- •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
550 Section III / Subspecialty Surgery |
|
What are the associated |
50% of cases occur with |
abnormalities? |
abnormalities of the GI tract, |
|
cardiovascular system, GU tract, |
|
musculoskeletal system, CNS, and |
|
chromosomes |
Of what “pentalogy” is |
Pentalogy of Cantrell |
omphalocele a part? |
|
What is the pentalogy of |
“D COPS”: |
Cantrell? |
Diaphragmatic defect (hernia) |
|
Cardiac abnormality |
|
Omphalocele |
|
Pericardium malformation/absence |
|
Sternal cleft |
GASTROSCHISIS |
|
|
|
What is it?
How is it diagnosed prenatally?
Where is the defect?
On what side of the umbilicus is the defect most commonly found?
What is the usual size of the defect?
What are the possible complications?
Defect of abdominal wall; sac does not cover extruded viscera
Possible at fetal ultrasound after 13 weeks’ gestation, elevated maternal AFP
Lateral to the umbilicus (Think: gAstrochisis lAteral)
Right
2 to 4 cm
Thick edematous peritoneum from exposure to amnionic fluid; malrotation of the gut
Other complications include hypothermia; hypovolemia from third-spacing; sepsis; and metabolic acidosis from hypovolemia and poor perfusion, NEC, prolonged ileus
How is the diagnosis made? |
Prenatal U/S |
|
Chapter 67 / Pediatric Surgery 551 |
What is the treatment? |
Primary—NG tube decompression, IV |
|
fluids (D10 LR), and IV antibiotics |
|
Definitive—surgical reduction of viscera |
|
and abdominal closure; may require |
|
staged closure with silo |
What is a “silo”? |
Silastic silo is a temporary housing for |
|
external abdominal contents; silo is slowly |
|
tightened over time |
What is the prognosis?
What are the associated anomalies?
What are the major differences compared with omphalocele?
How can you remember the position of omphalocele vs. gastroschisis?
How do you remember that omphalocele is associated with abnormalities in 50% of cases?
90% survival rate
Unlike omphalocele, relatively uncommon except for intestinal atresia, which occurs in 10% to 15% of cases
No membrane coverings Uncommon associated abnormalities
Lateral to umbilicus—not on umbilicus
Think: OMphalocele ON the umbilicus
Think: Omphalocele “Oh no, lots of abnormalities”
POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
What are the differences between omphalocele and gastroschisis in terms of the following characteristics:
Anomalies?
Peritoneal/amnion covering (sac)?
Position of umbilical cord?
Common in omphalocele (50%), uncommon in gastroschisis
Always with omphalocele—never with gastroschisis
On the sac with omphalocele, from skin to the left of the gastroschisis defect
552 Section III / Subspecialty Surgery |
|
Thick bowel? |
Common with gastroschisis, rare with |
|
omphalocele (unless sac ruptures) |
Protrusion of liver? |
Common with omphalocele, almost never |
|
with gastroschisis |
Large defect? |
Omphalocele |
APPENDICITIS |
|
|
|
What is it? |
Obstruction of the appendiceal lumen |
|
(fecalith, lymphoid hyperplasia), |
|
producing a closed loop with resultant |
|
inflammation that can lead to necrosis |
|
and perforation |
What is its claim to fame? |
Most common surgical disease requiring |
|
emergency surgery in children |
What is the affected age? |
Very rare before 3 years of age |
What is the usual |
Onset of referred or periumbilical pain |
presentation? |
followed by anorexia, nausea, and |
|
vomiting (Note: Unlike gastroenteritis, |
|
pain precedes vomiting, then |
|
migrates to the RLQ, where it |
|
intensifies from local peritoneal |
|
irritation) |
|
If the patient is hungry and can eat, |
|
seriously question the diagnosis of |
|
appendicitis |
How is the diagnosis made? |
History and physical exam |
What are the signs/ |
Signs of peritoneal irritation may be |
symptoms? |
present—guarding, muscle spasm, rebound |
|
tenderness, obturator and Psoas signs; |
|
low-grade fever rising to high grade if |
|
perforation occurs |
What is the differential |
Intussusception, volvulus, Meckel’s |
diagnosis? |
diverticulum, Crohn’s disease, ovarian |
|
torsion, cyst, tumor, perforated ulcer, |
|
pancreatitis, PID, ruptured ectopic |
|
pregnancy, mesenteric lymphadenitis |
What is the common bacterial cause of mesenteric lymphadenitis?
What are the associated lab findings with appendicitis?
What is the role of urinalysis?
Chapter 67 / Pediatric Surgery 553
Yersinia enterocolitica
Increased WBC ( 10,000 per mm3 in90% of cases, with a left shift in most)
To evaluate for possible pyelonephritis or renal calculus, but mild hematuria and pyuria are common in appendicitis because of ureteral inflammation
What is the “hamburger” |
Ask patients with suspected appendicitis |
sign? |
if they would like a hamburger or favorite |
|
food; if they can eat, seriously question |
|
the diagnosis |
What radiographic studies |
Often none; CXR to rule out RML or |
may be performed? |
RLL pneumonia; abdominal films are |
|
usually nonspecific, but calcified fecalith |
|
is present in 5% of cases; U/S to evaluate |
|
for ovarian/gynecologic pathology |
What is the treatment? |
Nonperforated—prompt appendectomy |
|
and cefoxitin to avoid perforation |
|
Perforated—triple antibiotics, |
|
fluid resuscitation, and prompt |
|
appendectomy; all pus is drained and |
|
cultures obtained, with postoperative |
|
antibiotics continued for 5 to 7 days, |
|
drain |
How long should antibiotics |
24 hours |
be administered if |
|
nonperforated? |
|
How long if perforated? |
Usually 5 to 7 days or until WBCs are |
|
normal and patient is afebrile |
If a normal appendix is |
Meckel’s diverticulum, Crohn’s disease, |
found upon exploration, |
intussusception, gynecologic disease |
what must be examined/ |
|
ruled out? |
|