Pathological, surgical, or traumatic formation of an opening between two normally seperate organs or spaces.
Secreation of the liver that emulsifies fats, preparing them for further digestion and absorption in the SI.
White liquid, consisting of products of digestion, mostly emulsified fats, passes in SI to lymphatics.
Portal venous system
System that carries blood to a second capillary bed prior to returning blood to general circulation.
What organs are located in the RUQ?
Rt lobe of the liver, gallbladder, transverse colon, hepatic flexure, Rt. kidney (back), duodenum, and head of the pancreas.
What organs are located in the LUQ?
Lt. lob of the liver, stomach, transverse colon, splenic flexure, Lt. kidney (back), spleen, and tail of the pancreas.
What organs are located in the RLQ?
Cecum, appendix, ascending colon, small intestines, Rt. ureter, Rt. ovary and tube, and Rt. spermatic cord.
What organs are located in the LLQ?
Small intestines, sigmoid colon, descending colon, Lt. ureter, Lt. ovary and tube, and Lt. spermatic cord.
What are the 9 regions in the abdomen?
From R-L: R hypochondriac region, Epigastic region, L hypochondriac region, R lumbar region, Umbilical region, L lumbar region, R iliac region, Hypogastic, L iliac region.
What are the tissue layers from superficial - deep?
Skin, subcuticular, subcutaneous, fascia, muscle (rectus abdominis, internal and external oblique), peritoneum, abdominal organs.
The Linea Alba literally means__________and will be found in the_______________abdominal wall.
white line, Rectus
What is the primary function of the peritoneum?
Provide a slippery surface over which the viscera can freely glide.
ID the 3 regions of the retroperitoneal space and the organs that are located in each.
1) Anterior pararenal: Pancreas, and parts of the duodenum and colon. 2) Parirenal: Holds structures of the urologic and vascular concern. 3) Posterior pararenal: contains NO organs.
What is the pathway of the Upper Gastrointestinal Tract?
Mouth-Uvula-Pharynx-Epiglottis-Esophagus-Cardiac sphincter-Fundus of the stomach-Cardia of stomach-Body of the stomach-Pylorus of the stomach-Pyloric sphincter- Duodenum(Biliary tree connects here)-Jejunum-Ileum-Ileocecal valve.
What is the pathway of the Lower Gastointestinal Tract?
Ileocecal valve-Cecum-Ascending colon-Hepatic flexure-Transverse colon-Splenic flexure-Descending colon-Sigmoid colon-Rectum-Anus.
In addition to a major general surgical instrumentation set, which of the following will also be needed for an open cholecystectomy?
CBD exploration instruments
What position is used to displace the abdominal contents to enhance the surgeon's view of the lower abdominal region?
What position will be the patient be placed in to facilitate thyroidectomy?
Supine w/the neck hyperextended.
The flow of food and liquids from the stomach to the SI is controlled by_______.
What are the symptoms of hypothyroidism?
Fatigue or weakness, weight gain, decreased appetite, change in menstrual periods, loss of sex drive, feeling cold when others don't, constipation, muscle aches, puffiness around the eyes, brittle nails, and hair loss.
List one difference between a laparoscopic procedure and a endoscopic procedure.
Laproscopic~ go in through a hole you make w/a scope. Endoscopic~ go in through a natural oriface (mouth, nose, rectum).
Which retractor might be used on the fascia/muscle layer to assist in exposure or closure of an abdominal incision?
Where is the Midline/Longitudinal incision made?
A vertical incision centered above or below umbilicus. Ex~ all surgeries.
Where is the paramedian incision made?
A vertical or horizontal made lateral to the midline on either side in the upper or lower abdomen. Ex~ biliary tract, pancreas, and sigmoid colon.
Where is the Subcostal/Oblique(Kocher) incision made?
Just below the ribs on the L or R side. Ex~ gallbladder and spleen.
Where is a Transverse incision made?
A horizontal incision slightly above or below the umbilicus. Ex~ Choledochojejunostomy and transverse colostomy.
Where is a McBurney incision made?
RLQ incision just below umbilicus and aprox. 2 inches medial from anterior superior iliac spine. Ex~ appendix.
Where is a Pfannenstiel incision made?
A curved transverse incision across lower abdomen slightly above the pubis. Ex~ abdominal hysterectomy and cesarean.
Where is a Inguinal/Groin incisions made?
