Surgery Shelf Review

Esophagus ............................................................................................................................................................................... 2
Stomach / Duodenum ............................................................................................................................................................. 2
Small Bowel ............................................................................................................................................................................. 4
Colon / Rectum ....................................................................................................................................................................... 5
Gallbladder .............................................................................................................................................................................. 8
Liver......................................................................................................................................................................................... 9
Pancreas ................................................................................................................................................................................ 10
Spleen ................................................................................................................................................................................... 11
Carotid artery disease ........................................................................................................................................................... 11
Mesenteric ischemia ............................................................................................................................................................. 11
Peripheral vascular disease:.................................................................................................................................................. 12
Venous disease ..................................................................................................................................................................... 12
Aneurysms & dissections ...................................................................................................................................................... 13
Cardiac surgery ..................................................................................................................................................................... 13
Breast cancer ........................................................................................................................................................................ 14
Thyroid .................................................................................................................................................................................. 17
Parathyroid ........................................................................................................................................................................... 17
Endocrine (other) .................................................................................................................................................................. 18
Hernias .................................................................................................................................................................................. 19
Lung ....................................................................................................................................................................................... 19
Mediastinal masses ............................................................................................................................................................... 20
GU ......................................................................................................................................................................................... 20
Prostate cancer ..................................................................................................................................................................... 21
Renal cell cancer ................................................................................................................................................................... 21
Neurosurgery ........................................................................................................................................................................ 21
Skin cancer & Sarcomas ........................................................................................................................................................ 22
Congenital heart anomalies .................................................................................................................................................. 23
Pediatric surgery: Thoracic ................................................................................................................................................... 23
Pediatric surgery: Abdominal................................................................................................................................................ 23
ENT ........................................................................................................................................................................................ 24
Trauma .................................................................................................................................................................................. 26
Orthopedics........................................................................................................................................................................... 28
Orthopedic oncology ............................................................................................................................................................ 29
Burns ..................................................................................................................................................................................... 29
Complications ....................................................................................................................................................................... 30
Anesthesia............................................................................................................................................................................. 31
Nutrition................................................................................................................................................................................ 31
Pre-op Care ........................................................................................................................................................................... 32
Postop care ........................................................................................................................................................................... 32
Wounds ................................................................................................................................................................................. 34
Other miscellaneous topics: ................................................................................................................................................. 34

Esophagus
DDx Dysphagia
o If regurgitating food: get a barium swallow or upper GI endoscopy.
Zenker diverticulum: pulsion, abnormal cricopharyngeal mm constriction --> pulsion diverticulum. Can get

chronic regurg, halitosis, aspiration PNA. Treat bytransecting cricopharyngeal muscle. If large, may require
excision.
o Dysphagia itself: get barium swallow & scope (always r/o cancer).
Achalasia: dilated esophagus, birds beak appearance, losing smooth mm in Auerbachs plexus. A/w stress,

physical trauma, Chagas disease (T. cruzi). Classically liquids > solids; learning to sit straight and wait for
foods to make it through, can regurgitate large amts of undigested foods. manometry for definitive dx but
might want to get scope first to r/o cancer. Ca-channel blockers may help, but Heller myotomy / balloon
dilation more effective (myotomy is most effective).
Diffuse esophageal spasm: protracted high-amplitude contractions throughout esophagus, normal LES

pressure & relaxation. Usually get myotomy from level of aortic arch down to just before LES.
Esophageal cancer - classically a progressive dysphagia (solids, then liquids) with weight loss, constitutional

symptoms, etc.
Most tumors are malignant:
o Work-up: EGD, (PET)-CT. Can use endoscopic U/S to help stage (is it spreading through wall?) Most present

as advanced lesion (2/3 stenosis needed for sx), no serosa in esophagus so spreads.
o Squamous cell: EtOH, nitrosamines, achalasia, burns. Upper .
o Adenocarcinoma: Barretts is risk factor. Lower . Dont resect barretts alone, but do resect high grade

dysplasia (25% cancer risk). If Barretts, get q18-24mo surveillance EGD + bx.
o If advanced, no surgery, if less advanced, induction chemo to downstage then surgery. (but chemorad alone if

in cervical / upper esoph. - dont do surgery). May do proximal gastrectomy too if in distal .
Ivor-Lewis: abdominal & chest incision
Transhiatal: abdominal and neck incision
3-incision: chest, abd, neck
Most common benign tumor is a leiomyoma - think if esophageal lesion with no sx, can watch until sx develop
Most common motility disorder is achalasia - work up with barium swallow (birds beak), manometry with increased

LES pressure, esphagoscopy to r/o neoplasia. Increased cancer risk. Balloon dilation or esophagomyotomy (modified
Heller procedure) to treat.
Mallory-Weiss: vomiting bright read blood; endoscopy with possible need for coagulation, usually self-limiting
Boerhaaves: Sick looking patient with sudden, severe, epigastric / low sternal pain while vomiting. Gastrographin

swallow to diagnose, then emergency surgical repair (thoracotomy, try to patch & drain mediastinum; if esophageal
cancer at the same time or other obstructive disease, remove esophagus / Ivor-lewis / etc).. If esophageal perf from
instrumentation, same story. Early surgical repair (8h-24h) is key.
Free air under diaphragm (if perforated viscus suspected) - get CXR (not KUB) - most specific way to see. Duodenal
ulcer #1

Stomach / Duodenum
Peptic ulcer disease: linked to H. pylori; 3 or 4 drug therapy, can dx with serum tests, urease breath tests, biopsy.

o ASK ABOUT NSAIDS and steroids!!!!! Stop em if theyre taking em. If ulcer lower down (lower lesser curvature

or antrum), think acid as cause, acid blocking as therapy. If higher up (GEJ / upper lesser curve) think NSAIDs
blocking prostaglandins.
o Surgery if perf, massive bleeding (6 U), gastric outlet obstruction, non-healing ulcer for 6 weeks
V&P for older patients with med problems (quick!)
V&A for younger patients (best sx control)
Highly selective vagotomy if youre a killer surgeon who can do it right - minimal morbidity but high

recurrences if the surgeon isnt experienced

Gastrectomy for recurrences after previous operation (but high morbidity / mortality). Can

do antrectomy if antral ulcer doesnt resolve in 18 wks or so. If distal, can do Bilroth I (excise distal
stomach, gastroduodenostomy) or Bilroth II (if duodenum cant be mobilized; bring up jejunum &
do gastrojejunostomy)
o Gastric ulcers need to be biopsied: can be gastric cancer (esp if deep). Duodenal ulcers dont.
o Dieulafoys Lesion: abnormally large submucosal artery protruding through small, solitary mucosal defect; can

bleed spontaneously & massively. Upper endoscopy, then sclerotherapy / electrocoagulation.

Upper GI bleeds:
o Now: NGT, type & cross, HCt, place 2 large bore IVs. Lavage NGT until no blood left. Run IVF, monitor vitals
o Next: EGD as soon as stabilized. If ulcer found, H2 blockade, monitor pH. ?Misoprostol if taking NSAIDs. Check

for H Pylori & treat.

Ulcer with clean base: just observe on EGD. Fresh clot on ulcer: endoscopic hemostatic therapy
Ulcer with visible artery at base: attempt local control; may be post. duodenal --> gastroduod artery. May

want to operate electively in next 24-48h.

o If bleeding & in renal failure, remember uremia causes plt dysfxn - dialysis, desmopressin make it better, but plt

transfusion is ineffective!!!
o If bleeding & alcoholic / liver dz, remember liver dysfxn increases coag times. May want to give FFP.
o If crashing, take to OR before exsanguinating!
o Remember to give PPx (H2 blockers or PPI) if ICU pt & at risk for stress ulceration
o Diffuse gastritis: keep pH > 5 (antacids, H2 blockers, PPIs) - endoscopic control usually ineffective (multiple sites

of ulceration), so if surgery needed, may need subtotal gastrectomy (high mortality).

o Esophageal varices: treat with FFP to correct thrombocytopenia, vitamin K to fix coagulopathy, octreotide to

lower portal HTN, but endoscopic sclerotherapy / banding is key. Usually have to go back in 48h and ligate a
few rebleeders. Balloon tamponade only if you really need temporary urgent control. May need TIPS too.
discharge on oral beta blocker (may lessen rebleeding risk).
o Mallory-Weiss syndrome: tears through mucosa from forceful vomiting, linear erosions @ GEJ seen on EGD.

bleedign stops spontaneously usually; if not, inject / electrocautery / oversew if really severe.
o Gastric varices: harder to treat than esophageal; dont respond to banding / sclerotherapy very well. May

need TIPS or other surgical portocaval shunt or splenectomy.

Gastrinomas: elevated gastrin levels (can provoke with secretin stimulation test)
o found in gastrinoma triangle (confluence of cystic and common bile duct, , junction of the 2nd / 3rd parts of

duodenum, and junction of the neck / body of the pancreas)

o Treat with medical therapy (high dose H2 blockers) --> surgical resection

 Gastric cancer: most in antrum. Virchows node, Sister Mary Josephs node, Blumers shelf (pelvis), etc. Risk factors:

atrophic gastritis, H. pylori (chronic inflammation), ? high pickled food intake. Dx: EGD + bx > barium swallow.
o Stage first (endoscopic U/S for tumor invasion, CT/PET CT for distal mets). Worse prognosis if through

submucosa, positive LN. Better prog if intestinal type, worse if diffuse. If linitis plastica, pretty much out of luck
(may try total gastrectomy withsplenectomy but rare cure).
o Surgical resection: total gastrectomy + omentectomy!
o Gastric lymphoma: usually widespread on presentation. Stage first. Stage I = surgery + LN rxn) or surg + rad.

Stage II = total gastrectomy, node rxn, adjuvant chemorad. III may operate; / IV = no surg, just chemoradiation.
Note thatn 15 positive nodes = stage IV (nodes can push you forwards!)
Extent of surgery: Proximal: extended gastrectomy / distal esophagectomy. MIddle: total gastrectomy.

Distal: subtotal gastrectomy if adenoCa, total gastrectomy if diffuse type. Controversy re: LN rxn extent
MALT lymphoma is special case: usually just have to treat H. pylori and it goes away!
o GIST tumor - form of sarcoma; c-KIT mutation, tyrosine kinase, treat with imatinib(Gleevec!).
GERD: H2 blockers / PPIs. Avoid chocolate, tea, coffee, alcohol, sleeping flat in bed (help out LES). If sx persist - or

sometimes after 1st episode of significant epigastric pain in older pts, or pts with high risk tumor/ infection: EGD
o Nissen fundoplication if refractory to med tx, or if severe esophagitis / stricture. Not necessary for Barretts

alone if no esophagitis / intractable sx.

Hiatal hernia: if sliding, treat for GERD without surgery. If paraesophageal --> strangulation risk,fix surgically

Small Bowel
Small bowel obstruction: think adhesions (hysterectomy #1), hernias. If tumor related (melanoma > breast), need

rxn.
o Workup: obstructive series (upright PA / lateral CXRs, flat/upright KUB) of radiographs, BMP for fluid /

electrolyte abnormalities (losing HCL; hypochloremic, hypokalemic metabolic alkalosis)

o Observation for most (72h), but think internal hernia --> OR if 1) no prior surgery 2) no external hernias
o Surgery if internal hernia suspected, closed loop, or peritonitis (acute abd, WBC bump, fever, acidosis, etc)
If acidotic, think lactic acidosis / closed loop / necrotic bowel & other badness --> to OR
Ischemic bowel: if necrotic, go to OR. If just ischemic, hydrate & oxygenate, then sigmoidoscopy to

rule out ischemia in colon, then mesenteric angiogram to look for vascular problems; revascularize if
needed, put on aspirin afterwards.
Necrosis of left colon: resect back to well-perfused edges. If stable, good conditions, primary

anastamosis. If not, colostomy and Hartmann pouch with staged takedown later.
Necrosis of whole intestine (ligament of Treitz to transverse colon, etc) - hopeless. dont resect, just

close up, let patient succumb to illness. If young patient, may try to resect aggressively, leave with
short bowel syndrome / need for transplant or chronic TPN.
Necrosis of a few feet of small bowel - resect, reanastamosis if favorable condition, may do 2nd look,

or may bring out ileostomy to observe bowel initially.

If fails observation, go to OR. Free air = to OR, as long as no recent surgeries.
Surgery: ex lap, lyse adhesions, resect nonviable / dead bowel with primary anastamosis even if perfd as

long as you think itll heal (no active infection, not on steroids, etc). Can come back for 2nd look if viability
of bowel is in question (another ex-lap in 24h). If you make an enterotomy (whoops), usually primary
repair; may need to resect if big or multiple, risk of small bowel fistula.
4

o DDx: paralytic ileus (e.g. post surgery), whole bowel distended, NGT only helps a bit,confirm dx with UGS +

small bowel follow-through prior to ex-lap if considering paralytic ileus.

o Biliary gas = gallstone ileus - do cholecystectomy, ileostomy & take out stone @ ileocecal valve
Meckels diverticulum: get 99-tec scan which IDs gastric mucosa. Rule of 2s.
o Resect only if symptomatic, not if incidental.
Small bowel tumors: generally benign, rarely present as SBO.
o Carcinoid tumors: #1 endocrine tumors, most occur in appendix (actually maybe not, see Modlin, I. M., Lye, K.

