Gi_Pm_Surgery_Abd Wall&hernias

Front 1

What are Langer's lines of cleavage?

Back 1

Elastin creating skin tension transversely.

What are they like in lower abdomen?

Hint 1

Slightly more oblique in Abdomen

-Watch cleavage lines and cutaneous inntervation as they go all the way into Scrotom, can get numb spot in guys after surgery

Front 2

Describe the Camper's Fascia

Back 2

Superficial Layer

Fattier

Describe the Scarpa/s Fascia?

What is Colles Fascie

Hint 2

Deeper Layer

More fibrous, denser

Colles--contiguous into the perineum as the superficial perineal fascia of Colle's

Front 3

What layer remains muscular into the groin?

Back 3

Internal Oblique mm.

cremaster

What does External Oblique Mm. fuse with medially?

Hint 3

Coopers Ligament --not real

-Transversus Abd also attaches to this

Front 4

What does Transversus Abdominus form in inguinal canal?

Back 4

Forms Posterior wall of canal

Front 5

What forms uniterupted layer of fascia to interior of abdomen?

Back 5

Transversalis Fascia and Peritoneum

Front 6

The failure of what to obliterate causes indirect (congeital) hernias?

Back 6

Portion of Peritoneum that comes with scrotom (tunica vaginalis)

Front 7

How does abdominal wall form in 2nd trimester

Back 7

Ophalomesenteric duct disappears, Gut rotates and re-enters peritoneal vacity
Then Ab wall forms

Front 8

What is tubular diverticulum of embryonic hindgut?

Back 8

Allantois

Front 9

If the Omphallomesenteric duct doesnt close, what things might result?

Back 9

Vitelline Duct Cyst

What results if Allantois doesnt close

Hint 9

Urachal cyst or urachal fistula

Front 10

What do you do with Umbilical Hernias (not gastrochisis/omphalocele)

Back 10

Common up to age to and will close spontaenously.
--Operate if>2cm or if Incarcerated

--After age 2, ability to reduce back spontaneously drops a lot

Front 11

What causes a hydrocele & Communicated Hydrocele

Back 11

Indirect Inguinal Hernia
--Patent Processus vaginalis (20%)

Front 12

How does Inguinal Hernia result?

Back 12

Abdominal pressure increases size at INTERNAL Ring LATERL to Femoral Vessels
--Omentum and intestines can herniate

Front 13

How is Indirect Inguinal Hernia DX?

Back 13

Invaginate Scrotal Sac INTO Canal
-Cough
-Feel the Impulse? Vessels?

Front 14

Acquired Hernias are?

Where in canal does it occur, which mm.

Medial or Lateral to Groin vessels?

Back 14

Direct Inguinal hernias--Medial to Groin Vessels
--age, conn tiss dz, mm wasting
--Erodes through Floor of Transverus Mm.

What is diff appearance from indirect

Hint 14

Cant really tell until sugery

Front 15

Another acquired hernia type?
Where does it occur?

Back 15

femoral Hernia
--susceptable to incarceration
--presents lower below the inguinal canal.

Who gets these more often

Hint 15

Women More often--30%, still Inguinal Hernias are 70% more frequent!

Front 16

WHat is often confused with lipoma or lymph node in females

Back 16

Femoral Hernia

DON'T Put a Needle in IT

Hernia Breakdown in Fems?

Hint 16

70% Indirect
30% Femoral
Direct are RARE

Front 17

Breakdown for Hernias in Men?

Back 17

40% Direct--acquired
50% Indirect
10% Femoral

In children?

Hint 17

Children:
RARE Indirect
ALL Indirect (congenital)
RARE Femoral

Front 18

Basics of Hernia Repair

Back 18

Reduce any Abd Viscus into Abd Cavity
-Create new, TENSION Free Inguinal Floo
-Recreate a SNUG INTERNAL RING

--anything else?

Hint 18

Obliterate the Processus Vaginalis
-Obliterate the Femoral Space or Cover with MEsh

Front 19

Which Open Hernia repair does Bjerke use?

