36. What are some of the anatomic issues related to inguinal hernias?

Show answer
At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts.

The term conjoined tendon, although commonly used, is considered by many to be anatomically inaccurate and misleading. The internal oblique and transversus abdominis muscles that make up the conjoined tendon are obvious and can be used surgically either alone or together. The tendinous edge of the transversus abdominis muscle and the tendinous edge of the internal oblique muscle start at their insertion on the pubic tubercle and course laterally and superiorly to the medial edge of the internal ring. At this point, the tendinous elements diminish, leaving only muscle tissues, and continue laterally and superiorly to their origins.
Whether the lacunar ligament or the iliopubic tract defines the medial border of the femoral canal is controversial. The compromise position is that the iliopubic tract is the border whereas in the normal unstretched state, the lacunar ligament (Gimbernat’s ligament) is the border in the presence of hernia (stretched state). At surgery it is enough to say that a palpable, visible curved ligament is present and used in some femoral repairs.

37. What are some surgical issues in the repair of inguinal hernias?

Show answer

The controversy over implanting mesh, as in the Lichtenstein repair, has been resolved in favor of mesh. Another controversy concerns the use of the laparoscope for hernia repair. A further issue is intra-abdominal or preperitoneal placement of mesh. At present, most surgeons accept laparoscopic repair as an alternative for preperitoneal hernia repair. The indications for a preperitoneal approach to hernia repair are still being defined, although the preperitoneal approach is acceptable for repair of recurrent hernia and unusually large or difficult hernias. The preperitoneal approach is used with increasing frequency for repair of femoral hernias. The repair should be appropriate to the circumstance of the hernia. Thus, hernia location and size as well as the patient’s age, general condition, and recurrence status should be factored into the strategy of repair.

References
BIBLIOGRAPHY
1. Avisse C, Delattre JF, Flament JB: The inguinal rings. Surg Clin North Am 80:49-69, 2000. Medline Similar articles
2. Avisse C, Delattre JF, Flament JB: The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications. Surg Clin North Am 80:35-48, 2000. Medline Similar articles
3. Bendavid R, Howarth D: Transversalis fascia rediscovered. Surg Clin North Am 80:25-33, 2000. Medline Similar articles
4. Collaboration EH: Laparoscopic compared with open methods of groin hernia repair: Systematic review of randomized controlled trials. Br J Surg 87:860-867, 2000. Medline Similar articles Full article
5. Collaboration EH: Mesh compared with non-mesh methods of open groin hernia repair. Systematic review of randomized controlled trials. Br J Surg 87:854-859, 2000. Medline Similar articles Full article

1. “Groin” hernia refers to which three hernias?

Show answer
Direct and indirect inguinal hernias and femoral hernias.

2. Francois Poupart, a French surgeon and anatomist (1616-1708), described a ligament that bears his name. What is the anatomic name of the Poupart ligament?

Show answer
Inguinal ligament, which is a key element in most groin hernia repair.

3. Franz K. Hesselbach, a German surgeon and anatomist (1759-1816), described a triangle that is the common site of direct hernias. What are the anatomic margins of Hesselbach’s triangle?

Show answer
The triangle is defined inferiorly by the inguinal ligament, superiorly by the inferior epigastric vessels, and medially by the rectus fascia. The transversalis fascia forms the floor of the triangle. The original description used Cooper’s ligament as the inferior limit but because of the common use of the anterior approach to hernias, the more apparent inguinal ligament was substituted as the inferior limit of the triangle. With the increasing use of preperitoneal approaches to hernia repair, Cooper’s ligament is again much more apparent and useful as an anatomic touchstone.

4. Sir Astley Paston Cooper, an English surgeon and anatomist (1768-1841), described a ligament bearing his name. What is the anatomic name for the ligament and the proper name of Cooper’s ligament repair?

Show answer
The anatomic name of Cooper’s ligament is iliopectineal ligament. The Cooper’s ligament repair or McVay repair was popularized by Chester McVay (1911-1987). With Barry Aston, professor of anatomy at Northwestern University, McVay provided the modern description of the groin anatomy.

5. Antonio de Gimbernat, a Spanish surgeon and anatomist (1734-1816), had his interesting name attached to the lacunar ligament, which marks the medial margin of a groin area opening. What is the opening? What hernia protrudes into this opening?

Show answer
The opening is the femoral canal, which is defined medially by the lacunar ligament, anteriorly by the inguinal ligament, posteriorly by the pectineal fascia, and laterally by the femoral vein. A femoral hernia protrudes into the femoral canal.

6. Indirect inguinal hernia (particularly in children) and hydrocele are associated with which congenital abnormality?

Show answer
Persistence of an open processus vaginalis, in the case of a hernia, allows descent of bowel into the inguinal canal. With fluid accumulation, partial obstruction presents as a hydrocele of the spermatic cord.

7. What are the diagnostic criteria for hernia in an infant or child?

Show answer

* Inguinal, scrotal, or labial lump that may or may not be reducible
* History of a lump seen by a health care provider
* History of a lump seen by the mother
* The “silk sign” (the feeling of rubbing together two surfaces of silk cloth when gently rubbing together the two surfaces of a hernia sac)
* An incarceration sometimes felt on rectal examination

8. What can be done to reduce an incarcerated hernia in an infant or child?

Show answer
The four-point program is easier said than done, but it is worth the effort:

1. Sedate the patient.
2. Place the patient in the Trendelenburg position.
3. Apply a cold pack (over petroleum gauze to avoid skin injury) in inguinal area.
4. In the absence of spontaneous reduction-and if the patient is quiet-use gentle manipulation.

9. How often can incarceration be successfully reduced? What should be done next?

Show answer
About 80% of incarcerated hernias can be reduced in children; in adults, the percentage is lower. Despite the fact that 80-90% of inguinal hernias occur in boys, most incarcerations occur in girls. The hernia should be repaired electively within a few days after incarceration. The 20% of hernias that are still incarcerated are operated immediately.

10. What is a Bassini repair?

Show answer
The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring (Figure 56-1). This classic procedure, introduced in 1887 at the Italian Society of Surgery in Genoa, revolutionized hernia repair. Until recently, it has been the standard of repair. After graduation from medical school and while fighting for Italian independence, Eduardo Bassini (1844-1924) was bayoneted in the groin and, as a prisoner, was hospitalized for months with a fecal fistula.

Figure 56-1 The standard right inguinal hernia repair using the conjoined tendon and inguinal ligament.

11. What is the recurrence rate with indirect and direct hernias that have been repaired with classic Bassini repair technique?

Show answer
Over a follow-up period of 50 years, the recurrence rate of adult indirect hernias is 5-10%; of direct hernias, 15-30%.

12. Describe a McVay hernia repair.

Show answer
The line of interrupted sutures starts at a the pubic tubercle and joins the tendinous arch of the transversus abdominis muscle to Cooper’s ligament up to the femoral canal. At this point, two or three transitional sutures are placed from Cooper’s ligament to the anterior femoral fascia, effectively closing the medial extreme of the femoral canal. The final set of sutures joins the transversus abdominis arch and the anterior femoral fascia. The stitches usually incorporate the inguinal ligament at the upper limit of the repair, the site of the new internal inguinal ring and cord structures. About 15 years ago, McVay described laying in a mesh patch and stitching it, at its periphery, to the same anatomic structures. This application of mesh closely resembles the Lichtenstein repair (see question 17), except that it uses Cooper’s ligament.