An oblique incision of the R or L inguinal region. Ex~ inguinal herniorrhaphy.
What are some predisposing factors to developing a hernia?
Strain (type of enviroment, varicose veins, pregnancy, wt gain), Chronic cough (smoking, COPD), Urinary Obstruction, Constipation (hemorrhoids), and Congential defects.
Inability to return hernial contents to the normal cavity w/manipulation.
An incarcerated hernia that lacks adequate blood supply and may become obstructed. This becomes a surgical emergency to prevent necrosis and gangrene of the strangulated tissue.
Direct Inguinal hernia
Occurs when the peritoneal SAC containing intestines protrudes through the inguinal ring and passes down the inguinal canal. It's usually congenital and common in males.
Direct Inguinal hernia
A protrusion through a weakness in the abdominal wall in a region known as Hesselbach's triangle, NO SAC. Usually acquired due to straining, heavy lifting, and chronic coughing. Most difficult type to repair and more common in males.
A protrusion of the peritoneum through the umbilical ring. Most common congenital defect in children and sometimes aquired in females after childbirth.
A defect in the transversalis fascia below the inguinal ligament, as well as the protrusion of the peritoneal sac through the femoral ring. Most common in females.
Ventral (Incisional) hernia
A protrusion of peritoneal contents due to weakness in the abdominal wall, usually due to impaired healing of a previous surgical incision.
Hiatal (Diaphragmatic) hernia
Either fixed or sliding, a portion of the stomach protrudes through the hiatus of the diaphragm.
Transabdominal Perperitoneal Laparoscopy~ Uses a pnuemoperitoneum (Veres needle w/CO2) and the inguinal canal in entered via the abdominal cavity.
Total Extraperitoneal Surgery~ Avoids pneumoperitoneum by inflating and entering the preperitoneal space w/a balloon dissector which acts as a tissue expander.
What are some complications of Herniorrhaphy?
Recurrence,strangulated bowel, nerve injury, ischemic orchitits and testicular atrophy, loss of bowel or urinary function, infection, and damage to the contents of the sac
What is the landmark for a breast procedure?
Tail of spence~border of the sternum to the anterior axillary line.
What are some important considerations in breast surgery?
Size, location, type of diseased tissue, and stage of malignancy.
Cancer cells are present in either the lining of the glands that make milk (lobules) or the tubes (ducts) that link these glands to the nipple. But cancer cells have not spread to the nearby fatty tissue.
Cancer has spread from the lobules or ducts to nearby tissue in the breast. Cancer cells have not spread to surrounding lymph nodes, stays in the lining.
Cancer has spread from the lobules or ducts to nearby tissue in the breast. Sometimes cancer cells have also spread to the lymph nodes.
Later stage of breast cancer (locally advanced). Tumors have spread to lymph nodes under the arm, chest or above or below the collarbone. Tumors that have spread to other tissues near the breast may also be considered stage III.
Advanced stage of breast cancer (Metastatic). Cancer has spread from the breast and lymph nodes to other parts of the body such as the bone, liver, lungs, or brain.
If ductal or lobular carcinoma spreads into nearby tissue it is said to be________.
Invasive or infiltering.
Why is breast biopsy done?
To determine the exact nature of a mass in the breast. It involves the removal of breast tissue for pathologic examination.
Fine Needle Aspiration (FNA)
22 or 25 gauge needle and syringe are inserted into the mass and a few cells are aspirated and sent to pathology to cytologic studies.
A large bore trocar (True-cut needle) is inserted into the mass and a core of suspended tissue is w/d for histologic examination.
A computer-guided system used to digitally loacte and pinpoint nonpalpable breast leisons.
The breast mass in injected w/a radioisotope dye several hours before the procedure. The dye is taken up by the lymph nodes of the breast. The nodes are excised before the mass and a Geiger counter is used to locate the areas of radioactivity.
A flexable 0.9mm scope w/a 0.2mm working channel is used in the ductal lumens of the breast.
A partial mastectomy that consists of removal of the entire tumor mass along w/a least 1 to 2 cm surrounding nondiseased tissue.
A wedge or quadrant of breast tissue is removed including the tumor mass and the lobe in which it is growing.
Modified Radical Mastectomy
Includes the removal of the entire breast along w/all the axillary nodes. Pectoralis major muscle is left in place.
The entire breast is removed along w/axillary lymp nodes, the pectoral muscles, and all adjacent tissues.
