Surgical basics

• Peritoneum = a continuous membrane that lines the abdominal cavity and covers the abdominal organs

  Supports the viscera and provides pathways for blood vessels and lymph to travel to and from
• Types of peritoneum:

  • Parietal = attaches to the abdominal and pelvic walls
  • Visceral = wraps around abdominal organs e.g. stomach, liver and spleen
  • Mesentery = a double layer of peritoneum, attaches organs e.g. intestine to the abdominal wall and holds it in place
• Retroperitoneal organs = SAD PUCKER

  Suprarenal (adrenal) glands

  Aorta/IVC

  Duodenum (second and third part)

  Pancreas (except tail)

  Ureters

  Colon (ascending and descending)

  Kidneys

  (o)esophagus

  Rectum
• Omentum:

  • A fold of peritoneum
  • 2 omentums = greater and lesser
  • Greater = a fold of peritoneum that starts at the greater curvature of the stomach, hangs down like an apron over the intestines before folding up and attaching to the transverse colon
  • Lesser = hangs down from the liver to lesser curvature of the stomach. Creates potential space where fluid can collect.
• Functions of omentum:

  ·       Fat deposition

  ·      Immune contributions (collection of macrophages)

  ·       Infection and wound isolation – seals off area of infection or trauma
• Right hypochondrium pathology:

  ·       Basal pneumonia

  ·       Hepatitis

  ·       Biliary colic

  ·       Cholecystitis

  ·       Cholangitis
• Epigastrium pathology:

  ·       Oesophagitis/gastritis

  ·       PUD

  ·       Acute pancreatitis (radiates to back)

  ·       MI – inferior

  ·       AAA
• Left hypochondrium pathology:

  • Basal pneumonia
  • Ruptured spleen
• Flank pathology:

  • Pyelonephritis
  • Renal/ureteric colic
  • Renal infarct
• Umbilical pathology:

  ·       AAA

  ·       Acute pancreatitis

  ·       Gastroenteritis

  ·       Bowel obstruction

  ·       Ischaemic bowel

  ·       Testicular torsion

  ·       Early appendicitis
• RIF pathology:

  ·       Appendicitis

  ·       Mesenteric adenitis

  ·       Terminal ileitis

  ·       Crohn’s disease – ileitis

  ·       Perforated caecal carcinoma

  ·       Renal/ureteric colic

  ·       Ovarian cyst rupture/haemorrhage/torsion

  ·       Ectopic pregnancy

  ·       Salpingitis – inflammation of fallopian tubes

  ·       Testicular torsion
• Suprapubic pathology:

  ·       Cystitis/UTI

  ·       Urinary retention

  ·       Uterine fibroid
• LIF pathology:

  ·       Diverticulitis

  ·       Constipation

  ·       Renal/ureteric colic

  ·       Sigmoid volvulus

  ·       Colitis (ischaemic, infective, ulcerative)

  ·       Ovarian cyst rupture/haemorrhage/torsion

  ·       Ectopic pregnancy

  ·       Salpingitis

  ·       Testicular torsion
• Acute abdomen = sudden, severe abdominal pain that may require urgent treatment
• Surgical history:

  1. Introduction
  2. History of presenting complaint - SOCRATES (surgical pathology suggested by sudden onset abdominal pain)
  3. Past medical hx (diabetes important if making NBM)
  4. Past surgical history -including do they still have their appendix
  5. Drugs and allergies e.g. anticoagulants
  6. Social hx - including when did they last eat
  7. Family hx
• Surgical exam:

  Inspection:

  • Surgical scars, stomas, distension
  • Periumbilical ecchymosis = Cullen's sign
  • Flank ecchymosis = Grey turner sign

  Signs of peritonism

  Specific signs:

  • Troisier's sign
  • Rovsing's sign
  • Murphy's sign
• Peritonitis:

  • Inflammation of the peritoneum which suggests acute abdominal pathology that should be rapidly diagnosed and treated
  • Causes somatic pain all over the abdomen
• Causes of peritonitis:

  · Bacterial e.g. perforation of a viscus (appendix, diverticula) and resultant leak of intestinal contents/bacteria from GI tract into peritoneum

  · Chemical causes e.g. inflammation caused by a chemical reaction from exposure to body fluids e.g. bile, pancreatic fluid, urine and blood
• Signs of peritonitis:

  ·       Ask patient to blow up tummy like a balloon and then suck their tummy in – good way of detecting peritonitis with minimal discomfort for the patient

  ·       Percussion tenderness

  ·       Rebound tenderness – if only organ affected, palpation will hurt more than letting go
• Guarding:

  -          Voluntary contraction of the abdominal wall musculature by the patient to avoid pain

  -          Can often be overcome by having the patient purposely relax the muscles
• Rigid abdomen:

  -          Involuntary tightening of the abdominal musculature that occurs in response to underlying inflammation

  -          Cannot be overcome

  -          Is a sign of peritoneal inflammation
• Peritonitis bed side tests:

  ·       Urine dipstick – infection and haematuria. Pregnancy test for women of reproductive age.

