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Spigelian- lateral the anterior rectus medial to

the arcuate line


Grynfelt- superior lumbar triangle
Petits- inferior lumbar triangle
Litter’s- meckels diverticulum
Morgagni-right anterior diaphragmatic hernia
Bockdalech- posterolateral lateral hernia

Types of incision
Kocher-cholecystectomy
Chevron-gastrectomy bilateral subcostal
Mcburneys- appendectomy
Pfannensteil-OB
Fowler weir- medial extension of rocky Davis
Roterford morisson- lateral extension of rocky
Davis
Lanz incision- following the skin crease for
appendectomy
Cattel-is right release of peritoneal reflection
Mattox- left mobilization of descending colon
Kochers maneuver- mobilization of transverse
colon
Staples- Least reactive on skin (BUT NOT ON
FACE)
Pringles maneuver- hepatic pedicle (25%-
hepatic artery, 75%-portal vein, common bile
duct)
Cantle’s line- separates the right and left lobe
of liver

Greater auricular nerve- most common injured


in parotid surgery
Branches of facial nerve
Temporal
Zygomatic
Buccal
Maxillary
Cervical
Pleomorphic adenoma- most common benign
Warthins Tumor-second most common benign
Mucoepidermoid- most common cancerous of
the salivary gland
Recurrent laryngeal nerve-enervates all muscle
of the larynx except crycothyroid muscle-
external branch of the superior laryngeal nerve
Frey’s Syndrome- Cross Inervation of
Auriculotemporal nerve and symphatetic nerve
of the skin
All cancer of the oral cavity- supraomohyoid
dissection level I-III
Laryngeal cancer-II-IV lateral dissection
Thyroid-II-V posterolateral dissection
Spinal accessory,cervical branch of facial
nerve, omohyoid, SCM,Submandibular
Gland,Sensory Nerve of C2-C5-Radical Neck
Dissection
Type I- Spare Spinal accessory Nerve
Type II-Spinal Accessory, IJV
Type III-Spinal Accessory, IJV, SCM

Thyroid cancer
Most common-Papillary Thyroid Cancer in
iodine rich area-80%
Follicular-Iodine Deficient Area

Types of papillary thyroid cancer


Tall
Insular
Columnar
Diffuse
Clear cell
Poorly differentiated
Men2A-medullary plus pheochromocytoma
and parathyroid adenoma
Men2B-Medullary plus Trichelomonia,
Neuromas, ganglioneuromatosis
P16-Malignant Melanoma
E cadherin- Hereditary diffuse gastric cancer
BRCA 1- 4 fold increase in prostate cancer
BRCA 2-7 fold increase in prostate cancer and
more of breast cancer in men
APC-Colon Cancer
P53 Li Fraumeni Syndorme-Sarcoma
RB1-Retinoblastoma
C-kit-GIST
HPV 16 and 18-Cervical Cancer
Epstein Barr Virus-Burkitt’s Syndrome
Hodgkins disease
Nasopharyngeal carcinoma
Hepatitis B Virus- Hepatocellular Carcinoma
Hepatitis C Virus-Hepatocellular Carcinoma
HIV Type I-Kaposi sarcoma,Non Hodgkins
Lymphoma
3 to 4 works- to start radiation therapy to allow
wound healing
5 to 7years- one cancer cell to become a
malignant tumor
20 years-to declare cancer free

TRAUMA
patients under 11 crycothyroidectomy is
contraindicated for the risk of subglottilc
stenosis tracheostomy should be performed
CTT-Posterosuperior on 4th and 5th rib
First 12 hours-pulmonary contusion
progression
Types of injury tracheobronchcial
Type I- 2cms from the carina
Type II-more distal to tracheobronchial tree
bronchoscopy to confirm diagnosis

For patients less than 6years old first line is


CVP followed by IO
Galea Aponeurotica-Scalp Laceration profuse
Bleeding

Systolic BP
60mmHg-Carotid
70mmHg-Femoral
80mmHG-Radial

Life threatening blood loss


1500ml-adult
>25%-pedia

For Massive Hemorrhage


2L- Repeat once in adult
20mg/kg-repeat twice in Pedia

100 to 200ml-Rib Fracture


300 to 500ml-Tibial Fracture
800 to 1000ml-Femoral Fracture
>2000ml-Pelvic Fracture

