Thank you
for purchasing this e-book.
To receive special offers and news
about our latest products,
sign up below.
Or visit LWW.com
Sign Up
ADVANCED
SURGICAL RECALL
Fourth Edition
“‘SCUT’... Forgive me for this; I HATE this word. Ward work is patient care. It’s the work of Angels and Saints. It is a privilege to do. It’s fun. It is necessary to the care of patients. If you call this patient care scut, you (and your protégés) won’t do it. If you call an admission a ‘hit,’ you won’t take care of them. Your language defines your feelings. Your feelings determine what you have energy for. I get energy from getting a patient a cup of coffee, drawing their blood well, and closing their skin in a nice manner ... as much energy as I get from trans-planting their hearts and lungs, and bypassing their vessels. I can’t do what I don’t have energy for.”
ADVANCED
SURGICAL RECALL
Fourth Edition
Recall Series Editor and Senior Editor
Lorne H. Blackbourne, M.D., F.A.C.S.
Acute Care Surgery, Trauma, Burn, Surgical Critical Care
San Antonio, Texas
Advisor
Curtis G. Tribble, M.D.
Chief, Division of Cardiothoracic Surgery
Vice Chair, Department of Surgery
Medical Director of Transplantation
Product Manager: Lauren Pecarich Marketing Manager: Joy Fisher Williams Manufacturing Manager: Margie Orzech Design Coordinator: Terry Mallon Art Director: Jennifer Clements Compositor: Aptara, Inc.
Fourth Edition
Copyright © 2015 Wolters Kluwer
Copyright © 2015, 2008, 2004, 1997 Lippincott Williams & Wilkins, a Wolters Kluwer business. Two Commerce Square 351 West Camden Street
2001 Market Street Baltimore, MD 21201
Philadelphia, PA 19103 USA Printed in China
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at [email protected], or via website at lww.com (products and services).
9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data ISBN: 978-1-4511-1653-3
Available upon request
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300.
Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.
Dedication
vi
Editors and Contributors
Contributors
Will Cauthen, M.D. Chief Resident General Surgery
University of Mississippi Medical Center
Contributors to Previous Editions
Gina Adrales, M.D. Joshua B. Alley, M.D. Stephen Bayne, M.D. Gauri Bedi, M.D. Robert Benjamin, M.D. Kyrie Bernstein, M.D. Oliver A.R. Binns, M.D. Shawn A. Birchenough, M.D. Joshua Bleier, M.D. Carol Bognar, M.D. Lee Butterfield, M.D. Sung W. Choi, M.D. Vernon L. Christenson, M.D. Jeffery Cope, M.D. Sagar Damle, M.D. Jennifer Deblasi, B.S. Soffer Dror, M.D. Matthew Edwards, M.D. Brian Ferris, M.D. Anne C. Fischer, M.D. Kirk J. Fleischer, M.D. Charity Forstmann, M.D. Cynthia Gingalewski, M.D. Thomas Gleason, M.D. Penelope A. Goode, M.D. Sharon Goyal, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Huntington Hapworth, M.D. Sean P. Hedican, M.D.
Stanley “Duke” Herrel, M.D. Teofilo R. Lama, M.D. Jason Lamb, M.D. Scott London, M.D.
Tananchai A. Lucktong, M.D. Jana B.A. MacLeod, M.D., M.S.C. F.R.C.S. (C) Peter Mattei, M.D. Addison May, M.D. Joseph R. McShannic, M.D. Nancy E. Morefield, M.D. Paul Mosca, M.D. Mark Mossey, M.D. David Musante, M.D. Mark J. Pidala, M.D. John Pilcher, M.D. Philip Pollice, M.D. Cherie D. Quesenberry, M.D. Naveen Reddy, M.D. Brian Romaneschi, M.D. Janice Ryu, M.D. Moises Salama, M.D. Robert E. Schmieg, Jr., M.D. Donald B. Schmit, M.D. Carl Schulman, M.D. Paul Shin, B.A. Kimberly Sinclair, M.S. John Sperling, M.D. Akin Tekin, M.D. Pierre Theodore, M.D. Steven D. Theis, M.D. Michael Tjarksen, M.D. Stephanie VanDuzer, M.D. Jeffry Watson, M.D. Mark Watts, M.D. Joseph Wells, M.D. David White, M.D. Kate Willcutts, M.D.
Editors and Contributors vii Jonathan Winograd, M.D.
Jim Soo Yoo, M.D. Stephen Yung, M.D. Amer Ziauddin, M.D. Developmental Contributor Patricia Blackbourne Kingsbury, Texas Editor Jon D. Simmons, M.D. Assistant Professor
Associate Residency Director Department of Surgery Division of Trauma, Acute Care
Surgery, Burn, & Surgical Critical Care
University of South Alabama
Editors, Previous Editions
Oliver A.R. Binns, M.D. Anikar Chhabra, M.D. Kirk J. Fleischer, M.D. Tananchai A. Lucktong, M.D. Damle Sagar Joseph Wells, M.D. Associate Editors
Louis R. Pizano MD MBA FACS Associate Professor of Surgery and
Anesthesia
Chief, division of Burns
Director, Trauma/ Surgical Critical Care Fellowship Program University of Miami Brian J. Eastridge MD FACS Trauma Surgery
University of Texas San Antonio, Texas
Sara S. Kim Resident
Department of Surgery University of North Carolina Tad Kim, M.D.
Resident
Division of Cardiothoracic Surgery University of Mississippi Medical
Center
Peter Vezeridis, M.D. Orthopedic surgery Boston, MA
Associate Editors, Previous Editions
Fouad M. Abbas, M.D. Tekin Akin, M.D. Robert Benjamin, M.D. Kyle D. Bickel, M.D. Duke E. Cameron, M.D. H. Ballantine Carter, M.D. Bruce Crookes, M.D. Martin A. Goins, III, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Richard F. Heitmiller, M.D. David Holt, M.D. Billy Johnson, M.D. Brian Jones, M.D. Scott Langenburg, M.D Teofilo Lama, M.D. Jana Macleod, M.D. John Minasi, M.D. Stanley L. Minken, M.D. Michael A. Mont, M.D. Marcia Moore, M.D. Paul J. Mosca, M.D., Ph.D Charles N. Paidas, M.D. John Pilcher, M.D. Moises Salama, M.D.
Donald Schmit, M.D. Carl Schulman, M.D. Dror Soffer, M.D. R. Scott Stuart, M.D. Rafael Tamargo, M.D. Curtis G. Tribble, M.D. Reid Tribble, M.D. Craig A. Vander Kolk, M.D. Kate Willcutts, M.D. Leslie Wong, M.D. Jeffrey Young, M.D.
