Dr. Stevenson Surgery
rotation
Cat Lok celok01@atsu.edu
Purpose
I made this PPT in order to study and also to help future students rotating w Dr.
Stevenson with medical content knowledge.
Topics: It’s a party!
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Bariatrics Bonanza!
Stomach Shinanagins!
Gall Bladder Gala
Hernias Hoopla!
Anatomy Affair!
Anesthesiology Amusement!
Surgery Shindig
Random Rager!
Bariatrics Bonanza
Bariatric = Obesity
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Bariatric Surgeries
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*Sleeve- the best
Lapband: old surgery but lots of complications like infections and slipping off
Bypass: bypass the duodenum but then major vitamin deficiencies
Bariatric = Obesity
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*Gastric Sleeve
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Great vid of the surgery itself: https://www.youtube.com/watch?v=KM6UQzMwbWU
Need to do EGD first to check for stomach ulcers.
Cuts off most of stomach
Lose 1-2 lbs a week
Cures 70% of sleep apnea, htn, high cholesterol and diabetes
Peroperative
Liquid diet 3 weeks b4 surgery (to shrink liver)
Diet (7 weeks after surgery)
■ liquids
■ Creamy soupy at week 3
■ Work up in consistency till week 7
Things to watch for:
■ Dehydration from salty soups and not eating much food anymore so don’t get the water
that used to be in that food
Gastric Sleeve: BMI requirements
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Between BMI 40-50
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Can do BMI 30 if they have a serious health condition and can only get the lapband
Can do BMI 35 if they have an obesity caused disease: heart disease, diabetes, and sleep
apnea
Pimp Question!
Q: What arteries supply the stomach? (thus good cz wont become ischemic)
A:
Pimp Question!
Q: What arteries come off the celiac trunk?
A:
Pimp Question!
Q: In a gastric sleeve operation, what space are u in when you cut the connection
of the stomach and omentum?
A: Lesser omentum
Pimp Question!
Q: In a gastric sleeve operation, if it will rip, where will it rip?
A: eso-stomach junction
Pimp Question!
Q: What is the prevalence of the sleeve leaking/breaking? And where does it
happen in the stomach most?
A: 1% but could die because sepsis. It jumps to 10% if it’s a redo surgery. It
happens most at the eso-stomach junction. This is because of La Places law that
says if you have a larger radius then the tensions is more especially as a big
chunk of bread enters the stomach right there. To prevent this: stick to the post op
diet, no breads (bcz they expand) and give short staple lines.
Pimp Question!
Q: In a gastric sleeve operation, how do you know it was successful? And how
successful is it?
A: EWL(excess weight loss) >50%. It is 96% successful in 1st year and 73%
successful by year 5.
Stomach Shenanigans
Stomach ulcers
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EDG them all because they could all be cancer, especially H. pylori ones
H. pylori ulcers are singular and deep and in the antrum. Because they are
deep they can reach the lymphatics and cause MALT lymphoma
GallBladder Gala!
Match these!
Hint:
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Chole = Gallbladder or Common Bile Duct
Cyst = Gallbladder
Doco = Common Bile Duct
Lithiasis = Stone
Match these!
Cholecystitis
Stones in GallBladder
Cholelithiasis
Stones in Common Bile Duct
Cholidocholithiasis
Inflammation of GallBladder
Cholangitis
Ascending infection up biliary tree
Match these!
Cholecystitis
Stones in GallBladder
Cholelithiasis
Stones in Common Bile Duct
Cholidocholithiasis
Inflammation of GallBladder
Cholangitis
Ascending infection up biliary
tree
Match
Matchthese!
these!
Cholecystitis
Stones in GallBladder
Cholelithiasis
Stones in Common Bile Duct
Cholidocholithiasis
Inflammation of GallBladder
Cholangitis
Cholangitis
Cholelithiasis -> Cholecystitis -> Cholidocholithiasis -> Cholangitis
Note: inflammation proximal to stone
Cholelithiasis
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Stones
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Dx
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Cholesterol: green
Pigmented: black from dead RBCs
Mixed: most common
HIDA scan (contrast through liver)
Symptoms: cholicky RUQ pain
Tx
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Cholecystecomy: no rush
If can’t do surgery: ursodeoxycholic acid (bacteria’s bile acid)
Cholecystitis
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Stones now moved to cystic duct
Symptoms: constant RUQ pain
Murphys sign most specific for this
Dx
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US
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Pericholecystic fluid
Thickened wall
TX
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Fluids and antibiotics
Cholecystectomy: urgent because could burst
■ Cholecystostomy if can’t do surgery
Choledocholithiasis
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Now stone in biliary tree
So if really far then liver and pancreatic inflammation
Symptoms: now jaundice as well
Dx
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US: dialated ducts and stone
MRCP
Tx
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Cholecystisis tx plus
ERCP to get stone out
Cholangitis
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Infection ascends from CBD up tree
Fever now too
Symptoms: Charcot’s triad and Reynouds pentad
DX
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US
TX
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ERCP emergent first to get stone out!