13. For what type of hernias is the McVay Cooper’s ligament repair most useful?

Show answer
Femoral and direct hernias.

14. What is the Shouldice repair?

Show answer
The Shouldice repair, popularized at the Shouldice Clinic near Toronto, imbricates or overlays the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures. The suture tract runs from the pubic tubercle to a new internal ring. Care is taken with the inferior epigastric vessels. The result is layered approximation of the conjoined tendon to the inguinal ligament tract.

15. What is the reported recurrence rate for the Shouldice repair?

Show answer
The recurrence rate is 1%, the lowest reported rate for nonmesh repairs of inguinal hernias in adults.

16. For what type of groin hernia is the Shouldice repair not appropriate?

Show answer
Femoral hernia.

17. Describe the Lichtenstein repair.

Show answer
The Lichtenstein repair consists of a sutured patch of polypropylene mesh (Marlex, C.R. Bard, Inc., Covington, GA) that covers Hesselbach’s triangle and the indirect hernia area. It is considered a tension-free repair because the mesh is sutured in place without pulling ligaments or tissues together as in all other repairs. The mesh is divided at its upper end to wrap closely around the spermatic cord and its associated structures in the normal position of the internal inguinal canal. The Lichtenstein procedure is rapidly becoming the most widely used repair of adult inguinal hernia. The reported recurrence rate is < 1%.

18. What are the advantages of using the Marlex mesh?

Show answer
Central to acceptance and success of the Lichtenstein hernia repair has been the development of and experience with the Marlex mesh. The monofilament mesh is strong, inert, and resistant to infection. The interstices are rapidly and completely infiltrated with fibroblasts, and the mesh is not subject to deterioration, rejection, or fragmentation. (See Figure 56-2.)

19. For what groin area is the Lichtenstein repair not appropriate?

Figure 56-2 The Marlex mesh repair of a right inguinal hernia. Note that the same structures are used but not brought together; thus, the name of the “tension-free” repair.

20. Which type of repair is acceptable for the femoral hernia?

Show answer
Several different repairs can be used. Mesh in the form of a plug can be inserted into the femoral canal and fixed in place. A McVay Cooper’s ligament repair can be done. A preperitoneal approach to the hernia can be used to suture or plug the defect. A suture repair or a sartorius facial flap applied from below the inguinal ligament in a femoral approach also may be used. The preperitoneal approach is increasingly used for complicated inguinal and femoral hernias.

21. What is the preperitoneal or Stoppa procedure?

Show answer
The preperitoneal or Stoppa procedure is a groin hernia repair on the internal side of the abdominal wall between the peritoneum and fascial surfaces that do not open into the peritoneal cavity. The anatomic landmarks are very different and initially quite challenging to surgeons accustomed to the external abdominal wall approach. The technique is suited for recurrent hernias in which scarring and obliterated anatomy increase the risk of cord injury and recurrence. Other problems such as large hernias and femoral hernias are corrected with this approach. Conceptually, the laparoscopic hernia repair uses the same approach. (See Figure 56-3.)

22. Where are the spaces of Retzius and Bogros? Why are they increasingly important?

Show answer
Retzius’ space is between the pubis and the urinary bladder. Bogros’ space is between the peritoneum and the fascia and muscle planes on the posterior aspect of the abdominal wall below the umbilicus and down to Cooper’s ligament. Laterally, the space goes to the iliac spines. In either the open Stoppa procedure or the laparoscopic preperitoneal repair, the spaces of Retzius and Bogros are developed for mesh placement and surgical exposure.

23. How tight around the spermatic cord should a surgically fashioned, internal inguinal ring be?

Show answer
About 5 mm, which http://surgeryprocedure.info/wp-admin/media-upload.php?post_id=285&type=image&TB_iframe=true&width=640&height=525
Add an Imageis less than a fingertip and more than a forceps tip.

Figure 56-3 The different appearance and landmarks are seen in the anterior view (above) and the posterior view (below) of the inguinal-femoral area. In the posterior view the importance of the inferior epigastric vessels, bladder, and Cooper’s ligament as anatomic landmarks is apparent.

24. What is the common fascial defect of larger indirect and all direct inguinal hernias?

Show answer
Weakness or attenuation of the transversalis fascia.

25. On examination, the femoral hernia may be confused with what other inguinal hernia?

Show answer
The femoral hernia may be confused with a direct inguinal hernia because of the tendency of the femoral hernia to present at the lateral edge of the inguinal ligament.

KEY POINTS: TYPES OF INGUINAL HERNIA REPAIR

1. The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring.
2. The McVay repair is most useful for femoral and direct hernias.
3. The Shouldice repair imbricates the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures (not appropriate for femoral hernias).
4. The Lichtenstein repair consists of a sutured patch of polyprolene mesh that covers Hesselbach’s triangle and the indirect hernia sac.

26. What is the difference between an incarcerated and a strangulated hernia?

Show answer
Incarcerated: structures in the hernia sac still have a good blood supply but are stuck in the sac because of adhesions or a narrow neck of the hernia sac.
Strangulated: herniated structures, such as bowel or omentum, have lost their blood supply because of anatomic constriction at the neck of the hernia. The herniated, ischemic tissue is, therefore, in various stages of gangrenous changes. Strangulated hernias are surgical emergencies.

27. What operation is done for an uncomplicated indirect infant hernia?

Show answer
High ligation of the hernia sac.

28. What operation is done for an uncomplicated indirect hernia in young adults?

Show answer
The appropriate operation consists of high ligation and possibly one or two stitches in the transversalis fascia to tighten the internal ring. This is the basic Marcy technique, developed by Henry Orlando Marcy (1837-1924); it is smaller and more anatomically focused than the Bassini repair.

29. What operation is done for an uncomplicated but sizable direct hernia in elderly adults?

Show answer
Traditionally, the Bassini or McVay repair was chosen. More recently, because of the low recurrence rate, the Shouldice or Lichtenstein repair is favored.

30. What organ systems should be reviewed with particular care in the work-up of patients with hernia (especially elderly patients with recent onset of hernia)?

Show answer
The gastrointestinal, urinary, and pulmonary systems should be reviewed with particular care. One is looking for causes of chronic strain or sudden forces that may have induced the hernia. Straining during defecation or urination, unusual coughing, or difficulty with breathing, if corrected, may be of great value to the patient and reduce the chance of recurrent hernia.

31. What is a sliding hernia?

Show answer
A sliding hernia is formed when a retroperitoneal organ protrudes (herniates) outside the abdominal cavity in such a manner that the organ itself and the overlying peritoneal surface constitute a side of the hernia sac.