International Editor
Gwinyai Masukume, MB ChB(UZ), Dip Obst(SA)
Department of Obstetrics and Gynaecology
Mpilo Central Hospital Bulawayo
ix
Foreword
Advanced Surgical Recall is a study aid for students and residents who have
pro-gressed past their introductory experiences in the discipline of surgery. In actu-ality, this group includes surgical residents, senior medical students, and even junior medical students who have progressed past the usual introductory materi-als. This book should also serve as a source of questions for teachers of surgery, particularly for the venerable activity of teaching rounds.
The best teachers usually are those individuals who have thought the most about how they themselves learned. The editors of Advanced Surgical Recall clearly are teachers who have given an enormous amount of thought to learning and teaching. They have used the principles of the Socratic method and of their own self-education techniques to develop this collection of questions. These edi-tors have a special knack for writing and editing these types of questions and study aids; through their impressive medical and surgical educational trajecto-ries, they have won teaching awards and created a plethora of study aids.
This collection of questions and answers is useful to students of surgery, not only because it will help them learn the answers they need to know, but also because it will help them remember the questions. Knowing the right questions is, in my opinion, more important than knowing the answers, at least in real life. After all, the answers will change over time. The questions are timeless.
Curtis G. Tribble, M.D.
Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery Medical Director of Transplantation University of Mississippi
x
Preface
ADVANCED SURGICAL RECALL Fourth ed. is written as the natural
exten-sion of SURGICAL RECALL. It is intended primarily for surgical residents, but advanced students will also find it can give them an extra competitive edge.
In addition to the previous features, this new edition includes a Rapid Fire Review for the ABSITE.
Lorne H. Blackbourne, M.D., F.A.C.S.
Acute Care Surgery, Trauma, Burn and Surgical Critical Care
xi
Contents
Editors and Contributors ... vi
Foreword ... ix
Preface ... x
SECTION I
OVERVIEW AND BACKGROUND SURGICAL INFORMATION
1. Introduction ... 12. Review of Surgical Acronyms and Memory Aids ...14
3. Surgical Syndromes ...26
4. Surgical Most Commons ...27
5. Surgical Percentages ...30
6. Surgical History ...32
7. Surgical Instruments ...36
8. Sutures and Stitching ...53
9. Surgical Knot Tying ...61
10. Incisions ...64
11. Surgical Positions ...66
12. Surgical Speak ...69
13. Preoperative 201 ...70
14. Advanced Procedures ...72
15. Surgical Operations You Should Know ...85
16. Cell Biology and Cytokines ... 108
17. Wounds ... 115
18. Drains and Tubes ... 118
19. Surgical Anatomy ... 123
20. Surgical Respiratory Care ... 138
21. Renal Facts... 144
22. Fluids and Electrolytes ... 154
23. Surgery by the Numbers and Surgical Formulae ... 157
24. Blood and Blood Products ... 162
25. Surgical Hemostasis ... 173
26. Surgical Medications ... 175
27. Complications ... 180
28. Common On-Call Pages ... 192
29. Surgical Nutrition ... 198
30. Shock ... 201
32. Fever ... 212 33. Surgical Prophylaxis ... 213 34. Surgical Radiology ... 215 35. Anesthesia ... 223 36. Surgical Ulcers ... 235 37. Surgical Oncology ... 237
SECTION II
GENERAL SURGERY
38. GI Hormones and Physiology ... 24339. Acute Abdomen and Referred Pain ... 251
40. Hernias ... 256 41. Laparoscopy ... 259 42. Trauma ... 262 43. Burns ... 287 44. Upper GI Bleeding ... 297 45. The Stomach ... 299 46. Bariatric Surgery ... 304 47. Ostomies ... 306 48. Small Intestine ... 310 49. The Appendix ... 316 50. Carcinoid Tumors ... 319 51. Fistulas ... 323
52. Colon and Rectum ... 324
53. The Anus ... 330
54. Lower GI Bleeding ... 333
55. Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis ... 335 56. Liver ... 338 57. Portal Hypertension ... 345 58. Biliary Tract ... 350 59. Pancreas ... 364 60. The Breast ... 370 61. Endocrine ... 379 62. Thyroid Gland ... 390 63. Parathyroid ... 399 64. Spleen... 402
65. Surgically Correctable Hypertension ... 406
66. Soft Tissue Sarcomas and Lymphomas ... 409
Contents xiii
68. Melanoma ... 417
69. Surgical Intensive Care ... 420
SECTION III
SUBSPECIALTY SURGERY
70. Vascular Surgery ... 437 71. Pediatric Surgery... 469 72. Plastic Surgery ... 490 73. Hand Surgery ... 50474. Otolaryngology Head and Neck Surgery ... 528
75. Thoracic Surgery ... 548 76. Cardiovascular Surgery ... 582 77. Transplant Surgery ... 640 78. Orthopedic Surgery ... 649 79. Neurosurgery ... 699 80. Urology ... 722 81. Ophthalmology ... 764
82. Obstetrics and Gynecology ... 775
SECTION IV
RAPID FIRE POWER REVIEW
83. Rapid Fire Review for the American Board of Surgery In-Training Examination (ABSITE) ... 7891
SECTION I
Overview and Background Surgical Information
Chapter 1
Introduction
HOW ADULTS LEARN
Learning is accomplished through motivation, repetition, and association.
Motivation must come from within; most medical students and residents are
obviously motivated to learn. Repetition is obtained by reading, rereading, and studying information until it is mastered. Association is obtained by connecting information that has already been mastered to some new knowledge, such as remembering the anatomic order of the trauma neck zones 3, 2, and 1 in con-junction with the Le Fort fractures 3, 2, and 1.
HOW TO STUDY
Always read about your patient’s disease as you are taking care of him or her. This habit serves two purposes: You will associate the information with that patient for life, and your increased knowledge will improve that patient’s quality of care.
USING THIS BOOK
After completing the surgical basics in Surgical Recall, focus your attention on this book. Review the answers on the right until mastered. This book is designed to foster the acquisition of surgical information and will not help you gain expe-rience in test taking; this skill can be learned from other books.
NURSES
Treat nurses with respect and professional courtesy at all times; they often know more than you in any given situation. If your relationship is based on mutual respect, it is also less likely that they will call you at 3 AM asking for Tylenol.
SLEEP DEPRIVATION
The best offense to combat sleep deprivation is to be in good physical shape and to be motivated. Staying up for 48 hr is no different than participating in an ultramarathon. Many residents find benefit from caffeine, orange juice, hot showers, brushing their teeth, doing push-ups, running steps, yelling, changing their socks, or listening to loud music. Try not to sit down, because sitting is conducive to falling asleep quickly. Studies have shown that in sleep deprivation physical abilities remain intact until extreme deprivation of sleep occurs. Tell yourself, “I am hardcore and I need no sleep!”