Antibiotics and fluid
Cholangiocarcinoma cancer
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Strictures
SLOW so neg murphys or pain
jaundice
Dx ERCP
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FOBT test pos but neg colonoscopy is ampula of vader cancer
r/o choledocholithiasis because jaundice
Antibiotics for GB issues
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G- and anerobes
Cipro and metro or
amp/gent and metro
Cholecystectomy
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Bad surgical outcome: accidently cutting common bile duct
Cholecystectomy: Pimp question!
Q: What is the critical view?
A: It is where you are trying to make sure you don’t cut anything you shouldn’t so
you meet these criteria: 1) see only two things coming out of the GB: cystic dyct
and artery 2) clear the hepatocystic junk (fascia and fat) 3) free up distal ⅓ of GB
Cholecystectomy: Pimp question!
Q: What is Charchot’s triad? And Reynoud’s pentad?
A: Charchot’s is to dx acute cholecystitis and cholangitis. Reynouds is that plus
now septic.
Charchot’s triad: jaundice, fever, abdominal pain
Reynoud’s pentad: same as triad plus hypotension and altered mental status
Pimp question:
Q: How do you diagnosis Cholecystitis?
A: Ultrasound. You will see 3 things. 1) thickened GB wall 2) **Pericholecystic
Fluid 3) Gallstones
Pimp question:
Q: Tx for Cholangitis
A: Antibiotics
Pimp question:
Q: Surgery to correct Common Bile Duct accidental transection?
A: hepaticojejunostomy that connects liver to jejunum (can’t do further up because
too crowded and intraperitoneal). This is a big procedure so they will be staying in
the hospital on average 9.5 days. Need to fix quick or else cholangitis, bilomas
and sepsis. If its a tiny knick then just sew up.
Pimp question:
Q: What’s it called when youre taking out a GB and its wedged in the liver
A: Intrahepatic. Just a longer surgery cz have to burn more to get it out.
Hernia Hoopla!
Hiatal Hernia Types (4)
1: sliding: stomach slides up
2: periesophageal: stomach not herniates out and around the esophagous
3: mixed: (of 1 and 2)
4: Whole stomach is now above the diaphram and maybe even other organs too
(hard to breathe now because compress lungs)
Naming Hernia
Reducible -> incarcerated -> strangulated
Bad if it progresses because ischemia or obstruction
Treatment
Dr. Stevenson will say do surgery because you don’t want to risk incarceration
causing bowel ischemia. Do it always for patients < 65 years old (if >65 then
consider their health)
This is even though abdominal surgeries cause 70% of bowel obstructions later on
and risk if ischemia is <5% unless femoral (25%)
Pimp Question
Q: What is in inguinal canal?
A: spermatic chord, vas deferens, vas deferens artery, vein leading into
pampiniform plexus, genital branch of genitofemoral branch, cremasteric muscle
surrounding it all
Pimp Question
Q: Type of hernia that is both an indirect and direct hernia?
A: “pantaloon” hernia because both legs of “pants” straddle the inferior epigastric
artery
Pimp Question
Q: Talk to me about post inguinal hernia repair pain.
A: You can get chronic pain from it. (defined by pain lasting >3 months after the
surgery). They did a study in 2014 found 39.4% of people had pain >6 months.
The found it was due to nerve injury. So to prevent this you need to visual the
inguinal nerves and triangle of pain. To Tx this you inject steroids near the nerve.
Pimp Question
Q: What’s so special about a femoral hernia?
A: In pregnant women because of pressure. Has a higher chance of bowel
incarceration (25%) than other hernias because its so slow so more weight.
Pimp Question
Q: Types of diaphragmatic hernias (don’t confuse with hiatal hernias). Remember
the diaphragm forms in the front first to protect the abdominal organs thus the
posterior hernias are most common.
A:
Bochdalek hernia (posterior diaphragm)
Morgagni hernia (anterior diaphragm)
Pimp Question
Q: How do you distinguish b/w direct and indirect hernia?
A: Placement relative to inferior epigastric a.