Back 19

McVay--uses Cooper's ligament

What repair uses a lot of layers of mm and wire suture?

Which uses plastic mesh

Hint 19

Shouldice is multiple layers+wire

Lichtenstein-mesh repair outside Transversus

Front 20

What are 2 Unique Hernias

Back 20

Spigelian--semilunar and semi-circular lines intersect

Grynfelt's: Superior Lumbar Triangle

dont worry about

Front 21

What is Richters Hernia?
Why serious

Back 21

Side wall of bowel
Can have gangrene

note: petits is inferior lumbar triangle--dont worry about

Front 22

What is hernia + meckels divert in it?

Back 22

Littre's Hernia

One with Appendix in Sac?

Hint 22

Armands Hernia

Front 23

What hErnia is both direct and indirect hernai---hernia coming out around both sides of groin vessels?

Back 23

Pantaloon Hernia

Pseudo hernia with midline buldge above umbilicus

Hint 23

Diastasis Recti--wide linea alba
--no surgery

Front 24

NOTE: THis is END of Hernia Lecture, Surgery Lec 1

USE LECTURE SLIDE b/c

Back 24

THere are Questions at end of LEcture WITH Answers!!!!

Front 25

Moving on to a Few notecards from Acute Abdomen Lecture

Back 25

Note: Rule for Possible Surgery:
1. Hold or limit pain meds
2. Majority of severe abd pains in Pts that were well, that last >6hours are usually conditions of surgical import

Front 26

WHat are most important meds a surgeon needs to be aware off?

Back 26

Steroids--maks a lot of Sx
-Herbals--crazy shit
-Stree Drugs
--ABX--can also mask

Note on Physical Exam--dont forget the?

Hint 26

Rectal or Vaginal Exam

Front 27

What other Dz can appear as appendicitis though it has NOTHINg to do with it

Back 27

Herpes Zoster

Front 28

Name for Bowel Sounds?

Where do you auscultate?

Back 28

Borborygmi

-All 4 quadrants for 2 minutes each
--Listen for Bruit in AAA

Front 29

Important note for Palpation in Acute Abd?

Back 29

Warm Hands, be gentle and

Start AWAY from the Pain
---feel mm underneath, feel for hernias and percuss when feasible

Front 30

When Palpating Acute Abd, what are 4 features/tests to consider?

Back 30

REbound Tenderness
Rigid Mm.
HyperEsthesia
Iliopsoas test

WHat is rebound tenderness?

Hint 30

REbound Tenderness--pain with removal of pressure--due to parital layer of peritoneum stretching

Front 31

What can lateral tenderness of rectum demonstrate

Back 31

Appendicitis
--Right side of rectum in contact

Front 32

Where does Foregut pain Present anatomically?

Back 32

Epigastric Pain

What can this be due to (4)

Hint 32

Ulcer, Gastritis, chlecystitis, Pancreatitis

Front 33

Where does Midgut pain Present anatomically?

Back 33

Periumbilical

What regions of GIT affected?

Hint 33

duodenum to Transverse Colon

Front 34

What describes location of Hindgut pain

Back 34

Seatbelt like
--Transverse colon to Anus

Front 35

Appendicitis which occurs in 1:15 peeps, is caused by what?

Back 35

Obstruction of the lumen due to Fecolith, Worms, Foreign Body
Lymph NOdes (peyers patches)

What is initial Sx?

Hint 35

Vomiting then nausea, anorexia
--caused by distention of app lumen

-With progression pain in focused as peritoneum becomes inflammed

Front 36

List some things the appendix, if inflammed can irritate?

Back 36

Ureter
Bladder
Uterus
Colon
Retroperitoneum

Front 37

What is term for Referred Rebound--ie pain when taking away pressure from opp side, ie on Left in Appendicitis?