INTERNSHIP
The Perfect Intern
Says only “Yes sir,” “No sir,” or “My fault, sir” and “Yes ma’am,” “No ma’am,” or “My fault, ma’am”
Is always honest Is a team player Has a “can do” attitude
Always brushes teeth before rounds
Is the first to arrive and the last to leave clinic Is always clean
Always makes the upper-level residents look good Teaches the students
Does not scut the students too much
Knows more about the patients than anyone else Is a physician, and not merely a scribe
Is never late Never complains
Is never hungry, thirsty, or tired Is always enthusiastic
Follows the chain of command Some thoughts for interns to live by:
“They can hurt you but they can’t stop the clock.” Internship only lasts for
12 months.
“Never trust your brain.” Write everything down, do not trust anything to
memory, and check off your chores when completed.
“Load the boat.” Inform your superiors when a patient is not doing well or if
you have any questions. That way, if your patient’s condition worsens (the proverbial sinking ship), you have loaded the ship with your superiors and they will go down with you.
“Bad news does not age well.” Call right away (see above). “Never lie.” Honesty is the best policy.
LIVING WITH MISTAKES
You will make mistakes, and many times these mistakes will harm your patients. Mistakes are forgivable if you are doing your absolute best. Do not make mistakes that result from laziness.
There is a saying in surgery: “You cannot hurt yourself by getting out of bed.” After a mistake is made and you have determined that you were doing your absolute best, you must then forgive and remember. That is, forgive your-self for the mistake, but always remember the mistake and be sure to learn something from it.
Chapter 1 / Introduction 3
Recovery Room Protocol
Several things need to be done before you can take time to eat some food, so the acronym F.O.O.D.D. is helpful:
Family: Talk to the patient’s family. Operative note: Write in the chart. Orders: Write postop orders. Dictate the procedure.
Doctor: Call the primary/referring doctor.
DEALING WITH ACHES AND PAINS IN THE OR
Many residents find that taking NSAIDs before and after long cases helps decrease muscle strains. Others do sit-ups to strengthen abdominal muscles and reduce backache, or use the OSHA back support belts. Support hose can lessen foot edema and the pain associated with venous lower extremity incompetence associated with long periods of standing.
AVOIDING MALPRACTICE
Do the right thing.
Talk to your patients and their families (never say “no comment” or “I can’t talk about it”).
Be nice to your patients and their families.
Honesty is the best policy. Document everything!
Seek advice from mentor, colleagues, and lawyer.
What should you do if you write the wrong word in a chart?
Put a line through the word, but make sure it is still legible, and then initial. Never blot out—it will look as though you are trying to hide something.
HIERARCHY AMONG SURGICAL RESIDENTS
Suggestions and ideas regarding patient care should flow freely among all surgi-cal residents (including interns), but the decisions follow a concrete chain of command.
ABBREVIATIONS
AKA Above the knee amputation
ALI Acute lung injury
AMF YOYO Adios my friend; you’re on your own
ARF Acute renal failure
ASIS Anterior superior iliac spine
ATFQ Answer the first question
AVN Avascular necrosis
BAL Bronchoalveolar lavage
BAM Bilateral augmentation mammoplasty
BCC Basal cell carcinoma
BMI Body mass index
BSO Bilateral salpingo-oophorectomy
Bx Biopsy
CMV Cytomegalovirus
CRF Chronic renal failure
CRNA Certified Registered Nurse Anesthetist
DJD Degenerative joint disease
DOE Dyspnea on exertion
ELAP Exploratory laparotomy
ER Estrogen receptor
ESRD End-stage renal disease
ETT Endotracheal tube (a.k.a. ET)
FDP Fibrin degradation product
Chapter 1 / Introduction 5
FIDO Forget it; drive on
FOS Full of stool
FROM Full range of motion
G1P1 Gravida (# of pregnancies), Para (# of children)
GI Gastrointestinal
GIST Gastrointestinal stromal tumor
GSW Gunshot wound
hCG Human chorionic gonadotropin
HNP Herniated nucleus pulposus
HOB Head of bed
HODAD Hands of death and destruction
ICH Intracranial hemorrhage
ICU Intensive care unit
IDDM Insulin-dependent diabetes mellitus
IM Intramuscular
INR International normalized ratio
IOC Intraoperative cholangiogram
IVC Inferior vena cava
KISS Keep it simple, stupid
KVO Keep vein open
LMD Local medical doctor
MAFAT Mandatory anesthesia fooling around time
MAP Mean arterial pressure
MCC Motorcycle collision/crash
ME Medical examiner
MODS Multiple organ dysfunction syndrome
MOF Multiple organ failure
MRA Magnetic resonance angiography
MRCP Magnetic resonance cholangiopancreatography
MRI Magnetic resonance imaging
MRSA Methicillin-resistant Staphylococcus aureus
MRSE Methicillin-resistant Staphylococcus
epidermidis
MVC Motor vehicle collision/crash
PEA Pulseless electrical activity
PFO Patent foramen ovale
PFTs Pulmonary function tests
pRBCs Packed red blood cells
PSV Pressure support ventilation
PVR Pulmonary vascular resistance
QD Once a day
RHIP Rank has its privileges
Chapter 1 / Introduction 7
RTC Return to clinic
SCIWORA Spinal cord injury without radiographic abnormality
SDH Subdural hematoma
SIMV Synchronized intermittent mandatory ventilation
SIRS Systemic inflammatory response syndrome
SVC Superior vena cava
SVR Systemic vascular resistance
SVT Supraventricular tachycardia
TAH Total abdominal hysterectomy
TAPP Transabdominal preperitoneal (groin hernia repair)
TEPA Totally extraperitoneal approach (groin hernia repair)
THE Transhiatal esophagectomy
TLC Triple lumen catheter
TPN Total parenteral nutrition
TURB Transurethral resection of bladder
Ucx Urine culture
UNOS United Network for Organ Sharing
VAP Ventilatory-associated pneumonia
VRE Vancomycin-resistant Enterococcus
WWDWWC “Wound was dry when we closed”
y Psychiatric (Greek letter psi)
mg Microgram
ADVANCED GLOSSARY
Antecolic In front of the colon (anterior)
Bezoar Undigested mass (“hair ball”)
Colloid IV fluid with large molecules (e.g., albumin)
Colonized Bacteria residing in the anatomic area but not causing infection, inflammation, signs, or symptoms
Demarcation Line defining borders between two anatomically distinct entities (e.g., between viable and dead tissue)
Eschar Thick dead skin seen after third-degree burns
Granulation Wound with a surface made of “proud flesh” consisting of collagen/fibroblasts and without an epithelial cover
Montgomery straps Straps affixed to a patient’s abdomen with tape; cloth straps are laced and tied after repeated wound changes, to avoid repeated taping of dressings
Pulsus paradoxus Seen with cardiac tamponade; >10 mm Hg decrease in systolic blood pressure on inspiration
Pyrosis Heartburn
Retrocolic Behind the colon (posterior)
Seldinger technique Placement of a tube over a previously placed wire (e.g., central line placement)
Chapter 1 / Introduction 9
Sterile All microorganisms are killed
Sterile field The prepped area of the patient, the drapes, and the instrument table: All items touching this area must be sterile
Strike through Wound drainage penetrating (“striking through”) all layers of a wound dressing
Thrill Palpable vibration of arterial turbulent
flow
ADVANCED SIGNS
Aaron’s sign Pushing on McBurney’s point in patient with acute appendicitis results in
epigastric pain!
