- •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
Chapter 59 / Parathyroid 457
Tertiary HPTH? Correct calcium and phosphate; perform surgical operation to remove all parathyroid glands and reimplant 30 to 40 mg in the forearm if REFRACTORY to medical management
Why place 30 to 40 mg of sliced parathyroid gland in the forearm?
What must be ruled out in the patient with HPTH from hyperplasia?
To retain parathyroid function; if HPTH recurs, remove some of the parathyroid gland from the easily accessible forearm
MEN type I and MEN type IIa
What carcinomas are commonly associated with hypercalcemia?
What is the most likely diagnosis if a patient has a PALPABLE neck mass, hypercalcemia, and elevated PTH?
PARATHYROID CARCINOMA
Breast cancer metastases, prostate cancer, kidney cancer, lung cancer, pancreatic cancer, multiple myeloma
Parathyroid carcinoma (vast majority of other causes of primary HPTH have nonpalpable parathyroids)
What is it? |
Primary carcinoma of the parathyroid |
|
gland |
What is the number of |
1 |
glands usually affected? |
|
What are the signs/ |
Hypercalcemia, elevated PTH, |
symptoms? |
PALPABLE parathyroid gland (50%), |
|
pain in neck, recurrent laryngeal nerve |
|
paralysis (change in voice), hypercalcemic |
|
crisis (usually associated with calcium |
|
levels 14) |
What is the common tumor |
Human Chorionic Gonadotropin |
marker? |
(HCG) |
What is the treatment? |
Surgical resection of parathyroid mass |
|
with ipsilateral thyroid lobectomy, |
|
ipsilateral lymph node resection |
458 Section II / General Surgery |
|
What percentage of all |
1% |
cases of primary HPTH are caused by parathyroid carcinoma?
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What are the possible postoperative complications after a parathyroidectomy?
Recurrent nerve injury (unilateral: voice change; bilateral: airway obstruction), neck hematoma (open at bedside if breathing is compromised), hypocalcemia, superior laryngeal nerve injury
What is “hungry bone |
Severe hypocalcemia seen after surgical |
syndrome”? |
correction of HPTH as chronically |
|
calcium-deprived bone aggressively |
|
absorbs calcium |
What are the signs/ |
Perioral tingling, paresthesia, |
symptoms of postoperative |
Chvostek’s sign, Trousseau’s sign, |
hypocalcemia? |
tetany |
What is the treatment of |
Acute: IV calcium |
hypoparathyroidism? |
Chronic: PO calcium, and vitamin D |
What is parathyromatosis? |
Multiple small hyperfunctioning |
|
parathyroid tissue masses found over the |
|
neck and mediastinum—thought to be |
|
from congenital rests or spillage during |
|
surgery—remove surgically (RARE) |
C h a p t e r 60
Which arteries supply the spleen?
What is the venous drainage of the spleen?
Spleen and
Splenectomy
Splenic artery (a branch of the celiac trunk) and the short gastric arteries that arise from the gastroepiploic arteries
Portal vein, via the splenic vein and the left gastroepiploic vein
|
Chapter 60 / Spleen and Splenectomy 459 |
What is said to “tickle” the |
Tail of the pancreas |
spleen? |
|
What percentage of people |
20% |
have an accessory spleen? |
|
What percentage of the total |
33% |
body platelets are stored in |
|
the spleen? |
|
What are the functions of the human spleen?
Filters abnormal RBCs (does NOT store RBCs like canine spleen!), stores platelets, produces tuftsin and properdin (opsins), produces antibodies (especially IGM) and is site of phagocytosis
What is “delayed splenic |
Subcapsular hematoma or |
rupture”? |
pseudoaneurysm may rupture some time |
|
after blunt trauma, causing “delayed |
|
splenic rupture”; rupture classically |
|
occurs about 2 weeks after the injury and |
|
presents with shock/abdominal pain |
What are the signs/symptoms |
Hemoperitoneum and Kehr’s sign, LUQ |
of ruptured/injured spleen? |
abdominal pain, Ballance’s sign |
What is Kehr’s sign? |
Left shoulder pain seen with splenic |
|
rupture |
What is Ballance’s sign? |
LUQ dullness to percussion |
What is Seagesser’s sign? |
Phrenic nerve compression causing neck |
|
tenderness in splenic rupture |
How is a spleen injury |
Abdominal CT, if the patient is stable; |
diagnosed? |
DPL or FAST exam if the patient is |
|
unstable |
What is the treatment? 1. Nonoperative in a stable patient with an isolated splenic injury without hilar involvement/complete rupture
2.If patient is unstable, DPL/FAST laparotomy with splenorrhaphy or splenectomy
3.Embolization is an option in selected patients
460 Section II / General Surgery |
|
What is a splenorrhaphy? |
Splenic salvage operation: wrapping vicral |
|
mesh, aid of topical hemostatic agents or |
|
partial splenectomy, sutures (buttressed) |
What are the other |
|
indications for splenectomy: |
|
Malignant diseases? |
Hodgkin’s staging not conclusive by CT |
|
scan (rare) |
|
Splenic tumors (primary/metastatic/ |
|
locally invasive) |
|
Hypersplenism caused by other |
|
leukemias/non-Hodgkin’s lymphomas |
Anemias? |
Medullary fibrosis with myeloid |
|
metaplasia |
|
Hereditary elliptocytosis |
|
Sickle cell anemia (rare, most |
|
autosplenectomize) |
|
Pyruvate kinase deficiency |
|
Autoimmune hemolytic anemia |
|
Hereditary spherocytosis |
|
Thalassemias (e.g., -thalassemia major |
|
a.k.a. Cooley’s) |
Thrombocytopenia? |
ITP (Idiopathic Thrombocytopenic |
|
Purpura) |
|
TTP (Thrombotic Thrombocytopenic |
|
Purpura) |
Miscellaneous |
Variceal bleeding with splenic vein |
indications? |
thrombosis, Gaucher’s disease, splenic |
|
abscess, refractory splenic cysts, |
|
hypersplenism, Felty’s syndrome |
Is G6PD deficiency an |
NO |
indication for splenectomy? |
|
What are the possible |
Thrombocytosis, subphrenic abscess, |
postsplenectomy |
atelectasis, pancreatitis gastric dilation, |
complications? |
and Overwhelming PostSplenectomy |
|
Sepsis (OPSS) |
What causes OPSS? |
Increased susceptibility to fulminant |
|
bacteremia, meningitis, or pneumonia |
|
because of loss of splenic function |
What is the incidence of OPSS in adults?
