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Inguinal Hernia. Controversies
CONTROVERSIES
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.
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Inguinal Hernia
56 INGUINAL HERNIA
Gregory P. Victorino M.D., Jyoti Arya M.D., James Bascom M.D.
1. “Groin” hernia refers to which three hernias?
Show answer
Direct and indirect inguinal hernias and femoral hernias.
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poupart 1616-1708,Congenital Diaphragmatic Hernia
86 CONGENITAL DIAPHRAGMATIC HERNIA
Denis D. Bensard M.D., Richard J. Hendrickson M.D.
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.
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congenital diaphragmatic hernia honeymoon period,Queries 5
Queries 3
Properties In Evaluation Of The Acute Abdomen
14 PRIORITIES IN EVALUATION OF THE ACUTE ABDOMEN
Alden H. Harken M.D.
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
Surgical Infectious Disease. Prophylaxis
PROPHYLAXIS
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.
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Gastroesophageal Reflux Disease
43 GASTROESOPHAGEAL REFLUX DISEASE
Michael E. Fenoglio M.D., Lawrence W. Norton M.D.
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.
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Acute Large Bowel Obstruction
49 ACUTE LARGE BOWEL OBSTRUCTION
Elizabeth C. Brew M.D.
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.
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gastrografin enema detorsion of sigmoid volvulus,Top 100 Secrets
These secrets are 100 of the top board alerts. They summarize the concepts, principles, and most salient details of surgical practice.
- 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. - 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. - The most common location of an undescended testicle is the
inguinal canal. - The most common solid renal mass in infancy is a congenital
mesoblastic nephroma and in childhood a Wilms’ tumor. - Ogilvie’s syndrome is acute massive dilatation of the cecum
and the ascending and transverse colon without organic obstruction. - The best screening method for prostate cancer is digital
rectal exam combined with serum prostate-specific antigen. - The most common histologic type of bladder cancer is
transitional cell carcinoma. - Carcinoma in situ of the bladder is treated with
immunotherapy with intravesical bacillus Calmette-Guérin. - Localized renal cell carcinoma is treated with surgery
(radical nephrectomy). - The most common cause of male infertility is varicocele.
- The most common nonbacterial cause of pneumonia in
transplant patients is cytomegalovirus. - 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. - OKT3 is a mouse monoclonal antibody that binds to and
blocks the T-cell CD3 receptor. - The most common disease requiring liver transplant is
hepatitis C. - 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. - 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%. - The most feared complication of diaphragmatic hernia is
persistent fetal circulation. - 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. - 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. - 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. - A solitary pulmonary nodule is < 3 cm and is discrete on
chest radiograph. It is usually surrounded by lung parenchyma. - 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. - The most common causes of aortic stenosis are now
congenital anomalies and calcific (degenerative) disease. - 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. - 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. - 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. - The surgical treatment of ulcerative colitis is total
colectomy with ileoanal pouch anastomosis. - 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. - 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. - 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. - Patients with colorectal cancer with lymph node involvement
(Dukes’ C) should receive chemotherapy postoperatively to treat
micrometastases. - 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. - 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. - 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. - The two surgical options for Graves’ disease are subtotal
thyroidectomy or near-total thyroidectomy. - The only biochemical test that is routinely needed to
identify patients with unsuspected hyperthyroidism is serum
thyroid-stimulating hormone concentration. - The surgically correctable causes of hypertension are
renovascular hypertension, pheochromocytoma, Cushing’s syndrome,
primary hyperaldosteronism, coarctation of the aorta, and unilateral
renal parenchymal disease. - The “triple negative test” or “diagnostic triad” for
diagnosing a palpable breast mass includes physical examination, breast
imaging, and biopsy. - 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. - Sentinel lymph nodes are the first stop for tumor cells
metastasizing through lymphatics from the primary tumor. - 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. - 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. - 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. - 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. - The microorganisms implicated in atherosclerosis include Chlamydia
pneumoniae, Helicobacter pylori, streptococci, and Bacillus
typhosus. - The cumulative 10-year amputation rate for claudication is
10%. - 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%). - Abdominal aortic aneurysm’s average expansion rate is 0.4
cm/year. - Heparin binds to antithrombin III, rendering it more
active. - The patient with suspected intermittent claudication should
initially be evaluated by obtaining ankle brachial index or segmental
limb pressures at rest. - Shock is suboptimal consumption of O2 and
excretion of CO2 at the cellular level. - Nitric oxide is synthesized in vascular endothelial cells
by constitutive nitric oxide synthase and inducible NOS, using arginine
as the substrate. - Saliva has the hightest potassium concentration (20 mEq),
followed by gastric secretions (10 mEq), then pancreatic and duodenal
secretions (5 mEq). - Basal caloric expenditure = 25 kcal/kg/day with a
requirement of approximately 1 g protein/kg/day. - 6.25 g of protein contains 1 g of nitrogen.