Chandelier’s sign Severe pain upon manual manipulation of the cervix on pelvic exam (patient “jumps for the chandelier”)
Claybrook’s sign Pneumoperitoneum (ruptured hollow viscus) results in transmission of breath and heart sounds when abdomen is auscultated
Deep sulcus sign Deep costophrenic angle in supine chest radiograph in patients with a
Dunphy’s sign Abdominal pain with coughing; sign of peritonitis
Jiffy Pop sign Colostomy bag full of air!
Mannkopf ’s sign Increase in heart rate upon pushing on a
point of maximal abdominal tenderness (seen with real pain, not in malingering)
Ring sign CSF and blood form rings when dropped on filter paper (or cloth), seen in CSF otorrhea and rhinorrhea
Soap bubble sign Retroperitoneal air seen in severe pancreatitis
Ten horns sign Pronounced tenderness upon manual tension applied to right spermatic cord, seen in acute appendicitis (think ten horns will make you go ten hut!)
MEDICAL STATS YOU NEED TO KNOW
Define the following terms:
Mean The average value of all data points (e.g., 5, 10, 5, 20; 40/4 = 10 is the mean)
Mode The most common numeric value of a set (e.g., in the set 2, 3, 4, 4, 4, 5, 6, 7; 4 is the mode)
Median The middle value within the ordered set (e.g., 4, 4, 5, 6, 6; 5 is the median)
False-positive A data point that is reported as positive but is really negative
False-negative A data point that is reported as negative but is really positive
Distribution A description of how the data look graphically (i.e., their shape)
Chapter 1 / Introduction 11
Describe some examples of common distributions.
Normal distribution A bell-shaped curve that is symmetrical around the middle
Skewed distribution Not symmetrical, but slanted to the right or left
Bimodal distribution Two graphical peaks of the distribution (i.e., two modes)
Define the following terms:
Sensitivity True-positives True-positives + false-negatives Specificity True-negatives
True-negatives + false-positives Blind study The patient is blind to the clinical
intervention
Double-blind study The patient and the care providers are blind to the clinical intervention; (NOT two orthopods trying to read an ECG!)
What is the Hawthorne
effect?
Improved outcomes in the control group due to increased medical staff vigilance during research
In statistical tests, what is
the null hypothesis?
It is the hypothesis that states that there is no difference between the population value and the hypothesized value, or no differ-ence among the groups being tested; the null hypothesis is often denoted H0
What is a type I error? Rejecting the null hypothesis when it is true
What is a type II error? Failing to reject the null hypothesis when it is not true
How is a paired t-test
performed?
For each subject or pair of subjects, the difference is calculated for the two variables (e.g., weight before diet minus weight after diet); the difference is then analyzed using a one-sample t-test to determine whether or not the differences are equal to zero When is the analysis of
variance (ANOVA) method used?
When there are more than two groups to compare
Is it unusual to observe an
effect with a placebo?
No, people often show an improvement with a placebo if they are blinded to the treatment
How is the incidence of a
disease defined?
It is the number of new cases that occur during a specified amount of time divided
by the number of people at risk of
develop-ing the disease at the beginndevelop-ing of the time interval
How is the prevalence of a
disease defined?
It is the number of cases existing in a given population at a specific period of time (period prevalence) or at a particular moment in time (point prevalence) What is the relative risk of
a disease?
It is a measure of the relative amount of disease occurring in different populations
Chapter 1 / Introduction 13 How do you calculate
relative risk?
Relative risk equals (incidence of disease in exposed group) divided by (incidence of disease in the unexposed group)
MEDICAL SPANISH
Translate the following words and phrases:
Hello Hola (o la)
Good-bye Adios
Please Por favor
Sir Senõr
Ma’am Señora
You Usted (respectful); Tu (familiar)
Speak Hablas
English Inglés
Where Donde (dohn-day)
Is Es; esta
Pain Dolor (dough-lore)
Worse Peor
Better Mejor (mehor) Nauseas Mareado or náuseas Where is the pain? Donde esta el dolor? Is the pain worse? Es peor el dolor? Is the pain better? Es mejor el dolor? Breathe deeply Respiro profundo
Cough Tocé (toe say)
Does it hurt to breathe? Le duele al respiro? (duele = doo-el-ay) Does it hurt if I push here? Le duele cuando aprieto aquí? Where does it hurt? Donde le duele?
Tetanus shot Inyección de tétano
X-ray Radiografía
Were you knocked out? Estuvo inconsciente?
Neck Cuello Abdomen Abdomen Arm Brazo Rectum Recto Chest Pecho Head Cabeza
Need an operation Necesita una operación
Chapter 2
Review of Surgical Acronyms
and Memory Aids
Memory aid for sodium seen with SIADH?
SIADH = “Sodium Is Always Down Here” = Hyponatremia
Cause of SIADH? Syndrome of Inappropriate AntiDiuretic Hormone (Think: Inappropriately Increased ADH)
Chapter 2 / Review of Surgical Acronyms and Memory Aids 15
Goodsall’s rule? Think of a dog with an anterior straight
nose and posterior curved tail
Grey Turner’s sign? Think: TURNer’s = TURN side to site = flank
Symptoms triad for pheochromocytoma?
PHE ochromocytoma: Palpitations Headache
Episodic diaphoresis Leriche’s syndrome? CIA = Claudication of buttocks,
Impotence, Atrophy of buttocks Gardner syndrome? SOD = Sebaceous cysts, Osteomas,
Desmoid tumors (Think: A “Gardner”
plants SOD)
Symptoms/signs and cells of carcinoid syndrome? B FDR in a COOL CAR: Bronchospasm Flushing Diarrhea
Right-sided heart failure KULchitsky cells CARcinoid Colon polyp with the highest
rate of malignancy?
Villous Adenoma (Think: VILLous =
VILLain) 40% malignant Radiolucent kidney stones? Uric = Unseen
Kidney stone due to UTI? Struvite = Sepsis Most radiosensitive testicular
cancer?
Seminoma = Sensitive
Billroth I vs. Billroth II? Billroth I has 1 limb and Billroth II has
2 limbs coming off the stomach Orientation of nerve and vessels
below a rib?