TRAM Flap procedure
Transrectus Abdominus Muscle Procedure~ The most popular of all reconstruction options, you get a new breast and a tummy tuck.
Complications from a Mastectomy procedures include...
Hemorrhage, wound infection, frozen shoulder, skin flap necrosis, seromas,lymphedema, phatom breast syndrome, cellulitis, hematoma formation.
The thyroid gland is controlled by the__________loacted within the brain which makes_____________.
Pituitary gland, TSH
Tests for diagnosing Thyroid disease
Blood tests (T4 and T3), Ultrasound exam (during pregnancy, tells is a thyroid humor is solid or cystic), Thyroid scan (tells if the tumor os functioning or nonfunctioning, Radioactive Iodine uptake (hyperthyroid), and TSH assay (increase for hypo and decrease intake for hyper).
Euthyroid (well) goiter
If dietary iodine is slightly inadequate, too little thyroxin will be secreated, and the pituitary will sense the deficiency and produce more TSH. The thyroid gland will enlarge to make sufficient thyroxin.
If dietary iodine is severely reduced, the gland will keep growing under the influence of TSH, but it may never be able to make enough thyroxin.
Symptoms of Hyperthyroidism
Fatigue, wt loss, nervousness, rapid heart beat, increased sweating, feeling hot when others don't, changes in menstrual periods, more frequent bowel movements, and tremors.
Increased fatty deposits behind the eyes causing the eyes to push foward. Usually seen in Graves Disease in someome w/Hyperthyroidism.
Removal of one or both lobes of the thyroid gland. Usually done due to hyperthyroidism or thyroid carcinoma. The parathyroid glands, imbedded posterially in the thyroid, MUST be spared for they produce CA.
Performed usually due to hyperparathyroidism. One to all four parathyroid glands may be taken. If all four are taken out, constant calcitonin level monitoring is needed. If one can be spared, usually they'll get implanted in the pt's forearm.
Partial Thyroid Lobectomy
Half of the thyroid lobe is removed. This operation is not performed very often, a benign leison must be ideally located in the upper or lower portion of one lobe for this operation to be a choice.
This is typically the "smallest" operation performed on the Thyroid gland. It is performed for solitary dominant nodules which are worrisome for cancer or those which are indeterminate following a fine needle biopsy.
Removes all the problem side of the gland as well as the isthmus and the majority of the opposite lobe. This operation is typical for small, non-aggressive thyroid cancers. Also a common procedure for goiters.
This operation removes all of the thyroid gland. It is the operation of choice for ALL thyroid cancers-many surgeons prefer this for all thyroid cancers regardless of the type.
Complications of Thyroidectomies
Be careful of the recurrent laryngeal nerve! Pneumonia, and Thrombophlebitis
Liver biopsy is used to determine...
Liver disease or transplant rejection, used when other non invasive exams ( abnormal liver function tests, staging for chronic hepatitis, ID alcoholic liver dz, FUO, evaluation of cirrhosis~hardening of liver tissue, and screening for familial dz) can not make a diagnosis.
Removal of the liver~ since the liver is a vital organ, only a lobe or segment can be removed w/o the need for a transplant. Resection is indicated for cysts, benign or malignant tumors, or severe penetrating or blunt trauma.
Complications of a Hepatic resection...
Hemorrhage, wound infection, systemic infection, bile leak (BAD!), liver failure, and tumor recurrence.
Cholesterol stones are a by product of liver bile that is supersaturated w/cholesterol. This cholesterol precipitates from the bile into crystals that become stones.
Made up of CA, bilirubinate, polymers, bile acids, iron, and phosphorus. Stones may be black, dark brown, yellow, or green.
Extracorporeal shock wave lithotripsy (ESWL)
Stones are fragmented and passed through the cystic and common bile duct to the alimentary system and excreated in the feces. GB-CBD-pancreas-stomach-SI-LI-colon-rectum.
Cholecystectomy w/intra-operative cholangiogram
"chole chole" 2 seperate surgeries, injection of dye into the ducts to check for blockages.
When preparing for intraoperative cholangiogram, ensure that there are no air bubbles in the syringe/catheter because they__________________.
resemble stones on X-Ray.
removal of the gallbladder. Usually done laprascopic, if not then a kocher incision is used for maximum exposure.
If bile leaks into the peritonieum during sx, then _________and_________needs to be done.
