Contents

Esophagus de VIRGILIO .................................. 2

Stomach de VIRGILIO ..................................... 3
Liver de VIRGILIO ............................................ 5
Biliary de VIRGILIO ......................................... 7
Pancreas de VIRGILIO ...................................... 9
Spleen de VIRGILIO....................................... 10
Hernia de VIRGILIO ....................................... 11
Small Bowel de VIRGILIO ............................. 12
Large Bowel de VIRGILIO.............................. 14
Anorectal de VIRGILIO ................................... 18
Endocrine de VIRGILIO .................................. 19
Head and Neck de VIRGILIO .......................... 21
Breast de VIRGILIO ........................................ 22
Vascular - Arterial de VIRGILIO ...................... 25
Vascular - Venous de VIRGILIO ...................... 26
Thoracic de VIRGILIO ..................................... 27
Pediatric de VIRGILIO .................................... 28
Transplant de VIRGILIO.................................. 29
Trauma de VIRGILIO ...................................... 30
Plastic de VIRGILIO ........................................ 34
Skin and soft tissue ........................................ 35

Talal AlQaisi, MD MPH GSR 1|Page

 oAbdominal part: esophageal branches from
Esophagus de VIRGILIO lt gastric artery
• Surgical approaches:
Achalasia o 1st + 3ed parts: Lt thoracotomy
• Primary motility disorder of esophagus o 2nd part: Rt thoracotomy
• Pathogenesis: neurogenic degeneration of
ganglion cells, which results in a failure of LES Thyrocervical trunk STAT
to relax on swallowing, which leads to increase 1. Supraclavicular artery
intraluminal pressure, marked esophageal 2. Transverse cervical artery
dilation, loss of progressive peristalsis 3. Ascending cervical artery
• Classic triad: dysphagia, regurgitation, weight 4. Inferior Thyroid artery
loss
• Dx: manometry “Gold standard” Surgical approaches in esophageal cancer
• Barium: bird’s beak • TransThorasic esophagectomy TTE
• Tx: • TransHiatal esophagectomy THE
• Pneumatic dilation • TTE + THE
• Lap esophagomyotomy w anterior
fundoplication, or partial 270 posterior • TTH (Ivor Lewis):
fundoplication o Upper midline laparotomy to mobilize the
• MTx helps in relieving symptoms only in < 10% stomach
o Rt thoracotomy to resect the esophagus
Barrett esophagus
• With high-grade dysplasia w/o nodules: • THE (in distally placed cancer)
endoscopic radiogrequency ablation o Lt cervical incision
o Midline laparotomy
• With low-grade dysplasia: repeat endoscopy
within 3-6 m
Mallory-Weiss tear
✓ Normal LES resting pressure: 6-26 mmHg • After forceful vomiting or coughing
✓ Normal UES resting pressure: 60-80 mmHg • Hiatal hernia is a predisposing factor
• Partial-thickness mucosal tear and bleeding (3-
Acute variceal bleeding AVB 5 cm above GE junction on the Lt side)
• Band ligation has superiority over endoscopic • Endoscopy to confirm Dx
sclerotherapy
• Infection is an important predictor of mortality Boerhaave syndrome
in AVB • Full-thickness tear causing perforation
• Beta blockers can prevent rebleeding • Leads to sepsis

Anatomy Paraesophageal hernia (type II hiatal hernia)

• Outer muscular layer is longitudinal • Rolling type
• Inner muscular layer is circular (extension of • Wide hiatus—- stomach protruding into the
cricopharyngeus muscle) chest
• Anatomical narrowing areas: cricopharyngeus, • GE junction is below the diaphragm
aortic arch, the diaphragm • Stomach can rotate counterclockwise
• Blood supply: • Stomach mucosa can suffers from ulcers
o Cervical part: thyrocervical trunk (off (Cameron’s ulcer) which leads to chronic blood
subclavian artery) loss, then anemia
o Thoracic part: branches off aorta • Dx: barium swallow, upper endoscopy

Talal AlQaisi, MD MPH GSR 2|Page

 Zenker diverticulum • Dietary restrictions are helpful (avoid fatty
• False diverticulum foods, chocolate, peppermint, alcohol, coffee,
• Pulsion diverticulum ketchup, mustard, vinegar)
• Is a MC type of esophageal diverticulum
• Commonly in elderly Hiatal hernia
• Mostly in Killian triangle (inferior fibers of • Types:
inferior constrictor muscle, superior border of I: sliding hernia (MC), GE junction moves
cricopharyngeus muscle upward
• Dx: barium swallow II: paraesophageal hernia, GE junction at the
• Tx: surgical normal position, gastric fundus is dislocated
• Size < 3cm is a contraindication for endoscopic upward
management III: I+II

Dysphagia lusoria Stomach de VIRGILIO

• Difficulty in swallowing due to compression of
the esophagus by an aberrant Rt subclavian Laparoscopic Roux-en-Y gastric bypass LRYGB
artery, which arise from the descending aorta • MCC of SBO post LRYGB is internal hernia
just distal to Lt subclavian artery (potential hernia site - Petersen’s space)
• Compression is between trachea and artery • Risk of SBO more in retrocolic than antecolic
• Associated with: Kommerell diverticulum approach
• Bovine arch: Lt common carotid artery and • 2nd MCC of SBO post LRYGB is Roux
innominate artery share the same origin from compression due to mesocolon scarring
aorta
✓ The MC extranidal non-Hodgkin lymphoma is
gastric lymphoma
Leiomyoma
✓ Tx of diffuse large B-cell lymphoma is
• MC benign tumor of esophagus is leioyoma
chemotherapy
• Small risk of malignancy
• Become symptomatic if > 5cm Gastroparesis
• Barium swallow: smooth, crescent-shaped • Delayed gastric emptying w/o mechanical
filling defect that encroaches on the lumen cause
• Endoscopy: mucosa intact, movable mass with • MC known cause is DM
swallowing • MCC is idiopathic
• TEU is helpful • Dx: gastric emptying scintigraphy (Nuclear
• Tx: enucleation medicine study) (if > 10% of meal remains in
• More common in males stomach, then it is gastroparesis)