VAN = Vein, Artery, Nerve under the rib Order of femoral vessels? Right side lateral to medial = NAVEL:
Navel Artery Vein
Extralymphatic material Lymphatics
(Thus, the vein is medial to the pulse)
What is the strongest layer of the small bowel?
SUbmucosa = SUperior (not serosa!!!!) Jejunum vs. ileum? Ileum is Inferior in thickness and arcade
Chapter 2 / Review of Surgical Acronyms and Memory Aids 17
What is the treatment of hyperkalemia? “CB DIAL K”: Calcium Bicarbonate Dialysis Insulin/glucose Albuterol Lasix Kayexalate
Differential for hypercalcemia? “CHIMPANZEES”: Calcium overdose
Hyperparathyroidism (1°/2°/3°) Hyperthyroidism/Hypocalciuric Hypercalcemia (familiar)
Immobility/Iatrogenic (thiazide diuretics) Metastasis/Milk–alkali syndrome (rare) Paget disease (bone)
Addison disease/Acromegaly
Neoplasm (colon, lung, breast, prostate,
multiple myeloma)
Zollinger–Ellison syndrome Excessive vitamin D Excessive vitamin A Sarcoid
Clotting factor in hemophilia A? Think: “EIGHT” sounds like “A”
Clotting factors deficient with hemophilia A and hemophilia B?
Think alphabetically and chronologically:
A before B—8 before 9
Hemophilia A = factor VIII Hemophilia B = factor IX
Fat-soluble vitamins? K, A, D, E (“KADE”) Causes of postoperative fever? W’s
Wind – atelectasis Water – UTI
Wound – wound infection Walking – DVT/Thrombophlebitis Wonder drugs – drug fever Curling’s ulcer? Curling iron burn = ulcer due to burn
injury stress
Cushing’s ulcer? Ulcer due to brain injury; Think: Dr. Cushing = NeuroSurgeon = CNS
Product of chief gastric cells? “PEPpy chief ” = PEPsinogen
GCS eye-opening score? 4 = 4 eyes
GCS motor score? 6 = 6-cylinder motor GCS verbal score? 5 = Jackson 5 Treatment of myoglobinuria? HAM:
Hydration with IV fluid
Alkalize urine with bicarbonate IV Mannitol IV diuresis (1 g/kg) Effect of food intake on
symptoms of duodenal ulcers?
Duodenum = Decrease in pain (thus,
many patients with duodenal ulcers gain weight!!)
Indications for surgery with duodenal ulcers? I HOP: Intractability Hemorrhage Obstruction Perforation Indications for operation with
gastric ulcers?
I CHOP: Intractability
Cancer or cancer rule out Hemorrhage
Obstruction Perforation
Chapter 2 / Review of Surgical Acronyms and Memory Aids 19
Product of G cells in stomach? G cells = Gastrin Causes of small-bowel
obstruction (SBO)?
ABC = Adhesions, Bulges (hernias), Cancer
Conditions that keep an enterocutaneous fistula open?
HIS FRIEND: High output
Intestinal destruction (>50%
circumference)
Short segment (<2.5 cm) Foreign body (e.g., 6-tube) Radiation
Infection
Epithelialization (e.g., colostomy) Neoplasm
Distal obstruction Major risk factor for
hepatocellular adenoma?
ABC = Adenoma Birth Control; thus,
birth control pills
Risk factors for gallstones? 4 Fs = Fat, Forty, Female, Fertile (has
children)
Causes of pancreatitis? I G.E.T. S.M.A.S.H.E.D.: Idiopathic Gallstones Ethanol Trauma Scorpion bite Mumps Autoimmune Steroids Hyperlipidemia/Hypercalcemia ERCP Drugs
Ranson criteria <24 hr? Georgia law = GA LAW: Glucose >200 Age >55 LDH >350 AST >250 WBC >16,000
Ranson criteria 24–48 hr? C HOBBS (Think: Calvin and HOBBes) Calcium <8 mg/dL HCT drop >10% Oxygen <60 Base deficit >4 BUN >5 increase Sequestration of >6 L Historical risk factors for
breast cancer?
NAACP: Nulliparity
Age at menarche (<13) Age at menopause (>55 yr) Cancer in breast (in self or family) Pregnancy with first child (>30 yr) Anatomic risk factors for breast
cancer? CHAFED LIPS: Cancer in past Hyperplasia Atypical hyperplasia Female Elderly DCIS LCIS
Inherited genes (BRCA I and II) Papilloma
Sclerosing adenitis
Tumors of MEN-I? Think: type 1 = Primary, Primary,
Primary = PPP = Parathyroid, Pancreas, Pituitary
Tumors of MEN-IIa? MPH = Medullary thyroid cancer, Pheochromocytoma, Hyperparathyroidism MEN-IIb? Think: 3 M plastics = MMM P:
Marfanoid body habitus Medullary cancer Mucosal neuromas Pheochromocytoma
Chapter 2 / Review of Surgical Acronyms and Memory Aids 21
Symptoms of acute arterial occlusion? The “6 P’s”: Pulseless Polar (cold) Paresthesia Pain Paralysis Pallor
P’s of papillary thyroid cancer? The “7 P’s” of Papillary cancer:
Popular (most common) Psammoma bodies
Palpable lymph nodes (spreads most
commonly by lymphatics, seen in ≈33% of patients) Positive 131I uptake Positive prognosis Postoperative 131I scan to diagnose/treat metastases Pulmonary metastases 4 F’s of follicular thyroid cancer? Follicular cancer:
Far away metastasis (spreads
hematogenously)
Female (3:1 ratio)
FNA … NOT (cannot diagnose cancer
with FNA)
Favorable prognosis 4 M’s of medullary cancer? Medullary cancer:
M II
aMyloid
Median lymph node dissection Modified neck dissection (if lateral
nodes positive)
Cause of ACUTE and SUBACUTE thyroiditis?
Alphabetically: A before S, B before V (i.e., Acute before Subacute and
Bacterial before Viral, and thus: Acute = Bacterial and Subacute = Viral)
I’s of ITP? Immune etiology
I = Immunosuppressive drugs
(steroids)
Immunoglobulins
Formula for pressure? Pressure = flow × resistance or P = F × R
(Think: Power FoRward)
Risk factors for sarcomas? “RALES”
Radiation AIDS
Lymphedema (chronic) Exposure to chemicals Syndromes (e.g., Gardner) Malignancy potential of actinic
keratosis?
Asset Kicker = Actinic Keratosis =
premalignant
Most common sites of melanoma?
