General Surgery with Dr. Stevenson Question Study Guide
Office
 Polly is office coordinator
Locations
 Clinic
 Mercy Gilbert
 Chandler Regional
Scrub in
 Every other case, close at end of day
 Bring snacks, might not get a break
Dress code
 Business casual
Answering pimp questions
1. Don’t repeat question
2. Don’t answer with a question
3. Answer with enough information to demonstrate understanding of topic (avoid word diarrhea)
4. That’s what she said
Best time to scrub in?
 When they are about to start prepping the patient
Pre-Op
 Small incisions
 If that is where you are most comfortable
Post-Op
 Recovery from ___ procedure
 Avoid heavy lifting
o Anything heavy enough where you have to hold your breath
 Weight 6 weeks from surgery for colonoscopy
Patient Q’s
 Mesh made of polyprophythene
Lullaby = baby born
Anesthesia
 Difficult airway algorithm
o #1 skill an anesthesiologist should have is being able to Bag valve mask ventilation!
Pelvic inflammatory disease -> Fitz-Hugh-Curtis
Colon cancer -> mets to Liver (1st), lung (2nd)
-Misc:
 Hypothetical situation -> milky fluid from pancreas -> check amylase/lipase
 The French scale or French gauge system is commonly used to measure the size of a catheter. It
is most often abbreviated as Fr, but can often be seen abbreviated as Fg, FR or F. It may also be
abbreviated as CH or Ch (for Charrière, its inventor). However, simply gauge, G or GA generally
refers to Birmingham gauge.
o The French size is three times the diameter in millimeters. Thus, the French size is
roughly equivalent to the circumference of a circular catheter; the true circumference
being slightly larger (circumference = diameter * π where π is approximately 3.14).
o A round catheter of 1 French has an external diameter of 1⁄3 mm,[2] and therefore the
diameter of a round catheter in millimetres can be determined by dividing the French
size by 3:
o 1 mm = Pi Fr
o 1 mm = 3 Fr
o 1 Fr = 1/3 mm


o
Co2 is used for insufflation because it is pretty absorbable and less likely to cause air embolism if
vein is nicked. Treatment for air embolism includes Trendelenburg and high flow oxygen
Falciform ligament attaches to liver and is a remnant of fetal umbilical vein
For port placement:
 Subclavian central line borders
o
o
o
o
o
https://www.youtube.com/watch?v=_VYHj4sRlkc
https://anwresidency.com/simulation/guide/subclavian.html
In the normal variant of human anatomy, the subclavian vein occurs bilaterally and is a
continuation of the axillary vein (a continuation of the brachial vein) from either upper
extremity. At the lateral border of the first rib, the axillary vein becomes the subclavian
vein where it passes over the rib in the groove of the subclavian vein. Just posterior to
the subclavian vein in this area is the axillary artery which becomes the subclavian
artery at the lateral border of the first rib and lies in the groove of the subclavian artery.
The subclavian vein continues beneath the clavicle heading towards the sternal notch
until at the medial border of the anterior scalene muscle it joins the internal jugular vein
and becomes the brachiocephalic vein, also called the innominate vein. Also important
to note is the pleural apex of the lung which lies inferior to the medial aspect of the
subclavian vein. The left side pleural apex often projects more superiorly than the right
leading to an increased risk of pneumothorax with left-sided access. The thoracic duct
also terminates at the junction of the left subclavian vein and internal jugular vein. This
is importantly related to subclavian venous access because it represents another area of
o

potential injury. A potential advantage of left-sided access is the easier sweeping curve
of the left innominate vein that leads to the superior vena cava located in the right
mediastinum
https://www.ncbi.nlm.nih.gov/books/NBK482224/
o
IJV borders
o


o
Seldinger technique
o Technique
1. desired vessel or cavity is punctured using a trocar (hollow needle)
2. soft curved tip guide wire is then inserted through the trocar and advanced into
the lumen
3. guidewire is held secured in place whilst the introducer trocar is removed
4. large-bore sheath/cannula/catheter is passed over the guidewire into the
lumen/cavity
5. guidewire is withdrawn leaving the introducer sheath in situ through which
catheters and other medical devices can be introduced
 https://radiopaedia.org/articles/seldinger-technique?lang=us
Pneumothorax
 Signs and symptoms
1. Tracheal deviation contralaterally
 Treatment
1. Needle decompression
2. Chest tube placement
For hernia procedures you should know:
 -the anatomical structures and boundaries of the triangle of pain
o The Boundaries are The Gonadal Vessels (Testicular artery and Vein) - Medially The
Iliopubic Tract- Superiorly and the Peritoneal Reflection below. Contents of this triangle
include Femoral branch of Genito femoral nerve, and Lateral cutaneous nerve of thigh.
 -the anatomical structures and boundaries of the triangle of doom
o

