Bab Terakir
Bab Terakir
Bab Terakir
1. Basal cell carcinoma (75%) 2. Squamous cell carcinoma (20%) 3. Melanoma (4%)
What is the most common fatal skin cancer?
Melanoma
What is malignant melanoma? A redundancy! All melanomas are
considered malignant!
SQUAMOUS CELL CARCINOMA
What is it? Carcinoma arising from epidermal cells
What are the most common sites?
Head, neck, and hands
What are the risk factors? Sun exposure, pale skin, chronic
in ammatory process, immunosuppression, xeroderma pigmentosum, arsenic
What is a precursor skin lesion? Actinic keratosis
478 Section II / General Surgery
What are the signs/symptoms? Raised, slightly pigmented skin lesion;
ulceration/exudate; chronic scab; itching
How is the diagnosis made? Small lesionexcisional biopsy
Large lesionsincisional biopsy
What is the treatment? Small lesion (, 1 cm): Excise with 0.5-cm
margin Large lesion ( 1 cm): Resect with 1- to
2-cm margins of normal tissue (large lesions may require skin gra / ap)
What is the dreaded sign of metastasis?
Palpable lymph nodes (remove involved lymph node basin)
What is Marjolins ulcer? Squamous cell carcinoma that arises in an area of chronic in ammation
(e.g., chronic
noninvasive Least aggressive type; very good prognosis Accounts for 10% of all melanomas
Acral lentiginous melanoma Occurs on the palms, soles, subungual
areas, and mucous membranes Accounts for 5% of all melanomas (most common melanoma in
African American patients; 50%)
Nodular melanoma Vertical growth predominates
Lesions are usually dark Most aggressive type/worst prognosis Accounts for 15% of all
melanomas
Amelanotic melanoma Melanoma from melanocytes but with
obvious lack of pigment
What is the most common type of melanoma?
Super cial spreading ( 75%) (T ink: SUPER cial SUPERior)
482 Section II / General Surgery
What type of melanoma arises in Hutchinsons freckle?
Lentigo maligna melanoma
What is Hutchinsons freckle? Lentigo maligna melanoma in the radial growth phase without
vertical extension (noninvasive); usually occurs on the faces of elderly women
STAGING
What are the American Joint Committee on Cancer (AJCC) stages simpli ed:
IA? 1 mm without ulceration
IB? 1 mm with ulceration or 12 mm
without ulceration
IIA? 12 mm with ulceration or 24 mm
without ulceration
IIB? 24 mm with ulceration or 4 mm
without ulceration
IIC? 4 mm with ulceration
; simply, the O
2
Sv
2
(low with inadequate delivery), lactic acid (elevated with inadequate delivery), pH
(acidosis with inadequate delivery), base de cit
What is FENa? Fractional Excretion of Sodium (Na ): (U
Na
) 100
What is the memory aid for calculating FENa?
P
cr
/P
Na
U
cr
T ink: YOU NEED PEE U (Urine) N (Na ) P (Plasma); U
Na
; for the denominator, switch everything, P
Na
P
cr
(cr creatinine)
What is the prerenal FENa value?
U
cr
1.0; renal failure from decreased renal blood ow (e.g., cardiogenic, hypovolemia, arterial
obstruction, etc.)
LAB VALUES ACUTE RENAL FAILURE
BUN:Cr:
Prerenal? 20:1
Renal ATN? 20:1
FENa:
Prerenal? 1
Renal ATN? 1
Chapter 65 / Surgical Intensive Care 489
Urine osmolality:
Prerenal? 500
Renal ATN? 350
Urine Na1 :
Prerenal? 20
Renal ATN? 40
Urine SG (Speci c Gravity):
Prerenal? 1.020
How long does Lasix e ect last?
6 hours LASIX LAsts SIX hours
What is the formula for ow/ pressure/resistance?
Remember Power FoRward: Pressure Flow Resistance
What is the 10 for 0.08 rule of acid-base?
For every increase of Pa
2
by 10 mm Hg, the pH falls by 0.08
What is the 40, 50, 60 for 70, 80, 90 rule for O
2
PaO
2
of 40, 50, 60 corresponds roughly to sats?
an O
2
sat of 70, 80, 90, respectively
One liter of O
2
via nasal cannula raises Fi
2
3%
What is pure respiratory acidosis?
by how much?
Low pH (acidosis), increased Pa
2
, normal bicarbonate
What is pure respiratory alkalosis?
High pH (alkalosis), decreased Pa
2
, normal bicarbonate
What is pure metabolic acidosis?
1
agonist; marked a erload increase from arteriolar vasoconstriction
Has renal dose dopamine been shown to decrease renal failure?
1
NO
Dobutamine What is the site of action?
1
agonist,
2
What is the e ect? c inotropy; c chronotropy, decrease in
systemic vascular resistance
Isoproterenol What is the site of action?
1
and
2
agonist
What is the e ect? c inotropy; c chronotropy; ( vasodilation
of skeletal and mesenteric vascular beds)
Epinephrine (EPI) What is the site of action?
1
,
2
,
1
, and
2
agonist
Chapter 65 / Surgical Intensive Care 491
What is the e ect? c inotropy; c chronotropy
What is the e ect at high doses? Vasoconstriction
Norepinephrine (NE) What is the site of action?
1
,
2
,
1
, and
1
agonist
What is the e ect? c inotropy; c chronotropy; increase in
blood pressure
What is the e ect at high doses? Severe vasoconstriction
Vasopressin What is the action? Vasoconstriction (increases MAP, SVR)
What are the indications? Hypotension, especially refractory
to other vasopressors (low-dose infusion0.010.04 units per minute) or as a bolus during
ACLS (40 u)
Nitroglycerine (NTG) What is the site of action? venodilation; arteriolar dilation
What is the e ect? Increased venous capacitance, decreased
preload, coronary arteriole vasodilation
Sodium Nitroprusside (SNP) What is the site of action? venodilation; arteriolar
dilation
What is the e ect? Decreased preload and a erload
(allowing blood pressure titration)
What is the major toxicity of SNP?
Cyanide toxicity
INTENSIVE CARE PHYSIOLOGY
De ne the following terms:
Preload Load on the heart muscle that stretches
it to end-diastolic volume (end-diastolic pressure) intravascular volume
492 Section II / General Surgery
A erload Load or resistance the heart must pump
against vascular tone SVR
Contractility Force of heart muscle contraction
Compliance Distensibility of heart by the preload
What is the Frank-Starling curve?
Cardiac output increases with increasing preload up to a point
What is the clinical signi cance of the steep slope of the Starling curve relating end-diastolic
volume to cardiac output?
Demonstrates the importance of preload in determining cardiac output
What factors in uence the oxygen content of whole blood?
