous cysts, Osteomas, Desmoid tumors (Think: A “Gardner” plants SOD)
Diabetes insipidus (DI)?
DI = DECREASED ADH
16 Section I / Overview and Background Surgical Information
Symptoms/signs and cells of carcinoid syndrome?
B FDR in a COOL CAR: Bronchospasm Flushing Diarrhea Right-sided heart failure KULchitsky cells CARcinoid
Colon polyp with the highest rate of malignancy?
Villous Adenoma (Think: VILLous = VILLain) 40% malignant
Radiolucent kidney stones?
Uric = Unseen
Kidney stone due to UTI?
Struvite = Sepsis
Most radiosensitive testicular cancer?
Seminoma = Sensitive
Billroth I vs. Billroth II?
Billroth I has 1 limb and Billroth II has 2 limbs coming off the stomach
Orientation of nerve and vessels below a rib?
VAN = Vein, Artery, Nerve under the rib
Order of femoral vessels?
Right side lateral to medial = NAVEL: Navel Artery Vein Extralymphatic material Lymphatics (Thus, the vein is medial to the pulse)
What is the strongest layer of the small bowel?
SUbmucosa = SUperior (not serosa!!!!)
Jejunum vs. ileum?
Ileum is Inferior in thickness and arcade length and has smaller plicae circulares
Chapter 2 / Review of Surgical Acronyms and Memory Aids 17
What is the treatment of hyperkalemia?
“CB DIAL K”: Calcium Bicarbonate Dialysis Insulin/glucose Albuterol Lasix Kayexalate
Differential for hypercalcemia?
“CHIMPANZEES”: Calcium overdose Hyperparathyroidism (1°/2°/3°) Hyperthyroidism/Hypocalciuric Hypercalcemia (familiar) Immobility/Iatrogenic (thiazide diuretics) Metastasis/Milk–alkali syndrome (rare) Paget disease (bone) Addison disease/Acromegaly Neoplasm (colon, lung, breast, prostate, multiple myeloma) Zollinger–Ellison syndrome Excessive vitamin D Excessive vitamin A Sarcoid
Clotting factor in hemophilia A?
Think: “EIGHT” sounds like “A”
Clotting factors deficient with hemophilia A and hemophilia B?
Think alphabetically and chronologically: A before B—8 before 9 Hemophilia A = factor VIII Hemophilia B = factor IX
18 Section I / Overview and Background Surgical Information
Fat-soluble vitamins?
K, A, D, E (“KADE”)
Causes of postoperative fever?
W’s Wind – atelectasis Water – UTI Wound – wound infection Walking – DVT/Thrombophlebitis Wonder drugs – drug fever
Curling’s ulcer?
Curling iron burn = ulcer due to burn injury stress
Cushing’s ulcer?
Ulcer due to brain injury; Think: Dr. Cushing = NeuroSurgeon = CNS
Product of chief gastric cells?
“PEPpy chief ” = PEPsinogen
GCS eye-opening score?
4 = 4 eyes
GCS motor score?
6 = 6-cylinder motor
GCS verbal score?
5 = Jackson 5
Treatment of myoglobinuria?
HAM: Hydration with IV fluid Alkalize urine with bicarbonate IV Mannitol IV diuresis (1 g/kg)
Effect of food intake on symptoms of duodenal ulcers?
Duodenum = Decrease in pain (thus, many patients with duodenal ulcers gain weight!!)
Indications for surgery with duodenal ulcers?
I HOP: Intractability Hemorrhage Obstruction Perforation
Indications for operation with gastric ulcers?
I CHOP: Intractability Cancer or cancer rule out Hemorrhage Obstruction Perforation
Chapter 2 / Review of Surgical Acronyms and Memory Aids 19
Product of G cells in stomach?
G cells = Gastrin
Causes of small-bowel obstruction (SBO)?
ABC = Adhesions, Bulges (hernias), Cancer
Conditions that keep an enterocutaneous fistula open?
HIS FRIEND: High output Intestinal destruction (>50% circumference) Short segment (55 LDH >350 AST >250 WBC >16,000
20 Section I / Overview and Background Surgical Information
Ranson criteria 24–48 hr?