Post weight loss surgery GS

Barrett esophagus
• Caused by increased calcium and mucin
• Occurs in 5-7% of GERD patients secretion into bile, increased arachidonic acid
• Hallmark feature: intestinal goblet cells concentration, bile stasis due to dietary
• More in males resections
• Uncommon in black • No need for prophylactic cholecystectomy
• Risk of adenocarcinoma is 0.5% per year • Weight loss > 25% is the strongest predictor of
• PPI more effective than H2 blockers post weight loss surgery GS formation
• No role of high dose of PPI
• Long Barrett segment has higher risk of high- Helicobacter pylori
• Helix-shaped, microaerophilic, gram negative
grade dysplasia
rod

Talal AlQaisi, MD MPH GSR 3|Page

• More prevalent in low- and medium-income • Mostly sporadic
countries • If inherited, then ass w MEN1
• Secrets local toxins that induce local immune • Ulcers most commonly in the distal duodenum
response and increase gastrin levels leading to or jejunum
hyperacidity • PPI highly effective
• H. pylori produce urease (splits urea into • Most of gastrinomas are located in 1st and 2nd
ammonia and bicarbonate) part of duodenum
• The best test to confirm H. pylori eradication is • If even intraOP you cannot localize
urea breath test gastronoma, the do blind proximal
• H. pylori serology for never treated patients duodenotomy to manually palpate the tumor
• The most sensitive test for gastrinoma
✓ 1sr manifestations of gastric leak post RYGB is localization is octrerotide scan
tachycardia and fever • But it is poor for localizing duodenal
gastrinoma if < 1.1 cm
Dumping syndrome • Duodenal gastrinoma best localized by
• Types: endoscopic US
o Early: 20-30 min after eating, more
common, has GI and cardiovascular Gastric cancer
symptoms (due to release of serotonin, • Proximal cancer: total gastrectomy
neurotensin, bradykinins, enteroglucagon • Proximal margins at least 6 cm
o Late: 2-3 Hr after eating, due to large • Virchow node: metastatic Lt supraclavicular LN
amounts of carbs suddenly reaching the • Irish node: metastatic Lt axillary LN
small intestine, leads to hyperinsulinemia • Bulmer shelf: palpable node in PR (drop
with hypoglycemia metastasis)
• Tx: low-carbs, high-fat and protein diet, if • Krukenberg tumor: ovarian mass form gastric
failed, then octreotoids cancer
• Sister Mary Joseph node: umbilical nodule
Gastric cancer (carcinomatosis)
• Intestinal type: more related to environmental
factors, well differentiated, ass w chronic Fat emboli syndrome
gastritis • Berman’s triad: mental status change,
• Diffuse type: poorly differentiated, in younger, petechiae, dyspnea)
ass w blood group A
• Early gastric cancer: adenocarcinoma limited Gastric volvulus
to mucosa and submucosa, regardless LN • Borchardt’s triad: sudden sever upper
status abdominal pain, recurrent retching with out
• Risk factors for LN metastasis: large size, vomiting, inability to pass a NG tube
lymphatic vessels involvement, invasion of • Organoaxial: between GE junction and pylorus
submucosa (MC)
• LN status is the most important determinant of • Mesenteroaxial: between lesser and greater
survival curvature
• Ass w wandering spleen
✓ MC metabolic disorder after gastric resection is
iron deficiency (reduced acidity impairs Risk of rebleeding form PU:
absorption)
• Active spurting 17-100%
✓ B12 deficiency occurs if > 50% of stomach is
• Active oozing 17-100%
resected
• Non-bleeding visible vessels 0-81%
• Adherent clots 14-36%
Gastrinoma
• Flat pigment spots 0-13%
• Uncontrolled gastrin secretion by
neuroendocrine tumor • Clean visible ulcer base 0-10%

Talal AlQaisi, MD MPH GSR 4|Page

 Dieulafoy lesion • CT scan could not differentiate them from FNH
• Congenital malformation in the stomach • On MRI: FNH- central scare, Adenoma-
(lesser curvature, submucosal artery) increased fat signal
• Not premalignant • Sulfur colloid scan: Adenoma- cold, FNH- hot
(kupffer cells)
• Tx: radiofrequency ablation
Liver de VIRGILIO
Hydatid cyst
Portal vein • Tapeworm- echinococcus granulosus (liver),
• Has no valves echin multilocularis (alveoles)
• Supplying 75% of liver blood • Dx: ELISA
• Formed by fusion of SMV and splenic v. • Types: Gharbi types
• Normal pressure 3-5 mmHg 1- simple cyst
• Portal is Posterior to CBD and hepatic a. in 2- cyst w hyperechogenic material “hydatid sand”
hepatoduodenal ligament 3- cyst w a rosette appearance “daughter cyst”
4- cyst w diffuse hyperechoic solid pattern
FNH • Tx of choice: surgical total pericystectomy w
• Mostly asymptomatic pre and post OP albendazole (lowest rate of
• No risk of rupture or malignancy recurrency, morbidity and mortality)
• Hallmark: hypodense central stellate scar on • If cyst rupture, then release of protoscolices,
CT with enhanced contrast then anaphylaxis
• MRI study of choice to confirm
• Usually located in periphery of the liver PerOP cirrhosis w ascites:
• Caused by early distribution in liver blood flow • 1 low-Na diet, spironolactone, furesemide
st