Medial = direct
Lateral = indirect
Note: indirect in baby boys
Anatomy Affair!
Pimp Question
Q: What is the borders and contents of the Triangle of Doom and Pain
A:
Pimp Question
Q: What is the Calot triangle? (aka hepatocystic
triangle)
A:
Calot triangle is inferior liver border, cystic duct and
common bile duct. Historically it was the cystic artery
not the inferior liver border but they expanded it
because the lymph node ended up being a little more
spread out. This is important because the contents is
the Calot lymph node and cystic artery so try to stay
awy from this area.
Pimp Question
Q: Length of trachea?
A: 11cm. Esophagus is double that (22cm)
Pimp Question
Q: What is this structure?
A: Falciform ligament that separates right and left lobe.
Anesthesiology Amusement!
Pimp question!
Q: What are the two classes of paralytics?
A: Depolarizing and Nondepolarizing. Depolarizing agents actually compete with
the Ach binding site to depolarize the muscle. Nondepolarizing don’t compete.
Thus you need higher concentrations of nondepolarizing. Rocuronium is the one
you need to know for nondepolarizing.
Pimp question!
Q: What is rocuronium?
A: Paralytic. Depolarizing so will actually spasm muscles that’s okay even though
it’s freaky. It’s also depolarizing so you dont have to use as much concentration.
It’s also nice because it’s longer acting that succinylcholine which is another
depolarizing paralytic.
Pimp question!
Q: Antidote for Rocuronium?
A: an acetylcholinesterase inhibitor like neostigmine. This makes sense because
you block the breakdown of Ach
Pimp question!
Q: what to give for malig hyperthermia caused by succynlcoa?
A: dantrolene. Dantrolene makes ranitidine not release ca so skel muscles dont
contract and cause heat
Pimp question!
Q: Side effect of paralytics?
A: ischemia because they are anti ach(parasympathetic) thus sympathetic
vasoconstricts. Thus brain ischemia, bowel ischemia, any ischemia
Pimp question! (one of the anesthesiologist points to
bottles)
Q: What do these meds do?
A:
rocuronium: paralytic
Propofol: knocks you out
Ketorolac: NSAID
Odansetron- 5HT blocker for nausea
Dexamethasone: steriod for nausea if odansetron isn’t enough
Surgery Shindig!
Pimp question!
Q: What is a seroma?
A: Serous fluid buildup in a surgical wound. That’s why you have to close them up
deep so it won’t build up.
Pimp question!
Q: What is a Nissen fundoplication?
A: where you wrap the fundus of stomach around bottom of esophagous so won’t
herniate up through diaphragm again
Random Rager!
Pimp Question!
Q: What is a Fitz Hugh Liver?
A: Perihepatitis from PID especially ghonorrea. Because remember ghonorrea
goes everywhere (joints etc) and also the dead chlamidia and ghonorrea proteins
have to be processed in the liver thus periherpatits
Pimp Question!
Q: when to not give nsaids (like *ketorolac) after a surgery?
A: when they are a bleed risk
Pimp Question!
Q: Treatment for H pylori
A: Triple therapy (or quadruple therapy if necessary). Triple Therapy: OAC:
Omeprazole, Amoxicillin and Clarithromycin
Pimp Question!
Q: what is this?
A: diastasis recti. Not a hernia so don’t do surgery. It’s just a seperation of the abs
from being fat
Pimp question!
Q: how does a H pylori ulcer look different from other stomach ulcers?
A: Deeper and only one because H pylori is a bacteria thus biofilm thus can
penetrate. It may cause MALT cancer. It is also in the antrum moreso than the
body.
Pimp question!
Q: how does stress cause stomach ulcers
A: the vagus nerve is emotionally regulated
Pimp question!
Q: What is a GIST?
A: GIST (GastroIntestinalStromalTumor) most often in the stomach.
Pimp question!
Q: Why is epinephrine injected with lidocaine?
A: epinephrine prolongs lidocaine action by it vasoconstricts thus lidocaine is
taken away from site by blood slower. A nice side effect is that is stops bleeding
because of vasoconstriction too.
Pimp question!
Q: Types of eso cancer?
A: Squamous cell and adenocarcinoma. Adenocarcinoma is worse prognosis
because it’s metaplasia (of squamous to pseudocolumnar)
Pimp question!
Q: Surgical margin around colon cancer?
A: 5cm (7cm if you’re a surgeon who cares)
Pimp question!
Q: How many lymph nodes do you need to be removed in colon cancer to be clear
A: 12
Pimp question!