C HOBBS (Think: Calvin and HOBBes) Calcium 10% Oxygen 4 BUN >5 increase Sequestration of >6 L
Historical risk factors for breast cancer?
NAACP: Nulliparity Age at menarche (55 yr) Cancer in breast (in self or family) Pregnancy with first child (>30 yr)
Anatomic risk factors for breast cancer?
CHAFED LIPS: Cancer in past Hyperplasia Atypical hyperplasia Female Elderly DCIS LCIS Inherited genes (BRCA I and II) Papilloma Sclerosing adenitis
Tumors of MEN-I?
Think: type 1 = Primary, Primary, Primary = PPP = Parathyroid, Pancreas, Pituitary
Tumors of MEN-IIa?
MPH = Medullary thyroid cancer, Pheochromocytoma, Hyperparathyroidism
MEN-IIb?
Think: 3 M plastics = MMM P: Marfanoid body habitus Medullary cancer Mucosal neuromas Pheochromocytoma
Chapter 2 / Review of Surgical Acronyms and Memory Aids 21
Symptoms of acute arterial occlusion?
The “6 P’s”: Pulseless Polar (cold) Paresthesia Pain Paralysis Pallor
P’s of papillary thyroid cancer?
The “7 P’s” of Papillary cancer: Popular (most common) Psammoma bodies Palpable lymph nodes (spreads most commonly by lymphatics, seen in ≈33% of patients) Positive 131I uptake Positive prognosis Postoperative 131I scan to diagnose/treat metastases Pulmonary metastases
4 F’s of follicular thyroid cancer?
Follicular cancer: Far away metastasis (spreads hematogenously) Female (3:1 ratio) FNA … NOT (cannot diagnose cancer with FNA) Favorable prognosis
4 M’s of medullary cancer?
Medullary cancer: M II aMyloid Median lymph node dissection Modified neck dissection (if lateral nodes positive)
Cause of ACUTE and SUBACUTE thyroiditis?
Alphabetically: A before S, B before V (i.e., Acute before Subacute and Bacterial before Viral, and thus: Acute = Bacterial and Subacute = Viral)
I’s of ITP?
Immune etiology I = Immunosuppressive drugs (steroids) Immunoglobulins Improvement with splenectomy
22 Section I / Overview and Background Surgical Information
Formula for pressure?
Pressure = flow × resistance or P = F × R (Think: Power FoRward)
Risk factors for sarcomas?
“RALES” Radiation AIDS Lymphedema (chronic) Exposure to chemicals Syndromes (e.g., Gardner)
Malignancy potential of actinic keratosis?
Asset Kicker = Actinic Keratosis = premalignant
Most common sites of melanoma?
SEA: Skin #1 Eyes #2 Anus #3
Most common type of melanoma?
SUPERior = SUPERficial spreading
Define ARDS:
CXR: Capillary wedge pressure 70 yr, nonsinus rhythm
Give the points by Goldman criteria for each of the following factors (more points = more risk): S3 gallop or JVD
11
MI within 6 mo
10
Ectopy or nonsinus rhythm
7
Chapter 13 / Preoperative 201 71
More than five premature ventricular contractions (PVCs)
7
Age >70 yr
5
Emergency surgery
4
Aortic stenosis
3
Intraperitoneal or thoracic surgery
3
Poor medical condition
3
Define poor medical condition:
Bedridden, abnormal blood gas (PO2 < 60; PCO2 >50), abnormal electrolytes (K+ 3.0), chronic liver disease
What is the mortality rate for patients who have less than 5 points according to the Goldman criteria?
0.2%
What is the mortality rate for patients who have more than 26 points according to the Goldman criteria?
50%
What are the two major risk factors for perioperative MI?
CHF and recent MI (3 mo)
What heart valvular disease is associated with the highest risk for postoperative cardiac complications? Why?
Aortic stenosis, because the heart responds poorly to fluid shifts
What are the signs and symptoms of aortic stenosis?