Penetrating Trauma- Small Intestine, Liver,


Colon
Blunt Trauma-Liver, Spleen, Kidney

Lateral Canthotomy- maybe needed to release


orbital pressure

GCS14-CT scan should be done


GCS 15 in Old patient with Antiplatelet should
undergo ctscan
Epidural hematoma-convex shape, lens shape
middle meningeal artery or emissary vein
Subdural Hematoma-Concave, Cresent Shape,
poor prognosis
Brown Squared Syndrome-Hemisection of the
spinal cord loss of motor function,
proprioception and vibration is lost on affected
side, temperature and pain on contralateral side

Hard signs-Massive Hemoptysis, expanding


hematoma, uncontrolled hemorrhage
Soft signs-dysphagia, subcutaneous
emphysema,hoarness,stridor,odynophagia,veno
us bleeding

Abdomen
DPL->250ml to have positive results
>10ml-positive
<10ml-do 1L PNSS Infusion and Syphoning
then send for cell cytology
For children less than 6years old-a transverse
incision is more advantageous

The goal for damage control surgery- to limit


GI spillage, and control bleeding
Indications
-metabolic acidosis Arterial PH less 7.2, base
deficit of less than 15
-DIC
-hypothermia
Head injuries
6-10mmHg and 20mmHg is indication for
surgery
>5mm Midline shift- surgery
70minutes-epidural hematoma should be
evacuated golden period
Abdomen
Spleen-strep pneumonia,neisseria
meningitides,haemophilus influenza
Planned or emergent splenectomy-2weeks prior
or after
<35mmHg- extremity compartment syndrome
2incisions and 4compartment release with
detachment of soleus muscle to decompress the
deep flexor compartment
>35mmHg-abdominal compartment syndrome
that requires surgery

B1-Indirect,unconjugated- prehepatic problem


B2-Direct, Conjugated- poshepatic problem
Cholecystokinin-gallbladder contraction
Somatostatin- gallbladder relaxation
11o'clock during sphincterotomy to avoid
pancreatic duct injury
chodedochal cyst- >15% cholangiocarcinoma
risk in adults
type 1 Fusiform- most common >50%
type 2 sacular-rare <5%
type 3- Bile duct dilatation within duodenal
wall
type 4a- intra and extrahepatoc ducts involved
type 4b- extrahepatic ducts only
type 5- intrahepatic ducts only

type I,2,IV-excision of extrahepatic biliary tree


including cholecystectomy with roux en y
hepatocojejunostomy
type 4- addistional segmented resection of liver
lobe
type 3-Sphincterotomy is recommended

Transected bile ducts <3 mm or those drain


ing a single
hepatic segment can safely be ligated. If th
e injured duct is
4 mm, it is likely to drain multiple segmen
ts or an entire lobe,
and thus needs to be reimplanted
surgical mortality rates of 10%
for patients with class A cirrhosis, 30% for
those with class B cirrhosis, and 75% to 80%
for those with class C cirrhosis.

pyogenic liver abscess- iv drug user treatment


of atleast 8weeks
amoebic liver abscess- most common
worldwide superior anterior of the right lobe of
liver metronidazole 7-10days
hydatid disease- anterior-inferior or posterior
inferior segments of the right lobe of liver-
surgical removal and albendazole
schistosomiasis- presinusoidal portal
hypertension prazequantel treatment of choice

caroli's disease- segmental cystic dilatation of


the intrahepatic biliary radicals
7% risk for cholangiocarcinoma

milan's criteria for liver transplant


solitary node <5cms
two or 3 nodes <3cms each
no gross vascular invasion
crystalloids- continous to be the mainstay of
fluid choice
colloids- increase risk of death in bleeding
sbp 90mmHg for penetrating injury
sbp 110mmHg for closed head injury blunt
trauma
cvp- 8-12mmHg
cvp 12-15mmHg for intubated patients