What is the incidence and overall mortality of OPSS in children?
Chapter 60 / Spleen and Splenectomy 461
1%
1% to 2% with 50% mortality rate
What is the typical presentation of OPSS?
What are the common organisms associated with OPSS?
What is the most common bacteria in OPSS?
What is the preventive treatment of OPSS?
What is the best time to give immunizations to splenectomy patients?
What lab tests are abnormal after splenectomy?
What are the findings on postsplenectomy RBC smear?
When and how should thrombocytosis be treated?
What is the most common cause of splenic vein thrombosis?
Fever, lethargy, common cold, sore throat, URI followed by confusion, shock, and coma with death ensuing within 24 hours in up to 50% of patients
Encapsulated: Streptococcus pneumoniae, Neisseria meningitides, H. influenzae
Streptococcus pneumoniae
Vaccinations for pneumococcus,
H. influenzae, and meningococcus Prophylactic penicillin for all minor
infections/illnesses and immediate medical care if febrile illness develops
Preoperatively, if at all possible If emergent, then 2 weeks
postoperatively
WBC count increases by 50% over the baseline; marked thrombocytosis occurs; RBC smear is abnormal
Peripheral smear will show Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies
When platelet count is 1 million, most surgeons will treat with aspirin
Pancreatitis
What opsonins does the |
PROperdin, TUFtsin (Think: |
spleen produce? |
“PROfessionally TUF spleen”) |
462 Section II / General Surgery
What is the most common cause of ISOLATED GASTRIC varices?
What is the treatment of gastric varices caused by splenic vein thrombosis?
Which patients develop hyposplenism?
What vaccinations should every patient with a splenectomy receive?
Define hypersplenism.
Define splenomegaly.
What is idiopathic thrombocytopenic purpura (ITP)?
What is the most common cause of failure to correct thrombocytopenia after splenectomy for ITP?
What are the “I’s” of ITP?
What is TTP?
Splenic vein thrombosis (usually from pancreatitis)
Splenectomy
Patients with ulcerative colitis
Pneumococcus
Meningococcus
Haemophilus influenzae type B
Hyperfunctioning spleen Documented loss of blood elements
(WBC, Hct, platelets) Large spleen (splenomegaly)
Hyperactive bone marrow (trying to keep up with loss of blood elements)
Enlarged spleen
Autoimmune (antiplatelet antibodies IgG in 90% of patients) platelet destruction leading to troublesome bleeding and purpura
Missed accessory spleen
Immune etiology (IgG antiplatelets ABs) Immunosuppressive treatment (initially
treated with steroids) Immune globulin
Improvement with splenectomy (75% of patients have improved platelet counts after splenectomy)
Thrombotic Thrombocytopenic Purpura
|
Chapter 61 / Surgically Correctable Hypertension 463 |
What is the treatment of |
Plasmapheresis (splenectomy reserved as |
choice for TTP? |
a last resort—very rare) |
What is the most common |
Splenomegaly |
physical finding of portal |
|
hypertension? |
|
C h a p t e r 61
Surgically
Correctable HTN
What is it?
What percentage of patients with HTN have a surgically correctable cause?
Hypertension caused by conditions that are amenable to surgical correction
7%
What diseases that cause |
Think “CAN I CHURP?”: |
HTN are surgically |
Cushing’s syndrome |
correctable? |
Aortic coarctation |
|
Neuroblastoma/neoplasia |
|
Increased intracranial pressure |
|
Conn’s syndrome (primary |
|
hyperaldosteronism) |
|
Hyperparathyroidism/hyperthyroidism |
|
Unilateral renal parenchymal disease |
|
Renal artery stenosis |
|
Pheochromocytoma |
What is the formula for |
Pressure flow resistance or P |
pressure? |
F R (Think: Power FoRward); thus, |
|
an increase in flow, resistance, or both, |
|
results in an increase in pressure |