Systolic ejection murmur, angina, syncope, CHF (think; Aortic Stenosis Complications = Angina, Syncope, Congestive heart failure)
72 Section I / Overview and Background Surgical Information
Which two kinds of noncardiac surgeries are associated with the highest rates of perioperative cardiac complications?
Operations on the aorta, followed by operations on the peripheral vascular system (because of associated CAD)
Is spinal or epidural anesthesia safer than inhalational anesthetics in patients with CAD?
No; although counterintuitive, the loss of vascular resistance associated with spinal or epidural anesthesia does not result in significantly lower rates of perioperative cardiac events
Which inhalational anesthetic has the highest degree of cardiac depression?
Halothane
What is the mechanism of cardiac depression with halothane?
Can lead to direct cardiac depression coupled with peripheral vascular dilatation, without the normal compensatory tachycardia
What are the two contraindications for epidural and spinal anesthesia?
1. Hypertrophic obstructive cardiomyopathy 2. Cyanotic congenital heart disease (because of loss of vascular tone and increased venous capacitance)
Chapter 14 Advanced Procedures CRICOTHYROIDOTOMY Indications?
Failure to obtain airway by endotracheal oral intubation
Landmarks?
Feel thyroid cartilage and then right below it is the depression between the cricoid and the thyroid cartilage; that is where the tube goes
Chapter 14 / Advanced Procedures 73
Cricoid cartilage
Incision?
Longitudinal skin incision—then transversely through cricothyroid membrane; (Note: If you make the skin incision transversely and you are in the wrong spot you are going to make a second incision! Landmarks can be hard to find in obese persons or those with hematoma)
How to maintain the route into the trachea before the tube is placed?
Place an instrument (Kelly works well) into the lumen to maintain the tract
Thyroid cartilage Cricoid cartilage
74 Section I / Overview and Background Surgical Information
Insert tube?
Insert trach tube or endotracheal tube after placing instrument into airway to maintain access into trachea
What is a perc trach?
A percutaneous tracheostomy placed by Seldinger technique
Chapter 14 / Advanced Procedures 75
VENOUS CUTDOWN Indications?
Inability to get standard percutaneous intravenous access
Incision?
Transversely over saphenous vein above the medial malleolus
Procedure?
Ligate distal vein with 3-0 silk, place tie proximal (do not tie), then make transverse cut in vein with a 15 blade; place catheter and then tie proximal silk around the catheter
76 Section I / Overview and Background Surgical Information
CENTRAL LINE Landmarks: Subclavian?
Curve of the clavicle aim for the sternal notch
Suprasternal notch Subclavian vein
Clavicle First rib
Superior vena cava
Internal jugular (IJ)?
Apex of sternal triangle: Aim for ipsilateral nipple at 45 degrees with small “seeker” needle first, followed by a larger needle after successful venous cannulation
Sternocleidomastoid muscle Internal jugular vein Suprasternal notch
Clavicle
Chapter 14 / Advanced Procedures 77
Femoral?
Think NAVEL (Nerve, Artery, VEin, Lymphatics) on right (medial to femoral arterial pulse) 45 degrees
Femoral artery Femoral nerve
Femoral vein Saphenous vein
What is the sequence of events for placing the central line?
Seldinger technique: Cannulate vein, then place wire in vein, cut skin at wire entrance site after removing needle, dilate, then advance catheter over wire; (The wire must always have free movement within the catheter while advancing)
Rule concerning handling of wire?
Never, ever lose contact with the wire; always have finger contact with the wire at all times
What must you get before using an IJ or subclavian central line?
Chest x-ray to confirm position and rule out pneumothorax
If you have a chest tube in the patient, in which side do you put the IJ or subclavian central line?
Same side as chest tube (You have already treated for a pneumothorax!)
78 Section I / Overview and Background Surgical Information
SWAN–GANZ Indications?
Confusion regarding a patient’s fluid status/hypotension, pulmonary edema, poor cardiac output, and need to maximize inotropic/pressor support
Are there any prospective, double-blind studies showing a clear benefit from Swan–Ganz catheters?
No
Relative contraindications?
