Friday, February 26, 2010

71 - Pfannensteil incision

The Pfannenstiel incision has become popular in the past decade for cosmetic reasons. This is particularly true in younger women having surgery for benign gynecologic and pelvic problems. If properly placed, it is generally concealed by regrowth of pubic hair.

The purpose of the technique is to provide a cosmetic incision for pelvic surgery.

Physiologic Changes. The Pfannenstiel incision transects neurovascular pathways in the skin of the abdominal wall and frequently requires partial or compete transection of the rectus abominis muscle. It is rarely associated with incisional hernia, has a low incidence of wound dehiscence, and heals without significant scarring. The latter fact may be due to the copious blood supply in the mons pubis.

Points of Caution. A Pfannenstiel incision should never be used in oncologic surgery. It does not give exposure to the upper abdomen and provides only limited exposure to aortic and lymph nodes for their analysis and dissection. Care must be taken to avoid incidental laceration of the inferior epigastric artery and vein on the lateral margin of the rectus muscles. If the muscles are to be transected, the epigastric artery and vein should be identified, clamped, and ligated prior to transection of the muscle. In addition, care should be taken with regard to the point of entry into the peritoneum. If the incision is made too low, the bladder can be entered.

Hemostasis is particularly important during this incision. The vascularity of the mons pubis increases the risk of hemorrhage, formation of hematoma, and infection. The surgeon should ensure that the incision is dry before closure of the wound. If there is any question, a small suction drain should be left in the incision for 24-48 hours.

*This incision is commonly called the bikini line incision.

Studies on the abdominal incision

70 - Abdominal incisions

*Abdominal incisions are made through all portions of the abdominal walls according to the organs it is desired to gain access to.

*They should be so planned as to avoid unnecessarily wounding the muscles, arteries, and nerves. It having been found that incisions through fascia alone are more liable to be followed by hernia than those through muscles, incisions through the linea alba and lineae semilunares are to be avoided.
*Incisions through the recti muscles are best made near their inner edge. If made in the outer edge the nerves supplying the muscle will be divided, causing subsequent paralysis and weakness. If made through the middle, only the nerves supplying the inner half will be divided, but the main trunks of the deep and superior epigastric arteries will be cut and cause troublesome bleeding.There is least harm done by making the incision through the inner edge of the muscle.

*If the method of Battles is resorted to, of dividing the outer edge of the sheath of the rectus longitudinally and displacing the muscle inward, or of dividing the muscle itself longitudinally, then not only are large branches of the deep epigastric arteries met but in dividing the posterior layer of the sheath the nerves are divided.

*If the rectus is divided transversely (as Kocher advises in operations on the gall-bladder) care must be taken to avoid wounding the nerves; he claims that the scar acts only as an additional linea transversa and does not injure the functions of the muscle. Injury to the nerves and rectus muscle both can be avoided by incising the sheath transversely and then pulling the rectus to one side (Weir), or by dissecting up the sheaths of both recti transversely and separating the muscles in the median line (Pfannenstiel and Stimson).

*Incisions through the transverse muscles if made in the same direction through all three muscles are bound to cut some in a direction more or less transverse to their fibres. The incision of McBurney - for appendicitis - avoids wounding the muscles. He separated the external oblique in the direction of its fibres downward and inward, crossing a line from the anterior superior spine to the umbilicus, 4 to 5 cm. (1 1/2 to 2 in.) to the inner side of the spine. The internal oblique and transversalis are then separated in the direction of the fibres and drawn in the opposite direction. This method is applicable where small openings suffice; but when large incisions are essential, as in bad suppurating cases of appendicitis and in operations to expose the kidney and ureter, it is customary with many to incise all the muscles in the line of the fibres of the external oblique. Should nerves be encountered they are if possible to be drawn aside. In this incision the internal oblique and transversalis are incised nearly transversely, and bleeding from the deep circumflex iliac artery which runs between them will be encountered.

*Edebohls exposes the kidney by incising alongside of the outer edge of the erector spinae muscle. The latissimus dorsi is separated in the direction of its fibres, the lumbar aponeurosis is incised and kidney exposed. A normal kidney can be delivered through this incision, but not one much enlarged. When the kidney is much enlarged the incision is to be prolonged anteriorly along the crest of the ilium. The relation of the pleura is to be borne in mind: it crosses the twelfth rib about its middle to reach its lower edge posteriorly. Hence the upper end of the incision should always be kept anterior to it.