Triangle of Doom is an anatomical triangle defined by the vas deferens (male) or round
ligament of the uterus (female) medially, spermatic vessels laterally and peritoneal fold
inferiorly.[1] This triangle contains external iliac artery and vein, the deep circumflex
iliac vein, the genital branch of genitofemoral nerve and hidden by fascia, the femoral
nerve.
o It bears significance in laparoscopic repair of groin hernia. Surgical staples are avoided
here.
Circle of death – corona mortis
o The circle of death (corona mortis) refers to the anastomotic branches of vasculature in
this region formed by the common iliac, internal iliac, obturator, inferior epigastric, and
external iliac vessels
o

o
-the anatomical structures and boundaries of hesselbach’s triangle
o Medial border: Lateral margin of the rectus sheath.[1][2]
o Superolateral border: Inferior epigastric vessels.[1][2]
o Inferior border: Inguinal ligament.[1][2]
o This can be remembered by the mnemonic RIP (Rectus sheath (medial), Inferior
epigastric artery (lateral), Poupart's ligament (inguinal ligament, inferior).
o The inguinal triangle contains a depression referred to as the medial inguinal fossa,
through which direct inguinal hernias protrude through the abdominal wall
o
o
o
o
o
o
o
o
o

An appendix hernia is called Amyand hernia

o
The term used when someone has ipsilateral direct and indirect hernias at the same time
o Pantaloon hernia
o
o

o
-know how to differentiate between a direct and indirect hernia
o -medial vs lateral to the inferior epigastric vessels
Direct
Indirect
Femoral
Umbilical
Direct through
Hesselbach
triangle
Internal deep ring, along canal, out
superficial ring. (external oblique
muscle aponeurosis) Into the scrotum
Below
inguinal
ligament
Failure of the umbilical ring to close during fetal
development causes congenital umbilical hernia.
The midgut develops outside the abdominal cavity
, inferior
lateral to
PT.
Medial
to the
inferior
epigastri
c artery
Medial to
epigastric
artery
Lateral to epigastric artery. (INFERIOR
EPIGASTRIC VESSELS)
Requires
surgical
intervent
ion
(more
incarcer
ation/str
angulati
on)
Older men:
weak wall
(transversalis
fascia)
Commoner in the young. M>F
More
common
in
women
MDs don't
LIe" (MedialDirect and
LateralIndirect.)
congenital defect of the processus
vaginalis when it fails to close (can
also form a hydrocele)
herniated
bowel is
covered in
external
spermatic
fascia alone
Covered by all 3 layers of spermatic
fascia
The processus vaginalis descends
anterior to the testis via the gubernaculum
during embryonic development. Failure of
this conduit to obliterate after testicular
descent into the scrotum causes
outpouching of the parietal peritoneum
(and bowel) through the deep inguinal
ring, the inguinal canal, and the superficial
inguinal ring, leading to an indirect
inguinal hernia. These hernias are located
until the second trimester, when it physiologically
herniates back into the abdomen. If the umbilical
ring fails to close or the fascia in this region is
underdeveloped, abdominal content may bulge
through the umbilicus. Umbilical hernias are more
common in children with chromosomal
abnormalities (e.g., Down syndrome, Edwards
syndrome) or congenital hypothyroidism, as seen
here. Most congenital umbilical hernias resolve
spontaneously by 5 years of age.
outside the Hesselbach triangle, lateral to
the inferior epigastric vessels, and can
manifest with a communicating hydrocele,
as seen in this patient.