Oxygen content is composed largely of that oxygen bound to hemoglobin, and is thus determined
by the hemoglobin concentration and the arterial oxygen saturation; the partial pressure of
oxygen dissolved in plasma plays a minor role
What factors in uence mixed venous oxygen saturation?
Oxygen delivery (hemoglobin concentration, arterial oxygen saturation, cardiac output) and
oxygen extraction by the peripheral tissues
What lab test for tissue ischemia is based on the shi from aerobic to anaerobic metabolism?
Serum lactic acid levels
De ne the following terms:
Dead space T at part of the inspired air that does not
participate in gas exchange (e.g., the gas in the large airways/E tube not in contact with
capillaries) T ink: space air
Shunt fraction T at fraction of pulmonary venous blood
that does not participate in gas exchange T ink: shunt blood
Chapter 65 / Surgical Intensive Care 493
What causes increased dead space?
Overventilation (emphysema, excessive PEEP) or underperfusion (pulmonary embolus, low
cardiac output, pulmonary artery vasoconstriction)
At high shunt fractions, what is the e ect of increasing Fi
2
At high shunt fractions ( 50%), changes
arterial P
2
?
on
in Fi
2
have almost no e ect on arterial P
2
because the blood that does see the O
2
is already at maximal O
2
absorption; thus, increasing the Fi
2
has no e ect (Fi
2
can be minimized to prevent oxygen toxicity)
De ne ARDS Acute Respiratory Distress Syndrome: lung in ammation causing respiratory failure
What is the ARDS diagnostic triad?
A CXR:
C: Capillary wedge pressure 18 X: X-ray of chest with bilateral
in ltrates R: Ratio of Pa
2
to Fi
2
300 (AKA P/F Ratio)
De ne ARDS:
Mild? P/F ratio 200300
Moderate? P/F ratio 100200
Severe? P/F ratio 100
What does the classic chest x-ray look like with ARDS?
Bilateral u y in ltrates
How can you remember the Pa
2
T to Fi
2
, or PF, ratio?
ink: PUFF ratio: PF ratio Pa
2
: Fi
2
ratio
At what concentration does O
2
of toxicity occur?
Fi
2
60% 48 hours; thus, try to keep Fi
2
below 60% at all times
What are the ONLY ventilatory parameters that have been shown to decrease mortality in
ARDS patients?
Low tidal volumes ( 6 cc/kg) and low plateau pressures 30
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What are the main causes of carbon dioxide retention?
Hypoventilation, increased dead space ventilation, and increased carbon dioxide production (as
in hypermetabolic states)
Why are carbohydrates minimized in the diet/TPN of patients having di culty with
hypercapnia?
Respiratory uotient (R ) is the ratio of CO
2
of 150; O
2
sats do not tell you anything about the P
2
(key point!)
What can increase P
2 (oxygenation) in the ventilated patient?
Increased Fi
2 Increased PEEP
What can decrease P
2
in the ventilated patient?
Increased RR Increased tidal volume (i.e., increase
minute ventilation)
De ne the following modes:
IMV Intermittent Mandatory Ventilation: mode
with intermittent mandatory ventilations at a predetermined rate; patients can also breathe on
their own above the mandatory rate without help from the ventilator
SIMV Synchronous IMV: mode of IMV
that delivers the mandatory breath synchronously with patients initiated e ort; if no breath is
initiated, the ventilator delivers the predetermined mandatory breath
A-C Assist-Control ventilation: mode in which
the ventilator delivers a breath when the patient initiates a breath, or the ventilator assists the
patient to breathe; if the patient does not initiate a breath, the ventilator takes control and
delivers a breath at a predetermined rate
CPAP Continuous Positive Airway Pressure:
positive pressure delivered continuously (during expiration and inspiration) by ventilator, but no
volume breaths (patient breathes on own)
Chapter 65 / Surgical Intensive Care 497
Pressure support Pressure is delivered only with an initiated
breath; pressure support decreases the work of breathing by overcoming the resistance in the
ventilator circuit
APRV Airway Pressure Release Ventilation: high airway pressure intermittently released to a low
airway pressure (shorter period of time)
HFV High Frequency Ventilation: rapid rates of
ventilation with small tidal volumes
What are the e ects of positive pressure ventilation in a patient with hypovolemia or low
lung compliance?
Venous return and cardiac output are decreased
De ne PEEP Positive End Expiration Pressure:
positive pressure maintained at the end of a breath; keeps alveoli open
What is physiologic PEEP? PEEP of 5 cm H
2
O; thought to approximate normal pressure in normal nonintubated
people caused by the closed glottis
What are the side e ects of increasing levels of PEEP?
Barotrauma (injury to airway pneumothorax), decreased CO from decreased preload
What are the typical initial ventilator settings:
Mode? Synchronous Intermittent mandatory
ventilation
Tidal volume? 68 ml/kg
Ventilator rate? 10 breaths/min
Fi
2
? 100% and wean down
498 Section II / General Surgery
PEEP? 5 cm H
2
O From these parameters, change
according to blood-gas analysis
What is a normal I:E (inspiratory to expiratory time)?
1:2
When would you use an inverse I:E ratio (e.g., 2:1, 3:1, etc.)?
o allow for longer inspiration in patients with poor compliance, to allow for alveolar
recruitment
When would you use a pro- longed I:E ratio (e.g., 1:4)?
COPD, to allow time for complete exhalation (prevents breath stacking)
What clinical situations cause increased airway resistance?
Airway or endotracheal tube obstruction, bronchospasm, ARDS, mucous plug, CHF (pulmonary
edema)
What are the presumed advantages of PEEP?
Prevention of alveolar collapse and atelectasis, improved gas exchange, increased pulmonary
compliance, decreased shunt fraction
What are the possible disadvantages of PEEP?
Decreased cardiac output, especially in the setting of hypovolemia; decreased gas exchange; T
compliance with high levels of PEEP, uid retention, increased intracranial pressure, barotrauma
What parameters must be evaluated in deciding if a patient is ready to be extubated?
Patient alert and able to protect airway, gas exchange (Pa
2
70, Pa
2
50), tidal volume ( 5 cc/kg), minute
ventilation ( 10 L/min), negative inspiratory pressure ( 20 cm H
2
O, or more negative), Fi
2
40%, PEEP 5, PH 7.25, RR 35, obin index 105
What is the Rapid-Shallow Breathing (a.k.a. Tobin) index?
Rate: Tidal volume ratio; obin index
105 is associated with successful extubation (T ink: Respiratory Therapist RT Rate: Tidal
volume)
Chapter 66 / Vascular Surgery 499
What is a possible source of fever in a patient with an NG or nasal endotracheal tube?
Sinusitis (diagnosed by sinus lms/C )
What is the 35 45 rule of blood gas values?