Thursday, February 4, 2010

68 - Inflammatory mediators of shock

*Proinflammatory mediators of shock :
- IL-1alpha/beta
- IL-2
- IL-6
- IL-8

*Anti-inflammtory mediators of shock :
- IL-4
- IL-10
- IL-13
- IL-1ra
- PGE2
- TGF beta

Wednesday, January 20, 2010

67 - Arterial disease Mcqs

1q: Abdominal aortic aneurysms should be repaired if their diameter is larger than ?
a. 3 cm
b. 4 cm
c. 5 cm
d. 6 cm

2q: In the United States, the most common organism responsible for mycotic aneurysms of the abdominal aorta is ?
a. Streptococcus
b. Staphylococcus
c. Salmonella
d. Treponema

3q: The most common peripheral artery aneurysm is ?
a. Brachial
b. Radial
c. Popliteal
d. Tibial

4q: The compartment most commonly affected in a lower leg compartment syndrome is the ?
a. Anterior compartment
b. Lateral compartment
c. Deep posterior compartment
d. Superficial posterior compartment

5q: The preferred procedure for treatment of typical occlusive disease of the aorta and both iliac arteries is ?
a. Endovascular stenting
b. Extra-anatomic bypass
c. Aortoiliac endarterectomy
d. Aortobifemoral bypass

6q: What is the treatment of acute embolic mesenteric ischemia ?
a. Observation
b. Anticoagulation
c. Thrombolysis
d. Operative embolectomy

7q: The treatment of nonocclusive mesenteric ischemia is ?
a. Observation
b. Catheter infusion of papaverine
c. Stenting to prevent further spasm
d. Operative bypass of the superior mesenteric artery

8q: The most accurate diagnostic test with the lowest morbidity in the diagnosis of renal artery stenosis is ?
a. Angiography
b. CT scan
c. Magnetic resonance angiography
d. Renal systemic renin index

9q: The bypass graft of choice in children with renovascular hypertension is ?
a. Saphenous vein
b. Hypogastric artery
c. Prosthetic
d. Dacron

10q: Which of the following is the most prevalent inherited risk factor for peripheral vascular disease ?
a. Elevated HDL
b. Elevated LDL
c. Elevated VLDL
d. Elevated Lipoprotein a (Lp(a))

11q: Which of the following statements regarding carotid body tumors is true ?
a. Occur more commonly in patients who live at high altitudes
b. Require resection of the underlying carotid artery with reconstruction for cure
c. Are associated with catecholamine release
d. Are usually malignant

12q: Rest pain seen with occlusive peripheral vascular disease in the lower extremity most commonly occurs in ?
a. The buttock
b. The quadriceps
c. The calf muscles
d. The Metatarsophalangeal joint (MTP)

13q: A patient with a creatinine of 1.8 who is scheduled for angiography should
a. Not proceed with angiography
b. Be given oral acetylcysteine the day before and day of study
c. Be given lasix and a fluid bolus after the study
d. Have a dialysis catheter inserted at the time of the study

14q: Which of the following can be used in the treatment of hyperhomocysteinemia ?
a. Statin drugs
b. Aspirin
c. Niacin
d. Folic acid

15q: The best initial treatment for a groin pseudoaneurysm after angiography is ?
a. Surgical repair
b. Ultrasound-guided compression
c. Ultrasound-guided injection of thrombin
d. Observation

16q: Which of the following statements concerning cilostazol is true ?
a. It is more effective than pentoxifylline in the treatment of claudication
b. It works by inhibiting platelets and lowering LDL cholesterol
c. It works with in 2 weeks of starting the drug
d. It should not be used in patients with acute coronary syndromes

17q: The most common nonatherosclerotic disease of the internal carotid artery is ?
a. Thrombosis from protein C deficiency
b. Trauma
c. Takayasu arteritis
d. Fibromuscular dysplasia (FMD)

18q: What is the earliest detectable lesion of atherosclerosis ?
a. Fatty streak
b. Fibrous plaques
c. Subendothelial monocytes
d. Platelet deposition

19q: Carotid artery dissection is best treated by ?
a. Surgical resection and reconstruction with graft
b. Surgical resection and reconstruction with vein
c. Endoluminal stenting
d. Anticoagulation