Left bundle branch block (must float Swan with a pacer or external pacer as the patient may go into complete heart block; severe acidosis/hypoxia as this may lead to v tach with floating)
With LBBB, what is the risk of complete heart block when you float the Swan?
≈5%
How do you get the swan–Ganz catheter into the heart?
Central venous access via the subclavian or IJ approach: Place a large “introducer” catheter; (The Swan is placed through this catheter and is introduced into the central venous system)
How does the Swan–Ganz catheter give you volume status?
The catheter wedges in the pulmonary artery and then all flow ceases; since there are no valves in the pulmonary arterial system, the back pressure the catheter tip records is the pressure in the pulmonary capillaries, which is then an indirect measure of the left atrial pressure
What is the ultimate pressure for determining volume status?
Left ventricle diastolic pressure (next best left atrial mean pressure)
When do you inflate the Swan–Ganz balloon?
Only when advancing; start at ≈20 cm
Chapter 14 / Advanced Procedures 79
What is the average distance to the right ventricle tracing?
20–25 cm
What is the average distance until you “wedge”?
50 ± 5 cm
As you “float” the Swan balloon, what tracings should you get for the following positions: 1. Right atrium
2. Right ventricle
3. Pulmonary artery
80 Section I / Overview and Background Surgical Information
Dicrotic Good trace
Notice dicrotic notch 4. Pulmonary capillary wedge pressure (a.k.a. “wedge pressure”)?
What does the overall tracing from the superior vena cava to the pulmonary wedge pressure look like?
What is an “overwedged” pressure tracing?
CVP Right atrium
Right ventricle
Pulmonary artery
Wedge
Wedge pressure that increases to a very high-pressure tracing; it may be due to balloon obstructing distal pressure port
Overwedged trace Balloon inflation
Chapter 14 / Advanced Procedures 81
What is the wedge tracing with bad mitral regurgitation?
V waves (looks almost like a PA tracing and not a wedge tracing!) V wave
Balloon inflation
When withdrawing the Swan–Ganz catheter, should the balloon be inflated or deflated?
Always deflated!
How should the balloon be inflated when in the pulmonary artery?
Very slowly; if there is any resistance, stop inflation
What is a dreaded complication of inflating the balloon for a wedge pressure?
Pulmonary artery rupture
Other complications?
Arrhythmias, tying a knot with the catheter in the ventricle, pulmonary infarction; (Always deflate the balloon after getting a wedge pressure!)
Classic Swan–Ganz findings with cardiac tamponade?
Equalization of pressures: mean RA pressure, diastolic RV pressure, diastolic pulmonary pressure, and wedge pressures all about the same
Classic Swan–Ganz findings with a pulmonary embolus?
Rise in CVP, RA, RV, and pulmonary pressures but no change in the wedge pressure
82 Section I / Overview and Background Surgical Information
ER THORACOTOMY Incision?
Below left nipple to the “table”
Where do you put the crank handle on the Finochietto chest retractor?
Key point: Handle and “t” must be on the patient’s left so you can go across the sternum and clamshell if you need to; otherwise, the retractor will block you! See arrow:
First move to mobilize the lung?
Cut the inferior pulmonary ligament
Inferior pulmonary ligament
Chapter 14 / Advanced Procedures 83
Where should you cut the pericardial sac?
Above the phrenic nerve (think A-P = Anterior to Phrenic nerve)
How should you clamp the thoracic aorta?
First open the pleura!
DIAGNOSTIC PERITONEAL LAVAGE Incision?
Safest to do “open” DPL incision: Vertical incision above the umbilicus if any possibility of a pelvic hematoma
Dissection?
Incise skin and subcutaneous fat, and then fascia in midline to reveal peritoneum and then into peritoneal cavity
84 Section I / Overview and Background Surgical Information
Tube placement?
Place tube down into the pelvis gently (i.e., do not puncture the bowel!)
How do you get the fluid in?
Hang and let flow in by gravity
How much fluid?
1 L LR or NS
How do you drain fluid out?
Place the bag on floor and the fluid will drain out
Chapter 15 / Surgical Operations You Should Know 85
Chapter 15 Surgical Operations You Should Know BACKGROUND How should an area be prepped for operation?
