Posted by e-Medical PPT
commonly thought that repeated increases in intra-abdominal pressure contribute to hernia formation
collagen formation and structure deteriorates with age, and thus hernia formation is more common in the older individual.
Dull feeling of discomfort or heaviness in the groin
Focal pain – raise suspicion for incarceration or strangulation
Symptoms of bowel obstruction
Direct Inguinal Hernia
Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle
acquired weakness in the inguinal floor
Indirect Inguinal hernia
Abdominal contents protrude through internal inguinal ring
Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period
Remnant layer of peritoneum forms a sac at the internal ring
more frequently on the right
More common in females
Up to 40% present as emergencies with hernia incarceration or strangulation
Passes medial to the femoral vessels and nerve in the femoral canal through the empty space
Inguinal ligament forms the superior border
Trusses can provide symptomatic relief
Hernia control in ~30% of patients
Bassini (early 20th Century)
Transversus abdominis to Thompson’s ligament and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament
Multilayer imbricated repair of the posterior wall of the inguinal canal
Edge of the transversus abdominis aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament and the iliopubic tract (transition suture)
Lichtenstein -First pure prosthestic, tension-free repair to achieve low recurrence rates
Polypropylene mesh most common and preferred
allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect
Polytetrafluoroethylene (PTFE) mesh
often used for repair of ventral or incision hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided..
Posted by e-Medical PPT
Wall consists of mucosa, submucosa, and two complete muscle layers, inner circular, outer longitudinal.
12-15cm in length, reflection is 6-8cm above anus.
Upper 1/3 ant/lat covered by peritoneum, middle 1/3 only anteriorly covered, lower 1/3 completely retroperitoneal.
The rectum starts where tenia coli coalesce to form a complete layer of longitudinal muscle at level of sacral promontory.
Three distinct curves, proximal and distal curve to the right, middle curves to the left. These folds are called Valves of Huston. This area is great for biopsy purposes as they do not contain all layers so risk of perforation is less.
Waldeyer’s fascia is a dense connection between sacrum and rectum at 4th sacral body goes anteriorly to rectum, covering sacrum and overlying vessels and nerves.
Dennonviller’s fascia is a retrovesical septum in men, rectovaginal in women.
Pelvic floor is musculotendinous sheet formed by the levator ani muscle and is innervated by S4.
The pubococcygeus, iliococcygeus, and puborectalis make the levator ani. These are paired muscles that are intertwined and act as a unit.
The anal canal starts at pelvic diaphragm and ends at anal verge. Approximately 4cm long. The anatomic anal canal extends from anal verge to dentate line. Surgical anal canal is anal verge to anorectal ring, the circular upper border of puborectalis that is palpable by rectal exam. It is 1-1.5 cm from dentate line.
The anal verge is the junction between anoderm and perianal skin.
The dentate line is a true mucocutaneous junction located 1-1.5 cm from anal verge. A 6-12mm transitional zone exists above the line where squamous becomes cuboidal, then columnar.
Anal sphincter mechanism made by internal and external sphincters.
The internal sphincter is a specialized continuation of the circular smooth muscle layer of the rectum. It is involuntary, and contracted at rest.
The intersphincteric plane is a fibrous continuation of the longitudinal smooth muscle layer of the rectum..
These cushions are thought to act as a plug to the anal canal, and contribute 15-20% to the resting pressure of the anal canal. There are three of these cushions 11,3,7 o'clock.
Abnormal swelling of the cushions result in prolapse of the upper anal/lower rectal tissue thru the anal canal. This causes the symptoms of hemorrhoids: bleeding, discomfort, pruritis, prolapse, swelling, pain, discharge.
Bleeding is the most common symptom, pain is not common, unless a associated fissure is present (20%), or it’s a thrombosed external.
Classification of internal hemorrhoids.
Classification of Internal Hemorrhoids
I- Bleed, but do not prolapse.
II- Spontaneous prolapsing and reducing with or without bleeding.
III- Prolapsing,that require manual reduction.
IV- Prolapsed, cannot reduce...
Posted by e-Medical PPT
Inadequate tissue perfusion resulting from cardiac dysfunction
Clinical definition - decreased cardiac output and tissue hypoxia in the presence of adequate intravascular volume
Hemodynamic definition - sustained systolic BP <90 mm Hg, cardiac index<2.2 L/min/m2, PCWP >15 mm Hg
Causes of Cardiogenic Shock
Right ventricular infarction
Myocarditis (fulminant myocarditis)
Prolonged cardiopulmonary bypass
Septic shock with myocardial depression
Initial Approach: Management
Intubation and ventilation if needed
Continuous EKG monitoring
Fluid challenge if no pulmonary edema
Vasopressors for hypotension
Intra-aortic Balloon Counterpulsation
Reduces afterload and augments diastolic perfusion pressure
Beneficial effects occur without increase in oxygen demand
No improvement in blood flow distal to critical coronary stenosis
No improvement in survival when used alone
May be essential support mechanism to allow for definitive therapy
Pathophysiology of Cardiogenic Shock
Cardiogenic shock IS NOT simply the result of severe depression of LV function due to extensive myocardial ischemia/injury.