• Next: large-volume paracentesis (4-6L),

✓ HCC: best screening is AFP and u/s followed by IV 25% salt-poor albumin
✓ CT finding of HCC: hyperintense lesion on • Next: serial large volume paracentesis
arterial phase and rapid washout on venous Child-Pugh:
phase 1- cirrhotic can proceed w elective sur after MTx
✓ CEA used to measure response to Tx of 2- cirrhotic have increased risk during sur. OP
colorectal Ca decision should be individualized
3- absolute C/I for elective sur
Budd-Chiari
• Thrombosis of hepatic inferior vena cava or Liver pyogenic abscess
hepatic veins • Triad (same as Charcot): RUQ pain, fever,
• Leads to hepatic outflow abstraction, jaundice
postsinusoidal liver failure and cirrhosis • 10% have all 3
• Triad: abd pain, ascites and hepatomegaly • M C aetiology: biliary tract
• More in female • Tx: IV ABx w percutaneous aspiration
• Dx by duplex U/S
• Most prominent finding on CT: hypertrophic ✓ Ito cells (hepatic stellate cell) is a principle
1st segment mediator leading to liver fibrosis
• Tx: antiCoag, then percutaneous angioplasty ✓ Have lipid droplet (to store VitA)
✓ In liver injury they differentiates into
Hepatic adenoma myofibroblast-like cell
• Has risk of bleeding and malignancy ✓ MCC of splenic vein thrombosis is chronic
• Mostly symptomatic (abd pain) pancreatitis
• Ass w OCP ✓ MCC of isolated gastric varices is splenic vein
• Resection: symptomatic and > 5 cm OR not thrombosis
response to OCP cessation ✓ Splenectomy is curative in this case
• Acute episodes of bleeding- angioembolization

Talal AlQaisi, MD MPH GSR 5|Page

✓ Splenic vein thrombosis leads to gastric • After food ingestion, the inhibition of
varices, due to venous outflow obstruction cholesterol 7-hydroxylase decreases which
✓ Mortality 20% w bleeding form gastric varices increase the bile acids secretion

Amebic liver abscess MELD score

• Cause: Entamoeba histolytica • To prioritize pt awaiting liver transplantation
• Feco-oral • Including: Total bilirubin, Creatinine, INR
• Leads to liquefaction necrosis of the liver • Rang: 6-40
• Alcohol increase the susceptibility to disease • Becomes modified by adding Sodium
• CT findings: fluid collection in the Rt lobe w a
rim of peripheral edema Child-Pugh
• Dx: ELISA, become reliable after 7-10 days after • Including: bilirubin, albumin, INR, ascites or
infection encephalopathy
• Tx: conservative, if failed after 48-72 hr, then
percutaneous aspiration Hepatic veins
• Rt hepatic v drains: 5, 6, 7, 8 segments to vena
✓ M C benign liver tumor - haemangioma cava
✓ Typically asymptomatic • Caudate lobe drains directly to IVC
✓ Large one can leads to AV shunting and CHF • Middle hepatic v drains: 4a, 4b, 5, 8. It joint Lt
and thrombocytopenia (consumptive hepatic v via common orifice
coagulopathy - Kasabach-Merritt syndrome) • Lt hepatic v drains: 2, 3 segments
✓ Tx: if need, enucleation not resection • Round ligament marks the intrahepatic
location of Lt portal v
Polycystic liver disease • Ligamentum venosum marks the border
• AD between caudate lobe and Lt Lat sector
• Majority asymptomatic
• Lap fenestration as Tx with low risk of bleeding
• No MTx ✓ Common hepatic a gives gastroduodenal a and
• Estrogen medication leads to cyst growth Rt gastric a then become the proper hepatic a
which gives Rt and Lt hepatic aa
✓ To prevent 1st bleeding from oesophageal ✓ Variations: Rt hepatic a from SMA, Lt hepatic a
varices is endoscopic ligation from Lt gastric a
✓ The aim is to make portal pressure less than 12
mmHg ✓ MC primary liver malignancy in children-
✓ Beta blockers seems to give the same effect of hepatoblastoma
ligation as conservative Tx ✓ It is ass w FPS (FAP)
✓ Combination of ligation and beta blockers not ✓ Typically asymptomatic abd mass, anemia,
recommended thrombocytosis, elevated AFP
✓ May be elevated bHCG
Bile acids ✓ Tx: chemo then resection
• Bile composed of: bile acids, pigments, ✓ Indocyanine green clearance test most widely
phospholipids, cholesterol, proteins and used to measuring hepatic reserve before
electrolytes. hepatic resection
• Primary bile acids: choline and then ✓ MC cause of death in pt w fulminant hepatic
conjugated w glycine and taurine. failure is intracranial hypertension
• Secondary bile acids: deoxycholic, lithocholic. ✓ (Liver failure - high ammonia level -
They formed by intestinal bacteria accumulation of astrocyte glutamine -
• 95% of secreted bile reabsorbed in increased Intracranial osmolality - Increased
enterohepatic circulation (passively in ICP)
jejunum, actively in ileum) ✓ Warfarin acts on 1972
✓ Factor 7 has the shortest half life

Talal AlQaisi, MD MPH GSR 6|Page

✓ Male:Female (Mortality) amoebic liver abscess o I: most common, fusiform dilation of BD
10:1 (2-4%), pyogenic abscess 1.5:1 (10-20%) (90%)
✓ M C site of liver abscess is Rt lobe o V: Caroli disease, multiple intrahepatic
✓ Pyogenic abscesses mostly multiple dilations

TIPS Intraoperative cholangiography IOC

• Used in non-responsive pt to MTx of variceal • Allow early to recognition of CBD injury and
bleeding prevent complete transection of CBD
• It is nonselective shunt
• Short term - highly effective CBD intraOP injury
• Has a risk of encephalopathy • Small lateral injury can be treated by repair
• Helps in pt with refractory ascites over T tube and draining the site
• Absolute C/I - polycystic liver disease and Rt HF • CBD complete transection:
1- Early recognition: tension free, mucosa-to-
Liver hemangioma mucosa hepaticojejunostomy
• MRI: T2 peripheral nodular enhancement, T1 2- Delayed recognition: transhepatic drainage,
low signal intensity delayed repair for 6-8 weeks