Scrub skin with povidone-iodine (Betadine) in an enlarging circular motion from the center spiraling out to the periphery
How should you glove yourself?
Never allow the outside of the gloves to touch your skin: 1. Turn gloves upside down on forearm of opposite arm 2. Grasp back of cuff and turn over other hand 3. Draw cuff back to wrist
86 Section I / Overview and Background Surgical Information
Which drapes do you place first: top and bottom, or sides? Why?
Sides first, because 1. Your gown might touch the sides during placement of towels 2. If placed last, the side drapes will fall down due to gravity after placement of towel clips (whereas the top and bottom towels will keep the side towels in place)
What is the correct height of the OR table?
Operative field is elbow height
SURGICAL MANEUVERS What is the Pringle maneuver?
Occlusion of the porta hepatis; decreases blood flow to the liver to slow bleeding during repair of a traumatic liver injury
Chapter 15 / Surgical Operations You Should Know 87
What is the double Pringle maneuver?
Used to isolate the porta hepatis in portal vein injury
What is the Grey-Turner maneuver?
Incising the left hepatic attachments to retract the left lobe of the liver to the right
What is the Kocher maneuver?
Dissection of the lateral peritoneal attachments of the duodenum; allows inspection of the duodenum, pancreas, and other retroperitoneal structures
88 Section I / Overview and Background Surgical Information
What is the Cattel maneuver?
Mobilization of the ascending colon to the midline; if combined with a Kocher maneuver, exposes the vena cava; (Think: Cattel = Kocher = right sided)
What is the Blaisdell maneuver?
Medial rotation of left-sided viscera but leaving left kidney in situ
What is the Mattox maneuver?
Mobilization of the descending colon to the midline; exposes the abdominal aorta
Chapter 15 / Surgical Operations You Should Know 89
What is the Utley maneuver?
Used in tracheoinnominate fistula hemorrhage; placement of finger into tracheostomy or between innominate and trachea; this provides hemostasis with digital pressure, compressing the innominate artery hole against the sternum
OPERATIVE PROCEDURES Define or describe the following operative procedures: Kraske? Beger procedure?
Transcoccygeal rectal biopsy/resection Subtotal excision “duodenal preserving” of the head of the pancreas and anastomosed to a Roux-en-Y limb Stomach Common bile duct Pancreatic duct Pancreatic remnant
Cimino?
Radial artery to cephalic vein AV fistula for hemodialysis
Cephalic vein Radial artery
90 Section I / Overview and Background Surgical Information
Frey procedure?
What is a “functional end-to-end small-bowel anastomosis”?
Roux-en-Y limb to filleted opened dilated pancreatic duct
A side-to-side anastomosis that “functions” like an end-to-end anastomosis (EEA)
Chapter 15 / Surgical Operations You Should Know 91
How can you get control of a bleeding injured IVC?
Via two sponge sticks proximal and distal to injury
How can you get at a hemostasis with a throughand-through liver GSW?
Balloon tamponade (Penrose around a red rubber catheter)
92 Section I / Overview and Background Surgical Information
How should you reanastomose an SMA injury with a pancreatic injury?
Anastomose to distal aorta (away from the pancreas!)
What is a pulmonary “tractomy”?
For fixing a bleeding hole in the lung: fillet open with a GIA, then oversew all bleeding points
Chapter 15 / Surgical Operations You Should Know 93
Csendes?
Gastric resection with long gastrojejunostomy
Braun?
Enteroenterostomy between the limbs of a Billroth II
94 Section I / Overview and Background Surgical Information
Right hemicolectomy?
Extended right hemicolectomy?
Chapter 15 / Surgical Operations You Should Know 95
Transverse colectomy?
Left hemicolectomy?
96 Section I / Overview and Background Surgical Information
Sigmoid colectomy?
Retrocolic Roux-en-Y?
Limb of Roux-en-Y placed behind transverse colon
Chapter 15 / Surgical Operations You Should Know 97
Witzel?
Wrapping bowel wall around catheter; used in jejunostomies
Bogota bag?