32. What organs can be found in sliding hernias?

Show answer

* Colon
* Cecum
* Appendix
* Ovary
* Bladder
* Fallopian tubes
* Uterus (rare)

33. What are common operative and postoperative complications of hernia repairs?

Show answer
Intraoperative complications

* Injury to the spermatic cord, especially in children
* Injury to the spermatic vessels, resulting in atrophy or acute necrosis of testes
* Injury to the ilioinguinal nerve, genitofemoral nerve, and lateral femoral cutaneous nerve (the lateral femoral cutaneous nerve is uniquely vulnerable in laparoscopic and properitoneal procedures)
* Injury to the femoral vessels

Postoperative complications

* Infection-high risk in children with diaper rash and patients with bowel injury or necrosis
* Hematoma-should resolve in time
* Nerve injury-the nerve is not always divided and, with time, may improve. If pain persists, try lidocaine block for both diagnosis and treatment. If a nerve block is not successful, one may consider reexploration to free the nerve from scar or to excise a postsurgical neuroma.

34. What are the common sites of hernia recurrence?

Show answer
Direct hernias often recur at the pubic tubercle. Indirect hernias recur at the internal ring. The cause is usually related to poorly placed or insufficient stitches. Other possible causes include infection, poor tissue, poor collagen formation, or too much tension at the surgical suture line. A single line of repair under moderate tension fails in a significant number of patients, regardless of adequacy of repair or healing process. Tension is almost always bad in surgery.

35. How long should the patient avoid heavy lifting after a hernia repair?

Show answer
The standard advice for decades has been 6 weeks. The current advice varies from no limitation with the Lichtenstein or preperitoneal repairs to 6 weeks for a Bassini repair. The self-limitation of pain is an excellent guide.

1. What is the most common type of congenital diaphragmatic hernia (CDH)?

Show answer
Congenital abnormalities of the diaphragm include a posterolateral defect (Bochdalek hernia), an anteromedial defect (Morgagni hernia), or the eventration (central weakening) of the diaphragm. The Bochdalek hernia is the most common variant and generally occurs on the left (80%). Approximately 20% occur on the right, and < 1% are bilateral.

2. What signs and symptoms suggest CDH?

Show answer
Neonatal respiratory distress is the most common manifestation of CDH caused by associated lung maldevelopment. At birth or shortly thereafter, the infant develops severe dyspnea, retractions, and cyanosis. On physical examination, breath sounds are diminished on the ipsilateral side, heart sounds can be heard more easily in the contralateral chest, and the abdomen is scaphoid because of the herniation of abdominal viscera into the chest. Mediastinal shift may result impairing venous return and cardiac output.

3. How is the diagnosis confirmed?

Show answer
A chest radiograph demonstrates multiple loops of air-filled intestine in the ipsilateral thorax. If a chest radiograph is obtained before entry of significant amounts of air into the bowel, a confusing pattern of mediastinal shift, cardiac displacement, and opacification of the hemithorax may be observed. Insertion of a nasogastric tube followed by repeat chest radiograph often demonstrates the tube (i.e., stomach) in the chest and confirms the diagnosis.

4. Are other anomalies associated with CDH?

Show answer
Fifty percent of infants with CDH have associated anomalies. Fewer than 10% of patients with multiple major concurrent anomalies survive. Excluding intestinal malrotation and pulmonary hypoplasia, cardiac anomalies (63%) are the most frequent, followed by genitourinary (23%), gastrointestinal (17%), central nervous system (14%), and other pulmonary (5%) anomalies.

5. What therapeutic measures should be initiated before transport or operation?

Show answer
Perhaps the easiest and most effective palliative intervention is decompression of the stomach with a nasogastric tube, which prevents further distention of the bowel and lung compression. Endotracheal intubation permits adequate ventilation and oxygenation. Ventilatory pressures are kept low (< 30 mmHg), and the infant is ventilated at a rapid rate (40-60 breaths/min) to avoid barotrauma. Venous access and fluid resuscitation complete preliminary resuscitation.

6. What is the “honeymoon period”?

Show answer
The honeymoon period describes the interval of time in which a neonate demonstrates adequate oxygenation and ventilation in the absence of maximal medical therapy. Regardless of subsequent deterioration, a honeymoon period suggests that pulmonary function is compatible with survival.
7. Describe the operative approach. Show answer

CDH results in a physiologic derangement of the lungs that is not reversed by surgical reconstruction of the diaphragm. Thus, repair of CDH is not a surgical emergency. The infant must be stabilized before surgical repair is attempted. A transabdominal approach allows reduction of the herniated abdominal viscera from the chest, repair of the diaphgramatic defect without obstructed vision or tension, correction of malrotation, and stretching of the abdominal cavity or creation of a ventral hernia with a prosthetic patch if the reduced viscera are not easily accomodated in the abdomen.

8. What is the most feared complication of diaphragmatic hernia?

Show answer
The most feared complication is persistent fetal circulation (PFC). In CDH, one or both lungs are hypoplastic, the pulmonary vascular bed is reduced, and the pulmonary arteries exhibit thickened muscular walls that are hyperreactive. Newborns with CDH are particularly prone to the development of pulmonary hypertension. PFC arises from a sustained increase in pulmonary artery pressure. Blood is shunted away from the lungs, and the unoxygenated blood is diverted to the systemic circulation (right-to-left shunt) through the patent ductus arteriosus and patent foramen ovale. PFC results in hypoxemia, profound acidosis, and shock. PFC is triggered by acidosis, hypercarbia, and hypoxia, all potent vasoconstrictors of the pulmonary circulation.

9. Is PFC correctable? If so, how?

Show answer
Yes. Various strategies are used to prevent or reverse PFC:

1. Monitoring: Oximetry or arterial sampling (preductal in the right upper extremity; postductal in the lower extremity) permits early detection of shunting of unoxygenated blood to the systemic circulation.
2. Ventilation: Hypercarbia is corrected by mechanical ventilation; adequate sedation; and, if necessary, pharmacologic paralysis.
3. Oxygenation: Hypoxemia is corrected by adequate ventilation and high concentrations of inspired oxygen (generally FiO2 = 100%).
4. Resuscitation: Metabolic acidosis is managed by restoring adequate tissue perfusion (intravenous fluids or blood, inotropes, and sodium bicarbonate).
5. Rescue: Salvage therapies include administration of pulmonary vasodilators via the ventilatory circuit (nitric oxide) or systemic circulation (priscoline, prostaglandin E2), high-frequency ventilation, and extracorporeal membrane oxygenation (ECMO).

10. What is the survival rate for patients with CDH?

Show answer
The overall survival rate is 60%. The major determinants of survival are the degree of pulmonary hypoplasia and associated major congenital anomalies. Among infants surviving the early newborn period without significant lung dysfunction, the survival rate approaches 100%.

11. Does in utero intervention have a role in the treatment of patients with CDH?

Show answer
To date, fetal surgery for CDH remains experimental. In a prospective trial reported in 1997, the results of intrauterine repair of CDH were compared with conventional postnatal surgery with similar outcome. The investigators concluded that because open fetal surgery does not improve survival or outcome, prenatally diagnosed CDH should be treated postnatally.

References
BIBLIOGRAPHY
1. Clark RH, Hardin WD, Hirschl RB, et al: Current surgical management of congenital diaphragmatic hernia: A report from the congenital diaphragmatic hernia study group. J Pediatr Surg 33:1004-1009, 1998. Medline Similar articles
2. Fauza DO, Wilson JM: Congenital diaphragmatic hernia and associated anomalies: Their incidence, identification, and impact on prognosis. J Pediatr Surg 29:1113-1117, 1994. Medline Similar articles
3. Harrison MR, Adzick NS, Bullard KM, et al: Correction of congenital diaphragmatic hernia in utero VII: A prospective trial. J Pediatr Surg 32:1637-1642, 1997. Medline Similar articles Full article
4. Nobuhara KK, Lund DP, Mitchell J, et al: Long-term outlook for survivors of congenital diaphragmatic hernia. Clin Perinatol 23:873-887, 1996. Medline Similar articles
5. Weber TR, Kountzman B, Dillon PA, et al: Improved survival in congenital diaphragmatic hernia with evolving therapeutic strategies. Arch Surg 133:498-503, 1998.