Portal HTN GB
1- Presinusoidal: intrahepatic (schistosomiasis), • Rapidly absorbing Na and Cl (by active
extrahepatic (portal and splenic v thrombosis) transport and passive water absorption)
2- Sinusoidal: alcoholism, cirrhosis, chromatosis, • The hydrogen ions acidifies the bile (increases
Wilson disease the Ca solubility)
3- Postsinusoidal: normal LFT, Budd-Chiari, • Vagus innervation- contraction of GB
congenital webs in inferior vena cava • CCK leads to steady and tonic contractions of
GB
• Glucagon relaxes the sphincter of Oddi
Biliary de VIRGILIO
GB cancer
Hemobilia • Adenocarcinoma
• Quinke’s triad: UGI bleeding, jaundice, RUQ • More discoverable with open Chole (17 times
pain more)
• M c c iatrogenic injury to Rt hepatic a • Metastasis first to celiac axis LN
• Tx: angiographic embolization • If invade the perimuscular connective tissue,
• It is ass w arterial pseudoaneurysm then Tx: racdical cholecystectomy +
subsegmental resection 4b and 5 +
Choledochal cyst hepatoduodenal ligament LNectomy
• Mostly the problem due to pancreaticobiliary • PostOP Tx: Radio with flurouracil most
duct junction anomaly (CBD and pancreatic commonly used
duct fuse to form one duct 1 cm proximaly to
the ampulla, here the reflux of pancreatic Sclerosing Cholangitis
secretion to the CBD can increase the pressure • Presence of multiple inflammatory fibrous
and initiate inflammation which lead to thickenings resulting in irregular narrowing of
dilation and cyst formation) the entire biliary tree
• More in females • It is progressive
• In childhood: jaundice and abd mass and pain • Increases the risk of cholangiocarcinoma
• Dx: U/S, maybe antenatally (check CA19-9)
• Has a risk of malignancy • Twice common in men
• Tx: excision with biliary enteric bypass • Risk factors: IBD, pancreatitis, DM
• Types: • Strongly ass w UC
• ALP out of proportionally elevated

Talal AlQaisi, MD MPH GSR 7|Page

• +ve p-ANCA • Tx: cholecystectomy w transvers enterotomy
• No effect from colon resection proximal to stone and removal of stone
• Tx: steroids, methotrex, cyclosporine, biliary • **cholecystectomy with fistula closure for
stenting young, low risk pt

Klatskin tumor Chronic cholecystitis

• Types: • Rokitansky-Aschoff sinuses are seen as a result
o I: limited to CBD of atrophied mucosa of GB
o II: involve the bifurcation of Rt and Lt • Due to multiple bouts of symptomatic
hepatic ducts cholelithiasis or biliary colic
o IIIa: enter into the secondary Rt • Not a premalignant condition
o IIIb: secondary Lt • Dx: hepatobiliary iminodiacetic acid scan-
o IV: intrahepatic ducts visualize the GB within 2-3 hr (cholecystitis -
• Tx: will not visualize the GB even after 4hr)
o I+II: resection of entire extrahepatic tree+
portal LNectomy+ bilateral Roux-en-Y Lap Chole
hepaticojejunostomy • 5 mm umbilical port
o III: lobectomy • 12 mm epigastric port
• 5 mm Rt subcostal port
Emphysematous cholecystitis • 5 mm port inferior and lateral to Rt subcostal
• in less than 1% o 5mm to retract the fundus superiorly and
• Mostly in elderly DM neck laterally
• Hallmark: gas in the GB wall or lumen o 12mm for dissection and removal of the GB
• Gangrene seen in 3/4 of cases • M c c of CBD injury in LapChole is excess
• Mortality 25% cephalad retraction of neck (infundibulum)
• Tx: unstable pt- percutaneous drainage then
cholecystectomy ✓ The only benefit of early admission (with in
• Stable pt- cholecystectomy 24hr) for LapChole in acute cholecystitis is:
• ABx to cover Clostridia perfringens (anaerobic shortens the hospital stay
gram +ve)
Bile duct strictures
Bile • Majority are short and in CBD
• Bile acids 80%, phospholipids 15%, cholesterol • Due to iatrogenic injury
5% • Mostly seen after 5 years post OP
• Cholecystectomy increase the hepatoentric • Tx: stenting (risk of recurrent cholangitis due to
circulation obstruction) or bypass
• Pigmented stones colour- due to calcium
bilirubinate Choledochal cyst
• Brown stones mostly due to biliary stasis (in o I: MC type, dilation of entire CHD and CBD
CBD) or a segment of it
• Black stones- ass w haemolytic anaemia (in GB) o II: diverticula that project from CBD wall
o III: in intraduodenal portion of CBD
Gallstone ileus o IVa: multiple dilation in intra and extra
• More common in elderly females hepatic biliary tree
• CT: SBO and pneumobilia o IVb: multiple dilation in the extrahepatic
• Large stone >2.5 cm tree
• M c type of biliary fistula- cholecystoduodenal o V: Caroli disease: multiple dilations in
• Less common fistula with hepatic flexure or intrahepatic tree
stomach • If posterior wall adherent to portal vein: leave
the posterior wall, fulgurate or curette its
mucosa (Lilly procedure)

Talal AlQaisi, MD MPH GSR 8|Page

 • DM, GS, steatorrhea, HypoCl
Strawberry GB (Cholesterolosis) • Most commonly in the head of pancreas
• Due to accumulation of cholesterol in
macrophages in the GB mucosa VIPoma
• Benign condition • WDHA (watery diarrhea, hypoK, achlorhydria)
• Cholecystectomy not indicated • MTx: octreotoids