-the layers of the abdominal wall below the arcuate line
o Components of the anterior abdominal wall
o Layers (from superficial to deep)
 1. Skin and subcutaneous tissue
 2. Superficial fascia
 3. Superficial fatty layer (Camper fascia)
 4. Deep membranous layer (Scarpa fascia)
 5. External oblique muscle
 6. Internal oblique muscle
 7. Transversus abdominis muscle
 8. Deep fascia (transversalis fascia): fuses with the deep fascia of the thigh
(fascia lata)
 9. Preperitoneal adipose tissue
 10. Parietal peritoneum
o
For lap choles you should know:
 -how to define the critical view
o Critical view of safety: method for secure identification of the cyst duct and cystic artery
during laparoscopic cholecystectomy
o https://www.youtube.com/watch?v=K62kqwDjY_Q
o https://www.sciencedirect.com/science/article/pii/S221026121400368X
o https://ales.amegroups.com/article/view/3940/4771
o https://www.sages.org/safe-cholecystectomy-program/

-the structures of the portal triad
o The portal triad contains the extrahepatic segments of the portal vein, hepatic artery,
and bile ducts.
o The portal triad is contained within the hepatoduodenal ligament and contains the
portal vein (posterolateral), hepatic artery (medial), and bile ducts (lateral)

o
-that you need to be careful not to damage the hepatic duct

o
-the ligaments of the liver
o -also note the pars flaccida of the hepatogastric ligament
o
o
o
o
o
o
o

The hepatogastric ligament or gastrohepatic ligament connects the liver to the lesser
curvature of the stomach. It contains the right and the left gastric arteries. In the
abdominal cavity it separates the greater and lesser sacs on the right. It is sometimes
cut during surgery in order to access the lesser sac. The hepatogastric ligament consists
of a dense cranial portion and the caudal portion termed the pars flaccida.
-blood supply to the gallbladder
o

-important lymph nodes of the gallbladder
o
o
Cystohepatic triangle of calot




For bariatric surgeries you should know:
 -all of the blood supply to the stomach

o
-identify the most likely locations for H. pylori infection
 Antrum
 H. pylori (Helicobacter pylori) are bacteria that can cause an infection in the
stomach or duodenum (first part of the small intestine). It's the most common
cause of peptic ulcer disease.
o
For any cancers you will be asked:
 -the size of the margins to be excised
o -6-8 cm for gastric
o -5 cm for colorectal
o -5 cm proximal and 1 cm distal for rectal
 -know how many lymph nodes must be excised
o -15-16 minimum for gastric
o -12 for colorectal
 The National Quality Forum specifies that the presence of at least 12 lymph nodes
in a surgical resection is one of the key quality measures for the evaluation of
colorectal cancer. Therefore, the harvesting of a minimum of twelve lymph nodes
is the most widely accepted standard for evaluating colorectal cancer.
 https://www.hindawi.com/journals/grp/2018/1985031/
o
 Types of GI cancers
o Gastrointestinal stromal tumor (GIST)
 most common in the stomach but can be found throughout GIT
 Size of margins: ****
 Treatment: Resection and Imatinib (Gleevec) [Tyrosine kinase inhibitor of the cKIT receptor)
 Presentation
 Overt or occult GI bleeding – 28 percent (small intestine) and 50 percent
(gastric)

 Incidental finding (asymptomatic) – 13 to 25 percent
 Abdominal pain/discomfort – 8 to 17 percent
 Acute abdomen – 2 to 14 percent
 Asymptomatic abdominal mass – 5 percent
-know the management of rectal cancer
o -rectal cancer is primarily done by neoadjuvant therapy first
 Neoadjuvant chemotherapy is chemotherapy that a person with cancer receives
before their primary course of treatment. The aim is to shrink a cancerous tumor
using drugs before moving onto other treatments, such as surgery. Neoadjuvant
chemotherapy helps doctors target cancerous growths more easily at a later
stage
o

-major rectal cancer procedure types and the different indications for each
 -TES
 Transanal endoscopic surgery (TES) is an emerging technique that offers
transanal access to resecting benign, premalignant, or early malignant
lesions in the mid - to proximal rectum
 -TME
 Total mesorectal excision (TME) is a common procedure used in the
treatment of colorectal cancer in which a significant length of the bowel
around the tumor is removed. TME addresses earlier treatment concerns
regarding adequate local control of rectal cancer when an anterior
resection is performed
 -LAR
 Low anterior resection (LAR) is a surgery that's done to treat rectal
cancer. During LAR surgery, the part of your rectum with the cancer will
be removed. The remaining part of your rectum will be reconnected to
your colon. You'll be able to have bowel movements (poop) as usual once
you recover from your surgery.