20q: A patient who develops dizziness, drop attacks and diplopia with exercise most likely has ?
a. Carotid stenosis
b. Subclavian steal syndrome
c. Coronary subclavian steal syndrome
d. Coronary artery disease

21q: A patient who is taking metformin has an increased risk of which of these complications after angiography ?
a. Renal failure
b. Coagulopathy
c. Lactic acidosis
d. Hyperkalemia

22q: Which of the following is a risk factor specific for peripheral vascular disease ?
a. Family history
b. Hyperhomocysteinemia
c. Elevated HDL
d. Elevated LDL

23q: Cholesterol lowering drugs (statin therapy) should be recommended in patients with peripheral vascular disease who have ?
a. HDL less than 40 mg/dl
b. Triglycerides greater than 150 mg/dL
c. LDL cholesterol (LDL-C) greater than 130 mg/dL
d. Cholesterol greater than 185 mg/dL

24q: The osmolality of most contrast agents used for angiography is ?
a. 100-300 mOsm
b. 300-600 mOsm
c. 600-900 mOsm
d. 900-1200 mOsm

25q: All patients with peripheral vascular disease should have medical treatment aimed to achieve which of the following goal ?
a. Statin therapy to lower CRP to less than 1.0
b. Treatment of blood pressure to attain 130/85 mm Hg
c. Management of diabetes to obtain glycohemoglobin level less than 12%
d. Niacin to achieve normal homocysteine levels

26q: An Ankle-brachial index of 0.7 ?
a. is normal
b. indicates an incrased risk of CVS events
c. is indicative of moderate ischemia with rest pain
d. is indicative of severe ischemia with a risk for gangrene

27q: The primary event in the occlusion of a coronary artery is ?
a. Arterial narrowing at a bifurcation site
b. Development of an atrial arrythmia
c. Episodes of hypotension
d. Episodes of plaque disruption

28q: The most common presenting symptom of acute arterial occlusion is ?
a. Pain
b. Pallor
c. Paresthesia
d. Pulselessness

29q: Platelets are derived from ?
a. Eosinophils
b. Lymphocytes
c. Megakaryocytes
d. Monocytes

30q: Chronic occlusion of the popliteal artery may produce ?
a. Brawny discoloration of the skin over the ankle
b. Dilated collateral vessels in calf and foot
c. Pain in the calf that is relieved by dependency
d. Ulceration over the medial malleolus

31q: The most common type of aneurysm is ?
a. Degenerative
b. Dissecting
c. Poststenotic
d. Traumatic

32q: Each of the following is characteristic of causalgia of an extremity except ?
a. Anhydrosis
b. Burning pain
c. Coolness
d. Skin hypersensitivity

33q: What is the first change encountered in acute mesenteric ischemia ?
a. Severe periumbilical pain
b. Elevation of creatine phosphokinase levels
c. Hyperkalemia
d. Metabolic acidosis

34q: A 55 year old woman presents 6 days after experiencing an acute arterial occlusion in her left leg. After she undergoes an arterial reconstruction, pulses return to her foot, but 6 hours postoperatively, her urine becomes reddish brown and is found by dipstick to be positive for hemoglobin. Which of the following treatments would be absolutely contraindicated for this patient ?
a. Administration of mannitol
b. Administration of glucose and insulin
c. Administration of sodium bicarbonate
d. Administration of ammonium chloride

35q: Which of the following statements concerning patients who have an asymptomatic bruit located at the carotid bifurcation is true ?
a. Approximately 50% of these bruits originate in the external carotid artery
b. The loudest bruits are heard when the stenosis is tightest
c. If these patients develop symptoms, transient ischemis attacks usually precede frank strokes
d. Almost 50% of these patients will develop neurologic symptoms within 5 years

36q: Which of the following treatments is contraindicated in the management of frostbite of an extremity?
a. Rapid warming in warm water
b. Antibiotics and tetanus antiserum
c. Elevation of the extremity
d. Early amputation of demarcated areas

37q: A major difference between congenital and acquired arteriovenous fistulas is ?
a. The location affected
b. The hemodynamic stresses involved
c. The character of the bruits
d. The rates of surgical cure

38q: All of the following statements concerning popliteal artery aneurysms are true except ?
a. Approximately 50% are associated with aneurysms at other sites
b. Rupture into the popliteal space is a frequent complication
c. Associated thrombosis carries a high risk of amputation
d. Associated distal embolization may result in tissue loss

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