Abdominal wall closure using plastic sheet (e.g., urologic irrigation bag)
Urologic irrigation bag
98 Section I / Overview and Background Surgical Information
Splenorrhaphy?
Surgical repair of the spleen
Ripstein?
Rectopexy with mesh (think: Ripstein = “rip” a piece of mesh for repair)
Chapter 15 / Surgical Operations You Should Know 99
Grillo?
Pleural flap for buttressing an esophageal repair
Plug and patch inguinal hernia repair?
Plug
100 Section I / Overview and Background Surgical Information
Patch
Choledochojejunostomy?
Anastomosis of common bile duct to jejunum
Common bile duct
Jejunum
Truncal vagotomy?
Transection of vagal nerves (Note: while in the OR, get frozen section to confirm that you actually resected the nerve)
Truncal vagotomy
Chapter 15 / Surgical Operations You Should Know 101
Jaboulay pyloroplasty?
PEG?
Percutaneous Endoscopic Gastrostomy
Guidewire
Snare
Tube
102 Section I / Overview and Background Surgical Information
Finney pyloroplasty?
Stamm gastrostomy?
Open gastrostomy with purse-string suture
Stomach sutured to abdominal wall
Hasson?
Purse-string suture
Cut down under direct vision and placement of trocar for laparoscopy
Chapter 15 / Surgical Operations You Should Know 103
OPERATIVE PEARLS As a last resort, how do you obtain exposure of the iliac vein during trauma surgery?
Transect the iliac artery!
What is the smart operation to perform if you find extensive spread of cholangiocarcinoma at laparotomy?
Cholecystectomy—stents often block the cystic duct, causing cholecystitis!
How do you find the segment III hepatic duct?
Follow the falciform ligament into the umbilical fissure
How do you advance a dilator when placing a large IV catheter?
Always under fluoroscopic guidance, so the dilator does not have to follow a flimsy guidewire!
What intraperitoneal pressure is needed to release an abdomen to avoid abdominal compartment syndrome?
>25 mm Hg with compromise (think: “release >25—keeps the patient alive”)
Which is closed first: the top or bottom of a laparotomy fascial incision?
Bottom—get the guts in first! (Liver is up top)
What must be in place before doing a diagnostic peritoneal lavage (DPL) for trauma?
1. Foley catheter 2. Nasogastric tube (NGT) or orogastric tube (OGT)
How do you mark a specimen for orientation?
Short suture = Superior Long suture = Lateral
When should you biopsy an esophageal leiomyoma?
Never
When do you mark varicose veins?
Preoperatively, while the patient is standing; use nonpermanent ink; otherwise you might tattoo the skin!
104 Section I / Overview and Background Surgical Information
Should you ever use a Bovie during a tracheostomy?
Never on the trachea—100% oxygen can result in a fire!
When is the best time to cut the peritoneum?
During expiration, because the bowel falls away
Should you close the small bowel longitudinally or transversely?
Transversely—better to shorten than to stricture!
Where must the catheter be placed for a DPL with a pelvic fracture?
Supraumbilical position (pelvic hematoma tracks up the medial umbilical ligaments); even with a supraumbilical approach, there is up to a 20% false-positive rate!
What are the seven pearls for successfully placing a subclavian central line?
1. Place towels below scapulae transversely or between the scapulae 2. Place patient in the Trendelenburg position (think: headdownenburg) 3. Keep the needle flat 4. Go for the left subclavian, if all things are equal 5. Always have one hand on the wire at all times and never let go 6. Always go on the side of a chest tube (chest tube treats pneumothorax) 7. Always get a chest x-ray after the procedure, before moving the patient, or before trying the other side
What are the four pearls for easy placement of an NGT?
1. Flex the head (chin to chest) 2. Apply mild topical anesthetic (e.g., Cetacaine spray) 3. Apply lubrication 4. Have the patient drink water
How many rings on the stapler do you need after a successful EEA with a stapler?
Two
Chapter 15 / Surgical Operations You Should Know 105
What will help open the pylorus and stop the contractions of the stomach/ duodenum during an esophagogastroduodenoscopy (EGD)?
IV glucagon
What will help retain contrast dye during a biliary cholangiogram?
