SURGERY I POINTERS MODULE # 4

ESOPHAGUS CRIMINAL NERVE OF GRASSI

CONSTRICTIONS  Located at the posterior fundus, innervated by posterior vagus
 Easily missed during truncal or highly selective vagotomy
From incisor to: LENGTH DIAMETER
M – 15 cm GASTRIC HORMONE
CRICOPHARYNGEAL 1.5 cm
F – 14 cm
Hormone Function
TRACHEA 24-26 cm 1.6 cm
M – 40 cm GHRELIN Increase Acid secretion
DIAPHRAGM
F – 38 cm
1.6-1.9 cm (G cells) blocked by H2 – antagonist
Inhibits acid secretion
SOMATOSTATIN
Inhibits gastrin release]
(D cells)
BLOOD SUPPLY/ VENOUS DRAINAGE Decrease histamine release
Stimulates gastrin and somatostatin
GASTRIN
ARTERY VEIN Centrally  acid secretion inhibition
releasing peptide
Periphery  acid secretion increase
CERVICAL Inferior thyroid artery Inferior thyroid vein Appetite regulator
GHRELIN
“gutom” hormone
Bronchial vein
Bronchial artery
THORACIC Azygos or Hemiazygos
Esophageal artery
vein GASTRIC CA LYMPH NODE CLASSIFICATION
Left gastric artery (main) STATIONS
ABDOMINAL Coronary vein
Inferior phrenic artery  1, 3, 5 – lesser curvature
 2, 4, 6 – greater curvature
DIAGNOSTIC MODALITY FOR GERD
 1, 2 – superior gastric group
 24 hr ambulatory pH monitoring - GOLD STANDARD  5 – suprapyloric group
 4a & b – pancreaticolienal group
STOMACH  6 – inferior gastric subpyloric group
BLOOD SUPPLY  7 – left gastric artery
 8 – common hepatic artery
ARTERIAL BLOOD SUPPLY  9 – celiac artery
 10, 11 – splenic artery
LOCATION ARTERY From what artery
CLASSIFICATION
 R gastroepiploic  N1  PERIGASTRIC LN (lesser curve, greater curve)
GREATER  Gastroduodenal  N2  STATIONS 7-11
(2nd largest)
CURVATURE  Splenic  N3 & N4  PARAAORTIC LN (distant metastasis)
 L gastroepiploic

LESSER  R gastric  Hepatic ADDITIONAL MUST KNOW

CURVATURE  L gastric (largest)  Celiac
BILLROTH
 Short gastric  Splenic
Least post Most difficult
I GASTRODUODENOSTOMY
gastric syndrome to perform
VENOUS DRAINAGE
Most/ highest
II GASTROJEJUNOSTOMY incidence post easiest
LOCATION VEIN Drains to what vein gastric syndrome

 Superior
GREATER  R gastroepiploic MUST KNOW
mesenteric
CURVATURE  L gastroepiploic  BENIGN ULCER VS ULCER W/ MALIGNANCY
 splenic
o BENIGN ulcer – nadisturb ung flow ng rugae
LESSER  R gastric o MALIGNANT ulcer –continuous rugal fold
 Portal
CURVATURE  L gastric (largest)
 DUODENAL vs GASTRIC ulcer
o DUODENAL – acid hypersecretion
TYPES OF PEPTIC ULCER o GASTRIC – failure of mucosal defense

TYPE DESCRIPTION  GASTRINOMA  Zollinger-Ellison Syndrome

I Corpus to proximal antrum (true gastric) o Diarrhes
o Steatorrhea
II Gastric + duodenal ulcer (type II = 2 types) o Pernicious anemia
III Prepyloric/ distal antrum (type III = THREEpyloric)
 ACUTE GASTRITIS
IV Fundus (Four - Fundus)
o CURLING’S ulcer – burns, sepsis
V NSAID associated o CUSHING’S ulcer – CNS trauma

FORREST CLASSIFICATION LIVER

BLOOD SUPPLY/ VENOUS DRAINAGE
ACTIVE BLEEDING
ARTERIAL
1A SPURTING hemorrhage
 Dual blood supply
1B OOZING hemorrhage
 HEPATIC artery (25%)
RECENT HEMORRHAGE o R hepatic artery  cystic artery  Gall bladder
2A Visible vessel  PORTAL VEIN (75%)
2B Adherent clot
VENOUS DRAINAGE
2C Hematin on ulcer base  R HEPATIC vein  IVC
LESIONS WITHOUT ACTIVE BLEEDING  L MID HEPATIC vein  common trunk  IVC
 Caudate lobe  IVC (directly)
3 Without signs of recent hemorrhage