-APR

An abdominoperineal resection (APR) is a surgery in which the anus,
rectum and sigmoid colon are removed. This procedure is most often
used to treat rectal cancers located very low in the rectum. Often this
surgery occurs after you have completed radiation and/or chemotherapy
treatments.
Bariatric surgeries
 https://asmbs.org/patients/bariatric-surgery-procedures
 Sleeve Gastrectomy
 Roux-en-Y Gastric Bypass
 Adjustable Gastric Band
 Biliopancreatic Diversion with Duodenal Switch
 Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy
Goodsall’s rule
PART 2
●
Know subcutaneous and subcuticular closures
●
●
●
Know abdominal compartment syndrome
○ Abdominal compartment syndrome (ACS) occurs when the abdomen becomes subject to
increased pressure reaching past the point of intra-abdominal hypertension (IAH). ACS is present
when intra-abdominal pressure rises and is sustained at > 20 mmHg and there is new organ
dysfunction or failure.
Liquid diet -> shrinks liver
Hiatal hernia -> tighten
Ghrelin decreased, restriction with sleeve, issues with malabsorption
H. pylori
- Incisura angularis (angular notch), lesser curvature of stomach before the pylorus
- Typical site for H. pylori
- Can also be in the pyloric antrum or body of the stomach
Laparoscopic Cholecystectomy
- laparoscopic is preferred due to less postoperative pain, better cosmetic, short hospital stay
Indications
- symptomatic cholelithiasis w/ or w/o complications
- asymptomatic cholelithiasis in patients’ risk for gallbladder carcinoma/gallstone complication
- acalculous cholecystitis
- gallbladder polyps >0.5cm
- porcelain gallbladder
Contraindications
- absolute: inability to tolerate anesthesia, peritonitis w/ hemodynamic compromise, refractory
coagulopathy
- relative: previous abdominal surgery, pregnancy, morbid obesity and severe comorbidities
Preoperative
- elevated total bilirubin, ALK PHOS
intraoperative
- critical view of safety - Lap Chole’s
○
○
Safe method for gaining sufficient view of Calot’s triangle
identification of cystic duct, cystic artery and common hepatic duct, it’s the critical view so that
you won’t accidentally cut the CHD
○ you need to see this view before taking out the gallbladder= if cant: cholangiography/open
procedure
○ gallbladder extraction via umbilical insicion
● calot's triangle
○ Cystic duct (CD)
○ Common hepatic duct
○ Cystic artery (CA)
● Calot’s node (adjacent and anterior to the cystic artery)
Complications
- Vascular injury, gallbladder perforation, mesenteric injury, bile duct injury
Post complications
- Bile duct injury, bile leaks, bleeding, bowel injury , retained CBD stones
US findings for cholecystitis: stones/sludge, GB wall thickening >3mm, pericholecystic fluid, dilation of the CBD
- Nuclear cholescintigraphy/magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde
cholangiopancreatography (ERCP)
Triangles of doom/pain for inguinal hernias
●
angle of His
○ Esophagogastric angle
○ Can be obtuse in hiatal hernia
○ Acid reflux barrier??
Laparoscopic Inguinal Hernia Repair
- Lap. surgery is approached form the posterior aspect and repair involves placing the mesh in the
preperitoneal space
- Two approaches transabdominal preperitoneal hernia repair (TAPP) and totally extraperitoneal hernia
repair (TEP)
TEP
TAPP
-
Performed in the preperitoneal space (trocar never enter the intraabdominal cavity). Space is made b/w
the peritoneum and the anterior abdominal wall so that the perineum is not damaged during the repair
Mesh is placed in front of the inguinal canal
You enter into the abdominal cavity and make an incision into the preperitoneum
Repair involves the placement of mesh in a preperitoneal (inside the perineum) which the periteneum
keeps the mesh away from bowel
Damage intra-abdominal organs, adhesions resulting in intestinal obstruction or bowel herniation
Complications
-intraabdominal adhesions
●
TAPP vs TEP procedures for inguinal hernias
○ TEP = totally extraperitoenal
■ Peritoneal cavity not entered; mesh used to seal hernia from outside
○ TAPP
■ Mesh through the peritoneal cavity, mesh used to seal hernia from outside
Indication