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1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?

Show answer

1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home

2. Which is the most dangerous course?

Show answer
To send the patient home.

3. Is it important to make the diagnosis in the emergency department?

Show answer
No. Frequently time spent confirming a diagnosis in the emergency department is lost to inhospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.

4. If the essential goal is not to make the diagnosis, what should the surgeon do?

Show answer

1. Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.
2. Start a big IV line.
3. Replace lost electrolytes (see Chapter 7).
4. Insert a Foley catheter.
5. Examine the patient (frequently).

5. Are symptoms and signs uniquely misleading in any groups of patients?

Show answer
Yes. Watch out for the following groups:

* The very young, who cannot talk.
* Diabetics, because of visceral neuropathy.
* The very old, in whom, much as in diabetics, abdominal innervation is dulled.
* Patients taking steroids, which depress inflammation and mask everything.
* Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).

6. Summarize the history needed.

Show answer

1. The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.
2. Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.
3. Location of abdominal pain. Right upper quadrant: gallbladder or biliary disease, duodenal ulcer. Right flank: pyelonephritis, hepatitis. Midepigastrium: duodenal or gastric ulcer, pancreatitis, gastritis. Left upper quadrant: ruptured spleen, subdiaphragmatic abscess. Right lower quadrant: appendicitis (see Chapter 37), ectopic pregnancy, incarcerated hernia, rectus hematoma. Left lower quadrant: diverticulitis, incarcerated hernia, rectus hematoma. Note: Cancer, unless it obstructs (colon cancer), and bleeding (diverticulosis) typically do not hurt.
4. Duration of pain. The pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy. Note: Although the surgeon is rotating through a gastrointestinal service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.

17. Should systemic antibiotic prophylaxis be used in elective colon resection?

Show answer
Yes, beyond any statistical shadow of a doubt. At least two dozen clinical trials have been carried out using placebo controls against a variety of antibiotics, principally those active against at least the anaerobic-predominant flora, and nearly all have shown a reduction in infectious complications in the antibiotic group. Never again should this point need repeating, and no patient should be placed at risk when systemic antibiotic prophylaxis has been established as the standard of care. No new clinical trials against placebo in this group of patients with known risk can be performed ethically given the confirmed risk reduction.
Other risk groups (e.g., cesarean section after membrane rupture) besides patients undergoing colon resection have been standardized by trials in large patient populations and have shown similar risk reduction. The benefit of prophylaxis has been demonstrated. In other groups of patients that cannot be standardized because of unusual contamination factors or unique factors of host resistance impairment, guidelines for rational prophylaxis should follow similar principles.

18. Are two prophylactic doses better than one in preventing infection? Are three doses better still?

Show answer
Only one dose of prophylactic antibiotic can be proved, beyond statistical or clinical doubt, to be efficacious-the dose in systemic circulation at the time of the inoculum. Whether the dose needs to be repeated one or more times during the 24 hours after the inoculum depends on the blood levels of the drug, which are largely a function of protein binding and clearance rate. We also know for sure that 10 days of the same prophylactic drug that is efficacious if given immediately before the inoculum results in a higher risk of infection than no antibiotic at all.
KEY POINTS: PREOPERATIVE ANTIBIOTIC PROPHYLAXIS

1. Timing of administration is the most important factor.
2. Dose 30 minutes before incision so that antibiotic is circulating before the inoculum.
3. No evidence supports continuation of prophylaxis beyond 24 hours.

19. What factors determine the timing of antibiotic administration under the criteria of prophylaxis?

Show answer
The one immutable principle has been set out above-the most important element in timing of prophylaxis is that the drug be circulating before the inoculum. When should it stop? When the reduction in infection risk is no longer provable and before continued use will defeat the prophylactic purpose (as explained above). To summarize with an arbitrary rule of thumb: there is no justification for prophylactic antibiotic 24 hours after the inoculum of an invasive procedure.

What does this rule imply? Should we not continue prophylaxis for weeks to cover the presence of a prosthetic hip joint? Presumably, the prosthetic hip will be in the patient for many years-but surely you do not argue that the antibiotic should continue on a daily basis as long as the hip is in place! What is “prophylaxed” is not the prosthetic hip but the procedure of implantation. And it is not only implantation that poses a risk to the patient with a prosthesis-so does hemorrhoidectomy done years later, for which prophylaxis is made mandatory by the presence of the hip prosthesis.
The prosthetic or rheumatic heart valve is a risk, but the indication for the use of prophylactic antibiotics is an invasive procedure-a root canal is an example in which an inoculum is unavoidable. Operations are covered by prophylactic antibiotics; the conditions that are risk factors during the operation are not.

20. To be safe, why not administer prophylactic antibiotics to all patients undergoing any kind of operation?

Show answer
Can you give me the indication for a prophylactic antibiotic in a patient undergoing a clean elective surgical procedure that implants no prosthesis, such as hernia repair?
“Sure,” one of my brighter students once responded, “the patient who has a serious impairment in host response, such as acute granulocytic leukemia in blast crisis.”
I responded, “Why on earth are you fixing his hernia? That is a clean error [hopefully not a clean kill] in surgical judgment that has nothing to do with antibiotics at all. A patient with that degree of host impairment does not undergo an elective surgical procedure.”
Rule of thumb: If you can provide the indication for a prophylactic antibiotic to cover a clean elective nonprosthetic operation for a patient, you have provided the contraindication for the operation.

1. What symptoms suggest gastroesophageal reflux disease (GERD)?

Show answer
Substernal burning after meals or at night, associated occasionally with regurgitation of gastric juices, is one symptom. Discomfort is relieved by standing or sitting. Dysphagia, a late complication of GERD, is caused by mucosal edema or stricture of the distal esophagus. However, no symptom is specific for GERD, and therapeutic decisions should not be made on symptoms alone.

2. What is the difference between heartburn and GERD?

Show answer
Heartburn is a lay term for mild, intermittent reflux of gastric content into the esophagus without tissue injury. It is relatively common among adults. GERD implies esophagitis with varying degrees of erythema, edema, and friability of the distal esophageal mucosa. It occurs in 10% of the population.

3. What causes GERD?

Show answer
The underlying abnormality of GERD is functional incompetence of the lower esophageal sphincter (LES), which allows gastric acid, bile, and digestive enzymes to damage the unprotected esophageal mucosa. Achalasia, scleroderma, and other esophageal motility disorders are sometimes associated with GERD.

4. Is hiatal hernia an essential defect in patients with GERD?

Show answer
No. Not all patients with GERD have a hiatal hernia, and not all patients with a hiatal hernia have GERD. A total of 50% of patients with GERD have an associated hiatal hernia.