D. and Kidd, M. (2003), A 5-decade analysis of 13,715 carcinoid tumors. Cancer, 97: 934959. doi:
10.1002/cncr.11105). Labs: serotonin, 5-HIAA levels, CT abdomen / octreotide scan if recurrence suspected.
Considered malignant: if tumor < 1.5 cm, appendectomy alone suffices. If > 1.5 cm, need to do right

hemicolectomy after CT scan of liver! Even if found incidentally on appendectomy.

Carcinoid syndrome implies hepatic mets - can treat with somatostatin
o DDx (also in appendix) - can be adenocarcinoma, will need right hemicolectomy for that too

Colon / Rectum
IBD: bloody diarrhea, abdominal pain, mucosy stools, etc. Colonoscopy if suspected; barium enema can be done too.
o Crohns disease: surgery if stenosis, fistula, abscess, perf, bleeding not controlled with med tx. In generally

doing surgery for sx & active problems, not just incidental radiologic findings
Cant cure Crohns (whole GI tract). Med tx includes sulfasalazine, steroids , Flagyl, 6-MP.
May resect if intractable SBO, etc. If you take out terminal ileum, you dont absorb bile acids (diarrhea,

depletion of bile salt pool, oxalate gall stones) & B12 (megaloblastic anemia & neuropathy)
Perianal fistulas: open the tract if superficial; if deeper, insert seton to allow fistula to close slowly
o UC: can cure UC with surgery!
Surgery if intractable bleeding / obstruction, fail med therapy, toxic megacolon(abd pain, distention, fever,

bloody diarrhea - try NGT / NPO / TPN / IVF/ IV steroids, but observe closely & low threshold for OR).
If indicated but not urgent, generally do a total proctocolectomy withileal pouch creation & ileoanal

anastamosis to try to preserve continence and cure dz. If perfd or pneumatosis, may do a total
abdominal colectomy with Hartmann pouch of rectum & ileostomy instead (quicker but not definitive
for UC treatment since rectum left behind).
Pouchitis - fever, bloody diarrhea, pain on defecation several months after this procedure.

Rx metronidazole, which should resolve the problem.

Severe cancer risk (risk increases greatly after 10 years of active UC - get colo q1-2y after 8 years of disease

if pancolitis, after 10 years of disease if left colon only; remove colon & rectum if severe dysplasia on bx).
Lower GI bleeds: get NG lavage (brisk upper vs lower) if bright red blood. Think hypovolemiatx - 2 large bore IVs, 1-

2L of lac ringers or NS, monitor, routine blood studies, CXR, coags, Foley placement too. then do diagnostics.
o Dx stuff is next: tagged RBC, angiogram as part of workup if lower GI bleeding suspected. Proctoscopy can help

r/o hemorrhoids. Angiodysplasia can cause L-sided bleeding, #1 cause in the elderly. Most common cause of
LGI bleed? UGI bleed! Dont forget to w/u cancer, too
If bleeding has stopped - get a colonoscopy (r/o cancer, look for diverticulosis, treat vascular ectasia with

monopolar current, tattoo polyps or diverticula, etc.)

If sill bleeding:

 get angio if less stable (better monitoring in angio suite, can isolate those bleeding quickly). Angio is

essentially a pre-op test - these patients will go to the OR. Vasopressin in angio or embolization can
rarely be used for controlling big hemorrhage.
Get tec-labeled RBC scan if more stable, bleeding more slowly (more sensitive for slow bleeds, but

cant ID exact location). Rememberpacked RBCs if keep bleeding!

Diverticulosis: most common cause of lower GI bleed.
o Generally in right colon if bleeding (although most diverticula in L colon); eroding through into vasa recta
o Get R hemicolectomy or total colectomy after angio if bleeding recurrent or intractable (> 6 units). Generally

get primary anastamosis. Earlier surgery if becoming unstable, weird blood type, Jehovahs Witnesses.
Diverticulitis: think LLQ pain, fever, tenderness, tachy, etc. in older pt, maybe low fiber, maybe hx constipation
o Tx: liquid diet, O/P broad-spectrum ABX. No morphine (increases intracolonic pressure). High fiber diet.
May get CT to r/o complications. Follow up in a few weeks with colonoscopy / barium enema to confirm

diagnosis and r/o colon cancer.

Follow closely - if getting worse, think perforation or abscess, abd CT, drain if fluid collection / abscess, will

need single-stage colectomy with primary anastamosis, but if really nasty / septic, think Hartmann.
Surgery after 2nd episode (high recurrence rate & complications for pts with 2+ bleeds) - 4-6wks after pts

symptoms resolve. Colonoscopy first or intraop to figure out where to take out. Can do primary
anastamosis usually.
Complications: pneumaturia, think rectovesicular fistula, surgery to separate.
Colorectal cancer: Progression from adenoma to carcinoma
o Adenomatous polyps (e.g. FAP) - premalignant, should be removed.
o Hamartomas (e.g. Peutz-Jeuger) - not malignant.
o Screen starting @ age 50. Yearly stool occult blood or flex sig + FOBT q 5y, or colonoscopy q3-5 / 10y.
1st degree relative with CRC: Start at age 40
FAP hx: genetic counseling, yearly flex sig starting age 10-12, colectomy as soon as polyps found
HNPCC: genetic test, colonoscopy 1-2y starting @ 20yrs, or age 25 or 5 yrs before affected family member

if pt known to have germline mutation.

If s/p CRC resection, CEA q3mo, colonoscopy q1yr & resect polyps; when no polyps found, go to q3-5yr
o Colonoscopy findings:
Small pedunculated polyp (e.g. 1cm) - polypectomy
Larger pedunculated polyp (e.g. 5cm) - polypectomy or removal in piecemeal fashion
Flat, sessile lesion - can remove <2cm, but will need surgical rxn if >2cm
After polypectomy:
severe atypia means polypectomy OK, but close F/U with colonoscopy
carcinoma in situ without stalk extention: polypectomy alone OK (musc mucosa intact), no bowel

resection needed, F/U with colo in q3-6mo then qyr

carcinoma in stalk: polypectomy sufficient if well differentiated, no vascular / lymphatic inveasion,

margin > 2mm; otherwise mark with tattoo, resect that segment of bowel
carcinoma in sessile lesion: need bowel resection!
o Stage with CT C/A/P. If rectal cancer: endoscopic U/S or rectal MRI. Get CEA too.
Stage I: not through muscularis propria

 Stage II: through muscularis propria (T3 = full thickness, T4=adjacent structures), but LN neg
Stage III: positive nodes (regional). Remember rectal cancer <5cm from anal verge can go to inguinal nodes

(as well as internal iliacs, sacral, inferior mesenteric like colon cancer)
Stage IV: liver, distant mets.
o Surgery contraindicated for mets except for resectable liver / lung mets only.
Generally resectable if: no vascular involvement, can leave at least 20% of liver behind including two

adjacent segments, no extrahepatic mets, no local recurrence of primary cancer, not cirrhotic. Can be
lobectomy or segmentectomy or nonanatomic wedge resection, as long as good margin (<1cm) obtained.
If not resectable, could try chemembolization, R-F ablation, etc of mets.
o Surgery: L / R hemicolectomy, total colectomy, etc.
For rectal cancer, TME (total mesorectal excision) /LAR if sphincter can be spared (>5cm from anal verge).

APR (abdominoperitoneal resection) if < 5cm-ish - take out whole rectum, posterior wall of vagina if
female, get permanent colostomy, risk of impotence, bladder fxn dysruption.
Complications:
distention / vomiting - think leakage from anastamosis, obstructions from adhesions, internal hernia,

etc, get CT or small bowel series & NPO/IVF / NGT placement. gastrografin enema or colonoscopy if
worried about anastamotic obstruction, but be gentle!
wound infection = open, inspect fascia, local wound care.
fistulas (fecal stuff draining): most resolve with NPO / IVF alone. CT to look for internal

collection (drain percutaneously or operatively if not possible).

abscess - e.g. 10d post op with fever, RLQ abd pain. Dx: CT, Tx: perc drainage.
anastamotic recurrence: e.g. 6mo later, crampy abd pain, pencil thin stool, constipation.

Colonoscopy! Could be stricture as wel.

o Adjuvant radiation: for colon cancer, if T4 or positive margins (when fixed area). Forrectal cancer -

use neoadjuvant / adjuvant radiation in general (thick target). Neoadjuvant chemo with 5FU; adjuvant with
FULFOX, etc. if +nodes.
o Adjuvant chemo: generally if stage III (positive nodes)
Anal cancer: usually squamosu cell carcinoma. mets to inguinal or superior rectal LN. CT, transrectal U/S to get

dpth of invasion.
o If superficial, small, mobile --> local excision. If bigger but no local extension / negative LN, Nigro

protocol (chemo / rad to eliminate cancer). Get APR 4-6wks lateronly if bx-proven residual cancer. If big, nodes,
nasty, probably need radical resection
Volvulus: abdominal pain, distention, classic bent inner tube or coffee-bean on KUB.
o Sigmoid volvulus - get rigid sigmoidoscopy (can decompress at same time), then may need to resect / pexy to

sacrum during the same hospital stay.

o Cecal volvulus: need urgent surgical treatment (cant fix with barium enema, colonoscopy). Get right

colectomy with primary anastamosis in general if viable bowel.

o DDx: acute pseudoobstruction (Oglives) - acute, massive dilation of cecum, R colon w/o mechanical

obstruction. Seen in cancer pts, ICU pts, seriously ill. Generally manageconservatively until colon diameter 1112 cm, then endoscopic decompression & neostigmine to counteract dilation; surgical decompression of cecum
or R colectomy if not successful.
Appendicitis: #1 cause of urgent abdominal operations.

o Remember appy can be high in pregnant women; can U/S a pregnant womans pelvis to r/o GYN badness but

not good for appendix visualization. Still OK to do appendectomy (much worse for fetus, mom if ruptures!)
o Rectal exam can detect R pelvic pain from retrocecal appendix.
o Steroids can mask inflammatory resonse (high index of suspicion).
o During appendectomy, can amputate appendix if only tip inflamed & close stump, or - if base of appendix

necrotic - can additionally bury the stump into the cecum. If really big involvement, may need R hemicolectomy.
If perforated, remove appy, then incise, drain, irrigate abscess, leave drain, leave skin open.
If normal appy during exploration, still remove appendix but also look for mesenteric adenitis, Meckel

diverticulum, enteritis, ovarian / fallopian problems, diverticula.

Butt stuff:
o Hemorrhoids can be cause of rectal bleeding, but even if hx of hemorrhoids, rule out cancer with sigmoidoscopy

/ colonoscopy!
o Rectal prolapse: surgery if external prolapse, rectal bleeding, really bad for pt. Otherwise high fiber
Rectopexy (fix rectum to sacrum), LAR with anastamosis are options.
o Anal fissures: see ulceration in anal canal, painful when touched, skin tags @ verge, posterior midline
If really painful, consider exam under anesthesia
Tx: conservative: bulk agents, sitz baths, stool softeners.
If deep / chronic: lateral sphincterotomy (divide internal anal sphincter). Bx if suspicious
o Fistula-in-ano: peristent perianal drainage, sinus tract with granulation tissue.
unroof tract, drain collections, allow to reepithellialize, place seton if traversing sphincter
Think Crohns disease if not healing well
o Perianal abscess: anal pain, tender/fluctuant mass, fever. DRAINAGE is #1 tx (not abx.
o Pilonidal abscess: e.g. sacrococcygeal abscess, drainage - unroof, remove hair, heal by 2ary intention.

Gallbladder
Cholelithiasis: Female, Fat, Forty, Fertile; oral contraceptives, TPN, etc. Most are cholesterol stones. Chronic

hemolysis - could be pigment stones (black = calcium bilirubinate, vs brown = biliary infection). Sx: biliary colic. Most
asymptomatic. RUQ U/S is great for dx.. Getcholecystectomy if symptomatic or > 3cm gallstones; generally just
watch if asymptomatic & small stones only.
Cholecystitis: inflamed gallbladder, 95% from stones in cystic duct, 5% acalculus. RUQ pain / tenderness

thats unrelenting (not colic), fever, nausea / vomiting, palpable gallbladder. Murphys sign with RUQ U/S good for
dx, also see stones, distended gallbladder, thickened wall. Elevated WBC, slight elevation in alk phos / LFTs / amylase
/ bili (2-3). Get IVF, abx, early cholecystectomy (48-72h).
o Think acalculous if hx biliary stasis, on TPN, dehydrated, in ICU. Get U/S, HIDA.
Cholangitis: Fever, jaundice RUQ pain (charcots triad) + mental status changes & hypotension (reynolds pentad).

Often caused by choledocholithiasis, or ERCP; also from strictures / neoplasms. Markedly elevated WBC, bili, alk
phos. Give IVF with abx, definitive treatment later; can decompress by ERCP with papillotomy, percutaneous
cholecystosotomy with cath drainage, or laparotomy with T-tube placement.
o #1 organism: E. coli, then klebsiella for biliary tract infection
o Gallbladder emypema: distended GB, fluid with internal echoes, gallstones on ERCP - need emergent operation

with cholecystectomy (if in poor health, percutaneous cholecystostomy an option).

o Emphysematous gallbladder - urgent surgery needed. Same for palpable gallbladder(ready to rupture!)

