- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
368 Section II / General Surgery |
|
Biloma |
Intraperitoneal bile fluid collection |
Choledochojejunostomy |
Anastomosis between common bile duct |
|
and jejunum |
Hepaticojejunostomy |
Anastomosis of hepatic ducts or common |
|
hepatic duct to jejunum |
DIAGNOSTIC STUDIES |
|
|
|
What is the initial diagnostic study of choice for evaluation of the biliary tract/gallbladder/cholelithiasis?
Define the following diagnostic studies:
ERCP
PTC
IOC
Ultrasound!
Endoscopic Retrograde
CholangioPancreatography
Percutaneous Transhepatic
Cholangiogram
IntraOperative Cholangiogram (done laparoscopically or open to rule out choledocholithiasis)
HIDA/PRIDA scan |
Radioisotope study; isotope concentrated |
|
in liver and secreted into bile; will |
|
demonstrate cholecystitis, bile leak, or |
|
CBD obstruction |
How does the HIDA scan reveal cholecystitis?
How often will plain x-ray films see gallstones?
BILIARY SURGERY
Non-opacification of the gallbladder from obstruction of the cystic duct
10% to 15%
What is a cholecystectomy? |
Removal of the gallbladder |
|
laparoscopically or through a standard |
|
Kocher incision |
Chapter 54 / Biliary Tract 369
What is a “lap chole”? |
LAParoscopic CHOLEcystectomy |
hr
f
‘07
What is the Kocher incision? |
Right subcostal incision |
What is a sphincterotomy? |
Cut through sphincter of Oddi to allow |
|
passage of gallstones from the common |
|
bile duct; most often done at ERCP; also |
|
known as papillotomy |
How should postoperative |
1. Percutaneous drain bile collection |
biloma be treated after a lap |
2. ERCP with placement of biliary stent |
chole? |
past leak (usually cystic duct remnant |
|
leak) |
What is the treatment of |
Choledochojejunostomy |
major CBD injury after a |
|
lap chole? |
|
OBSTRUCTIVE JAUNDICE |
|
|
|
What is it?
What is the differential diagnosis of proximal bile duct obstruction?
Jaundice (hyperbilirubinemia 2.5) from obstruction of bile flow to the duodenum
Cholangiocarcinoma
Lymphadenopathy
Metastatic tumor
Gallbladder carcinoma
Sclerosing cholangitis
Gallstones
Tumor embolus
Parasites
Postsurgical stricture
Hepatoma
Benign bile duct tumor
370 Section II / General Surgery |
|
What is the differential |
Choledocholithiasis (gallstones) |
diagnosis of distal bile duct |
Pancreatic carcinoma |
obstruction? |
Pancreatitis |
|
Ampullary carcinoma |
|
Lymphadenopathy |
|
Pseudocyst |
|
Postsurgical stricture |
|
Ampulla of Vater dysfunction/stricture |
|
Lymphoma |
|
Benign bile duct tumor |
|
Parasites |
What is the initial study |
Ultrasound |
of choice for obstructive |
|
jaundice? |
|
What lab results are associated |
Elevated alkaline phosphatase, elevated |
with obstructive jaundice? |
bilirubin with or without elevated LFTs |
CHOLELITHIASIS
What is it?
What is the incidence?
What are the “Big 4” risk factors?
Formation of gallstones
10% of U.S. population will develop gallstones
The “four Fs”:
Female
Fat
Forty
Fertile (multiparity)
What are other less common |
Oral contraceptives |
risk factors for gallstones? |
Bile stasis |
|
Chronic hemolysis (pigment stones) |
|
Cirrhosis |
|
Infection |
|
Native American heritage |
|
Rapid weight loss/gastric bypass |
|
Obesity |
|
Inflammatory bowel disease (IBD) |
|
Terminal ileal resection |
|
Total parenteral nutrition (TPN) |
|
Vagotomy |
|
Advanced age |
|
Hyperlipidemia |
|
Somatostatin therapy |
|
|
Chapter 54 / Biliary Tract 371 |
What are the types of |
Cholesterol stones (75%) |
|
stones? |
Pigment stones (25%) |
|
What are the types of |
Black stones (contain calcium bilirubinate) |
|
pigmented stones? |
Brown stones (associated with biliary |
|
|
tract infection) |
|
What are the causes of |
Cirrhosis, hemolysis |
|
black-pigmented stones? |
|
|
What is the pathogenesis of |
Secretion of bile supersaturated with |
|
cholesterol stones? |
cholesterol (relatively decreased amounts |
|
|
of lecithin and bile salts); then, cholesterol |
|
|
precipitates out and forms solid crystals, |
|
|
then gallstones |
|
Is hypercholesterolemia a risk |
No (but hyperlipidemia is) |
|
factor for gallstone formation? |
|
|
What are the signs and |
Symptoms of: biliary colic, cholangitis, |
|
symptoms? |
choledocholithiasis, gallstone, pancreatitis |
|
Is biliary colic pain really |
No, symptoms usually last for hours; |
|
“colic”? |
therefore, colic is a misnomer! |
|
What percentage of |
80% of patients with cholelithiasis are |
|
patients with gallstones are |
asymptomatic! |
|
asymptomatic? |
|
|
What is thought to cause |
Gallbladder contraction against a stone |
|
biliary colic? |
temporarily at the gallbladder/cystic duct |
|
|
junction; a stone in the cystic duct; or a |
|
|
stone passing through the cystic duct |
|
What is Boas’ sign? |
Referred right subscapular pain of biliary |
|
|
colic |
|
What are the five major |
1. |
Acute cholecystitis |
complications of gallstones? |
2. |
Choledocholithiasis |
|
3. |
Gallstone pancreatitis |
|
4. |
Gallstone ileus |
|
5. |
Cholangitis |
372 Section II / General Surgery
How is cholelithiasis diagnosed?
How often does ultrasound detect cholelithiasis?
How often does ultrasound detect choledocholithiasis?
How are symptomatic or complicated cases of cholelithiasis treated?
History
Physical examination
Ultrasound
98% of the time!
About 33% of the time . . . not a very good study for choledocholithiasis!
By cholecystectomy
What are the possible complications of a lap chole?
What are the indications for cholecystectomy in the asymptomatic patient?
Define IOC.
Common bile duct injury; right hepatic duct/artery injury; cystic duct leak; biloma (collection of bile)
Sickle-cell disease
Calcified gallbladder (porcelain gallbladder)
Patient is a child
IntraOperative Cholangiogram (dye in bile duct by way of the cystic duct with fluoro/x-ray)
What are the indications for |
1. |
Jaundice |
an IOC (6)? |
2. |
Hyperbilirubinemia |
|
3. |
Gallstone pancreatitis (resolved) |
|
4. |
Elevated alkaline phosphatase |
|
5. |
Choledocholithiasis on ultrasound |
|
6. |
To define anatomy |
What is choledocholithiasis? |
Gallstones in the common bile duct |
|
What is the management of |
1. |
ERCP with papillotomy and |
choledocholithiasis? |
|
basket/balloon retrieval of stones |
|
|
(preor postoperatively) |
|
2. |
Laparoscopic transcystic duct or trans |
|
|
common bile duct retrieval |
|
3. |
Open common bile duct exploration |
What medication may |
Chenodeoxycholic acid, ursodeoxycholic |
|
dissolve a cholesterol |
acid (Actigall®); but if medication is |
|
gallstone? |
stopped, gallstones often recur |
|