- Dextrose has 3.4 kcal/g, protein 4 kcal/g, fat 9 kcal/g
(20% lipid solution delivers 2 kcal/mL). - Maximal glucose infusion rates in parenteral formulas
should not exceed 5 mg/kg/min. - 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. - 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. - 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. - Cardiac output = heart rate x stroke volume; normal CO is
5-6 L/min. - SVR = [(MAP - CVP)/CO] x 80; normal SVR is 800-1200
dyne.sec/cm-5. - Hypovolemic shock: low CVP and PCWP, low CO and SVO2,
high SVR. - Cardiogenic shock: high CVP and PCWP, low CO and SVO2,
variable SVR. - Septic shock: low or normal CVP and PCWP, high CO
initially, high SVO2, low SVR. - 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. - Rebound tenderness implies peritoneal inflammation and
irritation not simply abdominal tenderness. - The 5 Ws of post-operative fever are wound
(infection), water (UTI), wind (atelectasis,
pneumonia), walking (thrombophlebitis), and wonder
drugs (drug fevers). - Cricothyroidotomy should not be performed in
patients < 12 years old or any patient with suspected direct
laryngeal trauma or tracheal disruption. - The radial (wrist) pulse estimates SBP > 80 mmHg;
femoral (groin) pulse estimates SBP > 70 mmHg; and carotid (neck)
pulse estimates SBP > 60 mmHg. - A general rule for crystalloid infusion to replace blood
loss is a 3:1 ratio of isotonic crystalloid to blood. - Raccoon eyes (periorbital ecchymosis) and Battle’s sign
(mastoid ecchymosis) are clinical indicators of basilar skull fracture. - 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. - Violation of the platysma defines a penetrating neck wound.
- 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. - The most common site of thoracic aortic injury in blunt
trauma is just distal to the take-off of the left subclavian artery. - The most common manifestation of blunt myocardial injury is
arrhythmia. - 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. - Beck’s triad is hypotension, distended neck veins, and
muffled heart sounds. - 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%. - The Pringle maneuver is a manual occlusion of the
hepatoduodenal ligament to interrupt blood flow to the liver. - Splenectomy significantly decreases IgM levels.
- 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). - Intraperitoneal bladder rupture from blunt trauma:
operative management; extraperitoneal rupture: observant management. - 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). - 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. - Posterior knee dislocations are associated with popliteal
artery injuries and are an indication for angiography. - 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. - 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. - The metabolic rate peaks at 2.5 times the basal metabolic
rate in severe burns > 50% TBSA. - Gallstones and alcohol abuse are the two main causes of
acute pancreatitis. - Alcohol abuse accounts for 75% of cases of chronic
pancreatitis. - Isolated gastric varices and hypersplenism indicate splenic
vein thrombosis and are an indication for splenectomy. - The treatment for gallstone pancreatitis is cholecystectomy
and intraoperative cholangiogram during the same hospital stay once the
pancreatitis has subsided. - Proton pump inhibitors irreversibly inhibit the parietal
cell hydrogen ion pump. - Definitive treatment of alkaline reflux gastritis after a
Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm
efferent jejunal limb. - 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. - Curling’s ulcer is a stress ulcer found in critically ill
patients with burn injuries. - Marginal ulcer is an ulcer found near the margin of
gastroenteric anastomosis, usually on the small bowel side. - The most common cause of small bowel obstructions is
adhesive disease; the second most common cause is hernias.
Small Bowel Obstruction
46 SMALL BOWEL OBSTRUCTION
Joyce A. Majure M.D.