SEA: Skin #1 Eyes #2 Anus #3
Most common type of melanoma? SUPERior = SUPERficial spreading
Define ARDS: CXR:
Capillary wedge pressure <18 X-ray of chest with bilateral infiltrates Ratio of PaO2 to FiO2<200 (P:F ratio)
Ratio for ARDS diagnosis? Think P:F ratio or “PUFF” ratio
Medications that can be delivered by an endotracheal tube? Think: “NAVEL”: Narcan Atropine Vasopressin Epinephrine Lidocaine Conservative treatment for
claudication? Remember: “PACE”: Pentoxifylline Aspirin Cessation of smoking Exercise Differential diagnosis of mediastinal tumor/mass? Classic four T’s:
1. Thyroid tumor (neurogenic tumor, ganglioneuromas, neurofibromas) 2. Teratoma
3. Terrible lymphoma 4. Thymoma
Chapter 2 / Review of Surgical Acronyms and Memory Aids 23
Clinical findings associated with Brown-Séquard syndrome of spine?
Think: CAPTAIN Brown-Séquard = “CPT”
Contralateral Pain
Temperature loss
Liver clotting factors? Factors II, VII, IX, and X; Think: 2 + 7 =
9, and then 10
Formula for FENa? “YOU NEED PEE” = UNP (UNa+× Pcr/PNa+× Ucr) × 100
Modified Childs criteria? Think: “A BEAR”:
Ascites Bilirubin Encephalopathy Albumin
Prothrombin time (PT)
O2 Sats and FiO2? Think of the 40, 50, 60…, 70, 80, 90 Rule:
PaO2 of 40, 50, 60 corresponds roughly to
an O2 sat of 70, 80, 90 respectively
Position of hemorrhoidal cushions?
Think: TROL: “Two on the Right, One on the Left”
Orientation of incision of pericardium and the phrenic nerve?
A-P: Anterior-Posterior: “Anterior to Phrenic”
Breast location of cancer in patient with ductal carcinoma in situ (DCIS)?
Think: DCIS = Directly in same breast
Breast location of cancer in lobular carcinoma in situ (LCIS)?
Think: LCIS = Liberally in either breast
Felty’s syndrome? Think: “FELT a SURGE”: SRG =
Splenomegaly, Rheumatoid arthritis, Granulocytopenia
Three histological layers of the adrenal cortex?
1. Zona glomerulosa (think “salt”) 2. Zona fasciculata (think “sugar”) 3. Zona reticularis (think “sex”) (Think: GFR = salt, sugar, sex)
Signs of impending bowel necrosis with small SBO?
Think: FATAL: Fever, Acidosis,
Tachycardia, Abdominal pain, Leukocytosis
Gastric ulcers: Type II? II = 2 ulcers—one in stomach and one in
duodenum
Type III? III = 3 = PREpyloric Type IV? IV = 4 = “by the door” Treatment of most extremity
injuries?
RICE = Rest, Ice, Compression, Elevation “Signs” of life after blunt
trauma cardiac arrest?
PERM = Pupillary reaction, EKG activity, Respirations, Movement
Findings with central spinal cord syndrome?
CAM = Central = Arm Motor Loss or “CAMeL”
Findings with anterior spinal cord syndrome?
A.M. P.T. (“morning physical therapy” =
AM PT) = Anterior = Motor, Pain,
Temperature Loss
Side effect of bleomycin? Think: BLEomycin = BLEw with lungs and thus = pulmonary fibrosis
Functions of the two pneumocyte types?
Type 2 = 2 jobs = 1. surfactant; 2. convert into type 1
Type 1 = 1 job = to line the alveoli
How can you remember that addisonian crisis is adrenal insufficiency?
Think: ADDisonian = ADrenal Down
Treatment options for anaphylactic shock? Think: “BASE”: Benadryl Aminophylline Steroids Epinephrine
Chapter 2 / Review of Surgical Acronyms and Memory Aids 25
Memory aid for Ewing’s sarcoma?
Think: TKO:
Twenty or less (<20 yr old)
Knee joint (distal femur or proximal tibia) “Onion skinning”
How can you remember where to place skin incisions for a four-compartment fasciotomy?
“FATP”
FA = Fibula anterior TP = Tibia posterior How can you remember the
laboratory test for carcinoid?
“5 HIgh CAR pile up” = 5-HIaa
CARcinoid test What is the major nutrient of
the colon?
BUTyrate = BUTT = Think “BUTT is near
the colon!”
What is a memory aid for the surgical differential for eosinophilia?
Think: A MAD PA:
Addison’s disease Malignancy Atheroembolism Drugs Parasites Asthma What are the categories for
all causes of a surgical acute abdomen that you need to consider in your diagnosis?
I BOP:
Inflammation/Ischemia Bleeding (ulcers, etc.) Obstruction
Perforation How can you remember
the tumor, hormone, and stimulation tests for Zollinger– Ellison syndrome?
Think: Secret ZE Gas = Secretin =
ZE = Gastrinoma and gastrin
How can you remember Mackler’s triad for Boerhaave’s syndrome?
Think: BOER PEE:
Pain (lower chest) Emesis
Chapter 3
Surgical Syndromes
Define the following the syndromes:
Blue toe syndrome Painful, blue discoloration of the toes caused by microcirculatory blockage due to microemboli from aortic plaque
Bouveret’s syndrome Gallstone causing obstruction of
duodenum
DiGeorge’s syndrome Congenital absence of parathyroid glands and thymus
Li-Fraumeni syndrome p53 gene defect = tumors
Meigs’ syndrome Pleural effusion, ascites associated with an
ovarian mass
Münchausen syndrome Multiple hospitalizations for acute medical condition although no disease process is found
Nonketotic hyperosmolar
syndrome
Severe hyperglycemia without ketoacidosis
Paget–von Schröetter
syndrome
Axillary vein thrombosis (a.k.a. effort vein thrombosis)
Plummer–Vinson syndrome Syndrome of: 1. Esophageal web 2. Iron deficiency anemia 3. Dysphagia
4. Spoon-shaped nails
5. Atrophy of tongue and oral mucosa
Sick euthyroid syndrome Change in thyroid hormone regulation resulting from severe illness, trauma, or stress. Patient has normal thyroid-stimulating hormone (TSH) but has decreased ↓ T4, ↓ T3
Chapter 4 / Surgical Most Commons 27
Turcot syndrome Central nervous system (CNS) malignant tumor and colon polyps
Verner–Morrison syndrome Vipoma von Hippel–Lindau
syndrome
CAP:
Cystic cerebellar hemangioblastoma
Angiomatous malformation of the retina
Pheochromocytoma
Waterhouse–Friderichsen
syndrome
Adrenal insufficiency caused by bilateral adrenal hemorrhage, classically caused by meningococcal infection
Wernicke–Korsakoff
syndrome
Chronic alcohol abuse:
Cranial nerve VI palsy (bilateral) Ataxia
Delirium Strabismus Nystagmus Diplopia
What is a CN VI palsy? CN VI = abducens nerve; palsy results in
diplopia and inability to look laterally
Chapter 4
Surgical Most Commons
What is the most common:
Cause of traumatic death in
adults?