- Complicated hernia (develops bowel strangulation/bowel obstruction/incarcerated hernia that is not
reduceable)
- Inguinal hernia w/ moderate/severe symptoms
- Acute incarcerated inguinal hernia w/ failed reduction
- Femoral hernias
- Hernia that causes groin pain w/ exertion, inability to perform daily acitivities due to pain/discomfort
from the hernia, inability to reduce the hernia (chronic incarcerated)
- Uncomplicated hernias (not causing pain/issues)= watchful waiting
Contraindicated
- Patients that can’t tolerate general anethesia, patient’s that may be active groin infections/systemic
sepsis, ascites, pregnant patients, prior pelvic surgeries in the preperitoneum space
Mesh
-polypropylene w/ oven mesh (Marlex, Prolene, SurgiPro) is tacked on the abdominal wall
Complications
- Persistent groin pain, post-surgical hernia neuralgia, testicular complications (interference with the blood
supply to the testicles/damage to the vas deferens), sexual dysfunction, mesh infection/migration/erosion
into adjacent structures
Laparoscopic ventral hernia repair
-abdominal hernia is an organ that project through the body wall, usually through incisional sites but can include
epigastric, umbilical
Indication
-incarcerated/strangulated hernia, symptomatic ventral hernia
Contraindications
-inability to tolerate pneumoperitoneum or unable to access the perineum
-active skin infection
Complications
- Postoperative pain due nerve entrapment
- Wound complications
- Iatrogenic enterotomy
- Hernia recurrence
Open LAP for inguinal hernia repair
- You approach from the outside-in
- Can damage the ilioinguinal nerve (runs with the spermatic cord)
- Mesh is attached to the abdominal wall (internal oblique muscle) and the external oblique muscle is
closed over the hernia
- Tacked in the medial pubicle ligament, laterally to the cojoined tendon
o
Indications
- Same as the other hernias indications
Contraindications
- Inability to tolerate the anesthesia, coagulopathy, BMI>35 , tobacco use
Complications
- Recurrence of hernia, pain due to nerve damage
●
●
●
●
Know complications/indications for each procedure.
Engage the anesthesiologists and they will let you intubate.
blood supply to all abd organs
different fundoplication procedures
-
An inguinal/direct hernia at the same time is called pantaloon hernia
A hernia from the appendix is called Amyand hernia
Appendectomy
o Keep appendix in vs taking it out
o Must be <65
o Must be in hospital
The 5 W's of post-op fever
- Wind - atelectasis or pna - 24-48 hrs
-
Wound - infection >day 3, staph infection MC
Water- UTI’s, 2-3 days (or IV line infection)
Walking – DVT/ thrombophlebitis
Wonder drugs/Whopper - check all the pt.’s meds (anesthetic, antibiotics, salfa)
Parkland formula
-
The Parkland formula for the total fluid requirement in 24 hours is as follows: 4ml x
TBSA (%) [think rule of 9s] x body weight (kg); 50% given in first eight hours; 50% given
in next 16 hours
https://www.youtube.com/watch?v=iHsilm0Ybxw
●
colorectal cancer facts; → need 5-7cm minimum for colectomy, minimum 12 lymph nodes
Colorectal carcinoma
- painless bleeding and change in bowel habits in a patient 50-80Y
- you will see apple core lesion on barium enema, adenoma is the MC “premalignant” and evolve to
adenocarcinoma of the colon
- Tumor marker: CEA
- If malignant: sessile, >1cm and villous
- Less malignant: pedunculated, <1cm and tubular
- 25% change of an asymptomatic person that goes for colon screening may have an adenoma, increases
with age.
Tx
- Resection and chemo
Colonoscopy guidelines
●
●
IBD facts
sources and % blood to the liver
○
Blood Supply to the Liver
Portal Triad
- R/L hepatic duct “biliary duct”, R/L hepatic artery, portal vein
- Drains at the hepatic vein then into the inferior vena cava
- Blood supply starts at celiac trunk-common hepatic artery-proper hepatic artery-R/L hepatic artery
- Cystic artery “blood supply to the gallbladder” branches off the R. hepatic artery
- Located in the hepatoduodenal ligament
Laparoscopic Colectomy:
Indications:
Benign & malignant conditions
Contraindications:
Emergent (obstruction, perforation, massive bleeding)
Complications
Vascular injury (MC during abdominal access)