✓ RBC breakdown—- heme —- biliverdin—- Risk factors of pancreatic tumor

bilirubin—- bound to albumin in circulation—- • Smoking, obesity, DM, atypical multiple mole
transportation to liver—- conjugation—- GIT— melanoma, hereditary pancreatitis, FAP,
- deconjugation into urobilinogen by bacteria HNPCC, BRCA2, Peutz-Jeghers,
(some of it reabsorbed to the liver then cholecystectomy, cholelithiasis.
secreted in the urine)
✓ Pre Whipple procedure bile drainage increase Insulinoma
the SSI • MC functional pancreatic tumor
• Majority benign
GB polyp • Whipple triad: symptomatic fasting
• MC type: cholesterol polyp: benign , <10 mm, hypoglycemia, glucose level less than 50
multiple, pedunculated mg/dL, relief of symptoms after glucose
• 2nd MC: adenomyomatosis: sessile administration
• 3ed MC: Inflammatory polyp • Dx: low FBS (insulin : glucose ratio > 0.3),
• indication for cholecystectomy: elevated C-peptide
1. Symptomatic • Localization by CT and endoscopic US
2. Ass w GS • Tx: enucleation
3. >6mm • Diazoxide for preOP controlling of symptoms
4. Age >50 • Advanced stage Tx: debulking (streptozocin
and 5-FU)
Pancreas de VIRGILIO
Passaro triangle (Gastrinoma)
Pancreatic pseudocyst
• Junction of CD and CBD, 2nd and 3ed portion
• No need for admission
of duodenum, neck and body of pancreas
• Admission if not tolerating oral diet for TPN
• Management: observation BISAP Bedside Index for Severity in
• CEA level is the most accurate for Dx of Acute Pancreatitis
mucinous pancreatitis cystic lesion • Urea > 25 mg/ dL
• If > 6cm and more than 6 weeks, then need for • Impaired mentation
intervention • 2 or more SIRS criteria
• Internal drainage is preferred to external • Age > 65
• External drainage has more complications • Presence of pleural effusion
• The only indication for external drainage is
infected pancreatic pseudocyst that unstable ✓ MCC of acute pancreatitis is GS
for endoscopic procedure ✓ Severe GS pancreatitis, do cholecystectomy
after full recovery
Glucagonoma ✓ Mild-moderate GS pancreatitis, do
• 4 D’s: DM, dermatitis, DVT, Depression cholecystectomy early (within 48 Hr)
• Most commonly in the tail of pancreas
• Dx: fasting glucagon level Pancreatic cyst
• Tx: if < 2cm then enucleation or distal • Serous cystadenoma: benign, commonly in
pancreatectomy women, commonly in the head, often
asymptotic (if > 4cm, can induce vague
Samatostatinoma abdominal pain), resection if symptomatic

Talal AlQaisi, MD MPH GSR 9|Page

• Mucinous cystadenoma: premalignant, more ✓ Proinsulin—- insulin and C-peptide
in females, commonly in the body or tail, ✓ Insulin cleared by liver
should be resected ✓ C-peptide cleared by kidney (more slowly)
• Intraductal papillary mucinous neoplasm ✓ Normal insulin-C peptide ratio < 1
IPMN: 3 types (main-duct, side-duct, mixed)
• Main-duct 50% risk of malignancy, should be Autoimmune pancreatitis
resected • Diffusely enlarged hypoechoic pancreas
• Mixed should be resected • CT: diffuse narrowing of main pancreatic duct
• Side-duct can be observed (unless: w/o calcifications
symptomatic, > 3cm, ass w mural nodules) • Pathology: plasma cell + lymphocytic
infiltration
✓ Sever hyperTG, hyperglycemia leads to • Lab: Increased IgG and DM
pseudohypoNa • Tx: steroids

Pancreas divisum
• Fail of fusion of duct of Wirsung (main) and
Spleen de VIRGILIO
duct of Santoruni (accessory)
• The result is that the pancreatic juice drainage ✓ Splenic simple cyst may secreate CA19-9
is through the small duct of Santoruni via the ✓ M C intraOP complication in splenectomy-
lesser papilla haemorrhage during hilar dissection
• No marked dilation of dorsal duct, so surgical ✓ OPSI due to loss if IgM
decompression not successful ✓ OPSI treatment starts with 3ed generation
cephalosporins
Chronic pancreatitis ✓ M C organism causes OPSI is Strep pneumonia,
• MCC of surgical intervention in chronic then H. influ B, then N. meningitides
pancreatitis is pain ✓ PneumoVac: 14 day before elective and 14
• Surgical drainage of the ducts is more effective days after emergency splenectomy
than endoscopic approaches ✓ ABx prophylaxis for 2 years at least
✓ Annual vaccination with influVac is
✓ Most commonly, the adenocarcinoma of the recommended
pancreas arise from the main pancreatic duct, ✓ Because supra bacterial infection is common
mostly in the head
✓ First study in obstructive jaundice is US ITP
✓ Dynamic CT w contrast helps determining the • AantiPLT IgG aoutoAb
resectability of the mass • More if adult female
✓ Endoscopic US helps in determining the • Equally distributed in boys and girls
resectability in case of vascular invasion • Common ecchymosis and petechiae
✓ Alcohol induce spasm of Oddi, increase • Spleen not palpable
pancreatic duct permeability, decrease • Commonly followed by viral infection
pancreatic blood flow, inappropriately activate • Blood smear: large immature PLT
chymotrypsin • Bone marrow for >60 y.o.: increased
megakaryocyte
Type 3 DM (pancreaticogenic • Children with <30000 need admission
diabetes) • Tx: prednisolone then IV Ig if not effective
• Decreased levels of: glucagon, PP, insulin (due • Splenectomy if MTx filer
to pancreatic loss) • IntraOP: give PLT after splenic pedicle ligation!
• Increased peripheral insulin sensitivity But if there is bleeding prior to OP, then give
• Decreased hepatic insulin sensitivity PLT
• Common: hypoglycemia
• Rare: DKA, marked hyperglycemia Splenic a aneurysm
• m c visceral a aneurysm