Brain injury
Tumor causing an adrenal
incidentaloma?
Cortical adenoma (nonfunctioning)
Cause of chronic pancreatitis? Alcohol abuse Cause of Budd–Chiari syndrome in Western countries? Prothrombotic state
Benign breast mass in
women 18–36 yr of age?
Fibroadenoma
Nosocomial infection in
surgical patients?
Urinary tract infection (UTI)
Side with a traumatic
diaphragmatic rupture?
Left (liver protects the right)
Site of GI tract lymphoma? Stomach Cause of death in adults
<44 yr of age?
Trauma
Cause of liver bacterial
abscess?
Biliary tract obstruction or disease (used to be appendicitis)
Cause of intraperitoneal
fungal infection?
Severe pancreatitis
Injured vascular structure
in the neck?
Internal jugular
Injured portion of the
duodenum?
Second portion
Leg with a DVT? Left leg Gram-negative bacteria
causing a wound infection?
Escherichia coli
Anaerobic bacteria causing
a wound infection?
Bacteroides fragilis
Cause of ARDS? Sepsis Cause of postoperative renal
failure?
Hypotension (ATN)
Gastric sarcoma? Leiomyosarcoma Gastric site of a gastric
carcinoma?
Chapter 4 / Surgical Most Commons 29 Small-bowel benign tumor? GIST (GastroIntestinal Stromal Tumor) Small-bowel malignant tumor? Adenocarcinoma Site of small-bowel adenoma? Duodenum Endocrine surgical operation? Thyroid resection
Cause of spinal cord injury? MVC’s Cause of a false-positive
aortogram for aortic injury in trauma?
Ductus diverticulum
Cause of hypotension? Hypovolemia Cranial nerve injured in
blunt trauma?
Cranial nerve I (olfactory); easily missed initially!
Benign tumor of the
esophagus?
Leiomyoma
Cause of a visceral arterial
aneurysm?
Splenic aneurysm
Congenital bleeding
disorder?
von Willebrand’s disease
Cause of postoperative
premature labor?
Hypovolemia
Cause of viral transmission
with blood transfusions?
Cytomegalovirus
Cause of death of children
>4 yr of age? Trauma Cause of traumatic death in
children?
Chapter 5
Surgical Percentages
What percentage of spinal cord injuries occur in the cervical spine?
50%
What percentage of clean wounds become infected?
1.5%
What percentage of patients with resolution of mild gallstone pancreatitis will have a common duct stone on intraoperative cholangiogram?
≈5% (i.e., 95% of stones pass)
What percentage of
gastrinomas are found in the “gastrinoma triangle”?
80%
What percentage of patients with Crohn’s disease will need a laparotomy within 20 yr?
75%
What percentage of postop myocardial infarctions are silent (asymptomatic)?
75%
What percentage of patients with antibiotic-associated colitis have pseudomembranous colitis?
50%
What percentage of patients with pseudomembranous colitis have a positive assay for
Clostridium difficile toxin?
95%
What percentage of patients with antibiotic-associated colitis without pseudomembranes have a positive assay for C. difficile toxin?
Chapter 5 / Surgical Percentages 31
What percentage of patients who WILL resolve their partial small-bowel obstruction (SBO) with conservative treatment do so in 48 hr?
80%
What percentage of patients who have SBO (regardless of treatment) will have a subsequent bout of SBO?
≈33%
In what percentage of cases does a thoracic aortogram to rule out a torn thoracic aorta after blunt trauma yield a positive study?
≈10%
What percentage of patients undergoing laparotomy develop a postoperative SBO at some later time?
≈5%
What percentage of colonic villous adenomas contain cancer?
≈40% (Think: VILLous = VILLain)
Mets with VIPOMA at time of diagnosis?
50%
Gallbladder cancer with porcelain gallbladder?
50%
Percentage of penetrating injury to the chest treated with a chest tube?
85%
Percentage of patients with anal melanoma who will have metastasis on diagnosis?
Chapter 6
Surgical History
How are physicians and surgeons in England addressed?
The tradition of addressing physicians as “Doctor” and surgeons as “Mister” persists; it stems from the Medieval era’s disdain for surgeons
Who is widely considered to be the father of experimental surgery?
Hunter (1728–1793), born in Scotland
Who was Dominique Jean Larrey?
Napoleon’s surgeon; responsible for the first ambulance and Larrey’s point (subxiphoid)
Who was William Beaumont? A U.S. Army doctor; studied the gastric physiology of his patient, Alexis St. Martin, who formed a gastrocutaneous fistula from a musket wound in 1822
Who is responsible for the “germ theory”?
Louis Pasteur (1822–1895)
Who is considered the “father of aseptic surgery”?
Joseph Lister (1827–1912)
With what did Lister “disinfect” wounds, hands,
and instruments?
Carbolic acid
Who performed the first successful gastrectomy?
Billroth (1829–1894); he also developed the Billroth I and II
Who performed the first successful end-to-end vascular anastomosis?
Alexis Carrel (1873–1944), a Frenchman; his technique made transplantation a technical possibility
Who is credited with the first cholecystectomy?
Carl Langenbuch, in 1882; the patient endured 5 d of preliminary enemas, but smoked a cigar the day after surgery, got up on the twelfth day, and went home 6 wk later
Chapter 6 / Surgical History 33
When and at what hospital did McBurney describe the point named after him?
In 1889, at the Roosevelt Hospital in New York City
Who is credited with starting the routine use of sterile surgical gloves during operations?
William Stewart Halsted, in 1890; his head nurse, Caroline Hampton, complained about dermatitis caused by surgical chemicals; his solution “won her hand,” literally!
What role in surgery did Goodyear Rubber Company play?
It manufactured the first thin rubber gloves with gauntlets for Halsted
On whom did Halsted perform his first gallbladder operation?
His mother, in 1882; he was a pioneer in gallbladder disease research and the first professor of surgery at Johns Hopkins
What disease did Trousseau, of Trousseau syndrome, die of?
Pancreatic cancer; his syndrome was a deep vein thrombosis (DVT) associated with an abdominal malignancy
Why was Kocher’s (1841–1917) surgical career marked by tragedy as well as triumph?
He perfected the total thyroidectomy by 1898, reducing operative mortality from 13% to 0.5%, but to his horror, produced scores of cretinous and myxedematous patients; he swore thereafter never to remove a complete thyroid again
Who was Harvey Cushing? A neurosurgeon who trained at Johns Hopkins; Cushing (1869–1939) was responsible for advances in neurosurgery (Cushing’s ulcer), pituitary disease, and intracranial pressure (Cushing’s triad)
Why did Cushing insist upon complete silence in the OR?
To minimize droplet infection of wounds; this theory gained increasing acceptance because of the work by Flugge circa 1897, proving that although masks protected the patient against wound infection, they offered little protection if the surgeon was bearded
Who is considered the “father of the modern residency system” in surgery?