 Choledocholithiasis: Big bump in alk phos, bilirubin (>3-4),. Management: ERCP with papillotomy & basket / balloon

retrieval, or lap trans-cystic duct removal +/- intraop cholangiogram, or open CBD exploration; also need lap chole!
Gallstone pancreatitis: stone in ampulla. Like cholecocholithiasis, with amylase bump too. Tx: cholecystectomy,

intra-op cholangiography (mandatory imaging!). If pt really sick from pancreatitis, need to delay cholecystectomy
but decompress (consider ERCP instead)
Diagnostic tests:
o RUQ U/S pretty much always first
o ERCP / MRCP to define ductal anatomy. ERCP invasive but can take stones out;pancreatitis is complication
o HIDA can help (cholecystitis - gallbladder doesnt opacify since cystic duct is opacified)
o Only 15% of gallstones calcified / visible on X-ray (vs 85% kidney stones)
Remember to do cholecystostomy tube if patient is unstable & cant take out gallbladder at the moment.
If pregnant: try to manage symptomatic cholelithiasis, gallstone pancreatitis nonoperatively(hydrate, pain meds) . If

cholecystectomy needed, safest during 2nd trimester. In any case, remove gallbladder after delivery.
Complications of cholecystectomy:
o Biliary stricture after cholecystectomy (e.g. pt with biliary obstruction +/- cholangitis who is s/p recent

cholecystectomy) - usually do surgery, bypass withcholedochojejunostomy.

o Biliary leak / infection (postop fever, abd pain) - get RUQ U/S, HIDA scan (good for seeing leaks). Manage with

biliary drainage (temporary stent), then fix the problem (usually choledochojejunostomy - usually dont do
primary repair of ductal injuries).
Gallbladder adenocarcinoma: may look like gallstones. Stage first & see if resectable, then open cholecystectomy

with wide margins, wide resection of surrounding liver, hilar LN resection.

o Can get recurrence @ trocar sites (lap chole not advised).
o Gallbladder polyps: observe small polyps./ Remove polyps > 2cm (7-10% gallbladder adenoCa) or if sx
o Porcelain gall bladder: resect! 50% --> cancer! Get cholecystectomy + wedge resection of liver
Cholangiocarcinoma: painless jaundice. RUQ U/S usually first step, will show dilated intrahepatic ducts but normal

CBD. ERCP/ percutaneous transhepatic cholangiography to characterize level of obstruction, get bx/cytology.
o Generally poor prognosis (lots of vascular invasion).
o First stage with CT: unresectable? Mets? If OK, explore / resect bile ducts / gallbladder (rarely resectable

though). 5-yr survival 15% even with resection. Otherwise palliative stenting of strictures.
Hemobilia: Quinke triad of RUQ pain, jaundice, and GI bleeding. iatrogenic (instrumentation) or traumatic. angio /

endoscopy can be useful; control intrahepatic bleeding with withangiographic embolization

Liver
Segmental anatomy
Hepatic cyst on U/S
o Cystic on RUQ U/S, no internal echoes, asx: no management

needed unless symptomatic, then aspirate

o Multilocular: think Echinococcus, do serologic test, then sterilize with

hypertonic saline before excision, dont spill it!

Tumors: 5% are benign
o Hemangioma: resect only if sx. #1 solid lesion in adults. Labeled RBC

scan useful for diagnosis. Not really a risk for rupture.

o Adenomas, should resolve if you stop oral contraceptives. If large & doesnt go away, may need to resect (risk

of spontaneous rupture)
o Focal nodular hyperplasia: nodular lesion with central scar, radiating out on imaging. Treat like adenoma (can

rupture). Not really associated with OCP use.

Hepatocellular carcinoma:
o can get liver transplant (extra MELD points) - as opposed to mets.
o a/w HBV, HCC, cirrhosis, other stuff (hemochromatosis, schistosomaisis, nitrosamines, organic solvents,

aspergillus flavus).
o Sx: asx or dull, aching RUQ pain +/- fever, malaise, jaundice. abnormal LFTs, elevatedAFP.
o Chemo generally not helpful; resect if possible; if not, should get liver transplant.
Hepatic mets - can resect (e.g. CRC to liver) in many cases, but no liver transplant if mets from primary
Liver abscesses: bacterial = antibiotics & drain if single (only IV abx x 4-6wks if multiple), amebic = metronidazole

& no surgery or drainage (can lead to secondary bacterial superinfection), Echinococcus = sclerotic agents &
drainage

Pancreas
Acute pancreatitis: EtOH, choledocholithiasis, ERCP, viral infections, trauma, scorpion stings / snake bites.
o Ransons criteria: 0-2=2% mortality, 3-4=15% mortality, 5-6=40% mortality, 7-8=100% mortality
At admission: "GA LAW" (glucose > 220, age > 70, LDH > 400, AST > 250, WBC > 18k)
At 48 hours: "C HOBBS" : [calcium < 8, hematocrit fall > 10%, O2 < 60, BUN increase of 5 or more, Base

deficit > 5, sequestration (of fluid) greater than 6 L]

o Complications:
pseudocyst (pt with acute pancreatitis continues to have moderate abd pain, perisisten amylase elevation,

early satiety: watch with NPO/TPN/etc for 6 wks, then might do cystgastrostomy, always want to biopsy to
exclude cystadenoma/cystadenoCa)
abscess (signs / sx of sepsis over next few days after admission - sample / drain),
necrosis - operate
hemorrhage (e.g drain for abscess erodes into artery - angio & embolize!)
o NPO, TPN, IVF, pain control, observe, CXR for free air, etc.
Chronic pancreatitis: related to EtOH. Can drain or resect (subtotal pancreatectomy, not whipple) for pain
Pancreatic adenocarcinoma: DDx includes other things that cause obstructive jaundice.
o Imaging of head of pancreas / bile duct: get a CT (U/S obscured by bowel gas). ERCP if nothing seen. Can also

use upper GI endoscopy with U/S through duodenal wall; can do trans-duodenal bx that way.
o Most commonly head of pancreas (75%) Pathology: mostly ductal adenocarcinoma(islet cell tumors, cystic

tumors, lymphomas too.) Precursor: pancreatic intraepithelial neoplasia.

o Associated Sx: Vague abdominal pain (dull, radiating to back), Cholestatic sx: jaundice, pruritis, dark urine, light

colored stools (if obstructing), Weight loss, systemic cancer sx., Trousseaus syndrome: migratory superficial
thrombophlebitis
o Whipple (pancreaticoduodenectomy) + nodal bx / excision for stage I / II(resectable if no lymph node

involvement, no liver mets, no vascular involvement, etc). 3 anastamoses (pancreaticojejunostomy,

10

hepaticojejunostomy, gastrojejunostomy). Most common complication is leak from pancreaticojejunostomy.

Delayed gastric emptying, intra-abdominal abscess, hemorrhage, mortality (6.6%, lower in high volume) too.
If in body or tail, distal pancreatectomy. especially bad prognosis (grow for a long time before sx).
If lymphoma, treat with chemo / radiation (no surgery)
Endoscopic biliary stent or biliary/enteric bypass if obstructive jaundice bothering them.
o Medical: adjuncts: if metastatic disease. gemcitabine (nucleoside analog) combined with others. 5-FU,

capecitabine are second line. radiation only if for palliative care. If locally advanced: chemo + radiation. Pain
management (opioids, celiac axis alcohol infusion / block)
Others:
o Ampullary adenocarcinoma: workup like cholangiocarcinoma: U/S, then ERCP, then stage with CT; if resectable,

get a whipple (higher cure rate: 65% @ 5 yrs, so pretty good!)

o Duodenal adenocarcinoma: depends on size of lesion. Need whipple if involving ampulla. Otherwise may be

able to do a segmental resection. Poor prognosis.

o Pancreatic cystadenoma: mucinous (most common) F>M, in 50s, resect.
o Pancreatic cystadenocarcinoma: 50% 5 year survival rate: resect
Pancreatic exocrine cell tumors: most are nonfunctional / nonsecretory.
o Insulinoma: 90% are benign (islet cells). Palpitations, tremulousness, tachycardic after fasting

Whipples
triad: FBG < 45, symptoms during fasting, relief of symptoms with glucose. Get serum insulin, blood glucose,
serum C-peptide, urinary sulfonyluria. CT to localize. Treat by resection

o Gastrinomas: Z-E syndrome. Many of these tumors are also benign Most in gastrinoma triangle. recurrent

duodenal ulcers, ulcers in unusual locations, profuse watery diarrhea, with fasting serum gastrin > 750, dx:
secretin stimulation test, resect to treat.
o Glucagonoma: severe, migratory necrolytic dermatitis, stomatitis, mild diabetes. Getglucagon levels,

then CT/MRI pancreas, tumor resection with surgery. Somatostatincan be used medically if inoperable.

Spleen
Accessory spleens in 25% of population. If doing splenectomy, need to take out accessory spleens
#1 organ injured in blunt trauma
Splenectomy: for ITP, hypersplenism, some hemolytic anemias, staging for Hodgkins disease
Post-splenectomy sepsis (e.g. meningococcal, HiB) greatest in children, should give vaxbefore surgery (better

outcomes)

Carotid artery disease

#1 cause of stroke in USA. CEA if
o >50% stenosis and sx,
o Bilateral disease and sx (in R-handed pt, do L CEA first to protect L-sided speech centers early)
o or >60% and asymptomatic (better in higher volume centers, most benefit if > 75-80% stenosis if asx).

Mesenteric ischemia
Acute: Pain out of proportion to exam (think older pt with bad pain but no acute abdomen on PE).

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o Mechanisms: A-fib --> embolus, or MI --> embolus, or MI / heart failure & poor perfusion.
Distinguish with arteriography prior to presentation
Chronic: wt loss, abd angina, food fear, ddx vs malignant disease.

Peripheral vascular disease:

Acute disease: Pain, pallor, pulselessness, poikilothermia, paresthesias, paralysis (worst sign).
o Heparinize immediately, then straight to OR for revascularization (balloon embolectomy or bypass)
o No preop angiography, no thrombolytic therapy - emergency! Will do intra-op angio.
o Watch out for compartment syndrome after reperfusion. Low threshold for 4-compartment fasciotomy.
o F/U: warfarin chronically. Check for AFib / aortography/CT for aortic aneurysm with thrombus, etc.
Chronic disease: progression from claudication --> rest pain. Marker of diffuse atherosclerotic disease (remember to

think about carotids / TIAs, coronary artery disease too). SFA at adductor hiatus is #1 location.
o Surgery if severe chronic disease (rest pain, ischemia, gangrene, etc). If well localized / small lesion, think

angioplasty / stent. If more involvement, think bypass.

o Work up with ABI
0.6-1: c/w claudication: do smoking cessation, excercise, meds
0.3-0.5: c/w rest pain: consider revascularization or angioplasty
< 0.3: impending limb loss! think amputation, revascularization, angioplasty
o If buttocks / thigh claudicating, maybe some impotence (Leriche syndrome) & poor femoral pulse(s),

think aortoiliac disease.

Generally revascularize early (before rest pain) - PTA (percutaneous transluminal angioplasty) if short,

limited extent, aortobifem if more extensive disease. Can use axilobifem if wont tolerate big open
procedure, or fem-fem if one patent femoral.
o If ulcer in setting of chronic ischemia, revascularize. may amputate if short life span, wont tolerate surgery, etc
Before bypass, get arteriogram to define anatomy & lesions. Remember thatthis is a big cardiac risk - full

workup including pharm stress test (cant treadmill well). Delay for 3mo after MI.
F/U with heparinization in short term, then longer term aspirin for antiplatelet therapy, lipid control, foot

care education, smoking cessation

o If after revascularization, painful, cyanotic toes, think trash foot (atheroembolization during surgery).

Embolectomy if big vessel / accessible; just watch if small pedal / digital vessels only (usually heals)

Venous disease
PE: dx, Rx, complications. Heparinize, embolectomy if about to kill the patient, IVC filter if contraindication to

heparin (e.g. past HIT, bleeds elsewhere) or previous DVT / PE on heparin.

o Most common ABG abnormality for PE = decreased PCO2 (hyperventilating). get CXR for PNA, atx, PTX. V/Q

or spiral CT if PE suspected. Look for DVT at the same time. Treat PE just like DVT (heparin --> warfarin).
DVT: if suspected clinically, heparin (70-100 U/kg bolus, 15-25U/kg/hr x 4-6d, bed rest 24-48h, LMWH too), keep PTT

ratio at 1.5-2, watch out for HIT (follow plts), then eventually transition to warfarin x 3-6mo to INR 2.0-3.0, keeping
heparin on for several days after warfarin started (protein C deficiency @ start of warfarin --> temp hypercoag)
Thrombophlebitis: inflammation / thrombosis of superficial vein. Tender, palpable cords; warm, red vein
o Generally elevate extremity, heat for pain, compression stockings, NSAIDs for pain.

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o If supperative - associated with IV infusions, drop of pus @ needle site - excise infected vein, abx
Venous stasis ulcers: chronic LE swelling, ulcers on medial malleolus, get medical therapy(wrap, boot placement,

etc)
Phlegmasia cerulea dolens - acute interruption of venous outflow (e.g. obstruction 2/2 malignancy, from big

ileocaval DVT) - painful blue erythematous leg. Treat immediately! anticoagulate, elevate leg, obsurve viaility of
tissues; then evaluate with duplex U/S, CT pelvis. Rarely may need venous thrombectomy.
o Vs. phlegmasia alba dolens - same thing but white leg, seen in pregnancy, not DVT-related.

Aneurysms & dissections

Aneurysm rupture can be rapidly fatal - emergency dx, treatment if symptomatic aneurysm or dxn!
o AAA: if clearly rupturing (pusatile abd mass, pt in shock, hypotensive), straight to OR. If back pain but pt stable,

known AAA, could be other things on ddx - get CT, then to OR if confirmed that aneurysm is leaking.
Wait until clamped to resuscitate with lots of fluid (increased volume / pressure --> increased rupture risk).