  ·       ABG – if bleeding or acutely unwell can give a quick haemoglobin level, and show metabolic acidosis (tissue hypoperfusion)

  ·       ECG – part of pre-operative work up and also rules out referred MI pain
• Peritonitis lab tests:

  ·       FBC

  ·       CRP

  ·       U&Es

  ·       LFTs

  ·       Coagulation

  ·       Amylase

  ·       Group and save

  ·       Crossmatch if blood products or urgent surgery required
• LFTs:

  • Problem with liver = raised ALT and AST, usually ALT raised more than AST, except in alcoholic liver disease
  • Problem with biliary system = ALP and GGT will be raised (induces release of GGT)
  • Alcohol can also raise GGT - induces production
  • Problem with pancreas = amylase and lipase will be raised (lipase more specific, amylase more sensitive)
• Group and save:

  • Determines patient blood group, rhesus status and screens for atypical antibodies
• Acute abdomen imaging:

  • Erect CXR - looks for free air under diaphragm, patient needs to be sat up for >10 minutes beforehand. Also rules out lower lung pathology.
  • AXR - not used routinely. Can demonstrate characteristic signs of small or large bowel obstruction.
  • USS - most useful to assess renal tract (hydronephrosis), biliary tree and liver, and uterus
  • CT abdomen and pelvis - most useful in assessing pathology in GI tract such as bowel perforation
• Bowel obstruction 3/6/9 rule:

  • Small bowel - 3cm
  • Colon - 6cm
  • Caecum - 9cm
• Small bowel obstruction:

  ·       Dilated >3cm

  ·       Valvulae conniventes creating a coiled spring/stacked coin appearance

  ·       Central within the abdomen
• Large bowel obstruction:

  ·       Dilated >6cm

  ·       Haustral lines visible (lines not completely crossing bowel, indents that go halfway)

  ·       Peripheral

  ·       May also have signs of small bowel obstruction depending on competence of ileocaecal valve
• Gastrointestinal perforation:

  ·       Can occur at any point in alimentary canal from upper oesophagus to anorectal junction

  ·       Multiple possible causes:

  -          UGI: PUD, gastric or oesophageal Ca

  -          LGI: diverticulitis, colorectal Ca, appendicitis, severe IBD, toxic megacolon

  -          Any part: iatrogenic, trauma and ischaemia
• Clinical features of GI perforation:

  ·       Acute abdominal pain

  ·       Peritonism (rigid abdomen) due to bowel contents leaking out from perforation and irritating peritoneal lining

  ·       Absent bowel sounds

  ·       Systemically unwell/sepsis
• Management of GI perforation:

  • Resuscitation - fluids
  • Antibiotics
  • Analgesia
  • NBM
  • Urgent referral to surgeons
• Red = Kocher's - open cholecystectomy

  Grey = Mercedes Benz - same as rooftop but mostly seen in liver transplant

  Green = rooftop - oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resection or liver transplant

  Purple = midline laparotomy - emergency

  Orange = Lanz - open appendectomy

  Blue = Pfannenstiel's incision - caesarean sections, ovarian operations, access to bladder and prostate

  
  

  Name each scar in this picture

  
• Aneurysm = persistent, abnormal dilation of an artery above 1.5 times its normal diameter
• Causes of aneurysms:

  • largely unknown
  • Atherosclerosis
  • Trauma
  • Infection
  • Connective tissue disease
  • Inflammatory disease e.g. Takayasu's aortitis
• Aneurysm risk factors:

  • Abdominal aorta
  • Cerebral
  • Peripheral arteries
  • Visceral arteries
• Abdominal aorta bifurcates at L4 and branches to supply the pelvis (via internal iliac), buttocks and legs (via external iliac)

  • Common iliac
  • External iliac
  • Femoral (groin)
  • Popliteal (knee)
  • Tibial (calf)
  • Pedal (foot)
• Peripheral arteries aneurysms:

  • Popliteal artery most common site
  • Femoral artery
• Femoral artery aneurysm:

  • Usually pseudoaneurysm/false aneurysm from injury e.g. puncture following cardiac catheterisation or IV drug use
  • False aneurysm = damage to arterial wall resulting in blood accumulating between tunica media and tunica adventitia of the artery
• Visceral artery aneurysm:

  • Splenic artery most common site
  • Hepatic artery
  • Renal artery