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 SURGERY I MODULE 4

PRINGLE MANEUVER
 Clamp HEPATODUODENAL ligament and PORTA HEPATIS
(PORTAL TRIAD= CBD, hepatic artery, portal vein)
 EPIPLOIC FORAMEN/ formane of Winslow – passage for Pringle’s
 15 mins clamping; 5 mins reperfusion

PORTAL PRESSURE
 NORMAL = 3-5 mmHg
 PORTAL HYPERTENSION = can increase up to 20-30 mmHg

PORTAL HYPERTENSION
 INTRAHEPTIC – cirrhosis
 PREHEPATIC – thrombosis portal vein, congenital atresia
 POSTHEPATIC –myeloproliferative disorders (most common), Budd-
Chiari syndrome CHARCOT’S TRIAD
 RUQ/ epigastric pain
 Cruveilhier-Baumgarten murmur  Fever
o Audible venous hum in caput medusae  Jaundice
 Gastresophageal varices
 REYNOLD’S PENTAD
o Most significant finding in portal hypertension
o Charcot’s triad + hypertension + mental status change

LIVER FUNCTION TESTS

MIRRIZI SYNDROME
LIVER CELL DAMAGE  Gallstones become impacted in the cystic duct or neck of
 ASPARTATE TRANSAMINASE (AST) GB/infundibulum causing compression of CBD leading to sever
o Hepatocellular injury pericholecystic inflammation
 ALANINE TRANSAMINASE (ALT)
o More specific to liver diseases
o Hepatocellular injury POSITIVE FINDINGS ORAL CHOLECYSTOGRAM
 ALKALINE PHOSPHATASE (ALP)  Oral cholecystogram
o From bile duct epithelium o Oral administration of radiopaque contrast
o Increase in biliary obstruction o (+) stones on film  filling defects in a visualized opacified gall
 GAMMA-GLUTAMYL TRANSPEPTIDASE (GGTP) bladder
o Early marker for liver disease
MURPHY’S SIGN
LIVER FUNCTION TEST  INSPIRATORY arrest with deep palpation in the right subcostal area
 Serum albumin
 Prothrombin time (Clotting factors) APPENDICITIS
DIAGNOSTIC MODALITY DIFFERENTIAL DIAGNOSIS
HEPATIC VENOGRAPHY  Acute mesenteric adenitis - URTI, inflamed glands, diffuse pain
 Acute gastroeneteritis – hyperperistaltic abdominal cramps
 Most accurate method of determining portal hypertension
o Salmonella – history of contaminated food; intense abdominal pain
 (+) Portal hypertension:
o Typhoid fever – prostration, maculo-papular rash
o Portal vein = >5 mmHg than IVC
 Disease of male urogenital system – testicular torsion, acute
o Splenic vein = >15 mmHg
epididymitis, seminal vasculitis
o Portal vein = >20 mmHg
 Meckel’s diverticulitis – rule of 2; epigastric and ubilical region pain
TRIPHASIC CT SCAN  Intussusception – sudden colicky pain; bloody mucoid stool;
sausage shaped mass at RLQ
 TRIPHASIC: oral, IV, transrectal  Crohn’s enteritis
 Visualize liver parenchyma and adjacent tissues  Perforated peptic ulcer
 Colonic lesions
 ARTERIAL PHASE: hepatic tumors; hypervascular lesions  Epiploic appendagitis – colonic appendages infarction secondary to
 PORTAL PHASE: enhancement of normal liver parenchyma and torsion
hypovascular lesion  UTI, Renal stones
 Primary peritonitis
ANGIOPORTOGRAPHY  Henoch – Schonlein purpura – post-strep joint pain, purpura,
 Useful for assessing portal vein nephritis
 CT Scan contrast through catheter in the SMA  Yersiniosis