IV morphine
Can the suprarenal IVC ever be ligated?
No; a mortality rate of ≈100% is associated with such attempts
How can you tell if a body fluid is pus or tube feeding?
Check the glucose; tube feedings have a high glucose level
Can the infrarenal IVC be ligated?
Yes, but with a morbidity rate of ≈50%
How should a through-andthrough penetrating injury to the IVC be fixed?
Enlarge the anterior defect, fix the posterior defect, and then close the anterior defect
Which three veins must be ligated during a Warren distal splenorenal shunt for esophageal varices?
1. Coronary vein (left gastric vein) 2. Right epiploic vein 3. Left gonadal vein
If a 12-French Foley catheter cannot be inserted into the bladder, what should be tried next?
1. Larger Foley catheter 2. Lidocaine jelly to anesthetize the urethra 3. Coude catheter
During an inguinal hernia repair, the suture needle goes through the femoral vein or artery. What should be done?
Remove the suture and hold pressure; do not tie the suture down!
How should an anal fistula that goes above the anal sphincters be treated?
Seton suture, which will allow subsequent tightening and scarring down of the sphincter muscles
106 Section I / Overview and Background Surgical Information
What test should be performed after a tracheostomy?
Chest x-ray
After the mesoappendix is stapled off during a lap appy, the appendiceal artery continues to pump blood. What should be done?
A metallic clip (as used for lap chole) can be applied or a suture must be placed
How should the skin be closed after a grossly contaminated abdominal case?
It should be left open, and closed by secondary intention or delayed primary closure
How should a vas injury be repaired during a procedure to correct an inguinal hernia?
A urologist should be called in to perform an end-to-end repair (unless the patient is elderly)
How should an ilioinguinal nerve transection be repaired during a procedure to correct an inguinal hernia?
A metallic clip should be applied to prevent neuroma formation
What can help identify the ureters during a difficult pelvic dissection (e.g., postradiation)?
Preoperative ureteral stents placed by a urologist
What can help identify an occult ureteral injury?
IV indigo carmine (collects in urine and most likely will be seen in operative field with ureteral injury)
Why do some surgeons “bowel prep” for gastric cancer surgery?
In case of the unexpected gastrocolonic fistula
Prior to prepping a patient, what mental checklist should be reviewed?
Position? Antibiotics? Clip hair? Sequential decompression device (SCD) boots? NGT? Foley? Special equipment ready and available? Fluoroscopy needed?
What are the five intraoperative signs of Crohn’s disease?
1. 2. 3. 4. 5.
Creeping mesenteric fat Thickened mesentery Thickened bowel wall Serositis Abscesses/fistulae/strictures
Chapter 15 / Surgical Operations You Should Know 107
Should a frozen section be taken to rule out microscopic disease at the margins before an anastomosis after a smallbowel resection for Crohn’s disease?
No; microscopic disease at an anastomosis does not have any effect on the rate of anastomotic healing (1 cm of grossly normal bowel is needed for margins with Crohn’s disease)
A stable patient has a chestpenetrating wound in the box formed by the clavicles, nipples, and costal margins. How should this patient be evaluated for cardiac injury?
Subxiphoid pericardial window or echocardiogram if no hemothorax
What is the strongest layer of bowel for an anastomosis?
The submucosa (not the serosa; think SUbmucosa = SUperior strength)
Should you mobilize and dissect out the ureter?
No; dissecting out the ureter will devascularize it
How can you shrink a prolapsed rectum or colostomy?
Put sugar on it!
What condition contraindicates a hemorrhoidectomy?
Crohn’s disease
LAPAROSCOPIC PEARLS What must you do when you use the argon laser during laparoscopy?
Open a trocar vent; otherwise, intraabdominal pressure will build up and may result in CO2 embolus
What is the appropriate treatment for bladder Veress needle puncture?
Postoperative Foley drainage
What is the appropriate treatment for trocar bladder injury?
Closing by suture and placement of Foley drainage
How can placement of a trocar through an epigastric vessel be avoided?