hyperglycemia and insulin resistance


intensive insulin therapy 80-110mg/dl

uti-3 to 5days treatment


pneumonia- 7 to 10 days
bacteremia-7-14 days
perforated appendicitis-3 to 5days
peritoneal solliage-5 to 7 days
extensive peritoneal solliage- 7 to 14days

class I- clean Hernia, Breast biopsy 1-5.4%


class ID with mesh or prosthetics
class II- clean contaminated cholecystectomy,
lobectomy, urogenital instrumentation 2.1-
9.5%
class II- colorectal surgery 9.4-30%
class III- penetrating abdominal trauma,
enterotomy 3.4-13.2%
class IV- perforated diverticulitis 3.1-12.8%

primary microbial peritonitis- hematogenous


dissemination, direct inoculation- peritoneal
dialysis usually monomicrobial
secondary microbial perotonitis- perforation
and severe inflammation of intra abdominal
organ
tertiary (persistent) peritonitis-
immunosuppressed patients-50% mortality

hepatic abscess
<1cms multiple- sampled and treated 4-6weeks
course of antibiotics
large abscess- incision and drainage

bacillus anthracis-domesticated and wild


herbevores cipro and doxcycline
yersenis pestis-flea bites from rodents
small pox-cidofovir
fracisella tularensis-doxy and ciprofloxacin

Hyperacute Rejection- within minutes is caused


by ABO incompatibility
Accelerated Acute- first few days, cellular and
antibody mediated injury
Acute Rejection- days to few months,
predominantly cell mediated process with
lymphocytes being involved
Chronic- months to years slow deterioration
over months to years posttransplant

absolute contraindication to transplant is


untreated malignancy and active infection
after treatment of malignancy 2-5years is
recommended pretransplant

most common liver abscess worldwide is


Amoebic abscess

amoebic abscess is usually at the superior


anterior aspect of the right lobe of the liver near
the diagphgram
Hydatid cysts commonly involve the right lobe
of the liver, usually the anterior-inferior or
posterior-inferior segments.
schistosomiasis- presinusoidal portal
hypertension

left kidney is preferred because of longer left


renal vein
right iliac fossa is chosen for transplant site
because of superficial iliac vein on the side

nonmelanomatous skin cancer (3-7 fold


increased risk)
(2-3 fold for lymphoproliferative disease)
1% in renal allograft and 5-6% among small
bowel and multivisceral transplant

abdominal wall
-congenital umbilical hernia closes
spontaneously by 5years old.
-Omphalocele protudes through an open
abdominal ring with sac
-Gastroschisis protudes lateral to the umbilical
ring without a sac
-Rectus diastasis is associated with abdominal
wall bulging consequent to separation of the
rectus abdominis muscles in the midline.
-Fothergill’s sign is a palpable abdominal mass
that remains unchanged with contraction of the
rectus muscles and is classically associated
with rectus hematoma
-for laparoscopic mesh repair- atleast 4cms
overlap of mesh in an healthy abdominal wall.
-idiopathic retroperitoneal fibrosis, also known
as Ormond’s disease 90-100% 5year survival
rate
-fourth to the sixth decades of life.
-Corticosteroids, with or without surgery, are
the mainstay of medical therapy. Surgical
treatment consists primarily of ureterolysis or
ureteral stenting and is required in patients who
present with significant hydronephrosis.

chapter 12 patient safety


-Communication is the most common root of
sentinel events
-adverse event injury caused by medical
management rather than the underlying
condition of patient
-Negligience does not follow standard of care
-Near Miss error that does not result in patient
harm
-sentinel events is a never event, wrong site,
wrong surgery, retained foreign body
-DVT occurs 25% of all major surgery without
prophylaxis 50% in ortho cases, and 30%
Pulmonary embolism but decreases by 50%
with Prophylaxis
-needles smaller than 13mm have been found to
be undetectable on plain radiograph
complications!
CVP- pneumothorax in 1 to 6%, Arrythmia,
Arterial Puncture, Lost Guidewire- retrieved by
IR
Air Embolus- 0.2 to 1% futile if larger than
50ml
"crunching noise" upon auscultation place
patient on left lateral decubitus trendelenburg
to intrap air at right ventricle
pulmonary artery rupture- swans ganz catheter,
uncontrolled hemoptysis- reinflation of catheter
balloon is the initial step