Talal AlQaisi, MD MPH GSR 10 | P a g e

• Female more than male ✓ MC nerve injury during lap hernia repair-
• M c in the meddle to distal portion of the lateral femoral cutaneous nerve (lat thigh
splenic a sensation)
• Mortality rate up to 50% with rupture ✓ Ilioinguinal n injury- burning groin pain
• Ring like calcification on Xray LUQ ✓ Infants inguinal hernia - high ligation of the sac
• Size >2 cm indecate OP
• Majority are true aneurysm Femoral hernia
• Pseudoaneurysm ass w pancreatitis • More common in females
• Splenic a aneurysm ass w double rupture • MC overall hernia in females: indirect inguinal
phenomenon hernia
• Femoral canal:
Accessory spleen o Anterior: inguinal ligament
• Post splenectomy, low PLT, absent of Howell- o Posterior: Cooper ligament
Jolly bodies o Lateral: femoral vein
• Best detected by radiolabled RBCs o Medial: Lacunar ligament
• CT scan sensitive 60% • Tx: approximation of iliopubic tract to Cooper
ligament
TTP
• 1st line Tx: plasma exchange Spigelian hernia
• Splenectomy not effective. Used as a salvage • Often presented without abd wall bulge
therapy • Anywhere in the aponeurotic band at the
• Low PLT, microangiopathic haemolytic anemia, lateral border of the rectus abdominis muscle
neuro complications • Small with narrow neck
• Abnormal PLT clumping (large amount of • High risk of sepsis due to delay in diagnosis
vonWillbrand factor) resulting in episodes of
thrombosis in microvessels Umbilical hernia
• Blood smear: schistocyte, nucleated RBCs, • In children:
basiphilic stippling o congenital- failure of the umbilical ring
• MCC of death - intracranial haemorrhage to close
o Most of then small and closed by 2 years
Normal to see post splenectomy: (if defect <1cm)
• Target cell o Repair if not closed until 4-5 years old
o 8 times more in black
• Howell-Jolly bodies
• In adults:
• Heinze bodies
o Acquired
• Pappenheimer bodies
o Risk factors: increased intra-abdominal
• Spur cells
pressure
• Increase PLT, WBCs, monocytosis
o Strangulation uncommon
• Low IgM levels o Small asymptomatic one can be
• Low properdin, tuftsin observed
o Large symptomatic must be repaired
Splenic abscess o Less recurrency rate with mesh repair
• M C origin for hematogenous spread infected
endocarditis Petit triangle (inferior lumber)
• M C source is hematogenous 1- Latissimus dorsi m
• Tx: ABx. If unilocular then CT guided aspiration, 2- Iliac crest
if multilocular then splenectomy 3- External oblique m

Hernia de VIRGILIO Grynfeltt triangle (superior lumber):

1- Quadrantus lumborum m
2- Internal oblique m

Talal AlQaisi, MD MPH GSR 11 | P a g e

3- 12th rib
Arcuate line
Richter hernia involves on wall of the bowel • Below the umbilicus (1/3 of distance to pubic
in the sac crest)
• Above arcuate line:
Littre hernia: hernia containing Meckel o Anterior rectus sheath (aponeurosis of
diverticulum external, internal oblique)
o Posterior rectus sheath (internal oblique
Obturator hernia common in elderly with and transverse abdominal m)
mostly SBO • Below arcuate line:
o Anterior rectus sheath (external, internal,
✓ The MC risk factor for post hernia repair transverse)
ischemic orchitis is extensive dissection of o No posterior rectus sheath
spermatic cord

Genitofemoral nerve Small Bowel de VIRGILIO

• arise from L1-L2
• Its genital branch innervates the cremaster m ✓ SBO with no Hx of prior surgery most often
and sensation to the side of scrotum and labia requires surgery (Exploration).
• Responsible for cremasteric reflex
• Lies in iliopubic tract PostOP ileus
• NSAID usage ass w earlier resolution of postOP
Ilioinguinal nerve ileus
• lies on top of spermatic cord • NSAID increase the risk of bleeding
• Innervates internal oblique m and sensory to • Erythromycin effect on motilin receptor
the upper medial thigh (increase bowel motion)
• Arise from T12-L1 • Alvimopan (opioid receptor antagonist):
• Sensation to groin, base of penis removes the effect of opioid from GIT and do
not affect the opioid analgesia.
Iliohypogastric n
• lies on internal oblique m Crohn Disease
• Sensory innervation of the skin over pubis • Is the MC primary surgical disease of small
bowel
✓ Rt sided inguinal hernia more common • MC presentation: acute abd pain w diarrhea
✓ 10% of hernias are bilateral • Bimodal distribution (2-3ed and 6th decades)
✓ In infants, if there are signs of strangulation, • Risk factors include: smoking, familial
then NO manual reduction, GO to OR for repair inheritance
✓ Poupart (inguinal) ligament formed from the • MC in urban areas and high socioeconomic
anteroinferior portion of external oblique status
aponeurosis • Equally distributed among males and females
✓ Cremasteric m arise from internal oblique m • Breast feeding is a preventative factor
✓ Genital branch of genitofemoral n passes • MCC of surgery: fistula, abscess and
through the deep ring obstruction
✓ Ilioinguinal n passes through superficial ring • Rare cause for surgery: perforation
✓ Indirect inguinal hernia is laterally to inferior • The early sign: aphthous ulcer (due to
epigastric vessels submucosal lymphoid follicle expansion)
• Hallmarks: cobblestone ulcer, noncaseating
Hesselbach triangle: granulomas (in active areas and non-diseased
• medial – lateral border of rectus m areas), transmural inflammation, serosal
• inferior- inguinal ligament thickening, skip lesions
• lateral - inferior epigastric vessels • Tx:

Talal AlQaisi, MD MPH GSR 12 | P a g e

 o mild active disease: sulfasalazine • Can be treated endoscopically
o Acute flare-ups: prednisone • Commonly at 56-76 y.o
o If corticosteroids not effective, then • Majority asymptomatic
infliximab • Malabsorption due to bacterial overgrowth
• 3/4 of pt will require surgery can be treated by ABx
• Resection margins of 2cm
• Frozen section is unnecessary Meckel diverticulum
• Types of strictureplasty: • MC presentation: bleeding
o Heineke-Mikulicz pyloroplasty (<12cm) • MCC of LGI bleeding in children: Meckel
o Finney pyloroplasty (<= 25cm) • Ectopic gastric mucosa—- ulcer—- bleeding
• Creeping fat is pathognomonic (encroachment • True diverticulum
of mesenteric fat onto the serosal surface) • Due to failure of closure of vitelline duct
• Do not improve with bowel resection: • MC presentation in adult is intestinal
ankylosing spondylitis and primary sclerosing obstruction
cholangitis (ass w HLAB27) • More common in males
• Frequently presents at age of 2
GIST • Found in 2% of population
• Types: • 2 feet from ileocecal valve
1. Spindle cell 70% • 2 types of ectopic mucosa (gastric, pancreatic)
2. Epithelioid 20% • Dx: technetium-99 scan (light w gastric
3. Mixed 10% mucosa)
• GIST +ve for: CD34, human progenitor cell Ag,
CD117, c-kit proto-oncogene protein Chylous ascites
• MC site in GI- stomach • Due to exudation of chyle due to:
• Tx: resection w 1cm margins • Obstruction of cisterna chyli
• GIST of small bowel has high mortality rate • Direct leakage of chyle
• Risk of malignancy (rule of 5’s): • Through dilated retroperitoneal vessels
o Tumors >5 cm OR >5 mitoses per 50 high- • Dx: analysis of fluids (high TG, WBC >200,
power field protein 2.5-7)
• Adjuvant Tx should continue for a total of 3 • Culture: -ve, except for TB
years
• Tx: high-protein, low-fat w medium-chain TG
• Indicators of survival: diet
1. Size at presentation
• Next: NPO, TPN, octreotoids
2. Mitotic index
• Next: lymphoscintigraphy + closure
3. Location
Absence of tumor rupture
Short Bowel Syndrome
• MC site stomach
• Small bowel 6 m in length
• Cajal cell is a cell of origin of GIST
• SBS: < 180 cm of small bowel
• Small bowel cell types:
• Etiology:
1. Absorptive enterocytes MC
o adult- acute mesenteric ischemia,
2. Paneth cell- host mucosal defence
malignancy, Crohn
3. Enteroendocrine cell
o Pediatric- intestinal atresia, midgut
4. Goblet cell- mucus secretion
volvulus, NEC
• intact iliocecal valve reduces malabsorption
Duodenal diverticula
• Intact colon is important
• Acquired are false
• Tx of early phase of SBS:
• Commonly in the 2ed portion of the duodenum
o Slowing intestinal transit (narcotics, anti-
near the ampulla
motility agents)
• Arise at mesenteric border
o Reducing GI secretions
• Periampullary one is ass w cholangitis,
pancreatitis and Oddi dysfunction

Talal AlQaisi, MD MPH GSR 13 | P a g e

 o Maintaining nutrition (TPN), fluids, • Due to Anaesthesia or stress
electrolytes • Hypotension, bronchospasm, flushing,
• Massive SBS ass w hypergastrinemia + tachycardia
hyperacidity which inhabits the digestive • Tx: IV octreotoids 50-100 mg
enzymes (Tx H2blockers or PPI) • Dantroline for malignant hyperthermia
• Internal feeding must start ASAP
• Glutamine is useful (trophic factor and main Small bowel obstruction
fuel for small bowl) • MCC hernia
• Cholestyramine is useful in controlling • Lower abdominal surgery make more risk for
diarrhoea adhesions
• Octreotoids are controversial • Conservative Tx up to 48 hr
• Intestinal adaption within 1-2 years • Serum lactate may be normal with complete
closed loop obstruction (no back flow, so not
Small bowel neoplasm increased)
• MC small bowel tumor: carcinoid. Then
adenocarcinoma, then lymphoma, then GIST GI bleeding
• MC site of: • Obscure (no visible cause)- small bowel
o Lymphoma- ileum angiodysplasia
o Carcinoid- ileum • MCC of obscure GI bleeding in children- Meckel
o Adenocarcinoma- duodenum
(periampullary) SMA syndrome
o GIST- stomach • Compression of the SMA on the 3ed portion of
duodenum
Mesenteric ischemia (nonocclusive) • Due to profound weight loss
• In elderly w decreased CO • Dx: CT scan: decreased aortomesentric angle
• Dx: CT angio • Tx: conservative: weight gain. surgical:
• SMA thrombosis- Tx: surgical bypass duodenojejunostomy
• SMA embolism- Tx: operative embolectomy
• SMV thrombosis- Tx: heparin alone ✓ Chronic radiation enteritis results from
• Nonocclusive mesenteric ischemia- Tx: IV obliterative arteritis in submucosal vessels
vasodilators (papaverine)

Carcinoid tumor
Large Bowel de VIRGILIO
• MC site: Small bowel, then rectum, then
appendix. Pneumoperitoneum
• Carcinoid syndrome: flushing, diarrhea, • In symptomatic pt: need emergency surgery
bronchospasm, Rt sided HF • Post colonoscopy: due to micro perforation OR
• Carcinoid syndrome occurs in post hepatic transmural passage of the air, in asymptomatic
carcinoid pt can be managed by IV ABx and bowel rest
• 24-hr urinary 5-HIAA: sensitive and specific
(gold standard for Dx) Parastomal hernia
• Chromogranin A for Dx of nonfictioning • Highest risk with colostomy
carcinoid and for detecting recurrence and • Lowest risk with loop ileostomy
response to Tx • Risk factors: age, SSI, obesity, malnutrition,
• Vasoactive substances transported to Rt IBD, immunosuppression, COPD
heart—- endocardial damage—- thickening, • Prophylactic mesh reduces the risk
retraction, fixation of the valve • Tx:
• MC valve disorder with carcinoid: tricuspid o Asymptotic- support device or weight loss
insufficiency, then pulmonary lesions o Symptomatic- repair (preferred) or
relocation of stoma
Carcinoid crisis

