GI Surgery

implies severe abdominal pain arising rather suddenly and of less than 24 hours duration

pain arising from the foregut (stomach, pancreas, duodenum and biliary tree) localizes to the

pain from structures arising from the midgut (small bowel, and right transverse colon) localizes to the

pain from structures arising from the hindgut (left colon, sigmoid colon, rectum) localizes to the

intermittent colicky, poorly localized abdominal pain is found with

steady, well localized pain usually occurs after

classic signs and symptoms are mild fever and focal right lower quadrant pain with rebound tenderness

commonly occurs in women between the ages of 40-60 who are overweight and have a previous history of pregnancy

patients will have right upper quadrant pain that is accentuated on inspiration, and is accompanied by nausea and vomiting

Murphy's sign

McBurney point

laparoscopic approach has been proven safe in both acute and chronic settings

pain that localizes to right lower quadrant accompanied by anorexia, nausea, and vomiting is classic

the normal anatomic position of the appendix

results in an increased risk of perforation due to delayed diagnosis

during the 5th month of pregnancy the appendix may rise as high as the

in western populations the lifetime risk of appendicitis is __%

appendicitis is primarily a disease of

incidence of ____ declines after age 30

____ is seen in approximately 70% of appendicitis cases

the appendiceal lumen can be obstructed by

the number of ___ in the vermiform appendix peaks between the ages of 10-30

rare causes of appendicitis

after obstruction of the appendiceal lumen ___ continue

___ follows appendiceal obstruction

___ which ultimately leads to ulceration, necrosis, gangrene, and perforation

____ alone should make the diagnosis of acute appendicitis in most patients

after 1-12 hours of diffuse mild to moderate pain, appendicitis pain will usually

Vomiting and diarrhea may be present in acute appendicitis but ___

if vomiting precedes abdominal pain or if anorexia is not present ____

___ should be present in 75%-85% of all patients with acute appendicitis

a temperature will rarely be highter than __ unless the appendix is grossly perforated

with appendicitis vital signs are

patients with acute appendicitis prefer to

patients with colicky-type pain may appear

palpation of left lower quadrant causing right lower quadrant pain

deep palpation of right lower quadrant followed by a sudden release

assessing for rebound tenderness can lead to a

a positive ___ sign may indicate an inflamed appendix lying anterior to the ___ muscle

this sign is best demonstrated by extension of the hip or flexion against resistance

___ is produced by stretching this muscle with passive internal rotation of the thigh, with the hips in a flexed position

both the obturator and psoas signs are

a ___ exam is also important in evaluating any patient with abdominal pain

tenderness with a rectal exam is most commonly seen when the inflamed appendix lies

____ on fecal exam should be quite rare and lead to the consideration of a diagnosis other than appendicitis

administer prophylactic antibiotics

the base of the appendix is located at

the ___ lies posterior to the cecum or terminal ileum

after incision if appendicitis is not present

consider ___ of the wound for advanced and perforated appendicitis

the gold standard for the treatment of appendicitis is

laparotomy can be accomplished through a ____ incision

this is an oblique incision, which divides the fascia parallel to its fibers, and a muscle splitting technique is used (used for appendicitis)

a right-lower-quadrant transverse ___ incision is preferred by many for appendicitis

in the elderly where other disease processes may be encountered, many surgeons would prefer a ____ incision

____ are usually indicated if a well-formed intraabdominal or pelvic abcess is encountered

if a case of perforated appendicitis with generalized peritonitis is encountered, the wound should be considered grossly contaminated and

incindental appendectomy should not be performed if ___ is found to be affecting the cecum, as the incidence of fistulization may be quite high

as a diagnostic procedure ____ is by far the most accurate, but it is invasive

laparoscopic appendectomy is especially useful

laparoscopic appendectomy is especially useful

laparoscopic appendectomy is especially useful

laparoscopic appendectomy is especially useful

antibiotic therapy in early appendicitis

in uncomplicated appendectomy patients should be moved to a diet and discharged within ___hours

___ complications are by far the most frequently seen problem after appendectomy

once a wound infection is diagnosed the primary treatment is

if cellulitis is present in an infected wound

early recognition, aggressive surgical debridement, and administration of broad spectrum antibiotics are critical in