Laceration of inferior epigastric artery
Abdominal wall hematoma
Hemorrhage
Mechanical compression and application of hemostatic agents are appropriate
initial strategies
Clips, suture ligation, electrosurgical methods
Failure to convert to open procedure with hemorrhaging
Damage to organs like stomach can be avoided with decompression (NG or OG tube)
Nerve injury, surgical site infection, upper urinary tract injury, port site metastasis
Anesthesia
Port-a-cath
-
Central venous access, can allow other device access: pulm. art. Cath, plasmapheresis cath, hemodialysis
cath, extracorporeal life support cannula, inferior vena cava filter
Can get access internal jugular vein, subclavian vein, illiac vein, common femoral vein, brachicephalic vein,
superior/inferior vena cava
Lateral clavicle
Finger in substernal notch, thumb out along clavicle
Indicated
Sick people
Inadequate peripheral venous access (infusion regime- long term admin. Of continuous meds,
chemotherapy, parenteral nutrition
Hemodynamic monitoring (central venous pressure, venous oxyhemoglobin sat., cardiac parameters
Extracorporeal therapies- large bore venous access (hemodialysis/plasmapheresis)
Procedures: vena cava filters, venous thrombolytic therapy, pul art cath, pacemakers/defibrillators
Contraindicated
Coagulopathy/thrombocytopenia, INR >3, if emergency do it but get platelets/fresh frozen plasma
Site complications: skin infection, proximity to wound/burn/tracheostomy
Complications
Bleeding, arterial puncture, air embolism, thoracic duct injury, cath. Malposition,
Pneumothorax/hemothorax
S/S Pnuemo -> JVD, normal heart, decreased breath sounds, hyperresonance, tracheal
deviation contralterally.
Chest tube/Needle decompression, Midclavicular line 2nd intercostal space
Arrhythmia
-
Triggering SA node → A-fib
Different thyroid cx
Thyroid follicular epithelial derived cancers (4 types)
Papillary (85%), follicular (12%),=differentiated cancers anaplastic (undifferentiated)-3%,
medullary thyroid cancer
Cancers that metastasize to the thyroid: breast, colon, renal and melanoma
Surgery for differentiated thyroid cancers “papillary/follicular” and after endocrinologist handle
them
Preoperative: U/s evaluation of the central and later neck lymph nodes
Decision based on side of the tumor, <1cm w/ no extrathyroidal extension/no lymph=thyroid
lobectomy, tumor >1-4cm= total thyroidectomy w/ possible radioiodine therapy to ablate thyroid
tissue
Post-operative
Thyroid medication “levo” if they are not going to get ablation/radioiodine scanning
Obtain serum TSH/non stim serum thyroglubulin (Tg) in 4-6wks after postop to determine status
<5ng/mL after thyroidectomy, <30ng/mL after thyroid lobectomy
If high, suspect metastasis
Complications
Hypoparathyroid, recurrent laryngeal nerve injury
F/U
Ultrasounds, TSH and Tg to monitor thyroid activity
Goal in high risk <0.1 TSH, low risk 0.1-0.5 TSH
-
TSH suppression leads to menopause, tachycardia, osteopenia, osteoporosis, a-fib
What is shock?
 Lack of tissue oxygenation -> Anaerobic metabolism -> make lactic acid (metabolic acidosis)
 How to determine hemodynamic stability
o Urine (non-invasive)
o Lactic acidosis
o Base deficit
o Blood pressure
 Give LR (crystalloid) 1st as fast as you can
Different types of shocks and tx
circulatory failure no getting enough blood delivered to the tissues=tissue hypoxia- multiple organ dysfunction=
death
Distributive shock (systemic peripheral vasodilation)
Septic shock: MC, dysregulated response to infection leading to organ failure
Gram+ bac MC cause S. Entero
Sys. Inflam. Resp. Synd. (SIRS): robust inflammatory response- can be infectious or non-infectious
Pancreatitis, burns, hypoperfusion due to trauma, blunt trauma, amniotic fluid
embolism, air embolism, fat embolism, idiopathic systemic capillary leak syndrome
Neurogenic shock: severe TBI, spinal cord injuries, interrupted autonomic pathways causing
decreased vascular resistance and altered vagal tone
Anaphylactic shock
Drug/toxin induced shock
Endocrine shock
Cardiogenic shock
Cardiomyopathic
Arrhythmic
Mechanical
Hypovolemic
Hemorrhagic
Non-hemorrhagic
Obstructive
Pulmonary vascular
Mechanical
FAST (focused assessment of U/S for Trauma)