Q: Why do you check the liver pre-operatively
A: Because the liver makes clotting factors. This is because it makes fat soluble
proteins. Fat soluble clotting factors are 2,5,7-12 and c and s proteins. Thus you
need to check a PT and INR.
Pimp question!
Q: Symptoms of a pneumothorax?
A: fast respirations, chest pain, dyspnea, decreased lung sounds over that area,
hyper-resonance over that area, visiblly breaths not moving in that area, coughing,
confirm with x-ray (see the visceral-pleural line and shift maybe)
Pimp question!
Q: Tx for pneumothorax?
A: Need decompression 2nd intercostal area right above rib 3, midclavicular. If in
patient then can do thoracostomy in anterior axillary line under right rib 4 (nipple
line).
Pancreatic Cancer
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Will probably die within 5 years
Spreads to 3 surrounding organs (duodenum, GB, common bile duct)
Do a Whipple surgery where you whip out (remove) head of pancreas and 3
surrounding organs
Pimp question!
Q: Port Placement indication?
A: When need to give IV meds often like in cancer patients or
hemodialysis/plasmapheresis. Or if can’t get peripheral access. Also used for
fluids, parenteral feeding, and placing IVC filters and heart monitors
Note: relative contraindications
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if coagulopathy because would then bleed
Dialysis because then can’t use those site for dialysis
Pimp question!
Q: Port Placement where to find incision site?
A: 2cm below distal 2/3s of clavicle line then thread into into right subclavian then
down to right before the right atrium (because when pt stands up the line will rise a
little). You can get to the subclavian vein from the top of clavicle but then risk
hitting subclavian artery.
You can also put it in the internal jugular behind the SCM or between the heads of
SCM. (Don’t hit the carotid artery medially)
Pimp question!
Q: Port Placement risks?
A: Hematoma, infection, atrial arrhythmia, losing the wire then punctures heart,
pneumothorax, hemothorax, thrombus because vessel injury
Pimp question!
Q: Port Placement how to screen for placement?
A: fluoroscopy or xray to check for placement and pneumo
Pimp question!
Q: After you eat when would you feel the food (or pathology worsened by the food)
in the stomach? In the gallbladder?
A:
Stomach: seconds
Gallbladder: 5-10 minutes
Pimp question!
Q: You have a pt with inflamation somewhere in their bowel; where will there be a
perforation
A: No matter the location, the perforation may be in the cecum. This is because of
La-Place’s law that says the wide the radius, the more the tension therefore will
perforate. Well the cecum has the largest radius of the bowel.
Pimp question!
Q: What are the liver cirrhosis classifications
A:
Child Pugh (class A, B or C depending on points up to 15) (think like children get
graded in school A’s, B’s, C’s. and you want an A, can’t operate on C! But you
stop caring about grades when you get to high school aka age 15). Scoring
depends on ascites, encephalopathy, INR or PT(high), bilirubin(high) and
albumin(low). If has any one of these then 40% chance of death. If all of these
then 100% chance of death.
Meld Score: changes everyday in hospital
Pimp question!
Q: What is a pilonidal cyst
A: cyst on the top of your butt crack. There is a sinus
(tube connecting it to your skin). Pilo means hair and
nidal is arabic for struggle so an ingrown butt hair has
caused your struggle. It’s congenital or acquired in
that the skin above the butt crack is stretched when
bending then fascia rips and hair follicles are stuck
inside. Tx is incision and drainage then excise cyst if
needed. Will marsupialize it so layers won't grow into
eachother again
Misc. questions (not pimp questions)
Q: Pt comes in w diarrhea but also said he gets a feeling of feeling FLUSHED.
A: carcinoid syndrome (serotonin is a vasodialator thus will give u diarrhea +
flushing). Can also have wheezing. Usually in appendix. Mets to right heart and
lung. Dx with 5HIAA (breakdown of 5ht)
Diverticulitis Tx
Tx for diverticlitis
A: metronidazole and clindamycin (the two aneoribic antibiotics because you have
to get to the bacteria plus the bacteria in the diveticuli)
Abscesses
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This is a fancy name for a pocket full of anerobic smell bacteria
Tx I&D:
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Because they are anerobic you can incision and drain them and that will cure it along with
some antibiotics
Numbing agents won’t work because they have HCL in them. HCL can dissociate from
lidocaine with it’s in already acid environment (the abscess) thus the patient will feel the I&D
Spigelian hernia
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Type of ventral hernia
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Hernia between rectus abdominis and transverse (just medial to semilunaris fascia) and lower
in the abdomen (more weight)