5. What studies are useful to diagnose GERD?

Show answer
Endoscopy with biopsy is essential in diagnosing GERD. Barium swallow with or without fluoroscopy can diagnose reflux but cannot identify esophagitis. Twenty-four-hour esophageal pH testing associates reflux with symptoms and is useful in some patients. Gastric secretory or gastric emptying tests are occasionally helpful. Manometry of the esophagus and LES is required whenever an esophageal motility disorder is suspected and before any surgical intervention.

6. What is the initial management of a patient suspected of having GERD?

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* Change diet to avoid foods known to induce reflux (e.g., chocolate, alcohol, and coffee).
* Avoid large meals before bedtime.
* Stop smoking.
* Do not wear tight, binding clothes.
* Elevate the head of the bed 4-5 inches.
* Take antacids when symptomatic.
* Weight loss can be very effective in reducing GERD symptoms.

7. If initial treatment fails, what should be recommended?

Show answer
About 50% of patients show significant healing with H2 blockers, but only 10% of these patients remain healed 1 year later. Metoclopramide promotes gastric emptying but rarely relieves symptoms consistently in the absence of acid reduction.

KEY POINTS: DIAGNOSTIC WORK-UP OF GERD

1. Underlying anatomic abnormality may cause functional incompetence of the lower esophageal sphincter (LES).
2. Endoscopy and biopsy are paramount in diagnosis.
3. Swallow studies delineate possible anatomic causes.
4. 24-hour pH monitoring can link reflux to patient’s symptoms.
5. Manometry of the LES is required if esophageal motility disorder is suspected.

8. What is the role of proton pump inhibitor (PPI) in GERD?

Show answer
PPIs (omeprazole and others) irreversibly inhibit the parietal cell hydrogen ion pump and are > 80% successful in healing severe erosive esophagitis. Two thirds of patients who continue the medication remain healed. A concern in prolonged PPI therapy is hypergastrinemia secondary to alkalinization of the antrum. Gastrin is trophic to gastrointestinal mucosa, but the initial fear of induced neoplasia has not been borne out by follow-up studies.

9. When should operation for GERD be recommended?

Show answer
Failure of nonoperative (medical) therapy is the primary indication for surgery. Noncompliance with prescribed treatment is a frequent cause of failure and even stricture unresponsive to dilation. With PPIs, most patients’ symptoms can be controlled for long periods of time. Current recommendations for surgical intervention include: (1) failed medical therapy (e.g., intractable disease, intolerance or allergy to medications, noncompliance, and recurrence of symptoms while on medical therapy), (2) complications (e.g., stricture, respiratory symptoms, medicosocial changes, and premalignant mucosal changes), (3) patient preference (e.g., cost-long-term medical prescriptions can be expensive-or lifestyle issues).

10. What is the goal of surgical treatment?

Show answer
Operations for GERD attempt to prevent reflux by mechanically increasing LES pressure and, in most procedures, to restore a sufficient length of distal esophagus to the high-pressure zone of the abdomen. Hiatal hernia, when present, is reduced simultaneously.

11. What procedures can accomplish this goal and how do they do it?

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1. In the Nissen fundoplication, which is used in > 95% of patients, the fundus of the stomach is mobilized, wrapped around the distal esophagus posteriorly, and secured to itself anteriorly (i.e., 360-degree wrap). The procedure alters the angle of the gastroesophageal junction and maintains the distal esophagus within the abdomen to prevent reflux. The operation is performed transabdominally by either laparotomy or laparoscopy. (See Figure 43-1.)
2. The Belsey Mark IV operation accomplishes the same anatomic changes but is done via a thoracotomy. (See Figure 43-2.)
3. The Hill gastropexy restores the esophagus to the abdominal cavity by securing the gastric cardia to the preaortic fascia. (See Figure 43-3.)
4. The Toupet (partial) fundoplication is used in patients who have associated motility disorders. Because the wrap is not circumferential, the incidence of postoperative dysphagia is significantly reduced with this partial wrap compared with a full 360-degree wrap (Nissen fundoplication). However, long-term durability may not be as good as with a Nissen fundoplication. This operation can be done transabdominally by either laparotomy or laparoscopy. (See Figure 43-4.)

Figure 43-1 In the Nissen fundoplication, which is used in > 95% of patients, the fundus of the stomach is mobilized, wrapped around the distal esophagus posteriorly, and secured to itself anteriorly (i.e., 360° wrap). The procedure alters the angle of the GE junction and maintains the distal esophagus within the abdomen to prevent reflux. The operation is performed transabdominally by either laparotomy or laparoscopy.

Figure 43-2 The Belsey Mark IV operation accomplishes the same anatomic changes as the Nissen fundoplication but is done via a thoracotomy.

Figure 43-3 The Hill gastropexy restores the esophagus to the abdominal cavity by securing the gastric cardia to the preaortic fascia.

Figure 43-4 The Toupet (partial) fundoplication is used in patients who have associated motility disorders. Because the wrap is not circumferential, the incidence of postoperative dysphagia is significantly reduced with this partial wrap compared with a full 360° wrap (Nissen fundoplication). However, long-term durability may not be as good as with a Nissen fundoplication. This operation can be done transabdominally by either laparotomy or laparoscopy.

12. What are the success rates for such procedures?

Show answer
All of the procedures described in question 11 eliminate GERD in almost 90% of patients who are followed for

10 years. But the Nissen fundoplication wins in comparison studies. Recurrent symptoms should be thoroughly worked up because they are frequently associated with other disorders and not recurrent GERD.
13. What are the long-term complications of such procedures?

Show answer
The repair may fail, with recurrence of reflux, after any of these operations. Incorrect placement or slippage of the stomach wrap can complicate Nissen fundoplication and the Belsey Mark IV procedure. Dysphagia and the inability to belch (i.e., gas-bloat syndrome) result from too tight a wrap.

14. How can stricture from GERD be managed?

Show answer
Pliable (unfixed) strictures can be dilated. Fixed strictures require surgical repair. A Thal patch expands the stricture by interposing a piece of stomach.

1. What are the mechanical causes of large bowel obstruction?

Show answer
The three most common mechanical causes are carcinoma (50%), volvulus (15%), and diverticular disease (10%). Extrinsic compression from metastatic carcinoma is another cause of obstruction. Less frequent causes include stricture, hernia, intussusception, benign tumor, and fecal impaction.

2. How is the diagnosis made?

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1. The patient complains of crampy abdominal pain and bloating. Nausea and vomiting occur later in large bowel obstruction and may be feculent. An acute onset of symptoms is more consistent with volvulus compared with the gradual development of obstructive complaints from patients with colon carcinoma.
2. Physical examination reveals abdominal distention and high-pitched bowel sounds. Rectal examination may reveal an obstructing rectal cancer or evidence of fecal impaction. Absence of bowel sounds and localized tenderness may be signs of peritonitis. Progression of symptoms accompanied by a high fever or tachycardia requires immediate operative attention.
3. Flat and upright abdominal radiographs reveal dilated colon proximal to the obstruction. An upright chest radiograph may show free air under the diaphragm if a perforation has occurred.

3. How is the diagnosis confirmed?

Show answer
A contrast enema (barium or water-soluble contrast) is necessary to delineate the level and nature of an obstruction. A volvulus can be identified by a “bird’s beak” narrowing at the neck of the volvulus. Sigmoidoscopy or colonoscopy is an essential part of the evaluation; it allows visualization of the colon and may be therapeutic in the case of a sigmoid volvulus.

