220 Section II / General Surgery
What are the boundaries of	1.	Cooper’s ligament posteriorly
the femoral canal?	2.	Inguinal ligament anteriorly
	3.	Femoral vein laterally
	4.	Lacunar ligament medially
What factors are associated	Women, pregnancy, and exertion
with femoral hernias?
What percentage of all	5%
hernias are femoral?
What percentage of patients	85%!
with a femoral hernia are
female?
What are the complications?	Approximately one third incarcerate
	(due to narrow, unforgiving neck)
What is the most common	Indirect inguinal hernia
hernia in women?
What is the repair of a	McVay (Cooper’s ligament repair), mesh
femoral hernia?	plug repair
HERNIA REVIEW QUESTIONS
Should elective TURP or	TURP
elective herniorrhaphy be
performed first?
Which type of esophageal	Sliding esophageal hiatal hernia
hiatal hernia is associated
with GE reflux?
Classically, how can an	1.	Apply ice to incarcerated hernia
incarcerated hernia be	2.	Sedate
reduced in the ER?	3.	Use the Trendelenburg position for
		inguinal hernias
	4.	Apply steady gentle manual pressure
	5.	Admit and observe for signs of
		necrotic bowel after reduction
	6.	Perform surgical herniorrhaphy
		ASAP

What is appropriate if you cannot reduce an incarcerated hernia with

steady, gentle compression?

What is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia?

What is the Howship-Romberg sign?

What is the “silk glove” sign?

What must you do before leaving the O.R. after an inguinal hernia repair?

Chapter 36 / Hernias 221

Go directly to O.R. for repair

In babies and children it is rarely necessary to repair the inguinal floor; repair with “high ligation” of the hernia sac

Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia

Inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger

Pull the testicle back down to the scrotum

ESOPHAGEAL HIATAL HERNIAS

Define type I and type II	Type I sliding
hiatal hernias.	Type II paraesophageal
SLIDING ESOPHAGEAL HIATAL HERNIA
What is it?	Both the stomach and GE junction
	herniate into the thorax via the
	esophageal hiatus; also known as type I
	hiatal hernia

222 Section II / General Surgery

What is the incidence?

What are the symptoms?

90% of all hiatal hernias

Most patients are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration

How is it diagnosed?

What are the complications?

UGI series, manometry, esophagogastroduodenoscopy (EGD) with biopsy for esophagitis

Reflux S esophagitis S Barrett’s esophagus S cancer and stricture formation; aspiration pneumonia; it can also result in UGI bleeding from esophageal ulcerations

What is the treatment?

What is the surgical treatment?

85% of cases treated medically with antacids, H2 blockers/PPIs, head elevation after meals, small meals, and no food prior to sleeping; 15% of cases require surgery for persistent symptoms despite adequate medical treatment

Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus around the LES and suturing it in place

PARAESOPHAGEAL HIATAL HERNIA

What is it?	Herniation of all or part of the stomach
	through the esophageal hiatus into the
	thorax without displacement of the
	gastroesophageal junction; also known as
	type II hiatal hernia

What is the incidence?

What are the symptoms?

Chapter 37 / Laparoscopy 223

5% of all hiatal hernias (rare)

Derived from mechanical obstruction; dysphagia, stasis gastric ulcer, and strangulation; many cases are asymptomatic and not associated with reflux because of a relatively normal position of the GE junction

What are the complications?

What is the treatment?

What is a type III hiatal hernia?

What is a type IV hiatal hernia?

Hemorrhage, incarceration, obstruction, and strangulation

Surgical, because of frequency and severity of potential complications

Combined type I and type II

Organ (e.g., colon or spleen) / stomach in the chest cavity

C h a p t e r 37

What is laparoscopy?

What gas is used and why?

Which operations are performed with the laparoscope?

