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Essential Med Notes (General Surgery) 2012

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General Surgery Toronto Notes 2012

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Essential Med Notes (General Surgery) 2012

  1. 1. GS General Surgery AnDie Doan, Peter Szas2 and Nathalie Wong-Chong, chapter editors A1aina Garbeas and Moclupe Oyewum.I. associate editors Adam Gladwiah, EBM editor Dr. Tulin Cll and Dr. David Urbach, staff editors Basic Anatomy Review ................... 2 Differential Diagnoses of Common Presentations .......................... 4 Acute Abdominal Pain Abdominal Mass Gl Bleeding Jaundice Preoperative Preparations . . . . . . . . . . . . . . . . 6 Surgical Complications . . . . . . . . . . . . . . . . . . 7 Postoperative Fever Wound Complications Urinary and Renal Complications Postoperative Dyspnea Respiratory Complications Cardiac Complications Intra-abdominal Abscess Paralytic Ileus Delirium Thoracic Surgery ....................... 12 Esophagus Chest Wall Pleura, lung, and Mediastinum Stomach and Duodenum ................ 16 Peptic Ulcer Disease Gastric Carcinoma Gastric Sarcoma Bariatric Surgery Complications of Gastric Surgery Small Intestine ......................... 20 Meckel's Diverticulum Tumours of Small Intestine Hernia ................................ 21 Groin Hernias Bowel Obstruction ...................... 23 Small Bowel Obstruction (SBO) large Bowel Obstruction (LBO) Pseudo-Obstruction .................... 25 Toxic Megacolon Paralytic Ileus Ogilvie's Syndrome Intestinal Ischemia ...................... 27 Appendix ............................. 27 Appendicitis Tumours of the Appendix Inflammatory Bowel Disease (IBD) ........ 28 Crohn's Disease Ulcerative Colitis Diverticular Disease ..................... 30 Diverticulosis Diverticulitis Toronto Notes 2011 Colorectal Neoplasms ................... 32 Colorectal Screening Guidelines Colorectal Polyps Familial Colon cancer Syndromes Colorectal Carcinoma (CRC) Other Conditions of the large Intestine . . . . 36 Angiodysplasia Volvulus Fistula ................................ 37 Ostomies ............................. 37 Anorectum ............................ 38 Hemorrhoids Anal Fissures Anorectal Abscess Fistula-In-Ana Pilonidal Disease Rectal Prolapse Anal Neoplasms liver ................................. 41 Liver Cysts Liver Abscesses Neoplasms Liver Transplantation Biliary Tract • • . • • • • • • • • • • • . • • • • • • • • • • • • 44 Ch ole I ithiasis Biliary Colic Acute Cholecystitis Acalculous Cholecystitis Choledocholithiasis Acute Cholangitis Gallstone Ileus Carcinoma of the Gallbladder Cholangiocarcinoma Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Acute Pancreatitis Chronic Pancreatitis Pancreatic Cancer Spleen ................................ 52 Splenic Trauma Splenectomy Breast ................................. 52 Benign Breast lesions Breast Cancer Surgical Endocrinology .................. 58 Thyroid and Parathyroid Adrenal Gland Skin Lesions ........................... 58 Common Medications ................... 58 References ............................ 60 General Surgery GSI
  2. 2. GS2 General Surgery Common Acronyms AAA- abdominal aortic aneurysm ABG -arterial blood gas ABI - ankle brachial index APR- abdominal perineal resection BRBPR- bright red blood per rectum CBD- common bile duct CVA- costovertebral angle CVP - central venous pressure DPL - diagnostic peritoneal lavage EBL - estimated blood loss DGD/EGD- esophagogastro-duodenoscopy ERCP- endoscopic retrograde cholangiopancreatography EUA- examination under anesthesia FAST- focused abdominal sonogram for trauma FNA - fine needle aspiration FOBT- fecal occult blood test I&D- incision and drainage LBO -large bowel obstruction LES -lower esophageal sphincter LGIB -lower Gl bleed MAE- moving all extremities MEN - multiple endocrine neoplasia MIS - minimally invasive surgery MRCP- magnetic resonance cholangiopancreatography NGT - nasogastric tube POD- postoperative day SBO -small bowel obstruction SIADH -syndrome of inappropriate anti-diuretic hormone TEE- transesophageal echocardiogram TIE- transthoracic echo cardiogram UGIB- upper Gl bleed Basic Anatomy Review Basic Anatomy Review Figure 1_ Abdominal Incisions Layers from Superficial to Deep oblique muscle oblique aponeurosis Peritoneum Preperitoneal fat Inferior epigastric artery epigastric vein Transversalis fascia -, Deep inguinal ring Membranous layer of superficial fascia (Scarpa's fascia) Fatty layer of superficial fascia (Camper's fascia) Superficial inguinal ring Tunica vaginalis --1-ir.