4. What is the role of computed tomography (CT) scanning in the diagnosis of large bowel obstruction?

Show answer
CT scans may be valuable in distinguishing between mechanical obstruction or pseudo-obstruction. It can help with the diagnosis of diverticulitis or colon carcinoma. However, plain radiographs, colonoscopy, and physical examination exceed the benefits of CT scanning in the evaluation of large bowel obstruction.

5. Why is tenderness in the right lower quadrant (RLQ) important?

Show answer
The cecum is the area that is most likely to perforate. When the cecum reaches 15 cm at its widest diameter, the tension on the wall is so great that decompression is essential to prevent perforation. The larger diameter of the cecum causes more tension of the cecal wall at the same intraluminal pressure (law of Laplace). The other area at risk for perforation is the site of a primary colon cancer.

6. Where is the obstructing cancer usually located?

Show answer
Most obstructing colorectal carcinomas occur in the splenic flexure, descending colon, or hepatic flexure. In contrast, lesions of the right colon usually present with occult bleeding. Cecal and rectal cancers are uncommon causes of obstruction.

KEY POINTS: CAUSES OF LARGE BOWEL OBSTRUCTION

1. Carcinoma: most common cause: 50%
2. Volvulus: 15%
3. Diverticular disease: 10%
4. Stricture, hernia, intussusception, fecal impaction: 25%

7. What is a volvulus? Where is it located?

Show answer
A volvulus is an abnormal rotation of the colon on an axis formed by its mesentery and occurs either in the sigmoid colon (75%) or cecum (25%). Sigmoid volvulus occurs in an older population when chronic constipation causes the sigmoid colon to elongate and become redundant. Cecal volvulus requires a hypermobile cecum as a result of incomplete embryologic fixation of the ascending colon.

8. When is surgery indicated?

Show answer
Surgery is performed early in colon obstruction. Urgent laparotomy is necessary in patients with suspected perforation or ischemia. Danger signs are quiet abdomen, RLQ tenderness, and increasing pain. The patient’s cardiopulmonary status should be assessed and optimized preoperatively. It is essential to correct dehydration and administer perioperative antibiotics. Marking of possible stoma sites and deep venous thrombosis prophylaxis are other important preoperative considerations.

9. Which operation should be performed for a large bowel obstruction?

Show answer
The traditional procedure for a large bowel obstruction has been a decompressing colostomy. However, careful assessment of the patient’s condition, viability of the bowel, location of the obstruction, and absence of intra-abdominal contamination often allow resection with or without a primary anastomosis. In fact, an initial diverting colostomy has not been shown to have any survival advantage and incurs the risk of further surgeries.
An obstructing carcinoma may be resected satisfactorily under emergency conditions in 90% of patients. Carcinomas of the right and transverse colon (proximal to the splenic flexure) are routinely treated with resection and primary anastomosis. Recently, obstructing cancers of the descending colon have been treated either with resection and colostomy or intraoperative lavage followed by resection and primary anastomosis. Techniques for nonoperative decompression of the colon, such as balloon dilation, laser therapy, and stent placement, are under investigation. Theoretically, these techniques will allow palliation, bowel preparation, and elective colon resection.
A volvulus should be reduced and resected. Reduction of a sigmoid volvulus can be achieved nonoperatively by sigmoidoscopy or hydrostatic decompression with a contrast enema. The recurrence rate of volvulus after simple nonoperative reduction is 75%. Surgical therapy includes detorsion with colopexy or sigmoid colectomy. Cecal volvulus can be treated similarly with nonoperative decompression, cecopexy, or surgical resection.
The optimal treatment of diverticular disease is initial bowel rest; intravenous antibiotics; and percutaneous abscess drainage, if necessary. Colon resection and primary anastomosis can be performed after adequate bowel preparation.

10. What are the nonmechanical causes of large bowel obstruction?

Show answer
Paralytic ileus (i.e., colonic pseudoobstruction) or toxic megacolon.

11. What is Ogilvie’s syndrome?

Show answer
Ogilvie’s syndrome is an acute paralytic (adynamic) ileus or pseudoobstruction (i.e., enormous dilation of the colon without a mechanical distal obstructing lesion). Patients present with a massively dilated abdomen and a small amount of pain. Nonoperative management, including bowel rest, intravenous fluids, and gentle enemas, is the therapy of choice. Gastrografin enema or colonoscopy is diagnostic and therapeutic. Neostigmine is another treatment modality in patients with colons > 10 cm in diameter.

12. What is toxic megacolon?

Show answer
Toxic megacolon is dilatation of the entire colon secondary to acute inflammatory bowel disease. The disease is manifested by acute onset of abdominal pain, distention, and sepsis. Initial therapy includes intravenous fluid resuscitation, nasogastric decompression, and broad-spectrum antibiotics. If symptoms do not resolve within a few hours, the patient requires an operation to avoid perforation. Surgical therapy most often consists of an emergency abdominal colectomy with formation of an ileostomy.

References
WEB SITE
http://www.emedicine.com/emerg/topic65.htm
BIBLIOGRAPHY
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3. Frager D: Intestional obstruction: Role of CT. Gastroenterol Clin North Am 31:777-799, 2002. Medline Similar articles
4. Lopez-Kostner F, Hool GR, Lavery IC: Management and causes of acute large-bowel obstruction. Surg Clin North Am 77:1265-1290, 1997. Medline Similar articles
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1. Clinical determinants of brain death are the loss of the
   papillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and
   respiratory reflexes for > 6 hours. The patient should also undergo
   an apnea test, in which the pCO₂ is allowed to rise to at
   least 60 mmHg without coexistent hypoxia. The patient should be
   observed for the absence of spontaneous breathing.
2. The estimated risks of HBV, HCV, and HIV transmission by
   blood transfusion in the United States are 1 in 205,000 for HBV, 1 in
   1,935,000 for HCV, and 1 in 2,135,000 for HIV.
3. The most common location of an undescended testicle is the
   inguinal canal.
4. The most common solid renal mass in infancy is a congenital
   mesoblastic nephroma and in childhood a Wilms’ tumor.
5. Ogilvie’s syndrome is acute massive dilatation of the cecum
   and the ascending and transverse colon without organic obstruction.
6. The best screening method for prostate cancer is digital
   rectal exam combined with serum prostate-specific antigen.
7. The most common histologic type of bladder cancer is
   transitional cell carcinoma.
8. Carcinoma in situ of the bladder is treated with
   immunotherapy with intravesical bacillus Calmette-Guérin.
9. Localized renal cell carcinoma is treated with surgery
   (radical nephrectomy).
10. The most common cause of male infertility is varicocele.
11. The most common nonbacterial cause of pneumonia in
    transplant patients is cytomegalovirus.
12. Chimerism is leukocyte sharing between the graft and the
    recipient so that the graft becomes a genetic composite of both the
    donor and the recipient.
13. OKT3 is a mouse monoclonal antibody that binds to and
    blocks the T-cell CD3 receptor.
14. The most common disease requiring liver transplant is
    hepatitis C.
15. Cystic hygroma is a congenital malformation with a
    predilection for the neck. It is a benign lesion that usually presents
    as a soft mass in the lateral neck.
16. In neuroblastomas, age at presentation is the major
    prognostic factor. Children younger than 1 year have an overall
    survival rate > 70%, whereas the survival rate for children older
    than 1 year is < 35%.
17. The most feared complication of diaphragmatic hernia is
    persistent fetal circulation.
18. The three most common variants of tracheoesophageal fistula
    are (1) proximal esophageal atresia with distal tracheoesophageal
    fistula, (2) isolated esophageal atresia, and (3) tracheo-esophageal
    fistula with esophageal atresia.
19. Atresia can occur anywhere in the GI tract: duodenal (50%),
    jejunoileal (45%), or colonic (5%). Duodenal atresia arises from
    failure of recanalization during the 8th-10th week of gestation;
    jejunoileal and colonic atresia are caused by an in utero mesenteric
    vascular accident.
20. The types of aortic dissection are ascending (type A)
    dissection, which involves only the ascending or both the ascending and
    descending aorta, and descending dissection (type B), which involves
    only the descending aorta.
21. A solitary pulmonary nodule is < 3 cm and is discrete on
    chest radiograph. It is usually surrounded by lung parenchyma.
22. Mediastinal staging is indicated in patients with apparent
    or documented lung cancer who have (1) known lung cancer with
    mediastinal nodes > 1 cm accessible by cervical mediastinal
    exploration, as assessed by CT scan; (2) adenocarcinoma of the lung and
    multiple mediastinal lymph nodes < 1 cm; (3) central or large (>