Helps identify free intraperitoneal, pericardial fluid, hemoperitoneum, pneumothorax, hemothorax,
hemopericardium w/ or w/o tamponade, traumatic hypovolemia, rib fractures in blunt trauma injuries.
Indications: blunt trauma, penetrating cardiac/chest trauma, trauma in pregnancy, pediatric trauma,
undifferentiated hypotension, patients with ascites.
10 structures/spaces are imaged in 4 windows.
1. Cardiac (subxiphoid)
Percardium, heart chambers (right ventricle)
2. RUQ
Morrison pouch (hepatorenal recess)
Liver tip (right paracolic gutter)
Lower right thorax
3. LUQ
Subphrenic space
Splenorenal recess
Spleen tip (left paracolic gutter)
Lower left thorax
4. Pelvic
Rectovesical pouch (male patients)
Rectouterine “Pouch of Douglas” (females)
Fluid Replacement
Normal saline
Lactated Ringers
PORT Vagus Nerve Stim. for epilepsy
Indicated when the patient has resistance/refractory antiseizure drugs= usually refractory to three drugs
and having more than 6 seizures/mo
Mechanism of effect is not well established but think
afferent vagal projects through the pontine parabrachial nucleus and thalamus to the seizure
generating regions in the basal forebrain/insular cortex
Effects the locus ceruleus (recieves vagal afferent signal from nucleus tractus solitarius)
Dysynchronization of hypersynchronized cortical activity which is dependent on the stimulant
frequency/strength of the electrical current
Cortical inhibition secondary to the release of inhibitory NTs such gylcine/GABA
Indicated
Children >12Y/adults in well documented medically refractory seizures who do not want intracranial
surgery/are not candidates for surgery/refractory to antiseizure drugs
Focal/generalized seizures (>6/mo)= receiving high stimulation experienced >50% reduction in seizures
Contraindicated
Cardiac condition disorders “arrhythmias” due to potential efferent conduction through the vagus nerver,
especially on the right side can worsen cardiac conduction “think bradycardia”
Sleep apnea
Procedure
Cricoid cartilage is palpated- halfway b/w sternal notch and mandible
Incision is made 3cm medial to the SCM
Incision for the battery device in made 4cm (3-4fingers inferior to the L infraclavicular medial to the
sternum subQ
Device
Battery powered device similar to a cardiac pacemaker, stimulating leads are surgically placed around the
left vagus nerve in the carotid sheath (behind the SCM (internal carotid artery, internal jugular vein, vagus
nerve), and connected to an infraclavicular subcutaneous programmable pacemaker
Stimulation consist of a 30Hz stimulus delivered 30 seconds every five minutes
It detects high heart rate which is associated when a seizure occurs and the device detects and stimulates
the vagus nerve to disrupt the seizure.
Pt that have auras, on demand stimulation can be used with a magnet
Complications
-
Voice alterations (hoarseness, throat pain, cough, SOB, tingling, muscle pain)
Implant site infection (staph aureus)
Bradycardia
Vocal cord paralysis “manipulation of the recurrent laryngeal nerve)
NIH Criteria for Weight Loss
Adults that have a BMI >40, BMI of >35 w/ comorbidities DMT2, heart disease, GERD or sleep apnea, BMI
>30 with DMT2 that is difficult to control w/ meds/lifestyles changes
Restrictive procedures
Limit caloric intake by reducing the stomach’s reservoir capacity via resection, bypass, creation of a
proximal gastric outlet
Vertical banded gastroplasty/laparoscopic adjustable gastric band= limit solid food intake by restriction of
the stomach size
Malabsorptive
Shortening the small intestine by decreasing the effectiveness of nutrient absorption
Combination of restrictive and malabsorptive
Roux en Y gastric bypass
Small proximal pouch (30mL) that is divided and separated from the stomach and anastomosed to a roux
limb of small bowel that is 75-150cm in length- helps to restrict caloric intake.
Major digestion and absorption occurs in the common channel (gastric acid, pepsin, intrinsic factor,
pancreatic enzymes and bile mix with ingested food
The small intestine is divided at a distance of 50-150cm distal to the ligament of treitz
Biliopancreatic limb and roux limb are connected 75-150cm distally from the gastrojejunostomy