-.rr--i'r-- Testis Internal spermatic fascia Cremaster muscle External spermatic fascia Colle's superficial perineal fascia F----Dartos muscle .,;L----Skin of scrotum Kocher's (subcostall Upper midline Paramedian Lateral paramedian Lower midline Pfannenstiel McBurney's Toronto Notes 2011 Access to RUQ or WQ contents i.e. gallbladder, spleen Access to stomach, duodenum, gallbladder, liver, transverse colon Can make similar incision in each quadrant for access to each quadrant's contents Not commonly used Post-op ventral hernias common Incision made at outer 1/3 - medial 2/3 border of rectus Modification of paramedian but with lower risk of dehiscence or ventral hernia Not commonly used Access to pelvic organs, sigmoid colon, and rectum Suprapubic incision for access to pelvic cavity Access to appendix External oblique muscle Internal oblique muscle ----.,..-""'""-==-:i'-1:--Aponeurosis of internal oblique muscle Aponeurosis of external oblique muscle (cut edge) Cremaster muscle Spermatic cord / Figure 2. Continuity of the Abdominal Wall with Layers of the Scrotum and Spermatic Cord • skin (epidermis, dermis, subcutaneous fat) • superficial fascia • Camper's fascia (fatty)--+ Dartos • Scarpa's fascia (membranous)--+ Calles' superficial perineal fascia • muscle (see Figure 2 and Figure 3) • external oblique --+ inguinal ligament --+ external spermatic fascia --+ fascia lata • internal oblique --+ cremasteric muscle/fascia • transversus abdominus --+ posterior inguinal wall • transversalis fascia --+ internal spermatic fascia • preperitoneal fat • peritoneum --+ tunica vaginalis • at midline • rectus abdominus muscle: in rectus sheath, divided by linea alba • above arcuate line (semicircular line of Douglas), which is midway between symphysis pubis and umbilicus • anterior rectus sheath = external oblique aponeurosis and anterior leaf of internal oblique aponeurosis • posterior rectus sheath = posterior leaf of internal oblique aponeurosis and transversus muscle aponeurosis • below arcuate line • anterior rectus sheath = aponeurosis of external, internal oblique, transversus muscles • posterior rectus sheath = transversalis fascia • arteries: superior epigastric (branch of internal thoracic), inferior epigastric (branch of external iliac); both arteries anastomose and lie behind the rectus muscle
  3. 3. 'IbroDlo Nota 2011 Above Arcuate Line Figura 4. Bloed Supply to the Gl Tract Venous Row • end point is the portal vein Figura 5. Yanaus DraiMga of the Gl Tract Buic Anatomy Review c.lllctnn.(1) i) h.-m: artary (2) • Hepatic P!IIPIIr (3) -l..aft hapalic artary (4) - Right hllpllic arlely (51 • RiFt gastric artary (7) • Gntr11duodanal (B) ii) L.n: gqlrie arl8ry (6) iii) Spl111ic lrtllry (9) -lta'ic 1rtery 1101 i) Right artely ( 12) iii lrtllry U 1) iii) llccclic artarv (13) ivl Iaiii IIIII ja;,.nal biiiiChllll II 4) llillra -*riG .mary (15) i) iii Sigmoid .ai1111(17) iii Superior reclll arlely (1 8) tt.rlrllnm(1J Brltairlr ra-ltlniil:vain (J) i) IMiandjajlnlveins(13) iii llccclic vein (14) iii) Right vein (1 2) iv) Midde vein (1 1 I vi Pancreaticoduodenal win (I) vi) Right gal1rvepiploic vain (9) Splenic win 151 i) Wsrior maanlrlric vain ( 1 0) (114J1rior 1111:181 'IBi'l WJii cruning common iliac V8SS8Is) • left coic vans (151 • vainll16l • •rior l'lttll veins (17) ii) Plncreatil; vai111 iii) l..aft gulruapiplai:: vain iv1 Shart gulric wi111 (6) Laft pmic (cara'*JI vail (f) RWrt tulric vain (31 vail (4) l'lnurililillllwit ] ! 0 Geaeral Suqery GS3 1M! hal81i: IIUIBI lpliln Spllli; Qllbladder Sllmlcll 1. gulril; z. Qam arrwfijrtlalf lilt 11111'111,._.. 3.1iJDHDI1 ga1rics (off ll1llericl lllllllnrn l.lilltiDJodilllll 2.l'lnciBcolllod8nilllllll l'lrlnl 1. lnni:hll 2. l'lnciBcolllod8nill lrral inlllilll 1. ....... jljmll, IIIII, ilaocdc lllgam.Die 1. ....... ril#rt calc. ni .... calc z.wm-m:lirlnl:lles-lifteoli:. lligrqid.recllll