Transilluminate the abdominal wall and identify the vessels
108 Section I / Overview and Background Surgical Information
Name the four options for repair of a bleeding trocar site:
1. Insert a Keith needle into the peritoneal cavity, out the abdomen, under the vessel, and tie over a bolster 2. Cut down and tie off the vessel 3. Insert a Foley catheter through the trocar site; pressure should be held with outward traction 4. Carter Thomason port closure system ligation
Chapter 16 Cell Biology and Cytokines List the major characteristics of prokaryotic cells:
Simplest cells Few organelles Lack nuclear membranes (All bacteria are prokaryotes)
List the major characteristics of eucaryotic cells:
Sophisticated cells Specialized organelles Distinct nucleus (All animal cells are eucaryotes)
Describe the following phases of the mammalian cell cycle: G1
Slow biosynthesis (ploidy = 2n)
S
DNA synthesis (Think: S = Synthesis)
G2
Lag phase between DNA synthesis and mitosis (ploidy = 4n)
M
Mitosis (Think: M = Mitosis) Shortest phase Cell division (two daughter cells, each 2n)
Describe the following organisms: Gram-positive
Thick cell wall; single-layer plasma membrane; lacks mitochondria and a nuclear membrane
Chapter 16 / Cell Biology and Cytokines 109
Gram-negative
Thin cell wall; plasma membrane with inner and outer layers (outer = endotoxin); lacks mitochondria and a nuclear membrane
Fungus
Cell wall is structurally different than that of bacteria; has mitochondria and a nuclear membrane
Describe the function of the organelles listed as follows: Smooth endoplasmic reticulum
Steroid and lipoprotein synthesis, detoxification, fatty acid desaturation
Rough endoplasmic reticulum
Synthesis of proteins for export from cells
Free ribosomes
Synthesis of proteins for use within cells
Golgi apparatus
Protein modification prior to export
Lysosome
Proteolysis of cellular debris and exhausted organelles
Peroxisome
Enzymatic hydrolysis of fatty acids and amino acids; by-product is toxic H2O2, which is reduced by catalase
Nucleus
Contains most of the cell’s genetic material
Nucleolus
Also known as the nuclear organizing region; synthesizes ribosomal RNA (rRNA) for export to cytoplasm
Messenger RNA (mRNA)
Reads nuclear DNA to form the mRNA template; the template then moves to the cytoplasm for translation during protein synthesis
rRNA
Site of mRNA interpretation during protein synthesis
110 Section I / Overview and Background Surgical Information
Transfer RNA (tRNA)
Reads mRNA at the ribosome and delivers the appropriate amino acid for protein synthesis
Mitochondria
Site of cellular respiration and ATP production
What important biochemical reaction occurs in the mitochondrial matrix?
Krebs cycle (citric acid cycle) generates NADH and FADH2 to power the electron transport chain
What is the electron transport chain?
A series of closely linked oxidative phosphorylation reactions at the mitochondrial membrane that drives ATP production
What conditions inhibit the Krebs cycle (and therefore inhibit cellular respiration and ATP synthesis)?
Acidosis and excess pyruvate
What conditions inhibit the electron transport chain?
Hypoxia and cyanide poisoning; the clinical result is lactic acidosis
Describe the workings of the following second-messenger systems: cAMP
Generated by adenyl cyclase, it acts as an intracellular messenger by activating protein kinase A, which then activates target proteins
Phosphatidylinositol phosphate (PIP)
Receptor activation leads to phosphorylase C cleavage of PIP to IP3 and DAG, both of which act as intracellular messengers
Calcium (Ca2+)
Rapid increases in intracellular Ca2+ activate calmodulin, an intracellular protein that activates other cytoplasmic proteins
Chapter 16 / Cell Biology and Cytokines 111
Describe the location and/or function of the following cell types: Gastrointestinal parietal cells
Fundus/body of stomach; produce HCl and intrinsic factor
Chief cells
Fundus/body of stomach; produce pepsinogen
Mucous neck cells
Fundus/body of stomach; produce mucus and HCO3– to form a protective layer at the gastric mucosa
G cells
Antrum of stomach; produce gastrin in response to antral distention, vagal stimulation, and peptides; inhibited by pH