Is necessary for the detection of common bile duct stones. Sometimes stone(s) escape from the gallbladder and is lodged in the distal CBD. If left in the duct the stone often obstructs the duct causing cholangitis, CBD stricture, and pancreatitis.
CBD obstruction from stones, jaundice, hemorrhage, wound infection, atelectasis, Ileus, hepatic artery or bile duct damage, persistant bile drainage, and fistula formation.
Islets of Langerhans form the___________divison and secrete the hormones___________and_________.
endocrine, insulin, glucagon.
Whipples procedure-done on pt's w/pancreatic cancer. Involves the excision of the head of the pancreas, the distal 1/3 (antrum and pylorus) of the stomach, all of the duodenum, the proximal 10cm of the jejunum, the gallbladder, the cystic and CBD and nodes.
Severe complications associated w/Pancreaticoduodenectomy...
Abdominal sepsis, pancreatic fistula formation, petic ulcer, disrupted nutrient absorption, delayed gastric emptying, and death.
Removal of the spleen due to trauma, blood dyscrasia (blood disease), splenic anemia, nutropenia, tumors, cysts, and splenomegaly.
A new opening in the stomach and jejunum also known as a Roux-en-Y. This procedure may be done to reestablish continuity between the stomach and intestinal tract~ tumor obstruction or gastric bypass in bariatric sx.
The jejunum is divided, the distal end is anastomosed to the side of the stomach, and the proximal end is anastomosed to the side of the jejunum at the lower level. The result is a Y-shaped anastomosis that diverts the flow of bile and pancreatic enzymes directly into the jejunum bypassing the created gastric stoma.
Used to treat morbid obesity, the capacity of the stomach is reduced to approximately 30ml (size of a medicine cup) to restrict food absorption or intake.
Vertical Banded Gastroplasty
4 linear staple lines are placed vertically on the lesser curvature side of the stomach just left of the gastroesophageal junction. This allows for a small passage of gastric contents and the total intake at any given time is about 1 ounce. This surgery has better outcomes compared to gastric bypass.
If a patient has a chest tube, what 2 things need to leave w/the patient?
Xeroform sponge and a kelly clamp.
Colitis, diverticulitis, obstruction, and neoplasms are the most common reasons for surgical intervention to remove a diseased segment of the colon.
All instrumentation that enters the colon is considered________and must be isolated on the___________or in a____________.
dirty,back table,ring stand.
A new opening into the colon anywhere along the length of the colon to the exterior skin surface creating an artificial anus. This procedure is done and colostomy bag is usually placed.
Removal of the appendix. Appendicitis is the most common reason for this procedure. This procedure is usually done laprascopic but if opened, McBurney's is the incision of choice.
Wound infection, intestinal obstruction from adhesions, ileocecal dz, strangulated bowel, colorectal cancer, peritonitis, shock.
Chronic form of perianal abcess. Inflammatory tract based on relationship to anal sphincter. Caused by infectious dz, malignancy, trauma, Crohen's dz, TB.
Acute abcess in the sacrococcygeal area, ruptures spontaneously leaving unhealed sinus tract w/chronic damage. Leisons are secondarily invaded by hair.
Congestion and dialation of the submucosal venous plexuses that line the anal canal. Caused by heavy exertion, increased intra-abdominal pressure, constipation, age/heredity, and diet. They can be either internal or external.
Surgical removal of varicosities of veins or prolasped mucosa of the anus and rectum. Kraske/Jacknife position is commonly used,
Surgical removal of a fissure where the anus is dialated and the infected tissue is excised.
In Pilonidal cyst sx, the surgeon may want a______________________to clean away infected tissue and hair. They are usually then left_________to heal by____________.
small curette,open,second intention.
What are the A,B,C,D,E,F's of abdominal trauma?
A: Airway, B: Breathing, C: Compressions/circulation, D: Digestive system, E: External factors (bleeding,trauma to skin, bumps, bruises, road rash, burns), F: Fractures.
Injury to intra-abdominal structures can be classified into 2 primary mechanisms of injury...
Compression forces and Deceleration forces.
Also known as concussive forces may result from direct blows or external compression against a fixed object. Most commonly, these crushing forces cause tears and subscapular hematomas to the solid viscera. These forces also may deform hollow organs and transiently increase intraluminal pressure, resulting in rupture.