ARTERIAL LINES- 1% thrombosis,


hematoma, nonthrombotic pulselessness
ENDOSCOPY AND BRONCHOSCOPY-
perforation
TRACHEOSTOMY- tracheo innominate artery
fistula-0.3% carries 50 to 80% mortality can
occur 2 days to 2months-long gracile neck, thin
woman, sentinel bleed, most spectacular bleed.
PERCUTANEOUS ENDOGASTROSTOMY-
must be replaced within 8hours of
dislodgement
CTT-pain, subcutaneous emphysema
DPL- perforation of bowel
ANGIOGRAPHY- blue toe syndrome,
mesenteric ischemia- N acetylcysteine 2x a day
dosing 24hours before and on the day of
procedure and IV hydration
NEUROPRAXIA- will resolve 1-3months
THYROID-hypocalcemia, tetany
RLN INJURY-paramedian position
SLN INJURY- Hitting high notes
RESPIRATORY- Respiratory quotient
Carbohydrate- 1
Glucose->1
fatty acid oxidation- 0.7
protein- 0.8
ideal- 0.75 to 0.85
CARDIAC- Atrial fibrillation is the most
common arrhythmia
HEPATOBILIARY- bile leak confirmed with
Ctscan and ERCP is the treatment of choice
MUSCULOSKELETAL- pain with passive
motion if the hallmark of compartment
syndrome
greater then 20-25mmHg then four
compartment fasciotomy should be done
ABDOMEN- lncreased peak airway ventilator,
oliguria 20mmHg is Abdominal Hypertension
25-30mmHg is ACS
abdominal closure should be attempted 48-
72hours, wound opened for 5-7days results in
incisional hernia
DRAINS-drains 70-170mmHg at the level of
drain causes leak
FBC- can be treated for 3days
candida albicans- continuos bladder washing
with fungicidal for 72hours, replace Fbc and a
course of fluconazole
NECROTIZING FASCIITIS- clostrodium
perfringes and C septicum carry a 30-70%
mortality rate, debridement of necrotic tissue
GLYCEMIC CONTROL- 80 to 110mg/dl with
insulin infusion only for 215mg/dl but
maintained at 180-200mg/dl
tight glycemic control of 103mg/dl
HYPOTHERMIA- temp <35c arrythmia and
ventricular arrest
HYPERTHERMIA- Dantrolene 2.5mg/kg
every 5mins.

Appendix
-Carcinoid,
Treatment for tumors ≤1 cm is appendecto
my. For tumors larger than 1 to 2 cm located at
the base, involving the mesentery, or with
lymph node metastases, right hemicolectomy is
indicated.
-Adenocarcinoma, recommended treatment is
formal right hemicolectomy
-Stump appendicitis, >0.5cms stump
-2nd Trimester is safe for appendectomy and
rare on 3rd trimester

Esophagus Chapter 25
-aortic arch is T4
-lower sphincter is T11
-male 15cms/female 14cms
blood supply
upper 3rd-inferior thyroid artery
thoracic portion-bronchial arteries
abdominal portion-ascending branch of left
gastric and inferior phrenic arteries

swallowing mechanism
1 elevation of tongue
2 posterior movement of tongue
3 elevation of soft palate
4 elevation of hyoid
5 elevation of larynx
6 tilting of epiglottis

24hour pH monitoring- 5cms below the GE


junction
Schatzki Ring- Fibrotic Mucosal ring located at
the squamocolumnar junction may result in
dysphagia GE junction
Zenkers Diverticulum-Pharyngoesophageal
Junction if more than >2cms tx: Transoral
Cricopharyngotomy
Achalasia- Birds Beak
Diffuse Spasm- Corkscrew Deformity
Squamous Carcinoma- most common
esophageal carcinoma Most common location
Middle Thoracic-32%
Boerhaave's syndrome-just above the GE
junction and Left pleural cavity exceed
200mmHg
Mallory Weiss-mucosal tear, bleeding rather
than perforation is the problem exceed
150mmHg (VOMITING NOT
OBLIGATORY) retching,coughing,seizure
(alcoholics)
Sengstaken-Blakemore tube will NOT stop the
bleeding
xray should be done with patient on right
lateral decubitus position