___ is the result of the abdominal host defenses attempting to wall off an infectious threat

drainage and antibiotics are the treatments for

an abscess after appendicitis most commonly occurs in the

the most common treatment for postoperative abscess is

the radiographic finding of air in the portal vein

this is a rare presentation of an advanced septic process due to gas-forming organisms

is often seen in the elderly, immunocompromised, or in advanced sepsis, and is often a preterminal finding

appendicitis is seen in approximately 1 in ___ pregnancies

the most common nonobstetric emergency in pregnant women

WBC count in a pregnant woman is unreliable, however a ___ can be seen in appendicitis

the risk of conventional diagnostic radiographs such as a KUB or CT scans is ___ after the first trimester

abdominal wall hernias occur in __% of the United States population

a cleft in the anterior abdominal wall that is bound anteriorly by the external oblique aponeurosis and posteriorly by the transversalis fascia

the spermatic cord in males and the round ligament in females enter ____ through the transversus abdominis fascia at the interanl inguinal ring

the spermatic cord travels the length of the inguinal canal and exits through the

____ hernias come through the internal inguinal ring and enter the inguinal canal

with time indirect inguinal hernias may extend along the canal and exit through the internal ring into

____ are usually caused by a lack of obliteration by the processus vaginalis during development

____ hernias come through the posterior wall of the inguinal canal and are a defect in the transversalis fascia

direct inguinal hernias infrequently enter

the main etiologic factor in direct inguinal hernias is

risk factors for direct inguinal hernias

____ hernias are more common in women

because of the risk of ____ nonsurgical management of hernias is not recommended

wearing a ___ does NOT guarantee that a hernia will remain reduced and not incarcerate or strangulate

___ is a surgical emergency

the ___ approach is best for recurrent hernias (open or laparoscopic)

the us of a prosthesis for herniorrhaphies is mandatory

Ventral, incisional hernias frequently occur because of

when mesh prosthesis is used in inguinal hernia repair, the mesh is sutured to

the results of ____ in inguinal hernia repair have been very good

a large piece of material is fixed with only a few sutures

the anterior boundary of the inguinal canal

the posterior boundary of the inguinal canal

the inferior boundary of the inguinal canal

the superior boundary of the inguinal canal

___ come through the posterior wall of the inguinal canal

___ come through the internal or deep inguinal ring

inguinal herniorrhaphy in which the transversus abdominis aponeurosis and the internal oblique aponeurosis superiorly are sutured to the inguinal ligament

inguinal herniorrhaphy in which the conjoined tendon superiorly is sutured to Cooper's ligament inferiorly

the transversus abdominis aponeurosis, and the internal oblique aponeurosis

the anterior boundary of the femoral canal

posterior boundary of the femoral canal

medial boundary of the femoral canal

lateral boundary of the femoral canal

the only acceptable approach to the treatment of femoral hernias is

congenital umbilical hernias usually close spontaneously by age

umbilical hernias are usually

____ umbilical defects should be repaired

recurrence of umbilical hernia is

umbilical hernias have ___ complications

if a hernia bulges with a Valsalva maneuver it will reduce when the patient

if a primary repair can be accomplished without excessive tension, yet the tissues appear weak ____

inflammation of the gallbladder

in the vast majority of cases (>90%) of acute cholecystitis ___ is the initiating event

acute cholecystitis is distinguished from an attack of biliary colic by

acute cholecystitis is associated with ___ in 50-75% of cases

if cholecystitis is left untreated ___ may develop (most often seen in diabetic patients)

____ leads to increased morbidity and mortality from perforation of the gallbladder or overwhelming sepsis

patients suspected of having acute cholecystitis should

contraindications to cholecystectomy

unless contraindications exist, ___ should be performed in the first 24-36 hours after admission

the inflammatory process of cholecystitis is the most severe between ____ of the onset of symptoms, the technical challenge of successful laparoscopic removal is greatest during this period

if the patient is diagnosed with cholecystitis 4-5 days after onset of symptoms

the success rates with this technique where low, and the complications high. Therefore this procedure has been abandoned

contraindications for laparoscopic cholecystectomy

the treatment of choice for most patients with symptomatic gallstones

after laparoscopic cholecystectomy, N/V and increasing abdominal pain are often early warning signs of