  4. 4. GS4 General Surgery In all p-.nting with •n leuhlllld-n, '"**following: 1. AmylastVlipase 2. Urinalysis 3. Bni-IICG (in wom111) 4. Consider CXR + 1r0ponins This will help rule out "non-GI surgiclll" causasl ... • , l'lncrwtitis can look.liU 1 surgical abdomen, but is rarely an indication fur laparotomy. RlnrNIII'Iin Biliary colic: to right .tloulder or scapula Renal colic: to groin parilmbilical to right lowllr quodrant (RLQ) l'lnc1'8111itis: to back Ruptured llllltic anaurysm: to hack or flank Parforated ulcar: to RLQ (right paracolic gutter) Hip pain: to groin Differential Diagnose5 of Common Presentations Toronto Notes 2011 Differential Diagnoses of Common Presentations Acute Abdominal Pain T1ble 1. Differenti1l Di1gnosis of Acute Abdominal Pain RUQ EPIGASTBIC Hepallllililry Bilary calc Cholecptiti1 Cholengitia CBD abltnu:tion (siDne, tumourl llllpelilis Budd-Chilli Heplllic absc!ISIVmass Right subphrenic abscess Gllltroillfllllilal Pancrealilis Presentation of gastric, duodenal or pancralllic pathology Heplllic fteKUre pathology (CRC, subcostal incisional hernial Genitalmlry Nephrolitliasis Pyalonaplritis Renal: mass. ischemia. llauma C.nliapulmanary RLl PnaumDIIia CHF (causing hepatic congestion and R pleural elfusiDIII Ml Pericarditis Miscall-- Herpes mster Trauma Costochondritis RLQ Gllltroillflllli•al Appendic:ilil Crahn's di111111 Tuberculosis of the ileocecal junction Cacal tumour Intussusception Mesenteric lympadenilis (Yersinial Cecal Cacal volvulus Hernia: amy!llds, femoral, inguinal obstruction (and cecal distention) GynecolagiCII Sea 'suprapubic' Genitalmlry See 'suprapubic' Extraperitllnall Abdominal wall hemllloma/abscess Psoas Abscan Cardiac Aarlic llsstll:tiall/nlpCIINII AAA Ml l'llricarditis Gestrointeltinll Glllritis GERII/Esaphagilis Peptic ulcer llsease Pancredil Mallory-Weiss tear DIFFUSE Gestrointeltinll Peritonitis Eartr applllllc:itis, parfarllld appandi:itis Mlsenlllric: ilch1111il G•lnllntenis/Coitis Constipation BDWII obstruction Pancreatitis lnflamma!OIY bowel disease Irritable bowel syndrama Ogilvie's syndrome Cardiavuadllr/Himlltlllagil:ll Aortic dissectioniruptured AAA Sickle cell crisis Genitauliluy/Gynii:Oiagical Parfol'iltsd ec!Dpic pregnancy PID Acute urinary retEntion Endac:rinalagic:ll Carcinoid syndrome Diabstic kstoacidosis Addisonian crisis Hypercalcemia Other Lead poisoning Tertiary syphiis SUPRAPUBIC Gestrointestinll (He RLOI LLDI Acute appendicitis lBO Gynacalagical PID El:tupic pregnancy Endlllllllrialil Th....tlned/lnc:ampllllllllbarlion Hydmllphilllii'Salpilgilil Ovarian torsion Hernon1111gic fibroid abscess Gynecological tumours Genitauliii!Y Cyltitia (infuctious, hamonhagicl Hydroureter/Urillll'{ Colic Epididymitis Testicular torsion Acute urinary nrtantion Extraperitanlll Rectus sheath hematoma WD Panl:rlllk: PancnNrlitis (acute vs. chronic) Pancreatic pseudocyst Pancreatic tumours Gamuinteltinll Gutritil l'lptic ulcer di11111 Splenic flexure pathology (e.g. CRC, ischamial Spllni: Splllnk: infan:t/llblc .. Splenomegaly Splenic rupture Splenic anaurysm Cudiapulmanary (sse RUQ and Epigaatric:l Genitaurinuy (sea RUO) LlQ Gaslrllinteltinll Dherliculilil Diverticulosis Colon/Sigmoi!llllectal Cancer Fecal impaction Proctitis (ulclllilliw colitis, infuctious; i.e. gonococcus or chlamydial Sigmoid volvulus Hernia See gyrHICIIIogicel, lnlagi:al. end llllrllparitllnlllaspa' RLO and suprallliic
  5. 5. Toronto Notes 2011 Differential Diagnosea of Common Presentations Abdominal Mass Tabla 2. Diffarantial DiagnDiil Df AbdDminal M111 Right Upper lluldrant {RUQj Upper Midline Left Upper Quadrant {LUQj Galbladdw- cholacyrtitis. cholangiocarcinoma, cholelithiasis PancraiS - pancreatic adenocarcinoma, Spleen -splenomegaly, tumour, abscess, IPMT, other pancreatic cancer, pseudocyst subcapsular splenic hemonhage, can also present as RLQ mass W extnme iiplenomegaly Biliary tract- Klatskin tumour Liver- hepatomegaly,

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