    5 cm) lung cancers with mediastinal lymph nodes < 1 cm; and (4) lung
    cancer with risk of thoracotomy and lung resection.

23. The most common causes of aortic stenosis are now
    congenital anomalies and calcific (degenerative) disease.
24. In mitral regurgitation, the left ventricle ejects blood
    via two routes: (1) antegrade, through the aortic valve, or (2)
    retrograde, through the mitral valve. The amount of each stroke volume
    ejected retrograde into the left atrium is the regurgitant fraction. To
    compensate for the regurgitant fraction, the left ventricle must
    increase its total stroke volume. This ultimately produces volume
    overload of the left ventricle and leads to ventricular dysfunction.
25. The indications for CABG are (1) left main coronary artery
    stenosis; (2) three-vessel coronary artery disease (70% stenosis) with
    depressed left ventricular (LV) function or two-vessel coronary artery
    disease (CAD) with proximal left anterior descending (LAD) involvement;
    and (3) angina despite aggressive medical therapy.
26. Hibernating myocardium is improved by CABG. Myocardial
    hibernation refers to the reversible myocardial contractile function
    associated with a decrease in coronary flow in the setting of preserved
    myocardial viability. Some patients with global systolic dysfunction
    exhibit dramatic improvement in myocardial contractility after CABG.
27. The surgical treatment of ulcerative colitis is total
    colectomy with ileoanal pouch anastomosis.
28. Dieulafoy’s ulcer is a gastric vascular malformation with
    an exposed submucosal artery, usually within 2-5 cm of the
    gastroesophageal junction. It presents with painless hematemesis, often
    massive.
29. The role of blind subtotal colectomy in the management of
    massive lower gastrointestinal bleeding is limited to a small group of
    patients in whom a specific bleeding source cannot be identified. The
    procedure is associated with a 16% mortality rate.
30. Colorectal polyps < 2 cm have a 2% risk of containing
    cancer, 2 cm polyps have a 10% risk, and polyps > 2 cm have a cancer
    risk of 40%. Sixty percent of villous polyps are > 2 cm, and 77% of
    tubular polyps are < 1 cm at the time of discovery.
31. Patients with colorectal cancer with lymph node involvement
    (Dukes’ C) should receive chemotherapy postoperatively to treat
    micrometastases.
32. Goodsall’s rule states the location of the internal opening
    of an anorectal fistula is based on the position of the external
    opening. An external opening posterior to a line drawn transversely
    across the perineum originates from an internal opening in the
    posterior midline. An external opening, anterior to this line,
    originates from the nearest anal crypt in a radial direction.
33. Incarcerated inguinal hernia: structures in the hernia sac
    still have a good blood supply but are stuck in the sac because of
    adhesions or a narrow neck of the hernia sac. Strangulated inguinal
    hernia: hernia structures have a compromised blood supply because of
    anatomic constriction at the neck of the hernia.
34. Chvostek’s sign is spasm of the facial muscles caused by
    tapping the facial nerve trunk. Trousseau’s sign is carpal spasm
    elicited by occlusion of the brachial artery for 3 minutes with a blood
    pressure cuff.
35. The two surgical options for Graves’ disease are subtotal
    thyroidectomy or near-total thyroidectomy.
36. The only biochemical test that is routinely needed to
    identify patients with unsuspected hyperthyroidism is serum
    thyroid-stimulating hormone concentration.
37. The surgically correctable causes of hypertension are
    renovascular hypertension, pheochromocytoma, Cushing’s syndrome,
    primary hyperaldosteronism, coarctation of the aorta, and unilateral
    renal parenchymal disease.
38. The “triple negative test” or “diagnostic triad” for
    diagnosing a palpable breast mass includes physical examination, breast
    imaging, and biopsy.
39. Chest wall radiation is indicated after mastectomy in
    patients with greater than 5 cm primary cancers, positive mastectomy
    margins, or more than four positive lymph nodes, all of which are
    associated with heightened locoregional recurrence rates.
40. Sentinel lymph nodes are the first stop for tumor cells
    metastasizing through lymphatics from the primary tumor.
41. The most common site of origin of subungual melanomas is
    the great toe. Amputation at or proximal to the metatarsal phalangeal
    joint and regional sentinel lymph node biopsy are advised by most
    authors.
42. Ramus marginalis mandibularis, the lowest branch of the
    nerve that innervates the depressor muscles of the lower lip, is the
    most commonly injured facial nerve branch during parotidectomy.
43. Waldeyer’s ring is the mucosa of the posterior oropharynx
    covering a bed of lymphatic tissue that aggregates to form the
    palatine, lingual, pharyngeal, and tubal tonsils. These structures form
    a ring around the pharyngeal wall. This may be the site of primary or
    metastatic tumor.
44. A patient in whom the head and neck examination is
    completely normal but FNA of a cervical node reveals squamous cancer
    should have examination of the mouth, pharynx, larynx, esophagus, and
    tracheobronchial tree under anesthesia (triple endoscopy). If nothing
    is seen, blind biopsy of the nasopharynx, tonsils, base of tongue, and
    pyriform sinuses should be done at the same sitting.
45. The microorganisms implicated in atherosclerosis include Chlamydia
    pneumoniae, Helicobacter pylori, streptococci, and Bacillus
    typhosus.
46. The cumulative 10-year amputation rate for claudication is
    10%.
47. The absolute reduction in risk of stroke is 6% over a
    5-year period in asymptomatic patients with > 60% stenosis who
    undergo carotid endarterectomy plus aspirin versus patients treated
    with aspirin alone (5.1% versus 11%).
48. Abdominal aortic aneurysm’s average expansion rate is 0.4
    cm/year.
49. Heparin binds to antithrombin III, rendering it more
    active.
50. The patient with suspected intermittent claudication should
    initially be evaluated by obtaining ankle brachial index or segmental
    limb pressures at rest.
51. Shock is suboptimal consumption of O₂ and
    excretion of CO₂ at the cellular level.
52. Nitric oxide is synthesized in vascular endothelial cells
    by constitutive nitric oxide synthase and inducible NOS, using arginine
    as the substrate.
53. Saliva has the hightest potassium concentration (20 mEq),
    followed by gastric secretions (10 mEq), then pancreatic and duodenal
    secretions (5 mEq).
54. Basal caloric expenditure = 25 kcal/kg/day with a