Normal values:
pH 7.35 7.45 P
2
35 45
Which medications can be delivered via an endotracheal tube?
T ink NAVEL:
Narcan Atropine Vasopressin Epinephrine Lidocaine
What conditions should you think of with c peak airway pressure and T urine output?
1. ension pneumothorax 2. Abdominal compartment syndrome
0
5
H
1. Aorta 2. Internal iliac (hypogastric) 3. External iliac 4. Common femoral artery 5. Profundi
femoral artery 6. Super cial femoral artery (SFA) 7. Popliteal artery 8. rifurcation 9. Anterior
tibial artery 10. Peroneal artery 11. Posterior tibial artery 12. Dorsalis pedis artery
R
F
0
502 Section II / General Surgery
How can you remember the orientation of the lower exterior arteries below the knee on Agram?
Use the acronym LAMP:
Lateral Anterior tibial Medial Posterior tibial
What is peripheral vascular disease (PVD)?
Occlusive atherosclerotic disease in the lower extremities
What is the most common site of arterial atherosclerotic occlusion in the lower extremities?
Occlusion of the SFA in Hunters canal
What are the symptoms of PVD?
Intermittent claudication, rest pain, erectile dysfunction, sensorimotor impairment, tissue loss
What is intermittent claudication?
Pain, cramping, or both of the lower extremity, usually the calf muscle, a er walking a speci c
distance; then the pain/ cramping resolves a er stopping for a speci c amount of time while
standing; this pattern is reproducible
What is rest pain? Pain in the foot, usually over the distal
metatarsals; this pain arises at rest (classically at night, awakening the patient)
What classically resolves rest pain?
Hanging the foot over the side of the bed or standing; gravity a ords some extra ow to the
ischemic areas
How can vascular causes of claudication be di erentiated from nonvascular causes, such as
neurogenic claudication or arthritis?
History (in the vast majority of patients) and noninvasive tests; remember, vascular claudication
appears a er a speci c distance and resolves a er a speci c time of rest while standing (not so with
most other forms of claudication)
What is the di erential diagnosis of lower extremity claudication?
Neurogenic (e.g., nerve entrapment/ discs), arthritis, coarctation of the aorta, popliteal artery
syndrome, chronic compartment syndrome, neuromas, anemia, diabetic neuropathy pain
Chapter 66 / Vascular Surgery 503
What are the signs of PVD? Absent pulses, bruits, muscular atrophy,
decreased hair growth, thick toenails, tissue necrosis/ulcers/infection
What is the site of a PVD ulcer vs. a venous stasis ulcer?
PVD arterial insu ciency ulcerusually
on the toes/foot Venous stasis ulcermedial malleolus
(ankle)
What is the ABI? Ankle to Brachial Index (ABI);
simply, the ratio of the systolic blood pressure at the ankle to the systolic blood pressure at the
arm (brachial artery) A:B; ankle pressure taken with Doppler; the ABI is noninvasive
What ABIs are associated with normals, claudicators, and rest pain?
Normal ABI 1.0 Claudicator ABI 0.6 Rest pain ABI 0.4
Who gets false ABI readings? Patients with calci ed arteries, especially
those with diabetes What are PVRs? Pulse Volume Recordings; pulse wave
forms are recorded from lower extremities representing volume of blood per heart beat at
sequential sites down leg Large wave form means good collateral
blood ow (Noninvasive using pressure cu s)
Prior to surgery for chronic PVD, what diagnostic test will every patient receive?
A-gram (arteriogram: dye in vessel and
x-rays) maps disease and allows for best treatment option (i.e., angioplasty vs. surgical bypass
vs. endarterectomy) Gold standard for diagnosing PVD
What is the bedside management of a patient with PVD?
1. Sheep skin (easy on the heels) 2. Foot cradle (keeps sheets/blankets o
the feet) 3. Skin lotion to avoid further cracks in
the skin that can go on to form a ssure and then an ulcer
504 Section II / General Surgery
What are the indications for surgical treatment in PVD?
Use the acronym STIR:
Severe claudication refractory to
conservative treatment that a ects quality of life/livelihood (e.g., cant work because of the
claudication) Tissue necrosis Infection Rest pain
What is the treatment of claudication?
For the vast majority, conservative treatment, including exercise, smoking cessation, treatment of
H N, diet, aspirin, with or without rental (pentoxifylline)
How can the medical conservative treatment for claudication be remembered?
Use the acronym PACE:
Pentoxifylline Aspirin Cessation of smoking Exercise How does aspirin work? Inhibits platelets
(inhibits cyclooxygenase
and platelet aggregation)
What is an in situ vein gra ? Saphenous vein is more or less le in place, all branches are
ligated, and the vein valves are broken with a small hook or cut out; a vein can also be used if
reversed so that the valves do not cause a problem
What type of gra is used for above-the-knee FEM-POP bypass?
Either vein or Gortex gra ; vein still has better patency
What type of gra is used for below-the-knee FEM-POP or FEM-DISTAL bypass?
Must use vein gra ; prosthetic gra s have a prohibitive thrombosis rate
What is DRY gangrene? Dry necrosis of tissue without signs of
infection (mummi ed tissue)
Bypass from the FEMoral artery to a DISTAL artery (peroneal artery, anterior tibial artery, or
posterior tibial artery)
Chapter 66 / Vascular Surgery 507
What is WET gangrene? Moist necrotic tissue with signs of
infection
What is blue toe syndrome? Intermittent painful blue toes (or ngers)
due to microemboli from a proximal arterial plaque
LOWER EXTREMITY AMPUTATIONS
What are the indications? Irreversible tissue ischemia (no hope for
revascularization bypass) and necrotic tissue, severe infection, severe pain with no bypassable
vessels, or if patient is not interested in a bypass procedure
Identify the level of the following amputations:
1. Above-the- nee Amputation (A A) 2. Below-the- nee Amputation (B A) 3. Symes amputation
4. ransmetatarsal amputation 5. oe amputation
What is a Ray amputation? Removal of toe and head of metatarsal
1
2
3
4
5
508 Section II / General Surgery
ACUTE ARTERIAL OCCLUSION
What is it? Acute occlusion of an artery, usually by
embolization; other causes include acute thrombosis of an atheromatous lesion, vascular trauma
What are the classic signs/ symptoms of acute arterial occlusion?
T e six Ps:
Pain Paralysis Pallor Paresthesia Polar (some say Poikilothermiayou
pick) Pulselessness (You must know these!)
What is the classic timing of pain with acute arterial occlusion from an embolus?
Acute onset; the patient can classically tell you exactly when and where it happened
What is the immediate preoperative management?
1. Anticoagulate with IV heparin (bolus
followed by constant infusion) 2. A-gram
What are the sources of emboli?