____ in an otherwise healthy patient is carcinoma of the biliary system until proven otherwise

after laparoscopic cholecystectomy patients should have

what are the 4 F's of gall stones

cholelithiasis

choledocholithiasis

__% of gallstones are radiopaque

inflammation of the common bile duct

cholecystectomy is performed for

now the procedure of choice for gallbladder disease

causes less pain, shorter hospital stay

complications of laparoscopic cholecystectomy

what do you want to see on the critical view for cholecystectomy

common bile duct injury is ___ with lap approach

___ hernias go through Hesselbach’s triangle

It is defined by the following structures: Rectus abdominis muscle (medially), Inferior epigastric vessels (superior and laterally). Inguinal ligament, sometimes referred to as Poupart's ligament (inferiorly)

which is a recurrent hernia by definition

male:female ratio of inguinal hernia __:1

hernia below the inguinal ligament

elements of both direct and indirect hernia

____ is especially useful for obese patients when the differential diagnosis includes simple weakness of the abdominal wall in addition to an incisional or epigastric hernia

inability to reduce hernia contents

compromise of intestinal vascular supply secondary to incarceration

no mesh hernia repair

most common hernia repair using mesh

the only time you want to do a laparoscopic hernia repair

Laparoscopic hernia repair has not been shown ___ than open repair

function of the colon

Most common colonic bacteria

most common aerobes in colon

outpouching of the wall of a hollow viscus

true diverticula (13%)

pseudodiverticula (87%)

presence of multiple diverticula, present in majority of people >70 years, >90% in sigmoid, usually asymptomatic, common cause of massive lower GI bleed from right-sided location

inflammation or microperforation of diverticula, fever, LLQ pain, palpable mass, may produce abscess/colonic obstruction, does not usually cause bleeding

surgery for acute diverticulitis is indicated for

Non-operative management for diverticulitis

communication between colon and bladder

torsion of redundant sigmoid colon on itself

classical clinical picture of ____: elderly patients with a history of chronic constipation

bright red blood per rectum

most common cause of hematochezia

most common cause of lower GI bleed hematochezia

signs of hypovolemia

Inflammatory disorder of unknown etiology with non-caseating granulomas in submucosa

Discontinuous involvement --> skip lesions, Transmural (full-thickness) inflammation

Clinical Presentation: abdominal pain is most common symptom, frequent bowel movements - diarrhea, abdominal distention with nausea and vomiting, rarely blood in stool, symptoms caused by eating --> weight loss. Complications: fistula, stricture

most common area affected by Crohn's disease

Crohn's disease is a medical disease managed by __

mainstay of medical treatment for Chron's disease

indications for surgery in Crohn's

Surgery cannot cure __

Goal of surgery for Crohn's disease

Superficial inflammatory process involving mucosa of colon

Involves the rectum and moves proximally

Surgery can cure __

colorectal cancer is the __ leading cause of death in the US

colorectal cancer risk factors

colorectal cancer screening recommendations include and annual DRE and FOBT starting at age

Family History or Inherited Colon Cancer Syndrome. Annual screening with colonoscopy beginning at __ years of age younger than the earliest detected familial cancer

Presentation of ___ includes: Change in Bowel Habits (pencil thin stool), Rectal Bleeding, Change in Stool Caliber, Colon Obstruction, Perforation and Abscess Formation, Fistula Formation, Abdominal Pain, Weight Loss, Jaundice

four types of colon polyps

staging for colorectal cancer involves

Result from sliding downward of anal cushions

Predisposed by age, gravity, shear forces, increased abdominal pressure

below dentate line & covered by squamous epithelium, more common in women due to enlargement during pregnancy, large skin tags usually remain & may become inflamed, may thrombose

above dentate line & covered by columnar epithelium, may prolapse, bleed, and/or thrombose

internal hemorrhoidal disease without significant external disease or other benign anorectal disease, can be

____ use for large mixed hemorrhoids or when other benign anorectal diseases present