- •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
510 Section II / General Surgery
What are the possible postoperative complications after a CEA?
What is the mortality rate after CEA?
What is the perioperative stroke rate after CEA?
What is the postoperative medication?
What is the most common cause of death during the early postoperative period after a CEA?
Define “Hollenhorst plaque”?
CVA, MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis, vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of injury—“wheel- barrow” effect), intracranial hemorrhage
1%
Between 1% (asymptomatic patient) and 5% (symptomatic patient)
Aspirin (inhibits platelets by inhibiting cyclo-oxygenase)
MI
Microemboli to retinal arterioles seen as bright defects
CLASSIC CEA INTRAOP QUESTIONS
What thin muscle is cut right |
Platysma muscle |
under the skin in the neck? |
|
What are the extracranial |
None |
branches of the internal |
|
carotid artery? |
|
Which vein crosses the carotid bifurcation?
What is the first branch of the external carotid?
Which muscle crosses the common carotid proximally?
Which muscle crosses the carotid artery distally?
Facial vein
Superior thyroidal artery
Omohyoid muscle
Digastric muscle (Think: Digastric Distal)
Which nerve crosses approximately 1 cm distal to the carotid bifurcation?
Which nerve crosses the internal carotid near the ear?
What is in the carotid sheath?
Chapter 66 / Vascular Surgery 511
Hypoglossal nerve; cut it and the tongue will deviate toward the side of the injury (the “wheelbarrow effect”)
Facial nerve (marginal branch)
1.Carotid artery
2.Internal jugular vein
3.Vagus nerve (lies posteriorly in 98% of patients and anteriorly in 2%)
4.Deep cervical lymph nodes
SUBCLAVIAN STEAL SYNDROME
What is it? |
Arm fatigue and vertebrobasilar |
|
insufficiency from obstruction of the left |
|
subclavian artery or innominate proximal to |
|
the vertebral artery branch point; ipsilateral |
|
arm movement causes increased blood flow |
|
demand, which is met by retrograde flow |
|
from the vertebral artery, thereby “stealing” |
|
from the vertebrobasilar arteries |
512 Section II / General Surgery |
|
Which artery is most |
Left subclavian |
commonly occluded? |
|
What are the symptoms? |
Upper extremity claudication, syncopal |
|
attacks, vertigo, confusion, dysarthria, |
|
blindness, ataxia |
What are the signs? |
Upper extremity blood pressure |
|
discrepancy, bruit (above the clavicle), |
|
vertebrobasilar insufficiency |
What is the treatment? |
Surgical bypass or endovascular stent |
RENAL ARTERY STENOSIS |
|
|
|
What is it? |
Stenosis of renal artery, resulting in |
|
decreased perfusion of the juxtaglomerular |
|
apparatus and subsequent activation of the |
|
renin-angiotensin-aldosterone system (i.e., |
|
hypertension from renal artery stenosis) |
What is the incidence? |
10% to 15% of the U.S. population have |
|
HTN; of these, 4% have potentially |
|
correctable renovascular HTN |
|
Also note that 30% of malignant HTN |
|
have a renovascular etiology |
What is the etiology of the stenosis?
66% result from atherosclerosis (men women), 33% result from fibromuscular dysplasia (women men, average age 40 years, and 50% with bilateral disease)
Note: Another rare cause is hypoplasia of the renal artery
What is the classic profile of |
Young woman with hypertension |
a patient with renal artery |
|
stenosis from fibromuscular |
|
dysplasia? |
|
What are the associated |
Family history, early onset of HTN, HTN |
risks/clues? |
refractory to medical treatment |
|
Chapter 66 / Vascular Surgery 513 |
What are the signs/ |
Most patients are asymptomatic but may |
symptoms? |
have headache, diastolic HTN, flank |
|
bruits (present in 50%), and decreased |
|
renal function |
What are the diagnostic tests? |
|
A-gram |
Maps artery and extent of stenosis (gold |
|
standard) |
IVP |
80% of patients have delayed nephrogram |
|
phase (i.e., delayed filling of contrast) |
Renal vein renin ratio |
If sampling of renal vein renin levels |
(RVRR) |
shows ratio between the two kidneys |
|
1.5, then diagnostic for a unilateral |
|
stenosis |
Captopril provocation test |
Will show a drop in BP |
Are renin levels in serum ALWAYS elevated?
No: Systemic renin levels may also be measured but are only increased in malignant HTN, as the increased intravascular volume dilutes the elevated renin level in most patients
What is the invasive |
Percutaneous Renal Transluminal |
nonsurgical treatment? |
Angioplasty (PRTA)/stenting: |
|
With FM dysplasia: use PRTA |
|
With atherosclerosis: use PRTA/stent |
What is the surgical |
Resection, bypass, vein/graft |
treatment? |
interposition, or endarterectomy |
What antihypertensive |
ACE inhibitors (result in renal |
medication is |
insufficiency) |
CONTRAINDICATED in |
|
patients with hypertension |
|
from renovascular stenosis? |
|
SPLENIC ARTERY ANEURYSM |
|
|
|
What are the causes? |
Women—medial dysplasia |
|
Men—atherosclerosis |