Surgical Correlations Git

Front 1

esophageal atresia

Back 1

w here the hepatoduodenal
ligament forms its roof . The opening w hich is responsible for
the open communication betw een the lesser peritoneal sac
behind the stomach and the rest of the cavity

Front 2

congenital diaphragamatic hernia

Back 2

Also known as Congenital Hiatal Hernia
 Stomach pulled into esophageal hiatus
 Part of the stomach and intestine herniate through a large
posterolateral defect (foramen of Bochdalek) in the
diaphragm
 Lungs does not have room to develop  Pulmonary
hypoplasia and it is fatal

Front 3

esophageal stenosis

Back 3

Gradual narrowing of the esophagus. It occurs when scar
tissue builds up in the tube.
 Incomplete recanalization
 Vascular abnormalities
 Compromised blood flow
 It is treated by dilatation of the esophagus

Front 4

pyloric stenosis

Back 4

Hypertrophy of the circular muscle of the pylorus
 Extreme narrowing of the pyloric canal, causing an
obstruction
 The elongated overgrown pylorus is hard, and severe
stenosis (narrowing) of the pyloric canal is present, resisting
gastric emptying
 The proximal part of the stomach becomes secondarily
dilated because of the pyloric obstruction
 As a result, gastric contents are vomited out

Front 5

accessory hepatic ducts

Back 5

Segmental duct that joins the biliary system outside the liver
instead of within it
 Because it drains a normal segment of the liver, it leaks bile if
inadvertently cut during surgery
 May communicate with cystic duct, bile duct
 May be 2 or more

Front 6

duplication of gallbladder

Back 6

Double gallbladder is a rare congenital anomaly with an
incidence of one in 4000 patients
 The two main types of duplications are vesica fellea divisa or
bilobed gallbladder and vesica fellea duplex or true
duplication, with two different cystic duct.
 All three above are asymptomatic, provided that there is
no obstruction at the proximal portion

Front 7

extrahepatic/intrahepatic biliary atresia

Back 7

A rare condition in newborn infants in which the common bile
duct between the liver and the small intestine is blocked or
absent.
 If unrecognized, the condition leads to liver failure  But
not kernicterus, as the liver is still able to conjugate bilirubin,
and conjugated bilirubin is unable to cross the blood-brain
barrier
 In 1/15,000 live births
 15-20% of the population has patent proximal ducts
 Correctable (for extrahepatic biliary atresia)

Front 8

gastroschisis

Back 8

Birth defect in which an infant's intestines stick out of the body
through a defect on one side of the umbilical cord
 1/10,000 births
 It is not covered by amnion—exposed to destructive effects of
amniotic fluid
 Not associated with chromosomal abnormalities
 Survival rate is excellent
 Usually occurs in the right umbilicus

Front 9

omphalocoele

Back 9

Nirth defect in which the infant's intestine or other abdominal
organs stick out of the belly button (navel)
 Herniation of abdominal viscera through an enlarged umbilical
ring
 Herniated viscera are covered with amnion
 In babies with an omphalocele, the intestines are covered
only by a thin layer of tissue and can be easily seen.
 The defect is a failure of the bowel to return to the body cavity
from its physiological herniation (during 6th to 10th weeks)
 2.5/10,000 births
 Mortality rate: 25%
 Severe malformation such as cardiac anomalies (50%),
neural tube defects (40%) and chromosomal abnormalities
(15%) are present

Front 10

accessory pancreatic tissues

Back 10

A detached portion of pancreatic tissue, usually
the uncinate process (part of head of the pancreas), and
hence most often found in the vicinity of the head, but which
may occur within the gut wall (stomach or duodenum)
 Usually occurs within the mucosa of the stomach and in
Meckel’s diverticulum
 May occur in the distal part of esophagus to the tip of the
hindgut

Front 11

annular pancreas

Back 11

Ventral pancreatic bud becomes fixed so that, when stomach
and duodenum rotate -> ventral bud is pulled around the right
side of the duodenum to fuse with dorsal bud of pancreas
thus ENCIRCLING the duodenum (Snell)
 Obstruction of duodenum, and vomit may start few hours after
birth