INTROPERATIVE ULTRASOUND INCIDENCE RATE OF RUPTURE

 Gold standard for detecting liver lesions  Incidence of rupture  25.8%
 Used for:  Age group  <5 y/o, > 65 y/o
o Tumor staging
o Visualization of intrahepatic vascular structures
o Guide for resection NEOPLASM OF APPENDIX
o Guide for biopsy CARCINOID
o Guide for ablation of tumors  Most common site of GI carcinoid
 Located at the tip of the appendix
TUMOR MARKER LIVER CA  Firm, yellow bulbar mass
 Alpha fetoprotein (AFP)  Malignant potential related to size
o From embryonal hepatocytes, increased in 70% cases of liver ca
ADENOCARCNOMA
GB AND EHBS  Rare neoplasm
 Subtypes: mucinous, colonic, adenocarcinoma
UTZ FINDING CALCULOUS CHOLECYSTITIS  Clinical presentation: acute AP (most common), ascites or palpable
 CALCULOUS CHOLECYSTITIS mass
o An obstructing stone in the neck of the GB or cystic duct  Tx: formal right hemicolectomy
 Findings on UTZ
o Enlarged GB, thinned wall MUCOCELE
 Obstructive dilatation due to intraluminal accumulation of mucoid
TRAINGLE OF CALOT material
 SUPERIOR – Liver margin
 MEDIAL – common hepatic duct PSEUDOMYXOMA PERITONEI
 LATERAL cystic duct  Gelatinous fluid on peritoneal surfaces and omentum
*cystic artery is found within the triangle  Appendix – site of origin

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 SURGERY I MODULE 4

COLORECTAL  Skin incision is created and a disk of skin excised to prevent

premature close
DIAGNOSTIC MODALITIES  No packing necessary, and sitz baths are started the next day
COLONOSCOPY
 Most accurate and complete method to examine the colon ANAL FISTULA TYPICAL HISTORY
 Diagnostic and therapeutic  Drainage of anorectal abscess lead to 50% cure and 50% fistula in
 Necessary oral bowel prep; conscious sedation ano
 Visualization of colon and rectum  Fistula originated in the infected crypt (internal opening) and tracks t
the external opening, usually at the site of prior drainage
BARIUM ENEMA  Majority are cryptoglandular in origin
 Examines entire colon  Other causes: trauma, Crohn’s, malignancy radiation, or unusual
 Good sensitivity to polyps > 1cm infection (TB, actinomyces, and chlamydia)
 Requires bowel prep  Complex, recurrent or non-healing fistula should raise suspicion of
 Colonoscopy required if positive result one of this diagnosis
 Persistent drainage from the internal/ external openings
ANGIOGRAPHY
 Detection of bleeding within colon and small bowel
 To visualize, bleeding must be relatively brisk (approximately 0.5-
1.0mL/min)

ANOSCOPY
 Used for examination of anal canal

ENDOGRAPHY, ENDOANAL/ENDORECTAL UTZ

 Can differentiate most benign polyp from invasive tumors based on
integrity of submucosal layer
 ENDORECTAL: depth of invasion
 ENDOANAL: evaluate layers

TUMOR MARKER CEA

 May be elevated in 60-90% (colorectal cancer)
 Not an effective screening tool; non-specific; no survival benefit

FECAL OCCULT BLOOD TESTING

 Colon cancer screening test for asymptomatic, average risk individual
 Non-specific test: PEROXIDASE in hemoglobin
 POSITIVE (+) = occult bleeding GI source
 FALSE POSITIVE = red meat, beets, vitamin C
 Reduce mortality (33%) and metastatic disease (50%)

TOTAL MESORECTAL EXCISION

 Technique that uses SHARP dissection along anatomic planes to
ensure complete resection of the rectal mesentery during low and
extended low anterior resections
 At least 5 cm distal to the tumor
 TME decreases local recurrence rate and improves long term
survival rate
 Less blood loss and less risk to pelvic nerves and presacral plexus

HARTMANN PROCEDURE PURPOSE

 HARTMANN’S PROCEDURE – colon/rectal resection without an a
anastomosis in which a colonostomy or ileostomy is created and the
distal colon/rectum is left as a blind pouch
 When the left/ sigmoid colon is resected and the closed off rectum is
left in the pelvis

BOWEL PREP GOAL

 To remove/ excrete all feces in the colon for complete visualization

MANAGEMENT: COLONIC POLYP

 Pedunculated polyp  colonoscopic snare excision
 Sessile polyp  transanal operative excision

CHARACTERISTIC MANIFESTATION INTERNAL

HEMORRHOID
 May prolapse or bleed; rarely painful unless they develop thrombosis
and necrosis

GRADING
1ST DEGREE Hemorrhoids bulge into the anal canal; may
prolapse beyond dentate line in straining
2ND DEGREE Hemorrhoids prolapse through the anus; reduce
spontaneously
3RD DEGREE Hemorrhoids prolapse through the anal canal;
require manual reduction
4TH DEGREE Hemorrhoids prolapse; cannot be reduced; at risk
for strangulation

PERIANAL ABSCESS MANAGEMENT

 Drained under local anesthesia
 Larger, more complicated abscess may require drainage in the
operating room

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