Depressed Myocardial Contractility combined with Inadequate Systemic Vasoconstriction resulting from a systemic inflammatory response to extensive myocardial ischemia/injury results in cardiogenic shock .
The Overproduction of Nitric Oxide May Cause Both Myocardial Depression and Inappropriate Vasodilatation.
Thus, excess nitric oxide and peroxy nitrites may be a major contributor to cardiogenic shock complicating MI.
Acute Coronary Syndromes: Definitions
Acute coronary syndrome:
Constellation of clinical symptoms compatible with
acute myocardial ischemia
ST-segment elevation MI (STEMI)
Non-ST-segment elevation MI (NSTEMI)
Angina at rest (usually >20 minutes)
New-onset of class III or IV angina
Increasing angina (from class I or II to III or IV)...
Posted by e-Medical PPT
3-5% cases are life-threatening
60,000 hospitalized / 5,000 die
Fires are the 5th most common cause of death from unintentional injury
Deaths are highest among children <5 yr. and adults >65 yr.
Skin is the largest organ of the body
- Prevention of fluid loss by evaporation
- Barrier against infection
- Protection against environment provided by sensory information
Types of burn injuries
Thermal: direct contact with heat
(flame, scald, contact)
A.C. – alternating current (residential)
D.C. – direct current (industrial/lightening)
Burns are classified by depth, type and extent of injury
Every aspect of burn treatment depends on assessment of the depth and extent
First degree burn
Involves only the epidermis
Tissue will blanch with pressure
Tissue is erythematous and often painful
Involves minimal tissue damage
Second degree burn
Referred to as partial-thickness burns
Involve the epidermis and portions of the dermis
Often involve other structures such as sweat glands, hair follicles, etc.
Blisters and very painful
Edema and decreased blood flow in tissue can convert to a full-thickness burn
Third degree burn
Referred to as full-thickness burns
Charred skin or translucent white color
Coagulated vessels visible
Area insensate – patient still c/o pain from surrounding second degree burn area
Complete destruction of tissue and structures
Fourth degree burn
Involves subcutaneous tissue, tendons and bone
Criteria for burn center admission
Full-thickness > 5% BSA
Partial-thickness > 10% BSA
Any full-thickness or partial-thickness burn involving critical areas (face, hands, feet, genitals, perineum, skin over major joint)
Children with severe burns
Circumferential burns of thorax or extremities
Significant chemical injury, electrical burns, lightening injury, co-existing major trauma or significant pre-existing medical conditions
Presence of inhalation injury
Posted by e-Medical PPT
Duration of intubation
Nasal intubation less advantageous for potentially prolonged ventilator requirements
Underlying advanced intrinsic lung or neuromuscular disease
Presence of reversible intrinsic lung or neuromuscular disease
Protection of the airway due to depressed mental status
Presence of reversible upper airway pathology
Patient care needs (e.g., transport, CT scan, etc.)
Aspiration potential or increased respiratory secretions
Hemodynamic issues such as cardiac disease or sepsis
Renal or liver failure
Pathophysiology of the respiratory failure
Hypoxic respiratory failure
- In case of hypoxic respiratory failure, different noninvasive oxygen delivery devices can be used.
- The severity of hypoxia and presence or absence of underlying disease (such as COPD) will dictate the device of choice.
Hypercapnic respiratory failure
- The noninvasive device of choice for hypercapnic respiratory failure is BIPAP.
Assessment of above mentioned patient characteristics in conjunction with the mechanism of respiratory distress leads the clinician to proper choice and duration of invasive or noninvasive options for airway management.
Code status should be clarified prior to proceeding.
Respiratory rate and use of accessory muscles
- Is the patient in respiratory distress?
Amount of supplemental oxygen
- What is the patient’s oxygen demand?
Pulse oximeter or arterial blood gas
- Is the patient physiologically capable of providing appropriate supply?
- Will this patient be difficult to intubate?
- Is there a reversible anatomical cause of respiratory failure as opposed to intrinsic lung dysfunction?
Airway device in place
- Is there a nasopharyngeal airway or combitube in place?
Oxygen Delivery Devices
4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow = 45%)
At most delivers 40% at 10-15 L flow
Small amount of rebreathing
8 L flow = 40%, 15 L flow = 60%
Attached reservoir bag allows 100% oxygen to enter mask with inlet/outlet ports to allow exhalation to escape - does not guarantee 100% delivery.