Cause stretching and linear shearing between relatively fixed and free objects. These longitudinal shearing forces then to rupture supporting structures at the junction between free and fixed segments. Classic injuries include hepatic tears, liver and spleen injuries, and S and LI injuries.
The patient who has________on a abdominal x-ray needs a rapid___________________.
Usually seen by bullets and knives. The extent of injury depends on: the type of foreign object, the size of the object. distance of the victim from the object, body structure penetrated, and the amount of energy (velocity) of the penetrating object.
Never remove a_____________until the patient is in the OR. Why?
penetrating object, b/c they can bleed out for the object acts as a tamponade to control bleeding.
If a penetrating would in sticking out of someones neck, how will you secure the pt's airway?
You will do awake intubation and once the tube is in place, then they put the pt under.
Confirm that there is NO_________injury before moving the patient. How many people should help move the patient?
In a life threatening situation, counts may be eliminated-what is the procedure if a count is not done?
The total or partial removal of any extremity. The need to amputation is associated most often w/massive trauma, a malignant tumor, extensive infection, and vascular insufficiency.
Above-Knee Amputation (AKA)
Usually selected when gangrene or arterial insufficiency extends above the level of the malleoli. Hemostasis is important to prevent massive hemorrhage or painful hematoma. A prosthesis is fitted 4-6 weeks after sx.
Below-Knee Amputation (BKA)
Done at the middle third of the leg providing for more functional prosthesis fitting and the reduction of phantom limb pain. An immediate postoperative (IPOP) can be applied in the OR.
Usually a result from trauma and includes part or all of the distal phalanges of the digits. Attention is directed to keep the hand as a working unit when one or more fingers are removed.
Wrist, elbow, and humerus disarticulations are radical procedures performed for malignant tumors or extensive trauma.
ID the 5 major segments of the stomach and what there function is.
1) Cardia: secreates mucous to ease the passage of food. 2) Fundus: Produces hydrochloric acid 3) Corpus: Produces acid and secreates pepsinogen and mucous. 4) Antrum: non-acid producing, secreates mucous and gastrin. 5) Pylorus: Food storage area before it passes in the duodenum.
What two structures of the stomach are important areas of innervation and blood flow?
Lesser and greater curvature.
The breaking down of large fat globules in the intestines into smaller, uniformaly distributed particles.
The enzyme amylase secreted in the oral cavity begins digestion of the food substance__________.
The enzyme Pepsinogen (pepsin) secreted in the stomach begins digestion of the food substance_______.
The small intestine is responsible for the digestion and absorption of___________________________.
foodstuffs and nutrients.
The movement of food through the intestines by musckes of the alimentary canal is called___________.
What is the purpose of the mesentary?
Contain blood vessels, nerves, and lymph vessels that serve the adjoining organs.
Where is the location of the appendix? What is the purpose of the mesoappendix?
Attached to the cecum, which is an embryonic extension of the apex of the cecum. The mesoappendix supplies blood to the appendix.
What are the functions that are performed by the cells of the liver?
produce bile, metabolize carb's, fats, and protiens, store sugar as glycogen, store fat soluble vitamin A, D, E, and K, plus iron and copper, detoxify harmful substances via phagocytosis, and synthesize prothrombin and fibrinogen.
Why is lymphatic drainage important in the mammary gland?
Because of the frquencey of breast cancer in females. The mammary cutaneous lymphatics are part of the lymphatic network.
An enlarged, dilated superficial vien, can be painful. Most commonly seen in the lower extremities.
Chronic condition w/weight loss, diarrhea, abdominal pain, malabsorption, abscess, and bleeding.
Peptic ulcers are most frequently found in what location?
Lower end of the esophagus; in the stomach usually along the lesser curvature and sometimes found in the duodenum.
What is a stoma?
An artificially created opening between 2 passages or body cavities or between a cavity or passage and the body's surface.
A modification of the loop method in which the loop is divided w/a linear cutter and both ends are brought out through the skin incision.
Utilizes the transverse colon, not generally used as a permanent colostomy b/c it discharges a semifluid stool. The most frequently used method of stoma creation for temporary fecal diversion.
A modification of the loop method in which the loop is divided w/a linear cutter and both ends are brought out through the skin incision.
Most common type of permanent colostomy, created at the time os A/P resection, created as an end colostomy in the LLQ.
Attachment of the end of one section of bowel into the side of another section.