Just type & cross, EKG & to OR.

o If you just find the AAA on exam, or if no sx suggesting rupture, then U/S or CT to characterize size.
Aneurysm repair: 7 cm for thoracic aorta \ 5.5 cm for AAA \ 4 cm for iliac \ 2.5 cm forfemoral \ 2 cm for popliteal
o Complications of surgery for AAA:
cross-clamping above renal artery = inducing prerenal ARF
impotence from interfering with nerves crossing iliacs, anterior spinal syndrome (bowel/bladder probs,

loss of motor / fine touch but preserved dorsal columns = prop / vib),
ischemic colitis (interrupt IMA with poor colateral flow from SMA, hypogastrics - if theres brown/bloody

diarrhea, abd pain / tenderness, ileus, increased distention, sepsis / peritonitis, get sigmoidoscopy, then
NPO / TPN / abx, may need resection if non-viable).
graft infection (s. epi, s. aureus contamination) - fever, inflamed incision, may show up months/years later

(evade host with glycocalax). Need to remove graft, debride infected tissue, then revascularize by extraanatomic bypass, long term abx.
aortoenteric fistula: massive upper GI bleed into distal duodenum. Remove graft, repair GI tract, extra-

anatomic bypass.
Dissections: sudden tearing chest / back pain, hypertensive & tachycardic, diaphoretic (vs ruptured aneurysm, where

pt is hypotensive & has hx of aneurysm)

o Get aortogram / TEE / CT for diagnosis - whatevers fastest to make dx.
o Treatment: Thoracic aorta:
dxn of ascending Ao= surgery
dxn of descending Ao= medical therapy (beta blockers to reduce shear forces).

Cardiac surgery
CABG if > 70% stenosis, 3-vessel or L main disease. Biggest benefit for 3 vessel & reduced EF. IMA > saph graft
o PCTA - 30-60% reobstruct within one year. Use for less complicated disease.
Aortic stenosis repair if bicuspid valve or < 1cm surface area, or if symptomatic (SOB / angina / syncope).
2

o W/U: get a cardiac cath first to see coronary circulation status; also see Ao valve size, pressure gradient,

ventricular fxn, etc. Get carotid doppler to r/o ICA obstruction (similar sx).
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o Surgery: if high grade stenosis & preserve ventricular fxn, fix it - even if pt is in his/her 80s! Replace the valves

(mechanical = durable but need anticoagulation; tissue = nonthrombogenic but need replacement ~7yrs)
Aortic regurg after rheumatic fever, marfans, endocarditis, aortic dissection
Mitral stenosis mostly from rheumatic fever, surgery if fatigued / dyspnea. Repair / replace valve.
Dilated CM: may be after myocarditis. Low EF. beta-blockers help heart function, but still may deteriorate &

need heart transplantation, of which accelerated coronary artery atherosclerosis (?form of chronic rejection) is a
major complication (along with infections from immunosuppression).

Breast cancer
#2 cause of cancer death in women (after lung cancer). Risk factors: age, family / personal hx, atypical hyperplasia,

LCIS
Screening: controversial, but BSE qmonth, physician exam qyear, mammography qyear after age 40, consider more

frequent if higher risk (e.g. 1st degree relative with breast cancer, etc) - start BSE age 20, twice-yearly exam by
physcian, start mammograms @ age 30, etc.
Palpable lump in breast:
o Older woman (35-60): probably cancer. Any hx of trauma is probably incidental. W/U:mammogram plus:
Ultrasound if cystic feeling or hx cysts (aspirate only for sx)
Biopsy (core biopsy or open surgical > FNA) if solid feeling.
o Young woman (under 30): probably benign. Mammograms not as helpful (breasts too dense)
Still want to have suspicion of carcinoma. U/S before mammogram (spare radiation).
Cyst: observe, simple aspiration.
Solid & typical of fibroadenoma (98% of lesions in this age group): observe or may electively remove

without prior biopsy, but might still want to get FNA or core bx. Firm, rubbery, painless, moveable, wellcircumscribed.
If mass persists, enlarges, looks suspicious - get a core needle biopsy
o Phyllodes tumor: large, bulky mass, variable malignant potential, may have ulceration -excise with generous

margins. Generally in older women.

o Fibrocystic disease of breast: tender breasts before menstrual periods, lumpy breasts. May get

mammography, eliminate caffeine from diet, a/w low risk cancer.

Nipple-related presentations
o Nipple discharge: Most common cause of bloody discharge is intraductal papilloma. Clear discharge usually

related to fibrocystic chaneg. Bilateral discharge probably physiologic.

W/U: Mammography, close examination to look for single duct source, thenductogram (dye into

duct), surgical excision of localized lesion.

o Nipple lesions:
Crusty lesion in older woman: Can be benign, but r/o Pagets disease of breast (infiltraing ductal carcinoma

or DCIS). W/U: mammogram, breast exam. If more masses, stage --> mastectomy. If confined to
nipple, excise nipple/areolar complex or primary radiotherapy.
Mastitis if postpartum woman, low grade fever, firm/tender/red breast mass. Treat with warm

compresses, abx to cover strep, keep breastfeeding. If fluctuant, think abscess --> drain. If doesnt go
away after several weeks, may need biopsy (could be inflammatory ca). If the woman isnt lactating, then
high suspicion for cancer.
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 Mammography recs:
o Any breast abnormality that is new since last mammogram: mammogram +ultrasound (if palpable) to start

with, then needle biopsy to guide what youre going to do. Screening mammogram: takes a while to get on
schedule, read days later, called back later, etc - takes several weeks. Diagnostic mammogram: if you suspect an
abnormality. same technique as screening. but read by radiologist before woman leaves.
o Work up all breast nodules - never delay bx of suspicious lesion just because mammogram negative
If probably benign can follow closely, as long as patient compliant. If suspicious, bx
Suspicious: breast calcs smaller than 2mm, punctate / microlinear / branching, clustered > 5calcs / cm3;

stellate lesions; masses with ill-defined borders; solitary dominant masses; distorted archetecture.
o DCIS: observation or mastectomy. Microcalcs on mammography
o LCIS: risk for bilateral disease: observe, or bilateral prophylactic mastectomy (if big time family hx, etc)
Ways to get tissue:
o FNA: not great. Often produces nondiagnostic specimen (cant be sure you got the lesion if normal)
o Stereotactic core needle bx: more reliable sample, takes multiple cores, good for your general microcalcs

suspicious for DCIS

o Needle localization / open surgical biopsy: most reliable but most invasive; can also excise lesion at same time.

Best for highly suspicious lesions

Biopsy findings:
o DCIS: Excise. 10-20% of these lesions will actually have invasive component when excised.
Comedo pattern is higher malignant potential. (Vs micropapillary, cribiform) No nodal dxn in general for

DCIS, but comedo can go to nodes - consider SN ax node sampling

If diffuse or multicentric, do simple mastectomy.
If smaller, wide excision with path-free margins + radiation therapy,
o LCIS: usually an incidental finding (no lump). Surveillance is the strategy (marker ofbilateral risk). Treat

with close observation, exam / mammography q6mo x several years. If high risk pt, hx breast cancer, etc, may
consider bilateral simple mastectomies + immediate reconstruction.
o Sclerosing adenitis: clusters of microcalcs on mammography. Routine follow-up
o Atypical ductal hyperplasia: Similar to DCIS, 4-5x higher cancer risk, needle localization & complete excision

with close observation is key (15-50% will be malignant - treat those accordingly).
Staging: Get mammogram to look for other lesions in same breast, CXR / LFTs / CT to stage
o Stage I: T1N0M0 = tumor 2cm or less, no nodes, no mets
o Stage IIA: 2cm or less with moveable ax LN mets, or tumor 2-5cm with no nodes
o Stage IIB: 2-5cm with moveable ax LN mets, or tumor >5cm with no nodes
o Stage IIIA: Fixed, matted lymph axillary nodes and any tumor size
o Stage IIIB: Tumor directly extending to chest wall or skin
o Stage IV: Distant mets including supraclavicular nodes
o Worse prognosis if inflammatory (ulcerated, peau dorange, big edema), retraction of skin or nipple, fixed to

chest wall - if so, multimodality therapy is key.

Surgery:
o Dont hit the long thoracic nerve - serratus anterior, winged scapula
o DCIS treated like cancer (mastectomy, tamoxifen, etc). LCIS isnt.

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o Almost all women can choose between [lumpectomy+radiation] & mastectomy. No difference

in survival between [lumpectomy + radiation] vs mastectomy - more surgery not necessarily better.
If you cant get the radiation, then you cant choose the lumpectomy. Previous irradiation (e.g. previous

breast cancer with lump+rad, now recurring, or women with Hodgkins disease - higher risk breast ca!) or
scleroderma patients; also need a mastectomy if: multicentric disease, big tumor:breast volume ratio (poor
cosmetic outcome), or T4 tumors(inflammatory, chest wall, skin invasion)
Can get chemo if pregnant (esp in last 2 trimesters). Chemo first ifinflammatory cancers (risk of death

high from systemic spread)

Lumpectomy = excisional biopsy, which is preferred to incisional. NEVER do an incisional biopsy in breast -

if too big to excise, do a needle biopsy for your sample. Always lumpectomy AND RADIATION THERAPY
o Partial mastectomy = lumpectomy with intent of clearing margin (dont do for benigndisease - know its a

cancer, take margins along).

o Total mastectomy removes the breast, but doesnt affect the lymph nodes (if nodes negative, may have total

mastectomy + sentinel node bx; if prophylactic, just total mastectomy & leave LNs). May use for LCIS or DCIS.
Add in post-mastectomy radiation therapy if high risk of local recurrence (4+ nodes or T4 tumor).
o Modified radical mastectomy: a total mastectomy (any of above forms) + level I/II LN(lateral & posterior to pec

minor; level III is medial to pec minor). Can do sentinel node biopsy (although very recent evidence = maybe
not useful?) instead. Usually dont do this if tumor <2cm although varies with breast size, pt preference.
o Generally cant do mastectomy if involving chest wall, extensive local / regional dz, or stage III/IV cancer
o Reconstruction: usually do immediately (avoid second operation, good outcomes), often TRAM flap.
Neoadjuvant chemotherapy: consider if stage III (try to downsize). For stage IV, palliative rad / chemo only.
Adjuvant therapy:
o If < 1cm and no nodes: no adjuvant therapy
o If > 1cm and no nodes: chemo for everyone, tamoxifen if ER+
o If > 1cm and node positive: chemo for everyone, tamoxifen if ER+ andpostmenopausal
Pregnancy & breast cancer: prognosis is similar. get U/S + bx (avoid radiation of mammogram). ER/PR status

unreliable.
o Stage I/II: Mastectomy / lumpectomy usually safe for stage I/II (1% risk abortion); if lumpectomy, irradiate after

delivery (usually OK if third trimester since not much delay, but if earlier, get mastectomy).
o Stage III/IV: Need rapid chemo / rad treatment; may need abortion to allow treatment.
Men with breast cancer: rare, age >60, get bilateral mammogram if mass found, mastectomy + radiotherapy
Younger pts & breast stuff
o Adolescent boy: gynecomastia (most commonly in adolescents or men 40-50, can be unilateral, counsel that the

condition usually spontaneously remits)

o 6 year old girl with unilateral breast mass: probably breast bud with premature / asymmetric development;

observe & reassure parents

Pt with hx breast cancer s/p resection:
o Nodules in area of surgery are local recurrences until proven otherwise - BX (surgical or core-needle) Local

excision if previous mastectomy; mastectomy if previous lumpectomy + rad, staging with CT C/A, etc.
o Mammographic abnormality in opposite breast: Probably new primary. Treat like typical mammogram prob
o Elevated LFTs --> liver mets, pathologic fx or hyperCa --> bone mets, new weakness --> spinal met, seizure -->

brain mets
16

Thyroid
Solitary thyroid nodule: think past hx radiation, family hx, thyroid pattern, etc. 15% malignant. Dominant nodule in

multinodular gland = only 5% malignant unless prev irradiated. Also higher risk malignancy with hashimotos.
o If radiated in past - go straight to resection
o If FHx: screen for RET gene for MEN II
o If harseness, hard/fixed nodule, dypsnea, dysphagia, cervical nodes, vocal cord paralysis: think malignant
o Workup: Get an FNA. If a cyst, aspirate, remove if recurs or >4cm. Generally no need to scan with radioactive

iodine if solitary, but hot nodules rarely cancerous. U/S can help determine cyst vs solid. Generally dont even
need TFTs, but if using thyroxine to suppress TSH, monitor TSH. Colloid nodule = benign, no need for surgery.
o If a hot adenoma (making T4, hyperfunctional, etc) make sure to beta block before surgery
o If theres a lateral lump in neck & bx shows normal thyroid tissue, its not a lateral aberrant thyroid- its

metastatic thyroid cancer from an undetected primary. Get a thyroid scan, do surgery.
Papillary carcinoma: more closely associated with ionizing radiation. Psamomma bodies are marker. #1 type

thyroid cancer. Malignant. If mixed with follicular, behaves more like papillary cancer. Mets go to cervical nodes;
distant mets more uncommon, less aggressive than follicular.
o Surgery needed - total thyroidectomy if previous head/neck radiation, thyroid lobectomy & isthmusectmoy if

no pervious head or neck lesions. May be able to take out some LN mets (spreads via lymphatics).
o Postop- suppress thyroid with levothyroxine, may need iodine ablation.
Follicular carcinoma: #2 cancer, a/w iodine deficiency. Propensity for vascular, not lymphatic spread.
o Get thyroid lobectomy & isthmusectomy if well circumscribed, microinvasive, buttotal thyroidectomy if > 4cm.