Back 37

Rovsing Sign

Name some other common tendernesses in Appendicits

Hint 37

McBurneys
RLQ Hyperesthesia
Heel Tenderness
Right Rectal Pain
Not Distractable---

Front 38

List 3 DDX for Appendicitis

Back 38

Ruptured Ovarian Cyst
Tubal Pregger
Mesenteric Adenitis

List 1 hernia and 2 Diverticuli that are in DDX

Hint 38

Cecal or Sigmoid Divert
Meckels Divert
Right Spigelian Hernia

--Also Crohn's

Front 39

Diagnostic Pearls for Appendicits:
WBC?
U/S?
CT?
ABX?
Rupture time?

Back 39

WBC 12-16K
U/S helpful in females
CT most accurate
ABX do NOT work
-48-72 Hours till rupture

Front 40

List 4 operative choices for Appendicitis?

Back 40

-Open Appendectomy--McBurney Incision
-Laparo
-Right Hemicolectomy--nec in Carcinoids
-CT guided Drainage in perforation-

Note on Appendicitis

Hint 40

NOT a medical Dz. Always reqiures surgery

Front 41

What is Diagnosis:
Sharp Epigastric Pain, acute onset, peritonitis?

Back 41

Gastric or Duodenal Ulcers
perforating

What to look for on Xray?

Hint 41

Free Air on Upright
-Also in CT

Front 42

What do the following ulcers do?
Anterior?
Posterior?

Back 42

Anterior Ulcers perforate

Posterior Ulcers Bleed

Front 43

How might ulcer be patched

Back 43

Graham Patch with Omentum

Front 44

What do the 5 F's get?
What are the F's

Back 44

Acute Cholecystitis
-Female, Fat, Fertile, Forties, Flatulent
--cholesterol stones most frequent

What precedes the Acute Cholecystitis?

Hint 44

Preceded by Biliary Colic in 60%

Use U/S, CT or HIDA Scan

Front 45

Causes of Acute Cholecystitis? (2)

Back 45

Cholangitis--surgical emergency drainage
-Gall Stone Pancreatitis--

Front 46

What areas can have Colics? (7)

Back 46

Stomach
Small Intestine
Biliary
Renal Colic (will be dancing about)
Ureter
Uterus & Fallopian Tubes

Front 47

2 most common causes of Actue Intestinal Obstruction?

Back 47

1.Intra Abd Adhesions from previous surgery

2. Incarcerated Hernia---inguinal and femoral acount for 95%

What are another 3 causes of ObstructioN?

Hint 47

Colon Cx
Diverticulitis
Intususception (small and large bowel)

Front 48

OF two Acute Intestinal Obstructions, Cecal Volvulus and Sigmoid Volvulus, which might you delay surgery

Back 48

Sigmoid
-decompress first
--Ostomy may be necessary

Front 49

Common causes of Intussusception?

commonest site?

Back 49

Requires a Lead Point
--Peyers Patches
--Meckels

---Ileo-colic most common

Front 50

Which type of hernia is surgical emergency?

Back 50

strangulated Hernia

Incarcertated is not--inguinal and femoral are most common causes

Front 51

Five DDX for Acute Abd in WOmen

Back 51

Tubal Preggers
Ruptured Cyst
Torsion of the Ovary
PID
Tubo-Ovarian Abscess

Front 52

Presentation for Acute Peritonitis?

Back 52

Patient Lays quitely--hurts to move
--no crampy component
--rigid abs


Sign in infants?

Hint 52

erythema in infants--thinner ab wall

Front 53

Acute Abdomen in Tropics? (5)

Back 53

Malaria
Sickle Cell
Amebiasis
Worms
Tropical Pyomyositis

Front 54

Acute Abdomen form Blunt Injury (5)

Back 54

Splenic Rupture
Liver Laceration
Pancreatic Transection
Gastric Rupture
Small bowel Perforation

Front 55

Name for Free Air under Right diaphragm that's not really free air?

Back 55

Chiladiti's Syndrome

Front 56

Agian, End of LEcture

THESE Cards for this Second Lecture COver EVERYTHING, EXCEPT questions at end. SO

Back 56

Just use lecture pdf for questions at the End. NO need to review slides for Second Lecture.

May wish to for 1st.