1. Heart85% (e.g., clot from AFib, clot
forming on dead muscle a er MI, endocarditis, myxoma) 2. Aneurysms 3. Atheromatous plaque
(atheroembolism)
What is the most common cause of embolus from the heart?
AFib
What is the most common site of arterial occlusion by an embolus?
Common femoral artery (SFA is the most common site of arterial occlusion from atherosclerosis)
What diagnostic studies are in order?
1. A-gram 2. ECG (looking for MI, AFib) 3. Echocardiogram ( ) looking for clot,
MI, valve vegetation
Chapter 66 / Vascular Surgery 509
What is the treatment? Surgical embolectomy via cutdown and
Fogarty balloon (bypass is reserved for embolectomy failure)
What is a Fogarty? Fogarty balloon cathetercatheter with a
balloon tip that can be in ated with saline; used for embolectomy
How is a Fogarty catheter used? Insinuate the catheter with the balloon
de ated past the embolus and then in ate the balloon and pull the catheter out; the balloon brings
the embolus with it
How many mm in diameter is a 12 French Fogarty catheter?
Simple: o get mm from French measurements, divide the French number by , or 3.14; thus, a 12
French catheter is 12/3 4 mm in diameter
What must be looked for postoperatively a er reperfusion of a limb?
Compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MI
What is compartment syndrome?
Leg (calf) is separated into compartments by very unyielding fascia; tissue swelling from
reperfusion can increase the intracompartmental pressure, resulting in decreased capillary ow,
ischemia, and myonecrosis; myonecrosis may occur a er the intracompartment pressure reaches
only 30 mm Hg
What are the signs/ symptoms of compartment syndrome?
Classic signs include pain, especially a er passive exing/extension of the foot, paralysis,
paresthesias, and pallor; pulses are present in most cases because systolic pressure is much
higher than the minimal 30 mm Hg needed for the syndrome!
Can a patient have a pulse and compartment syndrome?
YES!
How is the diagnosis made? History/suspicion, compartment pressure
measurement
510 Section II / General Surgery
What is the treatment of compartment syndrome?
reatment includes opening compartments via bilateral calf-incision fasciotomies of all four
compartments in the calf
ABDOMINAL AORTIC ANEURYSMS
What is it also known as? AAA, or triple A
What is it? Abnormal dilation of the abdominal
aorta ( 1.52 normal), forming a true aneurysm
What is the male to female ratio?
6:1
By far, who is at the highest risk?
White males
What is the common etiology? Believed to be atherosclerotic in 95% of
cases; 5% in ammatory
What is the most common site? Infrarenal (95%)
What is the incidence? 5% of all adults older than 60 years
of age
What percentage of patients with AAA have a peripheral arterial aneurysm?
20%
Chapter 66 / Vascular Surgery 511
What are the risk factors? Atherosclerosis, hypertension, smoking,
male gender, advanced age, connective tissue disease
What are the symptoms? Most AAAs are asymptomatic and
discovered during routine abdominal exam by primary care physicians; in the remainder,
symptoms range from vague epigastric discomfort to back and abdominal pain
AAAs o en have large mural thrombi, which result in a falsely reduced diameter because only the
patent lumen is visualized
What are the signs of AAA on AXR?
Calci cation in the aneurysm wall, best seen on lateral projection (a.k.a. eggshell calci cations)
What are the indications for surgical repair of AAA?
AAA 5.5 cm in diameter, if the patient is not an overwhelming high risk for surgery; also, rupture
of the AAA, any size AAA with rapid growth, symptoms/ embolization of plaque
What is the treatment? 1. Prosthetic gra placement, with
rewrapping of the native aneurysm adventitia around the prosthetic gra a er the thrombus is
removed; when rupture is strongly suspected, proceed to immediate laparotomy; there is no time
for diagnostic tests!
2. Endovascular repair
What is endovascular repair? Repair of the AAA by femoral catheter
placed stents
Chapter 66 / Vascular Surgery 513
Why wrap the gra in the native aorta?
o reduce the incidence of enterogra stula formation
What type of repair should be performed with AAA and iliacs severely occluded or iliac
aneurysm(s)?
Aortobi-iliac or aortobifemoral gra replacement (bifurcated gra )
What is the treatment if the patient has abdominal pain, pulsatile abdominal mass, and
hypotension?
ake the patient to the O.R. for emergent AAA repair
What is the treatment if the patient has known AAA and new onset of abdominal pain or
back pain?
C scan:
1. Leak S straight to OR 2. No leak S repair during next
elective slot
What is the mortality rate associated with the following types of AAA treatment:
Elective? Good; 4% operative mortality
Ruptured? 50% operative mortality
What is the leading cause of postoperative death in a patient undergoing elective AAA
treatment?
Myocardial infarction (MI)
What are the other etiologies of AAA?
In ammatory (connective tissue diseases), mycotic (a misnomer because most result from
bacteria, not fungi)
What is the mean normal abdominal aortic diameter?
2 cm
What are the possible operative complications?
MI, atheroembolism, declamping hypotension, acute renal failure (especially if aneurysm
involves the renal arteries), ureteral injury, hemorrhage
Why is colonic ischemia a concern in the repair of AAAs?
O en the IMA is sacri ced during surgery; if the collaterals are not adequate, the patient will have
colonic ischemia
514 Section II / General Surgery
What are the signs of colonic ischemia?
Heme-positive stool, or bright red blood per rectum (BRBPR), diarrhea, abdominal pain
What is the study of choice to diagnose colonic ischemia?
Colonoscopy
When is colonic ischemia seen postoperatively?
Usually in the rst week
What is the treatment of necrotic sigmoid colon from colonic ischemia?
f
'
0
2
What is an endovascular repair?
Placement of a stent proximal and distal to an AAA through a distant percutaneous access
(usually through the groin); less invasive; long-term results as good as open
CLASSIC INTRAOP QUESTIONS DURING AAA REPAIR
Which vein crosses the neck of the AAA proximally?
Renal vein (le )
What part of the small bowel crosses in front of the AAA?
Duodenum
Which large vein runs to the le of the AAA?
IMV
Which artery comes o the middle of the AAA and runs to the le ?
IMA
Which vein runs behind the RIGHT common iliac artery?
LEFT common iliac vein
Which renal vein is longer? Le
516 Section II / General Surgery
MESENTERIC ISCHEMIA
Chronic Mesenteric Ischemia What is it? Chronic intestinal ischemia from
long-term occlusion of the intestinal arteries; most commonly results from atherosclerosis;
usually in two or more arteries because of the extensive collaterals
What are the symptoms? Weight loss, postprandial abdominal pain, anxiety/fear of food because
of postprandial pain, heme occult,
diarrhea/vomiting
What is intestinal angina? Postprandial pain from gut ischemia
What are the signs? Abdominal bruit is commonly heard
How is the diagnosis made? A-gram, duplex, MRA
What supplies blood to the gut? 1. Celiac axis vessels
2. SMA 3. IMA
What is the classic nding on A-gram?
wo of the three mesenteric arteries are occluded, and there is atherosclerotic narrowing of the
third patent artery
What are the treatment options?