If clearly follicular cell cancer on frozen section, then total thyroidectomy for anything > 1cm.
o Postop - iodine ablation.
Medullary carcinoma: 80% sporadic, 20% familial including MEN 2A/B, elevated calcitonin level, parafollicular C cell

hyperplasia & amyloid deposits on path. Really malignant. Needmandatory total thryoidectomy.
o Postop - can measure CEA, serum calcitonin
Anaplastic cancer - undifferentiated cells. Really nasty & advanced at presentation - chemo / radvs salvage surgery.
Hurthle cells - can be seen in adenoma or hurthle cell cancer; lobectomy indicated either way,total thyroidectomy if

its cancer.
Graves disease: T4 high, TSH low. Lymphocytes on FNA - think chronic lymphocytic thyroiditis vs lymphoma; get

flow cytometry, radiate if lymphoma (very sensitive)

Surgical options:
o Risks: recurrent laryngeal nerve damage (unilateral - hoarseness, bilateral = VCP, will need trach), external

branch of sup laryngeal (alters high-pitched signing voice),hypoparathyroidism --> hypocalcemia

Parathyroid
HyperCa: lots of causes. #1 is primary hyperPTH from parathyroid adenoma. Also thinkrenal disease (2ary

hyperPTH), MEN, lung cancer (PTHrp), malignancy, etc.

o Workup: PTH, serum alk-phos, phosphate levels. Pres: stones, bones, abd moans, Chovstek, Trousseaus if

symptomatic. Generally explore when Ca > 11.

17

o Generally explore neck without other pre-op studies for primary hyperPTH thought to be from adenoma
Generally resect adenoma, bx another gland to see if normal.
Some surgeons get preop sestamibi scan to see which ones enlarged, go get it(minimally invasive)
Risks: injury to recurrent laryngeal, external branch of superior laryngeal.
If only 3 glands found: look in thymus, inside thyroid, tracheoesophageal groove, carotid sheath.
If hyperCa persists afterwards - persistent hyperparathyroidism. Get setamibi, U/S, CT, MRI, angio to look

for missing parathyroid, then reexplore.

o Acute hyperCa with symptoms: still parathyroid adenoma; could be metastatic carcinoma, etc. Needs lots of

fluids & furosimide (loops lose calcium), then when stable, neck exploration
o If secondary hyperparathyroidism (e.g. chronic renal failure --> retain PO4 as GFR goes down --> hypocalcemia -

-> increased PTH - hypocalcemic!), pts have bone pain, pruritis, calcifications in soft tissues, fractures, etc. On
exploration, see hyperplasia of all glands
Tx: excision of all but 50mg of parathyroid tissue (3 gland excision, can implant in arm or neck).
o Hypercalcemic pt with uncontrollable HTN - think PHEOCHROMOCYTOMA (MEN II).
Get urinary catecholamines, metanephrines, VMA, MRI of adrenals. Alpha-block with phenoxybenzamine

before beta blocking, thensurgery(adrenalectomy)

o Hypercalcemic patient with recurrent duodenal ulcers - think ZE-syndrome (MEN I). Check family hx, look for

gastrinoma (secretin stimulation). Could also be insulinoma, pituitary adenoma

Localize with CT/MRI, then usually nonoperative treatment (often multifocal) but can be agressive - try to

remove as much tumor as possible, use surgical enucleation, may need whipple if near duct or distal
pancreatectomy if down in tale. If no other options, gastrectomy or HSV.

Endocrine (other)
Cushings: overproduction of cortisol, pituitary tumor (dz) or other causes (syndrome: steroids, etc)
Adrenal mass / incidentaloma: excise if symptomatic, has biochemical activity, or >4cmin size
o Hyperaldosteronism: (Primary = Conns syndrome = adrenal in origin, either adenoma or hyperplasia).

hypoK and HTN. W/U: serum aldosterone, renin (aldo high, renin low = probably adenoma related, making
aldosterone & suppressing renin). If adenoma, CT/MRI then surgery; if hyperplasia, aldactone /
spironolactone / etc. Adjuvant therapy may include mitotane after adenoma rxn (toxic for hyperfunctioning
adrenocortical cells).
Prolactinoma: #1 pituitary tumor, not malignant. Lactating woman / man, bitemporal hemianopsia. Dx with serum

prolactin level; bromocriptine or cabergoline (dopamine agonists) to shrink tumor, surgery if medical therapy fails.
Acromegaly: physical appearance (coarse features, etc), high GH, rx with surgery, XRT, bromocriptine
Pheochromocytoma: use phenoxybenzamine for irreversible alpha blockade, then start beta-blockade (otherwise

get unopposed alpha stimulation & refractory htn).

o DDx of refractory HTN: coarc (CXR, scalloping of ribs; HTN in upper extremities but normal in lower

extremities), renovascular HTN (bilateral stenosis, or fibromuscular dysplasia), hyperaldosteronism

MENs:
o I: Parathyroid, pancreas (islet cell), pituitary tumors
o IIa: MTC, pheo, parathyroid
o IIb: MTC, pheo, mucosal neuromas, marfanoid habitus

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Hernias
DDx: lymphadenitis (tender LN on palpation), testicular torsion / epididymitis.
Inguinal is #1, femoral more common in women than men - but indirect inguinal #1 in both sexes.
Incarcerated (cant reduce, maybe some N/V/distention) - operate urgently (next available OR time)
Strangulated (badness! no blood supply, sx, etc - with fever, leukocytosis, acidosis) - right to OR emergently
o Most common in femoral, then indirect hernias.
Umbilical: in kids, can follow until 4 years of age; offer elective repair for older adults
Also think about ventral / incisional hernias or internal hernias in ddx of abdominal pain. Should repair (risk of

bowel incarceratino and strangulation). Optimize medically, nutritionally, etc first

Repairs
o Bassini, Coopers, Shouldice: open repairs
o Lischtenstein repair: prosthetic mesh to approximate wall; tension free, most popular.
o Laparoscopic: various types, involve mesh, maybe faster recovery but no real benefit in efficacy, more $$
Artificial mesh OK if not infected; if accidental enterotomy, etc - need biomesh
o Complications in general: genitofemoral, ilioinguinal, iliohypogastric, lat fem cut nerves nearby. Also

recurrence in 1-10% depending on surgeon. Try to preserveilioinguinal nerve & spermatic cord.
o F/U: no heavy lifting for 6 wks.

Lung
Tension PTX: needle decompression immediately with clinical signs!
Spontaneous PTX: chest tube first time around, then blebectomy + pleurodesis if recurs
Solitary pulmonary nodule workup: neoplasm, infection, trauma, congenital, other
o Benign usually smooth, pts < 50 y/o; malignant irregular / spiculated, pts > 50
Granulomas can contain Ca, cancers dont
Hamartomas = popcorn (benign), bulls-eye probably benign
Consider fungal dz as well if in southwest (coccidio), mississippi river valley (histo)
Think TB if in prison, travel out of country, etc.
Can check previous scans (no change in 2 years = more likely benign)
o Get a CT, then needle biopsy with CT guidance (bronchoscopy, thoracetesis, mediastinoscopy, trans-thoracic,

etc) for definitive diagnosis. Resect if malignant / indeterminate. If you cant do biopsy, do PET CT (positive
PET for lung - 95% are true positive; negative PET - only 80% are really negative, so doesnt help). 1st morning
sputum cytology less likely to help. Bone scan only if high alk-phos, low GGT.
Symptomatic pulm nodules (e.g. in smoker with enlarged nodes as well): Get bronchoscopy to get tissue dx, location

of lesion; mediastinoscopy for node assessment.

Lung cancer:
o Risk factors: Smoking: 20 pk/yr hx is significant. 20 years until risk of Ca drops off significantly. Work exposures

(asbestosis in combo with smoking), radon too.

o Staging: Stage I = localized to lung, II = LN involvement, III = spread beyond lung (including contralateral hilar

mets or nodes in mediastinum).

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o Small-cell: think as systemic disease beginning in lungs; early mets, rarely resectable. Chemo is primary tx.

HIGHLY associated with smoking. DDx (path) includes carcinoid - same precursor.
For a young person with SCC vs carcinoid, recurring PNA - most likely carcinoid
o Non-small cell: think of as local disease. Mostly adenoCa / squamous cell. Resectgenerally for stage I/II.
o Surgery: Generally for stages I/II. Stage III --> neoadjuvant chemo/rad therapy; may be able to downstage
Dont want to do a wedge resection! At least a lobe should come out.
Lobectomy if confined to a lobe
Pneumonectomy if involving main bronchus / throughout lung
Sleeve lobectomy if involving mainstem bronchus (divide mainstem bronchus above / below involved lobar

bronchus, then resect lobe / put bronchus back together). Harder, lower initial mortality rate, but may not
always be feasible.
Pancoast tumor: if no mediastinal nodes, can irradiate x 6 wks, then resect chest wall / lung
Carcinoid tumor: syndrome is rare with lung disease. Bronchial adenomas, e.g. carcinoid tumors (young person,

nonsmoker with hemoptysis, partial lung collapse, recurrent PNA) -biopsy (although can bleed),
then lobectomy or sleeve resection if just on airway.
Empyema: drain it! Community: think strep pneumo. Hospital: think S. aureus, GNR, could be anaerobes.
o If PNA, ABX / evacuate pus / expand the lung (chest tube drainage).
o If organizing / loculated - may need thoracotomy & decortication (remove that tissue).
Pleural effusion without heart failure in an older person = cancer until proven otherwise. Thoracentisis, pleural bx

needed. If mesothelioma, could get extrapleural pneumonectomy(parietal, visceral pleura along with lung) - high
morbidity / mortality, but only chance for survival (chemo/rad dont work).

Mediastinal masses
Anterior mediastinum: generally just image / remove anterior mediastinal masses (if suspect thymoma - can seed).

Remember mediastinoscopy doesnt get you through to the anterior mediastinum (just around trachea)
o Thymoma: anterior medistinal mass + myasthenia gravis (muscles fatigue quickly, esp on upwards gaze; anti-

ACh receptor antibodies, classically tensilon / ephedronium test; medically can use neostigmine / pyridostigmine
- AChEis). Also a/w RBC aplasia. Remove the thymoma.
o Teratomas: anterior mediastinal mass, epidermal layer, hair/teeth/etc. Get beta-HCG, AFP, then remove.
o Lymphoma: rad & chemo (Hodgkins / non-hodg). Anterior mediastinal mass. Should get open biopsy first.

Surgery only if needed to confirm dx.

o Thyroid masses: superior mediastnum, do thyroid scan.
Middle mediastinum: usually bronchogenic cysts, pericardial cysts (water bottle shaped) -remove (can lead to

fistula, etc) via posterolateral thoractomy

Posterior mediastinum: think neurogenic tumros (neurilemoma > schwannoma, etc. Removeif in spinal canal.

GU
Trauma - if pelvic fx suspected or blood in meatus, get RUG before foley placement, then work your way up if

hematuria / blood seen: cystourethrogram (also for bladder rupture), then IVP / angio.
o Posterior urethral injury (e.g. high riding prostate, above findings) - SP cath & delay repair for 6mo
o Operate on a ruptured bladder if urine going into abdomen (superior aspect of bladder), otherwise delay.

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o Scrotal hematoma: only operate if ruptured testicle (get U/S to see)

o Penile shaft hematoma - pt usually has cover story, but this is from sex, with woman on top. Emergent surgical

repair is indicated.
Kidney stones: may pass if distal, < 0.5 cm; otherwise probably need IVP to look at grade of obstruction, and then

definitive treatment.
Abdominal testes: high incidence of carcinoma. may try chorionic gonadotrophin therapy for a month or so,

but orchiopexy into scrotum by age 1 if no descent.

Testicular tumors: painless, firm masses. Get AFP, beta-HCG, U/S. treatment: Orchietomy, abdominal LN dxn, +/-

XRT
o Seminomas are really radiation sensitive
Testicular torsion: Can try to open book (reduce in ER). Dx with doppler U/S. DDx includes epididymitis.
o Emergency surgery with bilateral orchioplexy (high incidence of bilateral bellclapper deformity - pex both!)

Prostate cancer
PSA > 4 is rough guide for abnormal. Get transrectal U/S with biopsy, then look at Gleason stage (~7 is badness)
Treatment: RRP avoids impotence, incontinence. XRT + hormonal rx has similar 10 year survival. Brachytherapy an

option if locally confined disease.

Renal cell cancer

Smoking is risk factor. Very vascular tumor, from proximal tubular epithelium. metastatic @ presentation
Presentation: gross, microscopic hematuria. Associated paraneoplastic dz: epo, PTH, ACTH, insulin, hepatic dysfxn
VHL: multifocal disease with renal cysts, cerebellar tumors, phenos.
Treatment:
o Radical nephrectomy is standard. Partial nephrectomy for small lesions or if borderline renal fxn
o Embolization for large tumors (palliative only). Immunotherapy with IL2 may have role

Neurosurgery
Epidural hematomas: middle meningeal, lens-shaped, brain herniation. Lucid interval with rapid deterioration.