CPAP is a continuous positive pressure
Indicated in hypoxic respiratory failure and obstructive sleep apnea
BiPAP allows for an inspiratory and expiratory pressure to support and improve spontaneous ventilation
Mainly indicated in hypercapnic respiratory failure and obstructive sleep apnea
If use of noninvasive modes of ventilation does not result in improved ventilation or oxygenation in two to three hours, intubation should be considered
These devices can be used if following conditions are met:
Patient is cooperative with appropriate level of consciousness
Patient does not have increased respiratory secretions or aspiration potential
Concurrent enteral feeding is contraindicated.
Facilitates early extubation, especially in COPD patients
Some devices allow respiratory rate to be set.
Up to 10 L of oxygen can be delivered into the mask for 100% oxygen delivery.
Nasal or oral (full face) mask can be used; less aspiration potential with nasal....
Posted by e-Medical PPT
Composed of a cortex and medulla, which have separate embryology.
The adrenal cortex arises fro m the coelomic mesoderm between the fourth and sixth weeks of gestation.
The adrenal medulla is derived from cells of the neural crest that also form the sympathetic nervous system and the sympathetic ganglia.Some of these neural crest cells migrate into the adrenal cortex to form the adrenal medulla, but chromaffin tissue may also develop in extraadrenal sites.
The most common site of extraadrenal chromaffin tissue is the organ of Zuckerkandl, located adjacent to the aorta near IMA.
The glands weigh about 4g each, located in the retroperitoneum along the superior-medial aspect of the kidneys.
Yellow appearance because of their high lipid content.
3-5 cm in length, 4-6mm in thickness
Receive arterial blood from branches of the inferior phrenic artery, aorta, and renal arteries.
The right adrenal vein is short and exits the gland medially to enter the vena cava. The left adrenal vein exits anteriorly and usually drains into the left renal vein. As a result, adrenal venous catheterization is accomplished more easily on the left than the right.
The adrenal cortex is composed of three zones histologically.
Outer zona glomerulosa, site for aldosterone synthesis.
Central zona fasciculata and inner zona reticularis produce both cortisol and androgens.
Most of the blood supply to the medulla comes from venous blood draining through the cortex. This provides the adrenal chromaffin cells with high concentration of the enzyme phenyethanolamine N- methyltransferase (PNMT) required for conversion of norepinephrine to epinephrine.
Zona glomerulosa is the exclusive site of production of aldosterone because it lacks the enzyme 17 alpha hydroxylase necessary for production of 17 a- progesterone and 17 a-pregnalone, which are the precursors to cortisol and androgens.
Zona fasciculata and reticularis function as a unit to produce cortisol, androgens, and small amounts of estrogen, but it lacks the enzymes necessary to convert 18-hydroxycorticosterone to aldosterone.
Cholesterol is the precursor from which all adrenal steroids are synthesized.
Conversion of cholesterol to pregnenolone is the rate limiting step in adrenal steroidogenesis and is the major site of action of ACTH..
Posted by e-Medical PPT
Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption.
Classification of surgical procedures
Procedures that are solely restrictive, act to reduce oral intake by limiting gastric volume, produces early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications. Some of these procedures are Vertical banded gastroplasty,Adjustable gastric band,Sleeve gastrectomy,Intragastric balloon (Gastric balloon),Gastric Plication ect
Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.
This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.
A trial study performed on rats involved placing a 10 cm long impermeable sleeve into the rat's intestine to block absorption of food in the duodenum and upper jejunum.
Complications from weight loss surgery are frequent.Common problems were gastric dumping syndrome in about 20% (bloatedness and diarrhoea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%.As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery is performed in dedicated or experienced units.
Posted by e-Medical PPT
Surgeon’s role in management of Benign Breast Disease includes:
Assessment of Breast Cancer Risk
Breast Cancer Screening
Providing Specific Diagnosis
Develops from Ectoderm Milk Streak
Lobules and Ducts
The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings.
Branches of Internal Mammary Artery, Intercostal arteries, Axillary Artery
Venous drainage via Internal Mammary, Intercostal, Axillary Veins
97% to Axillary Nodes
Internal Mammary and Supraclavicular nodes
Three Lymph Node Levels:
Level I – Lateral to Pectoralis Minor
Level II – Deep to Pectoralis Minor
Level III – Medial to Pectoralis Minor
Rotter’s – Between Pectoralis Minor & Major
Long Thoracic Nerve
Serratus Anterior m.
Breast Pain (Mastodynia)
More common during reproductive years (premenopausal)
Association with cancer is uncommon
Cyclic pain associated with Fibrocystic changes
Noncyclic pain associated with infection or cancer if associated with mass or bloody nipple discharge.
Tx: NSAIDs, Eve primrose oil, OCP, avoid caffeine
Simple cyst may be observed or aspirated
Bloody aspirate – send for cytology
Not considered “disease”
No increase risk of cancer
Common finding >50%
Most common mass in <30 y/o
Smooth, firm, rounded, mobile
Definitive dx by core or excisional bx.
Change size with menses, pregnancy
Excise if growing or >30 y/o
Long-term risk = 2.17 for cancer (IDC)
Tx is WLE
Associated with THC, spironolactone