Bypass, endarterectomy, angioplasty, stenting
Acute Mesenteric Ischemia What is it? Acute onset of intestinal ischemia
What are the causes? 1. Emboli to a mesenteric vessel from
the heart 2. Acute thrombosis of long-standing atherosclerosis of mesenteric artery
What are the causes of emboli from the heart?
AFib, MI, cardiomyopathy, valve disease/endocarditis, mechanical heart valve
Chapter 66 / Vascular Surgery 517
What drug has been associated with acute intestinal ischemia?
Digitalis
To which intestinal artery do emboli preferentially go?
Superior Mesenteric Artery (SMA)
What are the signs/symptoms of acute mesenteric ischemia?
Severe painclassically pain out of proportion to physical exam, no peritoneal signs until
necrosis, vomiting/ diarrhea/hyperdefecation, heme stools
What is the classic triad of acute mesenteric ischemia?
1. Acute onset of pain 2. Vomiting, diarrhea, or both 3. History of AFib or heart disease
Amaurosis fugax emporary monocular blindness (curtain coming down): seen with
microemboli to retina; example of IA
TIA Transient Ischemic Attack: focal
neurologic de cit with resolution of all symptoms within 24 hours
RIND Reversible Ischemic Neurologic De cit:
transient neurologic impairment (without any lasting sequelae) lasting 24 to 72 hours
CVA CerebroVascular Accident (stroke):
neurologic de cit with permanent brain damage
What is the risk of a CVA in patients with TIA?
10% a year
Chapter 66 / Vascular Surgery 519
What is the noninvasive method of evaluating carotid disease?
Carotid ultrasound/Doppler: gives general location and degree of stenosis
What is the gold standard invasive method of evaluating carotid disease?
A-gram
What is the surgical treatment of carotid stenosis?
Carotid EndArterectomy (CEA): the removal of the diseased intima and media of the carotid
artery, o en performed with a shunt in place
What are the indications for CEA in the ASYMPTOMATIC patient?
Carotid artery stenosis 60% (greatest bene t is probably in patients with 80% stenosis)
What are the indications for CEA in the SYMPTOMATIC (CVA, TIA, RIND) patient?
Carotid stenosis 50%
Before performing a CEA in the symptomatic patient, what study other than the A-gram
should be performed?
Head C
In bilateral high-grade carotid stenosis, on which side should the CEA be performed in the
asymptomatic, right-handed patient?
Le CEA rst, to protect the dominant hemisphere and speech center
What is the dreaded complication a er a CEA?
Stroke (CVA)
What are the possible postoperative complications a er a CEA?
CVA, MI, hematoma, wound infection, hemorrhage, hypotension/hypertension, thrombosis,
vagus nerve injury (change in voice), hypoglossal nerve injury (tongue deviation toward side of
injury wheelbarrow e ect), intracranial hemorrhage
What is the mortality rate a er CEA?
1%
520 Section II / General Surgery
What is the perioperative stroke rate a er CEA?
Between 1% (asymptomatic patient) and 5% (symptomatic patient)
What is the postoperative medication?
Aspirin (inhibits platelets by inhibiting cyclo-oxygenase)
What is the most common cause of death during the early postoperative period a er a
CEA?
MI
De ne Hollenhorst plaque? Microemboli to retinal arterioles seen as
bright defects
CLASSIC CEA INTRAOP QUESTIONS
What thin muscle is cut right under the skin in the neck?
Platysma muscle
What are the extracranial branches of the internal carotid artery?
None
insu ciency from obstruction of the le subclavian artery or innominate proximal to the vertebral
artery branch point; ipsilateral arm movement causes increased blood ow demand, which is met
by retrograde ow from the vertebral artery, thereby stealing from the vertebrobasilar arteries
Which artery is most commonly occluded?
Le subclavian
522 Section II / General Surgery
What are the symptoms? Upper extremity claudication, syncopal
attacks, vertigo, confusion, dysarthria, blindness, ataxia
What are the signs? Upper extremity blood pressure
discrepancy, bruit (above the clavicle), vertebrobasilar insu ciency
What is the treatment? Surgical bypass or endovascular stent
RENAL ARTERY STENOSIS
What is it? Stenosis of renal artery, resulting in
decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the reninangiotensin-aldosterone system (i.e., hypertension from renal artery stenosis)
Stenosis
What is the incidence? 10% to 15% of the U.S. population have
H N; of these, 4% have potentially correctable renovascular H N Also note that 30% of
malignant H N
have a renovascular etiology
What is the etiology of the stenosis?
66% result from atherosclerosis
(men women), 33% result from
bromuscular dysplasia (women men, average age 40 years, and 50% with bilateral disease)
Note: Another rare cause is hypoplasia of the renal artery
Chapter 66 / Vascular Surgery 523
What is the classic pro le of a patient with renal artery stenosis from bromuscular
dysplasia?
Young woman with hypertension
What are the associated risks/ clues?
Family history, early onset of H N, H N refractory to medical treatment
What are the signs/symptoms? Most patients are asymptomatic but may
have headache, diastolic H N, ank bruits (present in 50%), and decreased renal function
What are the diagnostic tests?
A-gram Maps artery and extent of stenosis (gold
standard)
IVP 80% of patients have delayed nephrogram
phase (i.e., delayed lling of contrast)
Renal vein renin ratio (RVRR)
If sampling of renal vein renin levels shows ratio between the two kidneys 1.5, then diagnostic
for a unilateral stenosis
Captopril provocation test Will show a drop in BP
Are renin levels in serum ALWAYS elevated?
No: Systemic renin levels may also be measured but are only increased in malignant H N, as the
increased intravascular volume dilutes the elevated renin level in most patients
What is the invasive nonsurgical treatment?
Percutaneous Renal Transluminal Angioplasty (PRTA)/stenting:
With FM dysplasia: use PR A With atherosclerosis: use PR A/stent
What is the surgical treatment? Resection, bypass, vein/gra interposition,
or endarterectomy
What antihypertensive medication is CONTRAINDICATED in patients with hypertension
from renovascular stenosis?
Why examine the rest of the arterial tree (especially the abdominal aorta)?