A German named von Langenbeck (1810–1887), who trained Billroth
Who established the first surgical residency program in America?
Halsted, at Johns Hopkins Hospital
With what eponym is Le Fort associated?
The Le Fort fractures were named for him, for experiments he conducted in 1900 in which he dropped cannonballs onto cadaver skulls, resulting in 1 of 3 fracture patterns
Who set the standard of requiring complete physical examinations of all patients, and started the first of many large clinics staffed with experts from various fields?
The Mayo Brothers; they built their famous clinic in Rochester, Minnesota, in 1910
Who was Sister Mary Joseph? The Mayos’ nurse; she noticed the paraumbilical adenopathy associated with advanced gastric cancer
Was Bovie an MD? No, he was a PhD in physics; he developed the electrocautery in Boston in the 1920s
Who discovered penicillin? Fleming, a surgeon, in 1928
Which surgeon performed the first human cardiac catheterization?
Forssmann (1904–1979), in 1929 in Berlin, passed a tube through an arm vein into his own heart while watching it on a fluoroscope screen!
Who is credited with developing the heart–lung machine (extracorporeal circulation)?
Gibbon (1903–1973) first used his device in 1953
Who performed the first heart–lung transplantation?
Reitz, in 1982
Who performed the first successful human pancreas transplantation?
Lillehei and Najarian, in 1966 at the University of Minnesota
Who performed the first human laparoscopic cholecystectomy?
Chapter 6 / Surgical History 35
Where and when was the first clinical use of general anesthesia?
Massachusetts General Hospital using ether on October 16, 1846 (by a dentist, William Morton)
Who performed the first appendectomy?
Claudius Amyand, in 1735
Who designed the ileoanal pull-through?
Sabiston and Ravitch, in 1947
Why was this unusual? Sabiston was a cardiovascular surgeon
On whom did Boerhaave first describe the syndrome named after him?
Baron van Wassenaer, admiral of the Dutch fleet
Who was the first to surgically correct Boerhaave’s syndrome?
Barrett, of Barrett’s esophagus
Which father of American academic surgery used cocaine and opium throughout his career?
Halsted
Which battle was the Battle sign named after?
William Battle (1855–1936) named it; (Trick question!)
Who developed the first chest tube?
Crosswell Hewett, in 1876
What was the first chest tube? A rubber catheter
Who developed the Swan–Ganz catheter?
Dr. Swan got the idea of placing a balloon at the end of a catheter and letting it sail to the pulmonary artery after watching sailboats at the beach!
Chapter 7
Surgical Instruments
Identify the proper technique: “Palming” an instrument when you are not using it
Chapter 7 / Surgical Instruments 37
Removing a clamp with your left hand
How do you put a blade on a scalpel?
Never with your hands; always use a clamp
Define the instrument: Adson–Brown tissue forceps
Angled DeBakey vascular clamp
Chapter 7 / Surgical Instruments 39
Bandage scissors Used to cut bandages
Bone-cutting forceps
Chapter 7 / Surgical Instruments 41
Bulldog clamp
DeBakey aortic clamp
Chapter 7 / Surgical Instruments 43
Doyen rib stripper Periosteal rib elevator
Duval clamp forceps Used as a lung clamp (a.k.a. Pennington clamp)
Ferris-Smith tissue forceps For fascia (often called Ferris Buellers!)
Finochietto rib spreader
Fish retainer A sheet of rubber that protects the bowel during laparotomy closure
Chapter 7 / Surgical Instruments 45
Frazier suction Designed initially for neurosurgery
Gigli saw
Gomez retractor
Chapter 7 / Surgical Instruments 47
Jamieson scissors
Keuttner Pronounced “kitner” or “peanut” by most; basically, a small cloth dressing held by clamp
Lahey thyroid clamp
Chapter 7 / Surgical Instruments 49
Lone Star retractor Used to expose anal/rectal mucosa
Loupes
Maryland dissecting forceps
Poole sucker Used for suctioning fluid (often irrigation) from peritoneal cavity
Chapter 7 / Surgical Instruments 51
Rat-toothed forceps
Russian forceps Used for fascia
Chapter 8 / Sutures and Stitching 53
# 12 Scalpel blade
Vein retractor
Chapter 8
Sutures and Stitching
Should the subcutaneous fat be closed with sutures?
No, because fat will not hold sutures, which then become a foreign body, increasing the rate of infection
SUTURE TECHNIQUES
What is a slipknot? It slips to tighten, but does not hold in place for long
How is a suture removed? Simply cut one side of the knot and then pull the knot out!
Chapter 8 / Sutures and Stitching 55
What is a Connell’s stitch? The first mucosa-to-mucosa layer in an anastomoses; basically a running
U stitch
How can one remember the order of the Connell’s stitch?
“Into the bar—have a drink then go out
of the bar—cross the street and go into the bar—have a drink—go out of the bar—cross the street . . . .”
What is a Halsted stitch? An interrupted horizontal mattress stitch
What is the Cushing stitch? A running horizontal mattress stitch used to approximate two adjacent surfaces
Chapter 8 / Sutures and Stitching 57
What is a retention suture bridge?
A bridge used to slowly tighten the retention suture as edema resolves
What is a taper needle? A needle used in easily penetrated tissues (e.g., bowel)
What is a cutting needle? A needle for getting through tough material (e.g., skin); the edge is on top of the needle
What is a “reverse” cutting needle?
A cutting needle with the edge on the
bottom
What is a “Keith” needle? A straight needle
SUTURE TECHNIQUE
How do you pass a suture on a “passer” around a clamped bleeding vessel?
“Tip to tip”
Chapter 8 / Sutures and Stitching 59
How do you repair a hole in the heart near a coronary artery?
Large U stitch under the coronary artery
Best way to suture an intercostal artery and avoid painful postop nerve injury?
SUTURE MATERIALS
How long do plain and chromic gut sutures retain their tensile strength?
Plain gut: 7–10 d Chromic gut: 10–12 d
How many throws are needed in a Prolene knot?
At least five (most use >6)
What are the following absorb-able sutures made of:
Vicryl? Polyglactic acid
PDS? Polydioxane
Maxon? Polyglyconate
Dexon? Polyglycolic acid
Why can PDS or Maxon be used for closing abdominal fascia?
Keeps its strength for >42 d
Why should silk be avoided in contaminated wounds?
Nonabsorbable, and its pores can harbor bacteria
Why do “train tracks” occur with sutures?
Because the suture track epithelializes after 7 d
What type of suture is used to repair the biliary tract or GU system?
Absorbable suture; otherwise, the suture
material acts as a nidus for stone formation
Suture material for diaphragm repair?
Nonabsorbable (e.g., Prolene)
Suture material for an umbilical hernia?