    requirement of approximately 1 g protein/kg/day.
55. 6.25 g of protein contains 1 g of nitrogen.
56. Dextrose has 3.4 kcal/g, protein 4 kcal/g, fat 9 kcal/g
    (20% lipid solution delivers 2 kcal/mL).
57. Maximal glucose infusion rates in parenteral formulas
    should not exceed 5 mg/kg/min.
58. Refeeding syndrome occurs in moderately to severely
    malnourished patients (e.g., chronic alcoholism or anorexia nervosa)
    who, upon presentation with a large nutrient load, develop clinically
    significant decreases in serum phosphorus, potassium, calcium, and
    magnesium levels. Hyperglycemia is common secondary to blunted insulin
    secretion. ATP production is mitigated, and the classic presentation is
    respiratory failure.
59. Glutamine is the most common amino acid found in muscle and
    plasma. Levels decrease after surgery and physiologic stress. Glutamine
    serves as a substrate for rapidly replicating cells (interestingly, it
    is also the number one metabolic substrate for neoplastic cells),
    maintains the integrity and function of the intestinal barrier, and
    protects against free radical damage by maintaing GSH levels. Glutamine
    is unstable in IV form unless linked as a dipeptide.
60. Fever is caused by activated macrophages that release
    interleukin-1, tumor necrosis factor, and interferon in response to
    bacteria and endotoxin. The result is a resetting of the hypothalamic
    thermoregulatory center.
61. Cardiac output = heart rate x stroke volume; normal CO is
    5-6 L/min.
62. SVR = [(MAP - CVP)/CO] x 80; normal SVR is 800-1200
    dyne.sec/cm^-5.
63. Hypovolemic shock: low CVP and PCWP, low CO and SVO₂,
    high SVR.
64. Cardiogenic shock: high CVP and PCWP, low CO and SVO₂,
    variable SVR.
65. Septic shock: low or normal CVP and PCWP, high CO
    initially, high SVO₂, low SVR.
66. Kehr’s sign is concurrent LUQ and left shoulder pain,
    indicating diaphragmatic irritation from a ruptured spleen or
    subdiaphragmatic abscess. Anatomically, the diaphragm and the back of
    the left shoulder enjoy parallel innervation.
67. Rebound tenderness implies peritoneal inflammation and
    irritation not simply abdominal tenderness.
68. The 5 Ws of post-operative fever are wound
    (infection), water (UTI), wind (atelectasis,
    pneumonia), walking (thrombophlebitis), and wonder
    drugs (drug fevers).
69. Cricothyroidotomy should not be performed in
    patients < 12 years old or any patient with suspected direct
    laryngeal trauma or tracheal disruption.
70. The radial (wrist) pulse estimates SBP > 80 mmHg;
    femoral (groin) pulse estimates SBP > 70 mmHg; and carotid (neck)
    pulse estimates SBP > 60 mmHg.
71. A general rule for crystalloid infusion to replace blood
    loss is a 3:1 ratio of isotonic crystalloid to blood.
72. Raccoon eyes (periorbital ecchymosis) and Battle’s sign
    (mastoid ecchymosis) are clinical indicators of basilar skull fracture.
73. CPP = MAP – ICP. Some debate exists on the minimum
    allowable CPP, but consensus indicates that a cerebral perfusion
    pressure of 50-70 mmHg is necessary.
74. Violation of the platysma defines a penetrating neck wound.
75. Tension pneumothorax is air accumulation in the pleural
    space eliciting increased intrathoracic pressure and resulting in a
    kinking of the SVC and IVC that compromises venous return to heart.
76. The most common site of thoracic aortic injury in blunt
    trauma is just distal to the take-off of the left subclavian artery.
77. The most common manifestation of blunt myocardial injury is
    arrhythmia.
78. Indications for thoracotomy in a stable patient with
    hemothorax include an immediate tube thoracostomy output of > 1500
    mL and ongoing bleeding of 250 mL/h for 4 consective hours.
79. Beck’s triad is hypotension, distended neck veins, and
    muffled heart sounds.
80. The hepatic artery supplies approximately 30% of blood flow
    to the liver while the portal vein supplies the remaining 70%. The
    oxygen delivery, however, is similar for both at 50%.
81. The Pringle maneuver is a manual occlusion of the
    hepatoduodenal ligament to interrupt blood flow to the liver.
82. Splenectomy significantly decreases IgM levels.
83. 90% of trauma fatalities due to pelvic fractures are due to
    venous bleeding and bone oozing; only 10% of fatal pelvic bleeding from
    blunt trauma is arterial (most common site is superior gluteal artery).
84. Intraperitoneal bladder rupture from blunt trauma:
    operative management; extraperitoneal rupture: observant management.
85. Pseudoaneurysm is a disruption of the arterial wall leading
    to a pulsatile hematoma contained by fibrous connective tissue (but not
    all three arterial wall layers, which defines a true aneurysm).
86. The earliest sign of lower extremity compartment syndrome
    is neurologic in the distribution of the peroneal nerve with numbness
    in the first dorsal webspace and weak dorsiflexion.
87. Posterior knee dislocations are associated with popliteal
    artery injuries and are an indication for angiography.
88. Management of suspected navicular fracture despite negative
    radiography is short-arm cast and repeat x-ray in 2 weeks; at high risk
    for avascular necrosis.
89. Parkland formula: lactated Ringer’s at 4 mL/kg x %TBSA
    (second- and third-degree only) of burn. Infuse 50% of volume in first
    8 hours and the remaining 50% over the subsequent 16 hours.
90. The metabolic rate peaks at 2.5 times the basal metabolic
    rate in severe burns > 50% TBSA.
91. Gallstones and alcohol abuse are the two main causes of
    acute pancreatitis.
92. Alcohol abuse accounts for 75% of cases of chronic
    pancreatitis.
93. Isolated gastric varices and hypersplenism indicate splenic
    vein thrombosis and are an indication for splenectomy.
94. The treatment for gallstone pancreatitis is cholecystectomy
    and intraoperative cholangiogram during the same hospital stay once the
    pancreatitis has subsided.
95. Proton pump inhibitors irreversibly inhibit the parietal
    cell hydrogen ion pump.
96. Definitive treatment of alkaline reflux gastritis after a
    Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm
    efferent jejunal limb.
97. Cushing’s ulcer is a stress ulcer found in critically ill
    patients with central nervous system injury. It is typically single and
    deep, with a tendency to perforate.
98. Curling’s ulcer is a stress ulcer found in critically ill
    patients with burn injuries.
99. Marginal ulcer is an ulcer found near the margin of
    gastroenteric anastomosis, usually on the small bowel side.
100. The most common cause of small bowel obstructions is
     adhesive disease; the second most common cause is hernias.