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General Surgery 2


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Why use clips (staples) to close a thyroidectomy?
-neck is fairly vascular region, therefore you just need something to hold the skin together for a few days while the skin heals
-sutures take up to 7-10 days to disappear, and will leave a mark
-vs clips: no mark
Why need to suture peritoneal area?
-fairly avascular region, therefore need sutures
After a appendictectomy, how fast does the pain disappear?
-very soon after (parietal/visceral) pain goes away quickly
-left with wound pain afterwards
Why need to use a local anaesthetic before wounds are sutured in surgery even though patient is already under a general anesthetic?
-local (bupivacaine or Marcain), lasts 3-4 hours postop, decreases need for pain relief postop
Why do you need a port for someone with bowel Ca?
-need to give chemotherapy through a port
(port - is like a Central venous cathetar, but there is a different opening)
If bleeding is not found on upper GI endoscopy, or colonoscopy, and Hb is rapidly dropping, what other investigation is there?
-capsule endoscopy or angiography
Requirements for capsule endoscopy or angiography for suspected upper GI bleed?
-capsule: patient must be stable (b/c it takes time)
-angiography: need to have ACTIVE bleeding (tf ask pt if they are still bleeding)
After an operation how long does it take for the small bowel to recover? Large bowel?
Small bowel -> recovers immediately (inaffected by anesthesia)
large bowel & stomach -> take more time (tf when listening to abdomen -> you are listening for stomach and large bowel sounds postop)
After abdo surgery with colostomy, what is important to note?
Is colostomy bag working? (is there output?, does the patient feel bubbles/gas coming out of the bag?
After a hernia repair, what 2 meds should the pt be discharged on?
pain meds
For cholecystectomy, what meds to give?
2nd generation cephalo (given at Mt Gambier), to cover for E. coil (MC organism), but 3rd generation is better
Pt had a CT, dilated bile ducts, no stone in the CBD. What is your DDx?
-tumour -> not always picked up by CT
After surgery, how long does it take for a postop infection to surface?
4-5 days (NOT immediately postop)
Fav surg board question: you have done laparotomy for sigmoid colectomy. Pt is 30 yr female. Do you remove the appendix while you are there?
-if pt is young, and still in age where she could get appendictis, then you could make argument to remove it
-sigmoid colectomy is a 'contaminated' surgery anyway
-may spare the patient an episode of appendicitis and need for removal of appendix later on in life
-if old lady, then keep it in
In which patients do you insert a drain?
Depends on
-type of surgery
-if you dissect through lymph node, then drain would be good way to get rid of excess lymph fluid w/o it collecting inside and necessitating another surgery
When can you remove the drain?
-depends on the operation
-thyroidectomy -> insert drain, just in case there is hematoma, can remove in 1-2 days if no drainage (CHECK)
-if colectomy -> must leave drain in for at least a few days, can remove once it stops draining (Dr. E removed drain at 30ml)
Pt with laparomtomy, wound dehisence (due to increased pressure from bladder). No wound taking long time to heal. Why?
-even though wound itself not erythematous, the fact that it is taking long time to heal is indication
Child comes in with one-sided lymphadenopathy. Initial workup?
Likely cause?
-exam: is there other lymph nodes elevated (if so, think of lymphoma)
-CXR -> r/o TB (TB can cause lymphadeonpathy)

-U/S -> determine if it's a lymph node, etc
-Dr. B: DO it for females to rule out pelvic pathology only! (eg ovarian torsion), so don't need U/S in boys
Likely: benign
-after infection, lymph nodes become elevated and may take a long time to subside in children. Not a worry.
Child with anal pruritis. Treatment?
-TELL parents to stop cleaning anus so thoroughly (v hard to do, explain that the region is naturally 'dirty')
-anus has thin skin, so if it's vigorously cleaned, it may break down ->gets irritated -> parents try to clean it more -> vicious cycle
Pt with BCC asked what will happen if you do nothing to treat it?
-BCC will just keep increasing in size, until it looks like a 'wound', when it gets that big, it's harder to remove
-explain that it's not dangerous, can't kill you, BCC does not travel through blood like colon cancer
Pt with suspected skin lesions. 2 options?
-punch biopsy -> send for histopath, then remove according to results
Evidence for doing an intra-operative cholangiogram for cholecystectomy?
-no evidence for it
BUT all the major teaching hospitals will teach their trainees to do this, but when you ask what will you do if you see a stone in the CBD, you don't get a good answer
What are the arguements against doing an intraoperative cholangiogram for cholecystectomy?
-do cholecystectomy, then do cholangiogram
-if cholangiogram shows stone in CBD, what do you do about it?
-Should you try to remove stone? What if you cause further morbidity to patient by doing so? Also, patient may very well just pass the stone anyway.
-also: it's time consuming to do intraoperative cholangiogram
Why were there so many CBD injuries when laparoscopic cholecystectomy first began?
-because you pull up on gallbladder and cause traction, also pulling up the CBD
-so when dissecting out gallbladder, it was unrecognized that CBD may also be in the region as well
-problem is well known now, so area around neck of gallbladder is carefully dissected out first
Complications of cholecystectomy?
-bleeding, infection
-CBD injury
-stones from gallbladder, if small enough, can enter CBD, chance of being trapped
PR exam. Ask patient to bear down and perineal area bulges out towards you. Why?
-perineal mm lax -> common in females, less common in males
Patient has mucous in stool. Potential worry?
Colon Ca. Needs colonoscopy.
PR. Ask patient to squeeze. What are you testing?
-puborectalis (sling)
-EXTERNAL anal spinchter
Which mm cut in sphincterotomy?
-internal anal spincter
Patient presents with constipation. Hx of sexual abuse. What can you do?
-patient has opposite response when told to relax mm as if going to toilet (they tense up muscles instead)
Rx: physio-type training
-note: this is unrecognized or ignored by most GPs
Parents worried about child's bowel movements. One option if problem is legit and severe enough to warrant treatment?
-try regular laxatives to encourage normal pattern
Treatment of bowel obstruction?
-not necessarily for surgical intervention
-fluids and NG to decompress stomach is important
Rx for anal fissure?
Ix: rigid sigmoidoscopy
Rx: -anal dilatation and fissurotomy (not standard practice in UK though)
FU for lap chole?
-gallbladder sent for histo (risk of Ca is rare)
-FU 7-10 days to remove clips/sutures
Pain under a wound made during surgery?
-possibly hematoma under wound (eg lap chole)
Rx for diarrhea?
coke (real coke not diet)
Pt's drain is draining increasing fluid after bowel surgery. Concerns?
-transected ureter (tf test for urea)
-transected a lymph node (don't care about this)
Define indurated? Fluctuant?
eg perineal abcsess

