- •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
660 Section III / Subspecialty Surgery |
|
What are the signs/ |
Murmur (new or changing) |
symptoms? |
Petechiae |
|
Splinter hemorrhage (fingernails) |
|
Roth spots (on retina) |
|
Osler nodes (raised, painful on soles and |
|
palms; Osler Ouch!) |
|
Janeway lesions (similar to Osler nodes, |
|
but flat and painless) (JaneWAY |
|
pain aWAY) |
Which diagnostic tests |
Echocardiogram, TEE |
should be performed? |
Serial blood cultures (definitive) |
What is the treatment? |
Prolonged IV therapy with bactericidal |
|
antibiotics, to which infecting |
|
organisms are sensitive |
What is the prognosis? |
Infection can progress, requiring valve |
|
replacement |
CONGENITAL HEART DISEASE
VENTRICULAR SEPTAL DEFECT (VSD)
What is its claim to fame? Most common congenital heart defect
What is it? |
Failure of ventricular septum to |
|
completely close; 80% of cases involve |
|
the membranous portion of the |
|
septum, resulting in left-to-right shunt, |
|
increased pulmonary blood flow, and CHF |
|
if pulmonary to systemic flow is 2:1 |
What is pulmonary vascular |
Pulmonary artery hyperplasia from |
obstructive disease? |
increased pulmonary pressure caused by |
|
a left to right shunt (e.g., VSD) |
What is Eisenmenger’s |
Irreversible pulmonary HTN from chronic |
syndrome? |
changes in pulmonary arterioles and |
|
increased right heart pressures; cyanosis |
|
develops when the shunt reverses |
|
(becomes right to left across the VSD) |
What is the treatment of Eisenmenger’s syndrome?
Only option is heart-lung transplant; otherwise, the disease is untreatable
Chapter 72 / Cardiovascular Surgery 661
What is the incidence of VSD?
30% of heart defects (most common defect)
PATENT DUCTUS ARTERIOSUS (PDA)
What is it? |
Physiologic right-to-left shunt in fetal |
|
circulation connecting the pulmonary |
|
artery to the aorta bypassing fetal lungs; |
|
often, this shunt persists in the neonate |
What are the factors |
Hypoxia, increased prostaglandins, |
preventing closure? |
prematurity |
What are the symptoms? |
Often asymptomatic |
|
Poor feeding |
|
Respiratory distress |
|
CHF with respiratory infections |
What are the signs? |
Acyanotic, unless other cardiac lesions |
|
are present; continuous “machinery” |
|
murmur |
Which diagnostic tests |
Physical examination |
should be performed? |
Echocardiogram (to rule out associated |
|
defects) |
|
Catheter (seldom required) |
What is the medical |
Indomethacin is an NSAID: |
treatment? |
prostaglandin (PG) inhibitor (PG keeps |
|
PDA open) |
What is the surgical |
Surgical ligation or cardiac |
treatment? |
catheterization closure at 6 months to |
|
2 years of age |
TETRALOGY OF FALLOT (TOF) |
|
|
|
What is it? |
Misalignment of the infundibular septum |
|
in early development, leading to the |
|
characteristic tetrad: |
|
1. Pulmonary stenosis/obstruction of |
|
right ventricular outflow |
|
2. Overriding aorta |
|
3. Right ventricular hypertrophy |
|
4. VSD |
662 Section III / Subspecialty Surgery |
|
|
What are the symptoms? |
Hypoxic spells (squatting behavior |
|
|
increases SVR and increases pulmonary |
|
|
blood flow) |
|
What are the signs? |
Cyanosis |
|
|
Clubbing |
|
|
Murmur: SEM at left third intercostal |
|
|
|
space |
Which diagnostic tests |
CXR: small, “boot-shaped” heart and |
|
should be performed? |
|
decreased pulmonary blood flow |
|
Echocardiography |
|
What is the prognosis? |
95% survival at specialized centers |
|
IHSS |
|
|
|
|
|
What is IHSS? |
Idiopathic Hypertrophic Subaortic |
|
|
Stenosis |
|
What is it? |
Aortic outflow obstruction from septal |
|
|
tissue |
|