75% of all patients with popliteal aneurysms have additional aneurysms elsewhere; 50% of
these are located in the abdominal aorta/iliacs
What size of the following aneurysms are usually considered indications for surgical repair:
oracic aorta? 6.5 cm
Abdominal aorta? 5.5 cm
Iliac artery? 4 cm
Femoral artery? 2.5 cm
Popliteal artery? 2 cm
MISCELLANEOUS
De ne the following terms:
Milk leg A.k.a. phlegmasia alba dolens
(alba white): o en seen in pregnant women with occlusion of iliac vein resulting from extrinsic
compression by the uterus (thus, the leg is white because of subcutaneous edema)
Phlegmasia cerulea dolens In comparison, phlegmasia cerulea dolens
is secondary to severe venous out ow obstruction and results in a cyanotic leg; the extensive
venous thrombosis results in arterial in ow impairment
526 Section II / General Surgery
Raynauds phenomenon Vasospasm of digital arteries with color
changes of the digits; usually initiated by cold/emotion White (spasm), then blue (cyanosis), then
red (hyperemia)
Takayasus arteritis Arteritis of the aorta and aortic branches,
resulting in stenosis/occlusion/ aneurysms Seen mostly in women
Buergers disease A.k.a. thromboangiitis obliterans:
occlusion of the small vessels of the hands and feet; seen in young men who smoke; o en results
in digital gangrene S amputations
Duodenum
Superior mesenteric artery
Vitelline duct Umbilicus
eM
What is ECMO? ExtraCorporeal Membrane Oxygenation:
chronic cardiopulmonary bypassfor complete respiratory support
What are the types o ECMO? Venovenous: Blood from vein S
oxygenated S back to vein Venoarterial: Blood from vein (IJ) S
oxygenated S back to artery (carotid)
What are the indications? Severe hypoxia, usually from congenital
diaphragmatic hernia, meconium aspiration, persistent pulmonary hypertension, sepsis
What are the contraindications?
Weight 2 kg, IVH (IntraVentricular Hemorrhage in brain contraindicated because of heparin in
line)
Chapter 67 / Pediatric Surgery 531
ek
What is the major di erential diagnosis o a pediatric neck mass?
yroglossal duct cyst (midline), branchial cle cyst (lateral), lymphadenopathy, abscess, cystic
hygroma, hemangioma, teratoma/dermoid cyst, thyroid nodule, lymphoma/leukemia (also
parathyroid tumors, neuroblastoma, histiocytosis X, rhabdomyosarcoma, salivary gland tumors,
neuro broma)
hyroglossal Duct yst What is it? Remnant of the diverticulum formed
by migration of thyroid tissue; normal development involves migration of thyroid tissue from the
foramen cecum at the base of the tongue through the hyoid bone to its nal position around the
tracheal cartilage
What is the average age at diagnosis?
What is the treatment? Antibiotics if infection is present, then surgical excision of cyst and tract
once in ammation is resolved
What is the major anatomic di erence between thyroglossal cyst and branchial cle cyst?
yroglossal cyst midline Branchial cle cyst lateral ( ink: brAnchial lAteral)
Str dor
What is stridor? Harsh, high-pitched sound heard on
breathing caused by obstruction of the trachea or larynx
What are the signs/ symptoms?
Dyspnea, cyanosis, di culty with feedings
What is the di erential diagnosis?
Laryngomalacialeading cause of stridor in infants; results from inadequate development of
supporting laryngeal structures; usually self-limited and treatment is expectant unless respiratory
compromise is present Tracheobronchomalaciasimilar to
laryngomalacia, but involves the entire trachea Vascular rings and slingsabnormal
development or placement of thoracic large vessels resulting in obstruction of trachea/bronchus
Acute Allergic Reaction
What are the symptoms o vascular rings?
Stridor, dyspnea on exertion, or dysphagia
How is the diagnosis o vascular rings made?
Barium swallow revealing typical
con guration of esophageal compression Echo/arteriogram
What is the treatment o vascular rings?
Surgical division of the ring, if the patient is symptomatic
534 Section III / Subspecialty Surgery
yst c Hygroma What is it? Congenital abnormality of lymph sac
resulting in lymphangioma
P ctus ar natum What is it? Chest wall deformity with sternum outward
(pectus chest, carinatum pigeon); much less common than pectus excavatum
Pectus carinatum
What is the cause? Abnormal, unequal overgrowth of rib
cartilage
What is the treatment? Open perichondrium and remove
abnormal cartilage Place substernal strut New cartilage grows into normal position Remove
strut 6 months later
Chapter 67 / Pediatric Surgery 537
esophag al Atr s a w thout rach o sophag al ( e) F stula What is it? Blind-ending esophagus from
atresia
What are the signs? Excessive oral secretions and inability to
keep food down
How is the diagnosis made? Inability to pass NG tube; plain x-ray
shows tube coiled in upper esophagus and no gas in abdomen
What is the primary treatment? Suction blind pouch, IVFs, (gastrostomy
to drain stomach if prolonged preoperative esophageal stretching is planned)
What is the de nitive treatment?
Surgical with 1 anastomosis, o en with preoperative stretching of blind pouch (other options
include colonic or jejunal interposition gra or gastric tube formation if esophageal gap is long)
esophag al Atr s a W th rach o sophag al ( e) F stula What is it? Esophageal atresia occurring
with a stula to the trachea; occurs in 90% of cases of esophageal atresia
What is the incidence? One in 1500 to 3000 births
De ne the ollowing types o stulas/atresias:
ype A Esophageal atresia without TE
stula (8%)
relatively uncommon
Chapter 67 / Pediatric Surgery 541
How to remember the position o the Bochdalek hernia?
ink: BOCH DA LEK BACK O HE LEF
Large bowel
Spleen
Hernia
What are the signs? Respiratory distress, dyspnea,
tachypnea, retractions, and cyanosis; bowel sounds in the chest; rarely, maximal heart sounds on
the right; ipsilateral chest dullness to percussion, scaphoid abdomen
What are the e ects on the lungs?
1. Pulmonary hypoplasia 2. Pulmonary hypertension
What inhaled agent is o en used?
Inhaled nitric oxide (pulmonary vasodilator), which decreases the shunt and decreases
pulmonary hypertension
What is the treatment? NG tube, ET tube, stabilization, and if
patient is stable, surgical repair; if patient is unstable: nitric oxide ECMO then to the O.R. when
feasible
542 Section III / Subspecialty Surgery
PULM AR SeQUeS RA i
What is it? Abnormal benign lung tissue with
separate blood supply that DOES NO communicate with the normal tracheobronchial airway
Pulmonary sequestration
Independent blood supply
De ne the ollowing terms:
Interlobar Sequestration in the normal lung tissue
meconium ileus, meconium plug, maternal narcotic abuse (ileus), maternal hypermagnesemia
(ileus), sepsis (ileus)
What is the di erential diagnosis o in ant constipation?