Laparoscopy

Minimally invasive surgical technique using gas to insufflate the peritoneum and instruments manipulated through ports introduced through small incisions with video camera guidance

CO2 because of better solubility in blood and, thus, less risk of gas embolism; noncombustible

Frequently—cholecystectomy; appendectomy; inguinal hernia repair; ventral hernia repair, Nissen fundoplication

Infrequently—bowel resection, colostomy, surgery for PUD (PGV, perforation), colectomy, splenectomy, adrenalectomy

224 Section II / General Surgery
What are the	Absolute—hypovolemic shock, severe
contraindications?	cardiac decompensation
	Relative—extensive intraperitoneal
	adhesions, diaphragmatic hernia, COPD
What are the associated	Pneumothorax, bleeding, perforating
complications?	injuries, infection, intestinal injuries,
	solid organ injury, major vascular injury,
	CO2 embolus, bladder injury, hernia at
	larger trocar sites, DVT
What are the classic findings	Triad:
with a CO2 gas embolus?	1. Hypotension
	2. Decreased end tidal CO2 (low flow
	to lung)
	3. Mill-wheel murmur

What prophylactic measure should every patient get when they are going to have a laparoscopic procedure?

What are the cardiovascular effects of a pneumoperitoneum?

What is the effect of CO2 insufflation on end tidal CO2 levels?

SCD boots—Sequential Compression Device (and most add an OGT to decompress the stomach; Foley catheter is usually used for pelvic procedures)

Increased afterload and decreased preload (but the CVP and PCWP are deceivingly elevated!)

Increased as a result of absorption of CO2 into the bloodstream; the body compensates with increased ventilation and blows the extra CO2 off and thus there is no acidosis

What are the advantages Shorter hospitalization, less pain and over laparotomy? scarring, lower cost, decreased ileus

What is the Veress needle? Needle with spring-loaded, retractable, blunt inner-protective tube that protrudes from the needle end when it enters peritoneal cavity; used for blind entrance and then insufflation of CO2 through the Veress needle

How can it be verified that the Veress needle is in the peritoneum?

Syringe of saline; saline should flow freely without pressure through the needle “drop test”

If the Veress needle is not in the peritoneal cavity, what happens to the CO2 flow/ pressure?

What is the Hasson technique?

What is the cause of postlaparoscopic shoulder pain?

What is a laparoscopicassisted procedure?

What is FRED®?

Chapter 37 / Laparoscopy 225

Flow decreases and pressure is high

No Veress needle—cut down and place trocar under direct visualization

Referred pain from CO2 on diaphragm and diaphragm stretch

Laparoscopic dissection; then, part of the procedure is performed through an open incision

Fog Reduction Elimination Device: sponge with antifog solution used to coat the camera lens

Give some tips for “driving” the camera during laparoscopy.

1.Keep the camera centered on the action

2.Watch all trocars as they enter the peritoneal cavity (and the tissues beyond, so they can be avoided!)

3.Watch all instruments as they come through the trocars (unless directed otherwise)

4.Ask if you want to come out and clean and re-FRED the lens

5.Look outside the body at the trocars and instrument angles to reorient yourself

6.Keep the camera oriented at all times (i.e., up and down); usually the camera cord is on the bottom of the camera—orient yourself to the camera before entering the abdomen

7.You may clean the camera lens at times by lightly touching the lens to the liver or peritoneum

8.Never let the camera lens come into contact with the bowel because the camera may get very hot and you can burn a hole in the bowel or burn the drapes!

226 Section II / General Surgery

9.Put your helmet on (i.e., expect to get yelled at!)

10.Never act agitated when the surgeons are a little abrupt (e.g., “Center— center the camera!”)

11.Always watch the trocars as they are removed from the abdominal wall for bleeding from the site and view the layers of the abdominal wall, looking for bleeding as you pull the camera trocar out at the end of the case

At what length must you close trocar sites?

How do you get the spleen out through a trocar site after a laparoscopic splenectomy?

What is an IOC?

5 mm should be closed

Morcellation in a bag, then remove piecemeal

IntraOperative Cholangiogram (done during a lap chole to evaluate the common bile duct anatomy and to look for any retained duct stone)

What is the safest time for	Second trimester
laparoscopy during
pregnancy?

C h a p t e r 38

What widely accepted protocol does trauma care in the United States follow?

What are the three main elements of the ATLS protocol?

Trauma

Advanced Trauma Life Support (ATLS) precepts of the American College of Surgeons

1.Primary survey/resuscitation

2.Secondary survey

3.Definitive care