indurated -> skin is thickened
fluctuant -> can feel the transmission of fluid if press on the lesion (if you put 2 fingers apart)
-means its either fluid(eg abscess) or cyst
What can you give for IBS?
Rx of adhesions?
1/3 same, 1/3 better, 1/3 worse
-can dev after surgery
-may not be evident until bowel gets caught (may not happen for years) then suddenly pt is symptomatic
-dilemma re: whether to treat these patients or not
Pt w/ pneumaturia, but gone now. Should you intervne?
-no, tell pt to come back when it recurts
-colovesical fistula has high change of reoccuring
Pt w/ inguinal hernia. What question are NB?
-bowels ok? (constipation can contribute to straining)
-urination ok? (straning can contribute to mm waekness)

Exam: check prostate (urinary retention)
Pt w/ bilat inguinal hernia. One complication of surgery?
-after surgery, mm in region of ooperation can spasm and can cause urinary retention
-if unilat hernia repair can go home but bilat need to stay until you know they don't have retention

-another complication: pins & needles (b/c of swelling) there is decreased space which irriates nerves
Pt w/ large lump on back of neck. Can get behind it. DDx?
Exam; can you get behind it (attached to underlying structures, eg thyroid?)
-roll skin over (see if it's attached to skin)
Generic name for tegretol?
carbamazepine (stabilizes nerve as in neuralgia)
Placebo effect and surgery, or medicine and determination of if pt gets better?
-important to 'sell the operation' to the patient to ge the maximum placebo effect
-also important in medicine too
-must convince patient that they will get better
Inserting a urinary catheter and you see blood. What do you do?
-if see blood, STOP! Probably tore the urethra. If you keep advancing catheter then you may go through tear and make it worse. Stop and call a more senior person. They will either try threading another cateher or use cystoscopy to thread catheter OR insert a suprapubic catheter.
Pulling out a suprapubic catheter and it's stuck. What do you do?
-apply constant pulling pressure. (not back and forth motion)
Female with chronic constipation. One DDx?
-Hx sexual abuse
-need biofeedback
-contact colorectal surgeon and ask if they have facilities to do so.
-need constant training
-takes long time for this to resolve
-should not be relying on "picoprep" and others to move bowels because they don't work after a few years
Patient with painful varicose veins. Varicose vein surgery 10 yrs ago. Dx?
-no more deep saphenous vein, so not varicose veins
-probably incompetence of deep perforating veins
Rx: Compression stockings
-if doesn't work, need to come back for Duplex US
What is the one complication of cholecystectomy you are worried about?
-wound infection
-subphrenic abscess
Just finished colonoscopy. Afterwards, patient with severe dyspnoea. Palpation of region lateral to substernal notch reveals 'crunching' to palpation. Dx?
subcut emphysema from perforated esophagus

CXR -mediastinal air
WHy? air crosses tissue planes so get crunching
Man with fractured tibula after a fall. Mx?
-fix plate with screws to tibular
-apply cotton, then plaster, then different material over top),
-apply plaster all the way to just under groin
-immobilize in plaster for 6 weeks
-remove plate & screws in 9-12 mos
Young man, 26, with fratured 2nd Metacarpal after punching someone. Mx?
-if no rotation of bone -> conservative Mx
-if there is rotation-> need ORIF

-ORIF: plate and screws
-cotton, then plaster, leave 1st MCP open, just immobilize the wrist in extension
-sutures out in 7-10 days
-will be able to weightbear in 3wks time (makes no diffence)
-remove plate and screws in 6 mos
What is the MC reason for atelectasis?
Pain, tf important to manage this.
Why pain? b/c pple DN breathe deeply
Why do pple complain of itching w/ varicose veins?
-swelling of legs -> pigment goes out into tissues (?lipofuscin) -> causes itching

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