Front 12

left sided colon

Back 12

Rotation arrests at first rotation, 90 degrees counterclockwise
 Large intestine settle on left

Front 13

reversed rotation intestinal loop

Back 13

idgut loop rotates through 90° anticlockwise normally but the second rotation occurs through 180° clockwise – i.e. a net rotation of 90° clockwise.
 Results in a normal deposition of gut tube, with the single exception that the transverse colon lies posterior to the duodenum instead of anterior to it - so the duodenum fails to become retroperitoneal, while the region of transverse colon posterior to it does
 Transverse colon also lies posterior instead of anterior to the superior mesenteric artery and may be compressed by it.
 Also the duodenum lies anterior of superior mesenteric artery
 May cause duodenal obstruction that leads to repeated vomiting

Front 14

imperforate anus

Back 14

Imperforate anus is a congenital defect in which the opening to the anus is missing or blocked
 May occur in several forms. The rectum may end in a blind pouch that does not connect with the colon. Or, it may have openings to the urethra, bladder, base of penis or scrotum or vagina.
 Condition of stenosis (narrowing) of the anus or absence of the anus may be present

Front 15

congential megacolon

Back 15

Aganglionic megacolon
 Hirschsprung Disease
 Normal nerve cells are not found in the rectum and for variable lengths of intestine above the rectum. The affected intestine lacks the normal nerve signals to allow it to relax and move intestinal contents through it.
 The consequence of the abnormal innervation is abnormal intestinal function that ranges from complete intestinal obstruction to problems with constipation

Front 16

meckel's diverticulum

Back 16

A Meckel's diverticulum is tissue left over from structures in the unborn baby's digestive tract that were not fully reabsorbed before birth.
 It is always at the site of attachment of the yolk stalk on the antimesenteric border (border opposite the mesenteric attachment) of the ileum
 An ileal diverticulum may become inflamed and produce pain mimicking that produced by appendicitis
 In 2% of the population
 2 ft. from ileocecal valve
 Approximately 2 inches long
 Bleeding and perforation may occur

Front 17

vitelline fistula

Back 17

Also known as Umbilical fistula
 Vitelline duct remains patent forming direct communication between umbilicus and intestinal tract (ileum lumen and outside)
 There may be fecal discharge in umbilicus

Front 18

vitelline duct

Back 18

Connects lumen of ileum to extraembryonic cavity. It should obliterate to free the ileum
 If it does not obliterate, distal part of vitelline duct may develop into vitelline ligament—anchors ileum to anterior abdominal wall
 The middle portion may form cysts, called enterocystoma

Front 19

vovulus

Back 19

Twisting of abdominal viscera around its mesentery due to extreme mobility
„« This may correct itself spontaneously or the rotation may continue until blood supply of the gut is cut off completely

Front 20

congenital megacolon

Back 20

Aganglionic megacolon
 Hirschsprung Disease
 Normal nerve cells are not found in the rectum and for variable lengths of intestine above the rectum. The affected intestine lacks the normal nerve signals to allow it to relax and move intestinal contents through it.
 The consequence of the abnormal innervation is abnormal intestinal function that ranges from complete intestinal obstruction to problems with constipation

Front 21

abdominal hernia

Back 21

Occurs when an abdominal organ or fatty tissue protrudes through a weakened area of the abdominal wall which results in a protrusion
 Hernia has 3 parts: sac, contents-omentum, coverings of sac
 Hernial sac: pouch of peritoneum, two parts are neck and body

Front 22

indirect inguinal hernia

Back 22

- Sac: Remains of processus vaginalis
- Processus vaginalis obliterates on right
- 1/3 bilateral
- Deep inguinal ring
- Outside Hesselbach’s triangle, lateral to inferior epigastric vessels
- Reaches the scrotum or labium majus
- Neck is narrow
- Most common, congenital
- More common in males (20:1)

Front 23

direct inguinal hernia

Back 23

 Sac: Bulges anteriorly
 Medial to epigastric vessels
 Conjoint tendon: Generalized bulge, wide neck
 Limited usually to region of superficial inguinal ring
 Most are bilateral
 Very common in old men with weak abdominal muscles