Treat with emergency decompression (burr holes)

Subdural hematomas: low-pressure bridging veins, venous bleeds. Think older pts on anticoagulation
Basal skull fracture: raccoon eyes, bruising around ear or mastoid bone, blood behind TM, CSF otorrhea/ rhinorrhea
o Dont place NGT / nasotracheal tube if at all possible - can go into brain!!
If suspect increased ICP: elevate head of bed, hyperventilate to PCO2 26-28, use mannitol(slowly - rapid can cause

asystole - but can decrease ICP in 15-20min), and give phenytoin loading & continue for 1 wk (for sz), try to avoid
sedating medicines (need to follow neuro exam).
o If blown pupil, lateralizing deficit, etc --> suspect focal lesion --> CT
Sodium problems seen in head trauma
o SIADH (low blood sodium with elevated urine sodium) - water restriction; if severe or with sx; 3% NaCl & correct

slowly (1/2 of deficit over 24h) to avoid central pontine myelinolysis

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o Diabetes insipidus (high blood sodium with low urine sodium) - can test by measuring urine osm before/after

ADH administered. Treat with subq vasopressin / ddAVP &free water administration.
Cavernous sinus thrombosis or orbital cellulitis: hx of sinusitis, then seeing double - get to hospital, high dose IV ABx,

drain surgically (paranasal sinus or orbit), CT guidance.

Tumors:
o Craniopharyngiomas: calcification; in epithelial remnant of Rathkes pouch, in sellar/suprasellar region,

compress pituitary / optic tracts / 3rd ventricle. Mostly in kids; can cause growth retardation (HPA dysfxn).
transsphenoidal excision + adjuvantradiotherapy
o Meningiomas: relatively benign, arise from arachnoid, tx by surgical excision
o

Skin cancer & Sarcomas

BCC is most common, a/w UV light, on head & neck, waxy in appearance. Treatment: complete

excision with biopsy to establish pathology, excision with primary closure, Mohs micrographicsurgery (tumor
mapping to determine adequacy of resection, best cure rate: 99%) useful. Cryotherapy / topical chemo not good.
Squamous cell carcinoma: #2 in frequency. Can grow rapidly, can metastasize via blood / lymphatics. Exposure to

sunlight is #1 risk (lips, paranasal folds, axilla), actinic keratosis is precursor lesion, can also arise in setting of old
burn scars or people exposed to arsenic, nitrates, hydrocarbons. Excisional biopsy is preferred. Also remove clinical
palpable nodes (but only those).
Melanoma: Stage with TNM, get Breslow depth (not diameter). ABCDE rule.
o Wide local excision with SN Bx key
CIS: 5mm margin
< 1mm thick: 1 cm margin
> 1mm thick: 2cm margin
o May do incisional bx first instead of excisional if on face or really big to aid in planning.
o Mets go to brain, liver, lungs, and even peritoneum (can cause obstruction).
o Resect palpable nodes (therapeutic lymphadenectomy). Sentinal node Bx important too.
If axillary lymphadenopathy, for instance, need regional lymphadenectomyand complete staging (CXR,

LFTs, CT abdomen, MRI brain) - positive nodes = clinical stage III, high risk of mets.
Treatment is +/- IFN-alpha therapy for more advanced disease.
o Bad prognosis if >0.75mm, BANS (back/arms/neck/scalp), female, ulcerated.
o Special situations
Old pt with slow enlargement: think lentigo maligna, superficial, not invasive, better prognosis. Excise the

lesion. Hutchinson freckle is precursor lesion.

On face: may consider slightly smaller margins for cosmetic result
Sole of foot of african american pt: acral-lentiginous, poor prognosis (thicker)
Subungual: amputate @ DIP
Anal: thicker lesions need APR, really bad prognosis.
Sarcomas: firm, painless masses, large, hx radiation. DDx = hematoma, lipoma, fibroma, hamartoma, hemangioma
o Bx: excise if small (<3cm), otherwise incisional bx along eventual surgical line.
o High rate of mets on presentation (liver, lung, bone, brain) - get CT / MRI for staging.

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o Surgery: generally extensive initial resection of primary tumor for long-standing control. If high grade, be even

more radical, may include adjuvant radiotherapy for limb salvage for high-grade sarcomas.
o Lung or liver mets: tissue dx by bx, then can do wedge resection if feasible (lung / liver mets resectable!)

Congenital heart anomalies

Most commonly: VSD, ASD, PDA
o L-->R shunts: ASD / VSD / PDA. See CHF, FTT, tachycardia / tachypnea / hepatomegaly
Can reverse (Eisenmengers syndrome) as pulmonary resistance increases: irreversible, fatal
o R-->L shunts: TOF, transposition. Blue babies with cyanosis, polycythemia, stroke, brain abscesses, endocarditis,

clubbing of fingers.
Surgery if:
o VSD: CHF, pulmHTN, large shunt
o ASD: large shunt
o PDA: CHF, failure of indomethacin to close
o TOF: do palliative modified B-T shunt, then delayed formal repair (hemi-fontan, then fontan)
o Coarc: PGE1 to keep PDA open, repair depends on age @ presentation
o Transposition: paliative atrial septostomy, then arterial switch for formal repair

Pediatric surgery: Thoracic

Esophageal atresia: most commonly blind pouch for upper esophagus with distal TEF. ThinkVACTERL (vertebral,

anal, cardiac, tracheal/esophageal, renal, limb anomalies).

Congenital lobar emphysema: big bullae, need emergency lobectomy
Congenital diaphragmatic hernia: Bochdalek, have pulmonary atresia - do ECMO first, then decide how / when to

repair (usually wait 36-48h for fetal circulation to convert to newborn).

Thyroglossal duct cysts: in midline, usually present < age 10, rise & fall with larynx. Treat with Sistrunk

procedure (total surgical excision including cyst & sinus to base of tongue, whole fistula if present, middle of
hyoid)

Pediatric surgery: Abdominal

Omphalocoele: viscera herniate @ umbilicus into sac covered by peritoneum, amniotic membrane. A/w beckwith

wiedemann. Polyhydramnios in utero. Management: Do C-sectionto prevent rupture of sac. If small, repair.
If large, cover with prosthetic material, reduce, & repair later (not a surgical emergency if sac intact).
Gastroschisis: no sac, herniation of intestine through abdominal wall lateral to umbilicus. Polyhydramnios in utero.

Management: surgical emergency (put Silastic silo over exposed bowel; reduce over days)
Pyloric stenosis: increasing projectile emesis (nonbilious) with olive shaped abdominal mass, visible peristaltic

waves; labs have hypochloremic metabolic alkalosis. 4x more common in males, 1st born kids; presents in 3rd-8th
wk life. Associated with erythromycin. dx: can confirm with abd U/S. Upper GI shows string sign (thin line of
contrast going through stenosis) Treatment: NGT; correct dehydration / alkalosis / etc. Pyloromyotomy when
stable.
Maltrotation / volvulus: in utero problem. bilious vomiting is initial presentation, if bloody stool, bad

news (ischemia / necrosis. Can see double bubble sign, upper GI can show abnormal lig of Treitz, beaked end of
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barium column @ point of twist. Need prompt surgery to put things int he right place, broaden
mesentery, appendectomy.
Intestinal atresia - due to ischemic insults usually. Ileum is #1 site. Associated with CF. Present with abd distention,

bilious vomiting after 24h of life. W/U: KUB, contrast enema if low lesion. end-end ileal anastamosis.
Duodenal atresia: A/w trysome 21, VACTERL, annular pancreas. Classic double bubble sign on KUB (separated by

pyloric sphincter) but can also see in malrotation. Bilious vomiting, not much distention. NGT, fluids, broad
spectrum abx. Usually duodenoduodenostomy, but duo-jejunum may need to be done.
Annular pancreas: dont mess with it - never divide it. can cause duodenal atresia or similar obstruction.
Intussuception: Kid crying, inconsolable, draws knees up to chest, currant-jelly stools if late. Doair contrast

enema (can fix the problem at the same time).

Hirschprungs: suspect in children with intractable chronic constipation without fecal soiling.

Neonatal
hx delayed passage of meconium - can have distention, N/V. Also at risk of developing enterocolitis.
o Bx is best for dx: increased acetylcholinesterase, absence of ganglia cells. Also havefailure of internal sphincter

to relax with balloon distention of the rectum on anal manometry. Can see transition zone on contrast
enema (dilated proximal bowel; abnormally narrow distal segment which is aganglionic).
o Tx: surgery (colostomy, pull-through)
Necrotizing enterocolitis: Ischemic / hypoxic insult --> sloughing. intolerance to formula, abd distention, heme+ or

grossly bloody stools. KUB: distended, edematous intestines, free air. Primarily medical management (decompress
with NGT, abx, fluids, nutrition support). Operate if acute & perfd - resect involved intestine; divert with ileostomy
/ colostomy. Also if not stabilizing, abd mass, peritonitis - operate. Many have stricture 3-6wks after surgery.
Meconium ileus: associated with CF, obstruction of colon from excessively thick meconium. Relieve obstruction.
Biliary atresia: direct hyperbilirubinemia, persistent, pogressive jaundice, presenting ~first few months of life, no

extrahepatic masses, no CF, no TORCH. Get HIDA scan, percutaneous liver bx, ex-lap, kasai procedure
(hepatoportoenterostomy - porta hepatis @ liver surface hooked straight into some part of small intestine)
Wilms tumor: #1 pediatric abdominal tumor. Doesnt cross midline. A/w hemihypertrophy, aniridia, Beckwith-

Wiedeman sydrome, cryptorchidism.

Neuroblastoma: #1 pediatric tumor in kids < 12 months of age. Crosses midline. Anywhere along sympathetic chain

is fair game, but most from adrenal or retroperitoneal. U/A for VMA & skeletal survey. Worse prognosis than
Wilms many metastatic; surgery with multimodality adjuvant therapy
Hydrocele: patent processus vaginalis, but not big enough for loop of bowel to get in like indirect hernia.
o if communicating - surgery. If non-communicating - usually resolve 6-12 wks.
Internal hernia: ice, sedation, position in a little bit of Trendelenburg, then pull skin towards you, massage hernia

back in (like ice cream cone). Reduce, hydrate, then fix the hernia! a/w patent processus vaginalis (more than
adults), high incidence of bilaterality (may repair both), repair with high ligation of sac (no need to fix abd wall, since
its not broken in the first place - just patent processus).
Appendicitis: if suspected, get CT in teenagers (esp females, PID, ovaries, etc) & toddlers who cant talk; otherwise

dont really need. Not a disease of the newborn (not < 1 year old).
o ABX: single dose cefotixin or cefotetan preoperatively, or if ruptured give continuous abx.

ENT
Workup of neck mass (including thyroid)If around for 7d, inflammatory; 7mo, malignant, 7yr, congenital
o Benign: reactive node = #1.
Abscesses (drain); can be retropharyngeal or peritonsillar (uvula deviation).

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 Branchial cleft cysts can present with signs of acute inflammation, enlarge during URIs,, extend to clavicle.

Often along SCM. Surgery. Look out forhypoglossal nerve.

Cystic hygromas are spongy, diffuse, seen in infants. Lymphatic origin. Surgery.
Teratomas: epidermoid cysts (squamous epithelium) most common. Present @ birth.
Hemangiomas are #1 tumor of head/neck in kids. Girls > boys, solitary. Capillary hemangiomas (nevus

flammeus = port-wine), strawberry nevus - primarily in kids, often regress after initial growth.
Cavernous hemangiomas - more perminant. AV hemangiomas: adults.
o Workup: H&P, recent illnesses, CBC with diff, CXR, TB test, monospot, TFTs, viral titers (EBV a/w nasopharyngeal

Ca, Burkitts lymphoma). Soft tissue X-ray of neck, barium swallow, upper GI or CT/MRI. Endoscopy if tumor /
neoplasm suspected. Get images & always try to bx before incision in neck.
Modified vs radical neck dissections + complications
o Radical: en bloc dissection of cervical lymphatics with removal of SCM, internal jugular, CN XI.
Use if SCC in neck mass with unknown primary or in conjunction with excision of primary tumor
o Modified: removes cervical lymphatics within facial compartments, sparing SCM / IJ / CN XI
use for elective neck dissections, single node < 3cm to be treated with radiation later, differentiated thyroid

cancers with neck mets, simultaneous bilateral LN dxns

Common malignancies: in general, radiation alone if not resectable or early lesion for ENT tumors. Inspect all skin,

muocosa of head / neck (including with scope).

o Squamous cell carcinoma is #1 (80%). Generally radiation & resection
o Nasopharyngeal tumors: radiation is primary therapy. A/W EBV. Dont biopsy neck nodes (just primary tumor)

- can seed tumor into skin of neck.

o Oral tumors: a/w tobacco, EtOH, ?HSV. lip is #1 site. Get mandibular X-ray for bony involvement. If T1, local

excision or radiotherapy; after that, combined surgery & radiation with en bloc resection of tumor, radical neck
dissection, partial mandibulectomy.
o Laryngeal cancer - a/w smoking. Mostly SCC (95-98%). Hoarseness, dysphagia, aspiration, no neck mass. direct

laryngoscopy & biopsy needed. Usually treat withradiation alone if T1; if larger, total laryngectomy and some
adjuvant chemo.
o Lymphoma: NHL or Hodgkin. Usually p/w single enlarged node, firm, rubbery. dx with excisional bx, then

stage. Stage I/II Hodgkins = radiotherapy, more advanced = MOPP. NHL - usually radiation for stage I/II, chemo
for III/IV.
Other lesions (benign)
o leukoplakia, keratosis = white lesions on mouth a/w repeated trauma / smoking EtOH. Bx to r/o SCC.
o Nasal polyps: allergic response? asthma associated, also aspirin. If in kids, check for CF with Cl sweat test
o Vocal nodules: bilateral, benign, a/w vocal abuse, tx by modifying speaking / singing, usually not surgery
o Vocal polyps: unilateral, will need microscopic excision
Parotiditis: give lemon drops. Most commonly S. aureus entering via Stensens duct. Drain if no response to candy.
Parotid tumors: resect superficial parotid (most tumors there), preserve facial nerve,
o Mixed tumors are #1 (pleomorphic adenoma). Slow growing, not malignant. May need re-excision.
o Warthins tumor: soft (cystic). Contain mucoid material (may appear purulent, but not infected). Not

malignant, but can degenerate if prior neck radiation.