Hirschsprungs disease, CF (cystic brosis), anteriorly displaced anus, polyps
i Ui AL HeR iA
What is the most commonly per ormed procedure by U.S. pediatric surgeons?
Indirect inguinal hernia repair
What is the most common inguinal hernia in children?
Indirect
What is an indirect inguinal hernia?
Hernia lateral to Hesselbachs triangle into the internal inguinal ring and down the inguinal canal
( ink: through the abdominal wall indirectly into the internal ring and out through the external
inguinal ring)
544 Section III / Subspecialty Surgery
What is Hesselbachs triangle? Triangle formed by:
1. Epigastric vessels 2. Inguinal ligament 3. Lateral border of the rectus sheath
What type o hernia goes through Hesselbachs triangle?
Direct hernia from a weak abdominal
oor; rare in children (0.5% of all inguinal hernias)
What is the incidence o indirect inguinal hernia in all children?
3%
What is the incidence in premature in ants?
Up to 30%
What is the male to emale ratio?
6:1
What are the risk actors or an indirect inguinal hernia?
Male gender, ascites, V-P shunt, prematurity, family history, meconium ileus, abdominal wall
defect elsewhere, hypo/epispadias, connective tissue disease, bladder exstrophy, undescended
testicle, CF
Which side is a ected more commonly?
Right ( 60%)
What percentage are bilateral? 15%
What percentage have a
amily history o indirect hernias?
10%
What are the signs/symptoms? Groin bulge, scrotal mass, thickened cord,
silk glove sign
What is the silk glove sign? Hernia sac rolls under the nger like the
nger of a silk glove
Why should it be repaired? Risk of incarcerated/strangulated bowel or
ovary; will not go away on its own
Chapter 67 / Pediatric Surgery 545
How is a pediatric inguinal hernia repaired?
High ligation of hernia sac (no repair of the abdominal wall oor, which is a big di erence between
the procedure in children vs. adults; high refers to high position on the sac neck next to the
peritoneal cavity)
Which in ants need overnight apnea monitoring/observation?
Premature infants; infants younger than 3 months of age
What is the risk o recurrence a er high ligation o an indirect pediatric hernia?
1%
Describe the steps in the repair o an indirect inguinal hernia
rom skin to skin
Cut skin, then fat, then Scarpas fascia, then external oblique fascia through the external inguinal
ring; nd hernia sac anteriomedially and bluntly separate from the other cord structures; ligate sac
high at the neck at the internal inguinal ring; resect sac and allow sac stump to retract into the
peritoneal cavity; close external oblique; close Scarpas fascia; close skin
De ne the ollowing terms:
Cryptorchidism Failure of the testicle to descend into the scrotum
Hydrocele Fluid- lled sac (i.e., uid in a patent
processus vaginalis or in the tunica vaginalis around the testicle)
Communicating hydrocele Hydrocele that communicates with the
peritoneal cavity and thus lls and drains peritoneal uid or gets bigger, then smaller
Noncommunicating hydrocele
Hydrocele that does not communicate with the peritoneal cavity; stays about the same size
Can a hernia be ruled out i an inguinal mass transilluminates?
NO; baby bowel is very thin and will o en transilluminate
546 Section III / Subspecialty Surgery
lass c intraop rat v Qu st ons Dur ng R pa r of an ind r ct ingu nal H rn a From what
abdominal muscle layer is the cremaster muscle derived?
Internal oblique muscle
From what abdominal muscle layer is the inguinal ligament (a.k.a. Pouparts ligament)
derived?
External oblique
What nerve travels with the spermatic cord?
Ilioinguinal nerve
Name the 5 structures in the spermatic cord
1. Cremasteric muscle bers 2. Vas deferens 3. Testicular artery 4. Testicular pampiniform venous
plexus 5. With or without hernia sac
Anteriomedially
What is a cord lipoma? Preperitoneal fat on the cord structures
(pushed in by the hernia sac); not a real lipoma Should be removed surgically, if feasible
Within the spermatic cord, do the vessels or the vas lie medially?
Vas is medial to the testicular vessels
What is a small outpouching o testicular tissue o o the testicle?
Testicular appendage (a.k.a. the appendix testes); should be removed with electrocautery
What is a blue dot sign? Blue dot on the scrotal skin from a twisted
testicular appendage
How is a transected vas treated? Repair with primary anastomosis
How do you treat a transected ilioinguinal nerve?
Should not be repaired; many surgeons ligate it to inhibit neuroma formation
What happens i you cut the ilioinguinal nerve?
Loss of sensation to the medial aspect of the inner thigh and scrotum/labia; loss of cremasteric re
ex
548 Section III / Subspecialty Surgery
UMBiLi AL HeR iA
What is it? Fascial defect at the umbilical ring
What are the risk actors? 1. African American infant
2. Premature infant
What are the indications or surgical repair?
1. 1.5 cm defect 2. Bowel incarceration 3. 4 years of age
eRD
What is it? GastroEsophageal Re ux Disease
What are the associated risks? Family history, rstborn males are a ected
most commonly, decreased incidence in African American population
What is the incidence? 1 in 750 births, M:F ratio 4:1
What is the average age at onset?
Usually from 3 weeks a er birth to about 3 months (3 to 3)
What are the symptoms? Increasing frequency of regurgitation,
leading to eventual nonbilious projectile vomiting
Why is the vomiting nonbilious?
Obstruction is proximal to the ampulla of Vater
What are the signs? Abdominal mass or olive in epigastric
region (85%), hypokalemic hypochloremic metabolic alkalosis, icterus (10%), visible gastric
peristalsis, paradoxic aciduria, hematemesis ( 10%)
What is the di erential diagnosis?
Pylorospasm, milk allergy, increased ICP, hiatal hernia, GERD, adrenal insu ciency, uremia,
malrotation, duodenal atresia, annular pancreas, duodenal web
550 Section III / Subspecialty Surgery
How is the diagnosis made? Usually by history and physical exam alone
U/Sdemonstrates elongated ( 15 mm) pyloric channel and thickened muscle wall ( 3.5 mm) If
U/S is nondiagnostic, then barium
swallowshows string sign or double railroad track sign
What is the initial treatment? Hydration and correction of alkalosis
with D10 NS plus 20 mEq of KCl (Note: the infants liver glycogen stores are very small;
therefore, use D10; Cl and hydration will correct the alkalosis)
What is the de nitive treatment?
Surgical, via Fredet-Ramstedt pyloromyotomy (division of circular muscle bers without entering
the lumen/mucosa)
What are the postoperative complications?
Unrecognized incision through the duodenal mucosa, bleeding, wound infection, aspiration
pneumonia
What is the appropriate postoperative eeding?