(connection of stomach pouch and jejunum)
Side effects
Lightheadedness, nausea, diaphoresis, abdominal pain, diarrhea with a high sugar meal in ingested
Hormones
Ghrelin, a peptide hormone is secreted in the foregut (stomach/duodenum) that stimulate the early
phase of meal consumption. Its inhibited in gastric bypass which leads to inhibit appetite
GLP-1 and CCK are increases after RYGB
Weight loss
70% weight loss after two years
Restrictive procedures
Sleeve gastrectomy
Majority of the greater curvature/fundus of the stomach is removed and a tubular stomach is created
The tubular stomach is small in its capacity and is resistant to stretching due to the absence of the fundus,
aiding in weight loss
Creating this type of procedure causes high pressure= GERD, leaks
Hormones
Ghrelin decreases (found in the fundus), GLP (secreted in the SI) , PKK increase (peptide YY)
Weight loss
60% weight loss after two years
Relative Contraindications
Anesthesia risk, severe uncontrolled psychiatric illness (eating d/o), and coagulopathy, Barrett’s
esophagus, uncontrolled GERD
Pre-operative
EGD to exclude ulcers, polyps, masses, dysplastic changes
Complications
-bleeding (w/i the greater curvature of the stomach- short gastric art., spleen injury)
-leak from the staples and high pressure in the stomach, usually in the gastroesophageal junction (eso-stomach
junction)
-strictures
-GERD
-portal vein thrombosis
Malabsorption
Biliopancreatic diversion with duodenal switch, used in super obese >50 or
reserve for revisional procedures for failure to lose weight
Gastric sleeve removal
Remove the 2st part duodenum
Distal ileum is anastomosed to the stomach and the proximal ileum,
with the output from liver, pancreas, and duodenum (biliopancreatic
limb) anastomosed to the terminal ileum 50-100cm away from the
ileocecal valve
Fat/starch malabsorption
70-80% weight loss
Single anastomosis doudenoileal bypass with sleeve gastrectomy (SADI-S)
-variant of BPD-DS but with the preservation of the pylorus
Stomach Blood Supply
Foregut
Stomach, esophagus, proximal duodenum, liver, gallbladder and pancreas get their supply from CELICAC
truck (T12), there is also the superior mesenteric artery (SMA-L1)) and inferior mesenteric artery (IMA-L3)
Coming off the celiac truck, the left gastic artery anastamose with common hepatic artery to supply the
lesser curvature of the stomach
Drain in the gastric/splenic veins
Child Pugh Score for Cirrhosis Mortality
Progressive hepatic fibrosis that disrupts the function of
the liver and is considered irreversible in late stages
Complications (decompensated cirrhosis)
Variceal hemorrhage, ascites, spontaneous bacterial
peritonitis, hepatic encephalopathy, hepatocellular
carcinoma, hepatorenal syndrome, hepatopulmonary
syndrome
Operative
High risk complications
Classification
Serum albumin, bilirubin, ascites, encephalopathy, and
prothrombin time. Score is from 5-15.
5-6= Child Pugh Class A cirrhosis (compensated), 7-9 =
Child Pugh Class B cirrhosis (significant functional
compromise) and 10-15 = Child Pugh Class C cirrhosis
(decompensated cirrhosis)
Class A mortality 10%, Class B mortality 30% mortality,
and Class C 82% mortality
Also classifies mortality if the patient does not do surgery
1yr survival with class A/B/C= 100%, 80% and 45%
MELD score
Predicts the prognosis in patients with cirrhosis and prioritization of patient’s waiting for liver transplant
Cervical Lymph Node Excision
Primary/secondary lymphedema
Indications
Localized primary lesions (microcytic/macroscopic lymphatic malformations)
Failed nonoperative management
Recurrent cellulitis
Leakage of lymph in the body cavities, organs or extremities
Limitations of function
Deformity or disfigurement
Pain
Diminished QOA
Staging of lymphedema “Campisi staging system”
Operation approach, physiologic vs. reductive techniques
Physio- used in early stage lymphedema prior to deposition of excess fat and tissue fibrosis (campisi stage
1/2/3)
Reductive- used in advance lymphedema (stage 4/5)
Complications
Pain, wound healing complications, infections, lymphatic fistulas, suboptimal cosmetic results