o Malignant parotid dz: often have pain, facial nerve paralysis (not in benign tumors)

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 Mucoepidermoid carcinoma: #1 parotid malignancy. Low-grade seen in childhood (surgery alone,

preserving facial nerve), high grade in older pts (surgery with total parotidectomy including removal of
facial nerve + adjuvant radiation).
Malignant mixed tumor: total parotidectomy including removal of facial nerve +/- radial neck dxn

Trauma
ALWAYS DO ABCs FIRST - and do them again if something changes
Primary survey:
o Airway obstruction --> cricothyroidotomy
o Cardiac tamponade --> emergency pericardiocentesis in ED --> pericardial windowin OR.
Think about this if hypotension and neck vein distention. May also see pulsus paradoxicus (SBP decrease of

10 on inspiration) or Kussmaul sign (elevated CVP on insp in spontaneously breathing pt)

DDx of distended neck veins & hypotension includes myocardial contusion(get EKG, cardiac enzymes) - but

tamponade should be fixed now. Could also be MI while driving.

o Tension Ptx (ptx + hypotension, tracheal deviation, no breath sounds) --> needle decompression, then tube
o Non-tension PTX--> chest tube; remove when lung inflated / no further leak.
If small, uncomplicated, no fluid in pleural space, asx, no significant injuries, can observe.
Put central line in same side as PTX (dont want to drop the other lung!)
GETA, endotracheal intubation, assisted ventilation --> positive pressure --> can convert to tension ptx
If not resolving, think wrong location / not functioning.
If large air leak continues, think major airway disruption, may needbronchoscopy for dx,

then thoracotomy for repair / partial lung rxn

o Massive hemothorax (1000cc immediately or 200mL/hr x 4 hrs) --> chest tube
o Open Ptx / sucking chest wound --> occlusive chest dressing, put chest tube in @ different location.
o Pulmonary contusion --> intubate, pain control PPV
o Flail chest: positive pressure ventilation
o Diaphragmatic rupture: needs to be repaired in OR, but evaluate other major injuries rapidly first.
If GCS is less than 8, then you have to intubate!
o Eyes (4): 1= no opening, 2= opens to pain, 3=opens to speech, 4=opens spontaneously
o Verbal(5): 1=no response, 2=incomprehensible, 3=inappropriate words, 4=confused, 5=oriented
o Motor (6): 1=no movement, 2=decerebrate (extensor), 3=decorticate (flexing), 4=withdrawal from pain,

5=localizes painful stimulus, 6=obeys commands,

Blood loss: tachycardia (>15%), then hypotension (>30%). If >15% blood loss, probably need transfusion.
o Follow UOP, heart rate, mental status, BP. Can also folow lactate, venous O2sat.
o If persistent hypotension despite adequate fluid resuscitation, look for underlying causewith laparotomy /

thoracotomy. Dont need CVP / PA cath right away (delays definitive treatment).
ER thoracotomy if sudden loss of VS after penetrating trauma (when VS were present in field) - to cross clamp aorta,

etc
o Hardly ever for blunt trauma

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 For abdominal pain in trauma or if bleeding suspected (high speed accident, fall), or if change in mental status, or if

will be lost to follow up, do abdominal workup: DPL, FAST, CT abdomen

Closed head trauma --> cushing reflex (bradycardia, hypertension, change in breathing pattern)
Clearing C-spine: stabilize, then palpate neck for tenderness, deformity, assess motor / sens fxn, C-spine x-rays
o cant clear C-spine if comatose, disoriented, combatitive. May need MRI to clear.
o Priaprism can be sign of fresh spinal cord injury - also loss of anal sphincter tone, ileus, bradycardia
Stab wounds:
o Chest: look for hemoPtx with chest tube insertion (left side, 5th ICS). Emergency thoracotomy if 1500mL out or

200mL/hr x 3hrs, or hypotensive.

o Just below clavicle: think subclavian injury. If stable, get angiogram to plan (difficult area), but if unstable, just

get in there.
o Below nipple: think diaphragmatic injuries & explore the abdomen too
Gunshot wounds: unpredictable path of bullet!
o Mark entrance / exit, get radiographs, if anywhere near abdomen / chest explore each one.
Abdominal trauma:
o Explore immediately if obvious penetrating wounds / lacs, or if unstable with rapidly distending abdomen or

severe abdominal pain. On opening, pack the abdomento stop bleeding quickly, then attack the various injuries
in order of severity. When bleeding stopped, focus on organ injuries.
o Otherwise, get DPL if not clearly abdominal injury and hemodynamically unstable(worried about bleeding into

abdomen)- but can miss retroperitoneal injuries (pancreas, duodenem). Positive if 100,000 RBC/mL, vegetative
material, bile. Could also useFAST as an alternative.
o CT if patient is stable and you still need more info about injury - but never take a really unstable pt to CT.
Evaluate pregnant women on left side (to avoid baby compressing IVC --> decreased venous return --> hypotension)
EKG is best to rule out blunt cardiac injury (SVT #1); later, a nuclear study can be used to characterize dysfunction.

Suspect if sternal fx
Aortic transection suspected if acute deceleration injury with widened mediastium / aortic knob indistinct, scapular

or 1st rib fx (big trauma should be suspected). If suspected,aortogram or CT chest --> toOR for repair
Organ lacerations:
o Spleen: Really try to preserve spleen if possible, avoid blood transfusions if safe. May explore / repair / take out

spleen, or angio --> embolize bleeding vessels. Infarction rarely a problem (rich collaterals). In kids, observe
splenic injury (try to preserve the spleen if at all possible for kids)
o Liver: explore regardless of grade of injury if pt is unstable. If stable, try to observe
o Mesenteric injury: means large forces - suspect bowel rupture too. Hard to see on CT.
o Kidney rupture: if unstable, operate - but document two kidneys first (e.g. with IVP in OR). If stable,

often observe, grade; may use angiography to characterize, may need vascular repair.
o Pancreas partially transected: explore, evaluate pancreas / duodenum, may need to do some pancreatic

resection / duodenal repair.

Centrally located hematoma: think damage to upper abd aorta, major branches, direct pancreas duodenum injury,
o Explore urgently
o Duodenal hematoma - e.g. in kids who hit their abdomen on handlebars: intramural, obstructs duodenal

lumen, can dx with upper GI series showing coiled spring of 2nd / 3rd portions of duodenum. If isolated
injury, observe, NPO until obstruction resolves (5-7d)
27

 Rib fractures: control pain to avoid atx / hypoxia / PNA risk

Explore retroperitoneal hematomas for penetrating trauma; for blunt trauma, observe --> to CVDL
Stabilize pelvic fx with anterior fixator, then to CVDL for angioembolization (often from branch of internal iliac)
o Pelvic hematoma: stabilize, angiography, evaluation (dont explore - bleeding tamponaded by peritoneum over

pelvis - would make it worse!)

If suspected rectal trauma, do a diverting colostomy
Foreign bodies: do rigid esophagoscopy if swallowed, bronchoscopy if aspirated.
Hypothermia: warming blankets. can cause platelet dysfxn, PT/PTT prolongation.

Orthopedics
Stress fx - dx with exam (point tenderness over bone), but dont show up for 2 weeks on Xray (repeat xray in 2 wks)
In general, image joint above/below from at least 2 angles at 90 degrees from each other.
Open / closed fx: Open = exposed to environment, closed = not.
Management of fx:
o Open fx: early debridement, splint in field, give antibiotics (ancef = cefazolin),tetanus ppx
o In kids: generally use cast immobilization; if displaced / serious, may use external fixation (growing) or internal

fixation if > 11 years old with flexible IM rods.

buckle / torus fx (incomplete) - only need cast immobilization
greenstick fx: disrupt remaining ctx at fracture, then immobilize.
o In adults:
closed reduction, cast immobilization if distal radius
Hip in old person: replace it.
ORIF for both forearm bones (vs cast in kids), femoral shaft fx (can also usetraction if too ill for surgery

immediately).
Finger fx: buddy taping if stable, or percutaneous pin; lots of early rehab to prevent tendon stiffness.
o When in doubt: ORIF - but remember opening = higher infection rijsk, more trauma at operative site, may have

higher chance of nonunion, but shorter period of immobilization (OOB much earlier than traction)
Complications:
o Vascular injuries to surrounding vessels
o Fat emboli if long bones broken (change in mental status, ARDS-type pictuer)
o Compartment syndrome: arterial insufficiency, supracondylar humeral / tibial / crush injuries, > 30-40 mmHg

pressure - but if clinically obvious, just do the fasciotomy right away!

Neurovascular associations

Anterior shoulder dislocation

Axillary nerve injury (numbness in shoulder over deltoid, arm

rotated outwards on presentation). Posterior dislocation - think sz

Supracondylar humeral fx

Median nerve, brachial artery

Posterior knee dislocation (car accident, football)

Popliteal artery (probably need bypass)

Distal radius fx

Median nerve

Fibular neck fx

Common peroneal nerve (foot drop)

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 Thoracic Outlet Syndrome o Neurologic (cant grab things, atrophy of hand mm) & vascular (pulseless, ulcers, etc) presentation
o Tests: Adson (extend, abduct slightly rotate arm; pt turns head towards affected side, positive if radial pulse

diminishes on inhalation) / Wright (hyperabduct, ext rotate affected arm, positive if paresthesias or decr pulse)
o Treatment: PT, surgical optinos very varied & controversial
Peds ortho:
o Developmental dysplasia of hip (bartlow/orlatani signs) - abduction splinting
o Legg-Calve-Perthes disease (avascular necrosis of femoral head) - insidious onset of limping, decreased hip

motion, possibly hip / knee pain in a youngish kid. AP/ lateral radiographs for dx, then casting & crutches
o SCFE: 13 year old obese kid with groin/knee/hip pain, limp --> AP/lat x-rays, pin femoral head in place.
o Scoliosis: brace if still growing.
o No X-rays in newborn (calcification too incomplete)

Orthopedic oncology
Benign lesions are more common; mets more common than primary lesions
o Benign: think sclerosis, well-circumscribed lesions
Osteoid osteoma: severe pain, relieved by aspirin, lucent lesion with reactive sclerosis, regress over 5-10y

but can excise to relieve symptoms

o Malignant: think moth-eaten, cortical disruption, bone expansion
Ewings: small cell, malignant, aggressive with early mets but responsive to chemo, think boys < 15,

in diaphysis of long bones, pelvis, scapula, ribs. Fever, wt loss. Tx: radiation,systemic chemo + resection of
tumor.
Osteogenic sarcoma: peak in men 10-20, often around knee, in metaphysis.

Not sensitive to radiation, but

responds well to combination chemo + surgical rxn / amputation

Malignant tumors are more symptomatic; pathologic fx need workup (CT, MRI, bone bx)

Burns
Initial resuscitation: ABCs. Can get central lines through eschar if needed
o Parkland formula: % BSA burned x 4cc x wt
give within 1st 8 hrs, rest over next 16
%BSA from rule of 9s; 2nd / 3rd degree burns. Head, upper extremities = 9% each; lower extremities,

anterior, posterior trunk = 18% each, neck = 1%. Hand is ~1%, for reference.
o Watch urine output. If urine dark, positive for blood, get microscopic inspection (can be myoglobinuria if no

RBC seen, which can lead to ATN & ARF - give IVF to UOP 2-3x normal, alkalinize urine, can use mannitol too).
o Can use silver sulfadiazine topical abx to help prevent infection if deep burn. Generally dont use prophylactic

systemic abx unless documented infection. Triple antibiotic cream near eyes (more gentle).
o Early excision & grafting for less extensive burns.
Complications: sepsis (Pseudomonas), circumferential eschar --> escharotomy to avoid compartment syndrome
o Methemoglobinemeia from smoke inhalation: chocolate brown blood, central cyanosis of blood, pulse-ox is

unreliable (cant tell metHb from Hb); use ABG instead. If asx: just supplemental oxygen. If symptomatic, can
use IV methylene blue.
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o respiratory burns (burns in enclosed space, charring) - dx with bronchoscopy, tx: respiratory support.
Electrical injuries: deep, exit > entrance in size, cant use parkland (big extension underneath), aim

for 2cc/kg/hr UOP instead of 1. Can cause renal failure 2/2 myoglobinuria - hydrate! - andcardiac arrhythmias.
Chemical burns (e.g. Drano) - need copious, immediate, profuse irrigation x 30m (e..g at homebefore going to ER)
Degrees of burns:
o First degree: superficial layer of epidermis. Like sunburn. Little clinical significance (still water barrier). Pain x

48-72h, then peeling in 5-10d with no scar is usual course.

o Second degree: through epidermis into dermis. partial thickness - still can have epithelial regeneration.