Front 24

femoral hernia

Back 24

Sac: Femoral canal – Medial compartment of femoral sheath
- Femoral ring: Plugged by extraperitoneal tissues
- More common in women, rare in males (women have wider pelvis and wider femoral canal)

Front 25

appendicitis and factors that lead to infection

Back 25

 Pain felt depends on how long and where the tip is located
 Usually located in retrocecal position
Factors that contribute to predilection to infection:
1. Long, narrow, blind ended tube – Stasis of contents
2. Lymphoid tissue – Numerous and inflamed
3. Tendency of lumen to obstruct (with enteroliths)  Further stagnation
Note: Enteroliths: very small and hard fecal material, like pebbles

Front 26

predisposition to perforation appendiz

Back 26

Predisposition of Appendix to perforation
 Supplied by long, small artery that does not anastomose
 Inflammatory edema of the wall – Arteries become compressed
 Thrombosis of artery  Necrosis of wall  Perforation
 Perforation will result into spread of infection into greater sac

Front 27

gastric ulcer

Back 27

Body (fundus) – Acid and pepsin
 Antrum and Pylorus – Mucous and weakly alkaline
 Acid and pepsin secretion – Controlled by nervous and hormonal signals
o Vagus
o Gastrin (G cells within antral mucosa stimulate production of HCl
A. Posterior
 Lesser sac
 Adhere to pancreas, splenic artery erodes, fatal hemorrhage
B. Anterior
- Escape of contents into greater sac -> diffuse peritonitis
- Sometimes; adhere to liver and may penetrate the liver substance

Front 28

surgical treatment

Back 28

Chronic gastric (on or close to lesser curvature)
 Duodenal ulcer – Anterolateral part of 1st portion of duodenum – This portion is exposed to acidic chyme
 To reduce amount of acid secretion:
 Vagotomy (transect Vagus nerves)
 Partial gastrectomy (antrectomy)— removal of antrum, area where G cells are
Chronic ulcer  Invades muscular coat  Peritoneum (perforates)  Adheres to neighboring structures

Front 29

greater omentum appendicitis

Back 29

Greater Omentum
 Lower Right and Left margins is free
 Moves about in response to peristaltic movement of gut
 Loss of appetite
 Visceral afferent fibers reach spinal cord at T10, first epigastric pain is felt (dull)
 Inflamed appendix – Parietal peritoneum becomes inflamed as well, and pain shifts to right lower quadrant
 Functions:
 ―Abdominal policeman‖, for localization of infection, tries to limit spread of infection
 Hernial plug – Plug neck of hernial sac – Prevent entrance of coils of small intestine
 Used to buttress an intestinal anastomoses or in the closure of a perforated gastric or duodenal ulcer

Front 30

internal hemorrhoids

Back 30

Above pectinate line: Internal hemorrhoid
 Internal hemorrhoids are prolapses of rectal mucosa containing the normally dilated veins of the internal rectal venous plexus
 Result from a breakdown of the muscularis mucosae
 Severity:
I. Grade I: Bleeding
II. Grade II: Mucosa prolapsed thru anal opening, but goes back
III. Grade III: Prolapse, can manually reduce it
IV. Grade IV: Can’t manipulate anymore

Front 31

hemorrhoids external

Back 31

Below pectinate line: External haemorrhoid
 External hemorrhoids are thromboses in the veins of the external rectal venous plexus and are covered by skin

Front 32

cholelithiases

Back 32

 Biliary colic (Snell)
 Usually asymptomatic
 Stone impacts into cystic duct, smooth muscle wall of gall bladder spasms to try to expel stones
 May developed jaundice
 Referred pain: Right upper quadrant or epigastric pain (T7-9 dermatomes)

Front 33

acalculous cholecystitis

Back 33

Inflammation of gall bladder may be due to irritation of subdiaphragmatic parietal peritoneum that is supplied by phrenic nerve.
 Discomfort right upper quadrant or epigastrium
 Referred pain to shoulder due to phrenic nerve