Caustic Injury- alkalies are most common than


acid because acid produces burning pain in
mouth
treatment- must be done within the first hour
lye or alkali-half strength vinegar, lemon or
orange juice
acid-milk,egg white, antacids
most common location of injury
esophagus- middle 65%
stomach- antrum 91%

1st degree burn- observation 24-48hours


2nd and 3rd degree burn- exlap
viable esophagus and stomach-intraluminal
esophageal stent, jejunostomy, biopsy of
posterior gastric wall
questionable esophagus and stomach- second
look at 36hours
full thickness necrosis- esophagogastric
resection,cervical esophagostomy,jejunostomy,
resection of adjacent organs

functional grades of dysphagia


I- Eating Normally
II- Requires Liquid with Meals
III- Able to take semisolids but unable to take
any solid foods
IV-Able to Take Liquids only
V-Unable to Take Liquids but swallows saliva
VI-unable to swallow saliva
Grades I-III radiation
Grades IV-VI Stenting except for GEjunction
Radiation only

Barrets Esophagus- from squamous to


columnar epithelium premalignant
Achalasia- Heller's Myotomy
types of diaphragmatic hernia
type I-sliding hernia upward dislocation of
cardia in the posterior mediastinum
type II-Rolling upward rolling of fundus in a
normally positioned cardia
type III-Sliding and Rolling Hernia- Upward
Dislocation of Cardia and Fundus

chapter 26 stomach
left gastric artery- largest artery
right gastroepiploic artery-second largest
D1 Gastrectomy- station 3 to 6
D2 Gastrectomy- station 1-2 and 7-12
Chief cells (zymogenic cells)- pepsinogen I-
fundus and body
Parietal Cells- HCL-body of stomach/fundus
G cells/Oxyntic cells-Gastrin (antral)
D cells-Stomatostatin-antral
Ghrelin-Anorexia and weight loss
12mins- Half emptying time of liquid
2hours-half emptying time of solid

modified johnsons classification


type I-lesser curvature
type II-body of stomach,incisura, duodenal
type III-prepyloric
type IV-high on less curvature
type V- anywhere in stomach (NSAID induced)

zollinger ellison syndrome- Increase gastrin by


duodenal or pancreatic neuroendocrine tumor
GIST- Interstitial cells of Cajal, CKIT
Hypertrophic Gastropathy (Menetrier's)-protein
losing gastropathy
watermelon stomach (Gastric Antral Vascular
Ectasia)-Mucosal blood vessels dilated
tx:estrogen and progesterone
Dieulafoy Lesion- Large Tortous Submucosal
Artery
Bezoars/Diverticula-papain,cellulase or
acetylcysteine, endoscopic distruption, surgical
Dumpings syndrome- destruction or bypass of
pyloric sphincter
15-30mins-diaphoretic,weak light headed
(early dumping)
2-3hours-late dumping
octreotide/Acarbose maybe helpful
roux syndrome-vomiting, epigastric pain,
weight loss
roux limb should be 45cms long
anemia,B12 and folate deficiency in patients
with gastric resection
calcium and Vitamin D metabolism which is
absorbed in duodenum but is bypassed by
gastrojejunostomy

Chapter 2 systemic response to injury

SIRS
Infection-identifiable source of microbial insult
SIRS-two or more are met:
-Temp >38 or less than 36c
-HR of more than 90BPM
-RR of more than 20CPM of <32mmHg
-WBC of more than 12,000 or less than 4000
and Bands more than 10%
Sepsis-Identifiable source of infection +SIRS
Severe Sepsis- Sepsis +Organ Dysfunction
Septic Shock- Sepsis +Cardiovascular Collapse
(requiring vasopressors)
Adrenocorticotrophic Hormone-Zona Fasculata
Cortisol-Adrenal cortex, in burn patients
elevated for 4weeks