1. Name three mechanisms of bowel obstruction, and give examples and incidence of each type.
Show answer
1. Extrinsic compression: adhesions (60%), malignancy (20%), hernias (10%), volvulus, and others (5%)
2. Internal blockage of the lumen by abnormal materials (obturation): bezoars, gallstone, worms, or foreign body (usually obstructs at the ileocecal valve)
3. Mural disease encroaching on the lumen (inflammatory bowel disease [5%]), fibrous stricture secondary to trauma, ischemia, or radiation, intussusception)
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partial small bowel obstruction sbo my story, baker tube small bowel, current management of small bowel obstruction, how long should oral gastrografin take to pass into colon, sbo and low urine output, small bowel obstruction-uti, urinary sbo,Penetrating Thoracic Trauma
22 PENETRATING THORACIC TRAUMA
Jeffrey L. Johnson M.D., Ernest E. Moore M.D.
1. How often do patients with penetrating chest wounds need an operation?
Show answer
Surprisingly rarely. Most civilian penetrating injuries are from knives and low-energy handguns. Consequently, although injuries to the chest wall and lung are common, the majority of patients can be treated with tube thoracostomy alone. Formal thoracotomy or median sternotomy is required in < 15% of isolated penetrating chest injuries.
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www answers com trauma diaphragm,Surgical Wound Infection
13 SURGICAL WOUND INFECTION
Steven L. Peterson D.V.M., M.D.
1. Why should we worry about surgical wound infection?
Show answer
Approximately 30 million patients undergo surgery each year in the United States, and 20% of these patients acquire at least one nosocomial infection in the postoperative period. Infections at surgical sites are the third most common form of these infections and complicate 1-12% of all operations. The risk of death is four times higher in patients who develop wound infections, and each infection costs $12,000-30,000 to treat.
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abdominal wound infection overview, define wound evisceration, how to clean a surgical wound spillage, http://www acssurgery com/abstracts/acs/acs0102 htm, iv antibiotic duration deep wound infection, list of common incisional wound infections, nutritional status and ssis, what steps can be taken to prevent wound infection and dehiscence, when does dehiscenceoccur, when should an infected laparotomy wound be reopened and cleaned?,Pediatric Urology
99 PEDIATRIC UROLOGY
Kirstan K. Meldrum M.D., Mark P. Cain M.D.
1. A healthy 3-year-old girl develops a urinary tract infection (UTI). How should she be evaluated?
Show answer
After treatment of the infection, the patient should undergo a urinary tract evaluation (this recommendation stands even in a little girl after only one UTI). Evaluation includes a renal-bladder sonogram and voiding cystourethrogram (VCUG). Approximately 50% of children younger than age 12 years who present with a UTI are found to have abnormalities of the genitourinary tract. The most common abnormalities identified are vesicoureteral reflux, obstructive uropathies, and neurogenic bladder.
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Incoming search terms
aua guidelines undescended testes, aua pediatric vesicoureteral reflux guidelines, aua update series, bladder outlet obstruction oligohydramnios pulmonary hypoplasia and undescended testes, cah and solitary kidney, cryptorchidism vur, duplicated sistem ecopic ureter and uretro cele, gearhart jp rink rc mouriquand pde, hemihypertrophy physicians, hydronephrosis children 50 percent, hypoplastic testicle surgery, peripelvic fibrosis poppas, position of ureteral orifice, prenatal ultrasound diagnosis of posterior urethral valve, treatment of vur in neurogenic bladder medline search, upj resolves spontaneously, what is a v u r disease, what is the most common solid renal mass in infancy,Spinal Cord Injuries
19 SPINAL CORD INJURIES
J. Paul Elliott M.D., Sanjay Misra M.D.
1. What is the difference between a spinal injury and a spinal cord injury?
Show answer
Spinal injuries include damage to the bone, disc, or ligaments. These injuries sometimes result in spinal instability. They also may be associated with spinal cord injury, which is damage to the neural tissue, often with clinical deficit. It is crucial to determine whether there is (1) a spinal injury, (2) a spinal cord injury, and (3) spinal instability.
2. Describe the evaluation of a patient with a suspected spine injury.
Show answer
First, be sure that the patient is adequately immobilized and everyone knows to maintain spinal precautions. Second, inspect and palpate the spine for external trauma and step-off. Finally, do a complete neurologic examination including all four extremities. Assess strength, sensation (light touch/proprioception and pain/temperature), muscle tone, reflexes, and rectal tone. Carefully document your results.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