What is the usual |
Similar to aortic stenosis |
|
presentation? |
|
|
COARCTATION OF THE AORTA |
|
|
|
|
|
What is it? |
Narrowing of the thoracic aorta, with or |
|
|
without intraluminal “shelf” (infolding of |
|
|
the media); usually found near ductus/ |
|
|
ligamentum arteriosum |
|
What are the three types? |
1. |
Preductal (fatal in infancy if untreated) |
|
2. |
Juxtaductal |
|
3. |
Postductal |
What percentage are |
60% (bicuspid aortic valve is most |
|
associated with other |
common) |
|
cardiac defects? |
|
|
What is the major route of |
Subclavian artery to the IMA to the |
|
collateral circulation? |
intercostals to the descending aorta |
|
What are the risk factors? |
Turner’s syndrome, male female |
|
Chapter 72 / Cardiovascular Surgery 663 |
What are the symptoms? |
Headache |
|
Epistaxis |
|
Lower extremity fatigue S claudication |
What are the signs? |
Pulses: decreased lower extremity pulses |
|
Murmurs: |
|
1. Systolic—from turbulence across |
|
coarctation, often radiating to infra- |
|
scapular region |
|
2. Continuous—from dilated collaterals |
Which diagnostic tests |
CXR: “3” sign is aortic knob, coarctation, |
should be performed? |
and dilated poststenotic aorta; rib |
|
notching is bony erosion from dilated |
|
intercostal collaterals |
|
Echocardiogram |
|
Cardiac catheterization if cardiac defects |
What is the treatment? |
Surgery: |
|
Resection with end-to-end anastomosis |
|
Subclavian artery flap |
|
Patch graft (rare) |
|
Interposition graft |
|
Endovascular repair an option in adults |
What are the indications for |
Symptomatic patient |
surgery? |
Asymptomatic patient 3 to 4 years |
What are the possible |
Paraplegia |
postoperative complications? |
“Paradoxic” HTN |
|
Mesenteric necrotizing panarteritis (GI |
|
bleeding), Horner’s syndrome, injury |
|
to recurrent laryngeal nerve |
What are the long-term |
Aortic dissection, HTN |
concerns? |
|
TRANSPOSITION OF THE GREAT VESSELS |
|
|
|
What is it? |
Aorta originates from the right ventricle |
|
and the pulmonary artery from the left |
|
ventricle; fatal without PDA, ASD, or |
|
VSD—to allow communication between |
|
the left and right circulations |
664 Section III / Subspecialty Surgery |
|
What is the incidence? |
From 5% to 8% of defects |
What are the signs/ |
Most common lesion that presents with |
symptoms? |
cyanosis and CHF in neonatal period |
|
( 90% by day 1) |
Which diagnostic tests |
CXR: “egg-shaped” heart contour |
should be performed? |
Catheterization (definitive) |
What is the treatment? |
Arterial switch operation—aorta and |
|
pulmonary artery are moved to the correct |
|
ventricle and the coronaries are reimplanted |
EBSTEIN’S ANOMALY |
|
|
|
What is it? |
Tricuspid valve is placed abnormally low |
|
in the right ventricle, forming a large |
|
right atrium and a small right ventricle, |
|
leading to tricuspid regurgitation and |
|
decreased right ventricular output |
What are the signs/symptoms? |
Cyanosis |
What are the risk factors? |
400 the risk if the mother has taken |
|
lithium |
VASCULAR RINGS |
|
|
|
What are they? |
Many types; represent an anomalous devel- |
|
opment of the aorta/pulmonary artery from |
|
the embryonic aortic arch that surrounds |
|
and obstructs the trachea/esophagus |
How are they diagnosed? |
Barium swallow, MRI |
What are the signs/ |
Most prominent is stridor from tracheal |
symptoms? |
compression |
CYANOTIC HEART DISEASE |
|
|
|
What are the causes? |
Five “Ts” of cyanotic heart disease: |
|
Tetralogy of Fallot |
|
Truncus arteriosus |
|
Totally anomalous pulmonary venous |
|
return (TAPVR) |
|
Tricuspid atresia |
|
Transposition of the great vessels |