Start feeding with Pedialyte at 6 to 12 hours postoperatively; advance to full-strength formula
over 24 hours
Which vein crosses the pylorus? Vein of Mayo
DU De AL A ReSiA
What is it? Complete obstruction or stenosis of
duodenum caused by an ischemic insult during development or failure of recanalization
What is the anatomic location? 85% are distal to the ampulla of Vater,
15% are proximal to the ampulla of Vater (these present with nonbilious vomiting)
What are the signs? Bilious vomiting (if distal to the ampulla),
epigastric distention
What is the di erential diagnosis?
Malrotation with Ladds bands, annular pancreas
Chapter 67 / Pediatric Surgery 551
How is the diagnosis made? Plain abdominal lm revealing double
bubble, with one air bubble in the stomach and the other in the duodenum
What is the treatment? Duodenoduodenostomy or
duodenojejunostomy
Appendix
What is the long-term medical treatment?
Pancreatic enzyme replacement
What is cystic brosis (CF)? Inherited disorder of epithelial Cl
transport defect a ecting sweat glands, airways, and GI tract (pancreas, intestine); diagnosed by
sweat test (elevated levels of NaCl 60 mEq/liter) and genetic testing
What is DIOS? Distal Intestinal Obstruction Syndrome:
intestinal obstruction in older patients with CF from inspissated luminal contents
Me iUM PeRi i iS
What is it? Sign of intrauterine bowel perforation;
sterile meconium leads to an intense local in ammatory reaction with eventual formation of calci
cations
What are the signs? Calci cations on plain lms
Me iUM PLU S DR Me
What is it? Colonic obstruction from unknown
factors that dehydrate meconium, forming a plug
What is it also known as? Neonatal small le colon syndrome
What are the signs/ symptoms?
Abdominal distention and ailure to pass meconium within rst 24 hours o li e; plain lms
demonstrate many loops of distended bowel and air- uid levels
What is the nonoperative treatment?
Contrast enema is both diagnostic and therapeutic; it demonstrates microcolon to the point of
dilated colon (usually in transverse colon) and reveals copious intraluminal material
Chapter 67 / Pediatric Surgery 553
How is the diagnosis made? Physical exam, the classic Cross table
invertogram plain x-ray to see level of rectal gas (not very accurate), perineal ultrasound
554 Section III / Subspecialty Surgery
What is the treatment o the
ollowing conditions:
Low imper orate anus with anal stula?
Dilatation of anal stula and subsequent anoplasty
High imper orate anus? Diverting colostomy and mucous stula;
neoanus is usually made at 1 year of age
HiRS HSPRU S DiSeASe
What is it also known as? Aganglionic megacolon
What is it? Neurogenic form of intestinal obstruction
in which obstruction results from inadequate relaxation and peristalsis; absence of normal
ganglion cells of the rectum and colon
What are the associated risks? Family history; 5% chance of having a
second child with the a iction
What is the male to emale ratio?
4:1
What is the anatomic location? Aganglionosis begins at the anorectal line and involves
rectosigmoid in 80% of cases (10% have involvement to splenic exure, and 10% have
involvement of entire colon)
What are the signs/symptoms? Abdominal distention and bilious vomiting;
95% present with failure to pass meconium in the rst 24 hours; may also present later with
constipation, diarrhea, and decreased growth
up in the RUQ
What are Ladds bands? Fibrous bands that extend from the
abnormally placed cecum in the RUQ, o en crossing over the duodenum and causing obstruction
Ladds bands
HRF 07
What is the usual age at onset? 33% are present by 1 week of age, 75% by
1 month, and 90% by 1 year
558 Section III / Subspecialty Surgery
What is the usual presentation? Sudden onset of bilious vomiting (bilious
vomiting in an in ant is malrotation until proven otherwise!)
Why is the vomiting bilious? Twist is distal to the ampulla of Vater
How is the diagnosis made? Upper GI contrast study showing cuto in
duodenum; BE showing abnormal position of cecum in the upper abdomen
What are the possible complications?
Volvulus with midgut infarction, leading to death or necessitating massive enterectomy (rapid
diagnosis is essential!)
What is the treatment? IV antibiotics and uid resuscitation with
LR, followed by emergent laparotomy with Ladds procedure; second-look laparotomy if bowel
is severely ischemic in 24 hours to determine if remaining bowel is viable
What is the Ladds procedure? 1. Counterclockwise reduction of midgut
volvulus 2. Splitting of Ladds bands 3. Division of peritoneal attachments to
the cecum, ascending colon 4. Appendectomy
In what direction is the volvulus reducedclockwise or counterclockwise?
D COPS:
Diaphragmatic defect (hernia)
Cardiac abnormality Omphalocele Pericardium malformation/absence Sternal cle
AS R S HiSiS
What is it? Defect of abdominal wall; sac does not
cover extruded viscera
How is it diagnosed prenatally? Possible at fetal ultrasound a er 13 weeks
gestation, elevated maternal AFP
Where is the de ect? Lateral to the umbilicus ( ink:
gAstrochisis lAteral)
On what side o the umbilicus is the de ect most commonly
ound?
Right
What is the usual size o the de ect?
2 to 4 cm
Chapter 67 / Pediatric Surgery 561
What are the possible complications?
ick edematous peritoneum from
exposure to amnionic uid; malrotation of the gut Other complications include hypothermia;
hypovolemia from third-spacing; sepsis; and metabolic acidosis from hypovolemia and poor
perfusion, NEC, prolonged ileus
How is the diagnosis made? Prenatal U/S
presentguarding, muscle spasm, rebound tenderness, obturator and Psoas signs; low-grade
fever rising to high grade if perforation occurs
What is the di erential diagnosis?
Intussusception, volvulus, Meckels diverticulum, Crohns disease, ovarian torsion, cyst, tumor,
perforated ulcer, pancreatitis, PID, ruptured ectopic pregnancy, mesenteric lymphadenitis
What is the common bacterial cause o mesenteric lymphadenitis?
Yersinia enterocolitica
What are the associated lab ndings with appendicitis?
Increased WBC ( 10,000 per mm3 in
90% of cases, with a le shi in most)
What is the role o urinalysis? To evaluate for possible pyelonephritis
or renal calculus, but mild hematuria and pyuria are common in appendicitis because of ureteral
in ammation
What is the hamburger sign? Ask patients with suspected appendicitis
if they would like a hamburger or favorite food; if they can eat, seriously question the diagnosis
What radiographic studies may be per ormed?
O en none; CXR to rule out RML or RLL pneumonia; abdominal lms are usually nonspeci c, but
calci ed fecalith is present in 5% of cases; U/S, CT
What is the treatment? Nonper oratedprompt appendectomy
and cefoxitin to avoid perforation Per oratedtriple antibiotics, uid
resuscitation, and prompt appendectomy; all pus is drained and cultures obtained, with
postoperative antibiotics continued for 5 to 7 days,
drain