Can blister; heal in 10-14d if not infected. If deep (white, nonviable dermis visible), can develop into third
degree - treat just like third degree!
o Third degree: full thickness of skin down to subQ tissue. waxy, white appearance, asensate, no cap refill,

leathery texture. Need skin graft for repair

Escharotomy for circumferential burns, fasciotomy if looks like compartment syndrome developing

Complications
Organ transplant: fever after transplant: think CMV / opportunists
o Hyperacute rejection: recipient serum has preformed antidonor Ab. Happening on the table. Can be prevented

by cross matching ahead of time. Cant be treated once it starts

cross-match: mix donor lymphocytes with recipient serum, C. If recipients serum has circulating

antibodies / cellular response to donor HLA antigens, cell lysis occurs.

o Acute rejection: CMI, helper T-cells mediating, after day 6 usually unless recipient pre-sensitized. Dx: biopsy

during surveillance; can treat & reverse by high dose immunosuppression in short course. Usually within 3 mo,
generally not after a year. Steroid boost, adding OKT3 (mAb against CD3) can be used.
o Chronic rejection: late onset, insidious onset, multifactorial (humoral & cell mediated), poorly understood so

not treatable or reversible.

o Drug toxicities: Azathioprine can cause leukopenia (decrease dose if WBC dropping); cyclophosphamide can

cause nephrotoxicity (decrease dose if Cr bumps in renal transplant pt).

Transfusion reactions: error in cross-matching is #1
o Febrile reactions - allergic - are #1, from cytokines or donor leukocyte contaminant, mild Ab response, self-

limited. Can prevent by leukodepletion of RBC & pretransfusion abx.

o Lytes after transplant: Hyperkalemia: from lysed cells. Hypocalcemia (citrate in stored blood binds Ca)
o Coagulopathy: pRBC dont have clotting factors, platelets. Factors V & VIII are more labile, most deficient.
o Acute hemolytic transfusion reaction: ABO incompatibility - intravascular immune rxn (humoral) --> clumping

of blood, fevers, chills / rigors, N/V, dyspnea, flushing, DIC, jaundice. Stop transfusion but leave IV in for acccess,
start diuresis & fluids, re-checkfor clerical error, re-do direct Coombs.
o Delayed hemolytic transfusion reaction: 3-7 days after transfusion. Fever, malaise, hyperbili, decreasing

hemoatcrit. Due to minor antigen incompatibility (e.g. Rh system).

o Indirect Coombs: mix RBC to be screened & patients serum, then add anti-human IgG Ab. If patient has Ab

against the donor RBC, theyll be cross linked & RBC will fall out of serum.
Type & screen: ABO + Rh type of pt, then screen for unexpected Ab in pts serum w/ indirect Coombs
Type & cross: ABO + Rh type of pt, but then crossmatch by doing indirect Coombs w/ donor RBC.

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o Dont transfuse through Ringers lactate - contains Ca, can cause clotting - or D5W, which can cause lysis of RBC

osmotically. Use IV NS instead.

Common post-op complications
o Chest pain after surgery: r/o PE/ MI / PNA
o Bleeding: medical vs operative causes (check coags)

Anesthesia
N2O has low solubility, less dense than air, so can distend air-filled spaces in prolonged anesthesia.
Side effects: Halothane = CV depression. Enflurane = sz/EEG changes. methoxyflurane =

nephrotoxic. Morphine = respiratory depression, risk of hypotension if given in large bolus dose. N2O can worsen
distention in bowel obstruction,
Sudden drop in CO2? Maybe endotracheal tube is disconnected
CO2 embolus: bradycardia, hypotension, abrupt drop in end-tidal CO2. Flood surgical field, then put into left lat

decub / Trendelenburg to try to trap in right side of heart, put in central lineand try to aspirate out of right atrium.
Malignant hyperthermia: not NO2 (supportive tx + dantrolene, hydrate & watch out formyoglobinuria, may want to

alkalinize urine). Also hyperventilate with 100% O2 (increased O2 consumption)

Local anesthesia: toxic doses
o 4-5 mg/kg for lidocaine
o 7 mg/kg for lidocaine + epi
o Dont use epi on extremities (fingers / toes)

Nutrition
Requirements:
o Calories: 25 /kg/day basal, +10 for sick pts
o Protein: 1 g / kg / day + 0.5-1.5 for sick pts. Try to get positive nitrogen balance if pts sick.
Energy yields (kcal/g): fat=9, protein=4, CHO=4.
RQ: VCO2 / VO2
o <0.7 = starving, underfed, ketotic. 0.8=balanced. >1.0 = overfed
Watch patients on TPN for hyperglycemia / hyperglycemic hyperosomolar nonketotic coma
o can also get elevated LFTs (transaminases and alk-phos) - reduce infusion rate.
o If skin is dry & scaly, probably too few free fatty acids. give more lipids.
Low Mg can produce tetany (e.g. on TPN, tetanic but normal Ca)
Hypocalcemia = long QT; a/w hypoMg, hypercalcemia = short QT.
Body fluids:
o Stomach: takes Na and substitutes H+ (Na 60, K 10, Cl 130, HCO3 0)
o Small intestine: replaces Cl from stomach with bicarb; H+ with Na (Na 140, K 5, Cl 104, HCO3 30)
o Colon & saliva have a lot of potassium
o Stool has bicarb too (diarrhea --> hypokalemic met acidosis)

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Pre-op Care
Pre-op abx (e.g. for elective colonic surgery) - give IV abx on call to OR, single dose, effective against aerobes &

anaerobes (e.g. cefoxitin, Ancef = cefazolin, etc). Alternatively can use preop oral abx one or more days prior to
surgery. Also important to have mechanical cleansing.
Highest risk if MI in last 7-30d, also unstable angina, decompensated CHF, bad arrhythmias, severe valvular disease.
o Delay surgery if possible if MI in last 7-30d or PCTA in last few weeks (risk of thrombosis increased)
o If s/p CABG: work up saphenous vein graft after 5-10 yrs, PTCA after 2 yrs (grafts restenose)
o If s/p stroke: get carotid duplex; may benefit from CEA before elective surgery
o Also depends on procedure (major operations, aortic reconstruction, peripheral vascular procedures, etc)
o High risk - cardiac w/u first (EKG, stress test, etc); may need CABG before elective procedure. Get pharmacologic

stress test if rest pain / PVD (cant go on treadmill). Cath if reversible ischemia on stress test.
o Work up anemia, polycythemia, etc. first.
Meds: hold aspirin for 7-10 days (irreversible plt inhibitor), NSAIDs 2 days (reversible)
o hold oral hypoglycemic agents, also metformin (lactic acidosis). Insulin: give dose
o give beta blockers on day of surgery (to avoid rebound HTN).
Try to get the patient to stop smoking before elective surgery (6-8wks). Also cant be drinking - need to abstain, go

through withdrawal if needed, detox, etc.

Delay elective surgery if glucose really high (like 300-400) - poor wound outcomes - orcellulitis / other acute

infection present (even if its just a hair follicle in the axilla), or UTI sx, or diastolic BP > 110
May want to avoid laparoscopy if high risk for acute pulmonary failure (e.g. COPD) - CO2 absorption.
o PFTs: FEV1 0.6= pulm wedge resection only, 1L = up to lobectomy, 2L = up to pneumonectomy can be tolerated.

Need to leave pt with 800cc / 60% predicted FEV1after lung surgery.

Always workup atherosclerosis in whole body in patients with PVD, angina, carotid disease, etc.
SBE prophylaxis: for prosthetic heart valves, previous endocarditis, complex congenital heart defects, prosthetic

vascular grafts, rheumatic valvular disease, MVP with regurgitation, HCM.

o NOT for previous CABG, repaired ASD/VSD, MVP without regurgitation, physiologic murmurs, pacemakers.
o Only if pts getting dental work or surgery on GI/GU/resp tracts. Think amp (or alternatives if PCN allergic) for

oral / resp / esophageal procedures, or amp+gent (or vanc) for GI/GU.

Postop care
Blood loss: 1mL EBL --> 3 mL isotonic fluid in OR; also insensible losses.
o May third-space if lots of injuries, etc; if suspected / dropping BP, give 1-2L IV NS or LR bolus.
o If no response, CVP measurement - low CVP means hypovolemia, give more; high CVP - heart problems.
o PA cath also useful to assess ventricular fxn.
Low PCWP = hypovolemia / low preload. High PCWP - think pulmonaryedema, fluid overload.
SVR: low: think sepsis or neurogenic (or vasodilator administration), high: think cardiogenic shock, HTN,

hypovolemic shock
Cardiac output: decreases in shock except for in early sepsis.
MIVF: D5W 1/2NS + 20 mEq KCl @ 4 / 2/ 1 mL/kg/hr (for 1st 10 kg, next 10 kg, all kg after that, respectively)
o Shortcut: if over 20kg, 40 + wt in kg = mL/hr for MIVF. Goal UOP generally 0.5-1 mL/kg/hr

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o May use lac ringers or IV NS immediately after blood loss / intraop

o Replace GI fistulas / tubes mL for mL with similar fluids, on top of MIVF.
Ventilation:
o PCO2: Try to get ~ 40. If too high, underventilated - increase vent rate or volume. If too low, overventilated.
Doesnt tell you about oxygenation at all
o PO2: Can adjust FIO2 to help with this parameter; also can add PEEP to pop open alveoli, but can drop cardiac

output by impairing venous return - may need to place PA cath to monitor cardiac fxn. Also PEEP is risk for
tension PTX.
o Indications for vent: RR > 35, PaO2 < 60, PaCO2 > 60, GCS > 8
Also VC < 15 mL/kg, A-a > 350 after 15m on 100% O2, Vd/Vt > 0.6,
Fever:
o Atx if immediately postop. think UTI around day 3. Wound infection @ any time.
o Supperative phlebitis: pt with fever, drop of pus around indwelling catheter - infected thrombus in vein. Need

to remove catheter & excise affected vein @ 1st non-infected collateral branch, IV abx, leave wound open.
Small bowel fistula: Can manage conservatively if no abd fluid collection, draining well, not peritonitic.
o If peritonitic --> to OR. If fluid collection, may be able to drain under CT.
o Conservative management: NPO, TPN, measure fistula output, look out for FRIEND (foriegn bodies, radiation

damage, infection / IBD, epithelialization, neoplasm, distal bowel obstruction) - be more aggressive then.
Nec fasc / gas gangrene, etc. Think C. perfringens, gram pos spore producers. Give high dose PCN G & debridement,

also need tetanus vaccination

Bowel function: stomach fxn returns in 24h, small bowel 4h (can feed with J tube quickly), colon 3-4 days.
Tracheostomy hasnt been shown to reverse or slow pulmonary failure in end-of-life pts that become vent-

dependent
Dehiscence of fascia: if low risk, small 1-2cm dehiscence, abdominal binder. If high risk, may still use binder for

larger dehiscence; if large dehiscence & patient can tolerate, back to OR to fix. Bed rest for these patients too.
SICU drugs:
o Dopamine: low doses - vasodilates renal, mesenteric vasculature; vasoconstricts peripheral bed (increase flow

to kidney, bowel). Medium doses: B1 activity; inotropic effects (increased CO, BP). Above 10 mg/kg/min: areceptor stimulation, peripheral vasoconstriction, decreased kidney fxn / hypertension.
o Dobutamine: synthetic catecholamine; peripheral vasodilator & inotrope but with not much chronotropic

effect; used in cardiogenic shock

o Nitroprusside: systemic vasodilator (arterial = venous); decreases afterload but hypotension if used in

cardiogenic shock without an inotrope

o Nitroglyercine: vasodilator, but venous > arterial (can cause venous pooling); reduces both preload & afterload,

but causes hypotension if given alone in cardiogenic shock.

o Isoproterenol: pure beta agonist --> vasodilatatory & chronotropic effects.
Paradoxic aciduria (acid urine in presence of metabolic alkalosis) a/w gastric outlet obstruction (vomiting out acidic

stomach contents --> metabolic alkalosis, but also depleting volume & potassium, so kidneys secrete H+ to get back
more Na+ for volume reasons, leading to acidic urine).

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Wounds
Primary intention: need 6-8 weeks to reach acceptable strength (no lifting for 2 months). 6mo for complete

remodeling.
Ventral / incisional hernias: fix em surgically.
Hypertrophic = inside scar borders, keloid = outside. Observe, revise if problems; treat with steroid inj / pressure

dressings to help prevent recurrence.

Wound infection: Drain, debride, dilute, leave open, wet-->dry (secondary intention). Usually no abx needed.
o Infection rates: clean = 1%, close primarily, clean-contaminated (colectomy after bowel prep) = 10%, usually

close primarily, contaminated (spillage of bowel contents intraop) = 5%, infected (appy) = 50%, usually leave
open. May be able to close contaminated wounds on face (good vasculature).
o Perioperative abx x1 dose preop, then x1 postop for clean-contaminated or if foreign bodies left inside
Skin graft: need less than 10 bacteria / gram of tissue to work. Split thickness grafts --> less contraction.
5

Other miscellaneous topics:

Simultaneous surgical problems (AAA / colon cancer) - first take care of most life-threatening
Surgical infections (bites) - human, cat, dog
o Human bite: really dirty, tetanus ppx, get ortho to look at it surgically.
GU / GYN problems
Post-MI complications (VSD, MR)
Soft tissue / venous infections
Peds masses (hemangiomas, neck mass, abd mass)
Compartment syndrome: get emergency fasciotomy. Pt drunk, laid on hand, or cast too tight
o Firm, tender muscles, passive motion --> excrutiating pain, pulses usually normal.

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