Talal AlQaisi, MD MPH GSR 14 | P a g e

 Colostomy ischemia • PSC increases the risk of colorectal cancer
• More commonly if the IMA ligated high • UC patients have to undergo screening
• Always check the extent of ischemia (down to colonoscopy (w random biopsies) 8 years from
the fascia) before management the diagnosis of UC
• Tx: • PSC patients have to undergo screening
o Ischemia is superficial: observation, re- colonoscopy (w random biopsies) at the time
evaluation within 12-24 hr of diagnosis of PSC, and follow up colonoscopy
o Ischemia down to fascia: re-exploration, every 2 years
revision • Patients w/o IBD or family Hx of colorectal
• IV ABx useless! cancer have to undergo screening colonoscopy
at age of 50 years
Stercoral ulceration • Patients w family Hx of colorectal cancer have
• In elderly w chronic constipation to undergo screening colonoscopy 10 years
• Hard fecaloma—- local ischemia—- ulcer before the age of diagnosis of any 1st degree
formation—- perforation relative w colorectal cancer
• MC location: antimesenteric border of • Factors increasing the anastomotic leakage
rectosigmoid, due to lower water content, following colorectal cancer:
poorer blood supply, higher pressure. 1- Low rectal cancer (< 7cm from anal verge)
• Dx criteria: 2- Tumor > 5cm
1- round antimesenteric colonic perforation 3- Multiple firing of the linear stapler
> 1cm 4- Lateral LN dissection
2- colon full of stool from perforation site 5- OP > 5 hr
3- multiple pressure ulcers and 6- High ASA score
inflammation around perforation 7- Male
4- absence of external cause! 8- Significant OP bleeding
• Has high mortality rate 9- NSAID (controversial)
• Ass w NSAID
• Tx: Hartman’s procedure Pouchitis
• Ciprofloxacin more effective than
Ogilvie’s syndrome metronidazole
• In severely ill pt w/o signs of mechanical • It is common w J-pouch anastomosis
obstruction • Dx: endoscopy w biopsy
• Tx: • Probiotics may help
• Stable- conservative (bowel rest, NG tube, • Excision of J-pouch rarely needed
rectal tube, electrolytes replacement
• Neostigmine (reversible cholinesterase Familial Adenomatous Polyposis FAP
inhibitor) may help: (cardiac monitoring • AD
mandatory) • Mutation in adenomatous polyposis coli (APC)
o single IV injection of 2 mg (2nd and 3ed tumor suppressor gene (Chromosome 5q)
injections can be given if 1st failed) • If not treated, cancer development occurs at
o Infusion 0.4-0.8 mg/hr age of 35-40
• C/I: acute urinary retention, ACS, asthma, • Polyps often begin at puberty
bronchospasm, 2nd or 3ed degree heart block • 1st degree relative w FAP and:
• Unstable- surgical intervention (colostomy, • APC +ve patient, then start screening at age 10-
transanal multiperforated tube, total or 12 years (flexible sigmoidoscopy)
subtotal colectomy w an ostomy) • APC -ve patients, then start screening at age of
50 years
Primary Sclerosing Cholangitis • FAP patients in risk of periampullary carcinoma
• Is a progressive and destructive disease of the (proctocolectomy dose not decrease the risk)
entire biliary tree • Upper endoscopy at age of 25-30, w follow up
• 80% of PSC patients have IBD (UC mostly) every 1-3 years

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• FAP ass w extraintestinal manifestations o Sudeck’s critical point ( rectosegmoid
junction): collaterals between segmoid a
Ulcerative Colitis and SRA
• Mucosal edema: Earliest finding (colonoscopy) o Ileocecal area
• Lead pipe: long-standing UC (barium enema) • Can leads to bacterial translocation
• Crypt abscess almost always seen in UC • Colonoscopy not necessary in acute phase
• Tx: conservative w ABx, surgery in case of
Diverticulitis peritonitis
• Stages: (Hinchey) • Fecal immunochemical test is better than
o I: pericolonic inflammation w pericolic occult guaiac blood test
abscess
o II: retroperitoneal or pelvic abscess Pseudomembranous Colitis
o III: purulent peritonitis • Due to Clostridium difficile (toxins A and B in
o IV: fecal peritonitis stool)
• Tx: • Due to ABx administration (not always) mostly
o Stage I: IV ABx clindamycin
o Abscess < 4cm: ABx, then colonoscopy and • May be after 1st dose, or 3-4 weeks later
elective sigmoid colectomy • Dx: PCR, sigmoidoscopy (yellow plaques)
o Abscess > 4cm: CT guided drainage, then • Can lead to toxic megacolon
colonoscopy and elective sigmoid • Tx:
colectomy o Uncomplicated (WBC <15, Creatinine < 1.5):
Oral metronidazole 10-15 days
Familial Juvenile Polyposis o 1st recurrence the same Tx
• AD o 2nd recurrence Tx: Oral vancomycin
• Polyps are hamartomas (benign growths of
normal and mature cells in abnormal location Cecal volvulus
and configuration) but can be developed into • Much less common than sigmoid volvulus
adenomas and malignancy (risk of colon cancer • In younger
10-38%) • Due to congenital mal-fixation of cecum
• Mostly in the Rt colon • Types:
• Colonoscopy screening at age of 10-12 years 1- Axial (90%): rotation up and over LUQ
• Upper endoscopy screening at age of 25 years 2- Cecal bascule (10%): flip upward and
anterior in horizontal plan
Colon polyps • Endoscopic decomposition is difficult
• Isolated hyperplastic polyps are benign • Tx: Rt hemicolectomy w primary anastomosis
• Hyperplastic polyposis can be premalignant • Detorsion and pexy have high recurrence rate
• Adenomatous polyps are neoplastic • If colon is gangrenous then add ileostomy w
• Types of Adenomatous polyps: mucus fistula
1- Tubular < 5% malignancy risk
2- Tubulovillous 20% malignancy risk Diverticular disease
3- Villous 40% malignancy risk • Due to low fiber diet
• Polys < 1cm: low malignancy risk • Sigmoid diverticula is false
• Polyps > 2cm: 50% malignancy risk • Occurs in the mesenteric side of the
• Inflammatory (pseudopolyps) seen in IBD antimesenteric taenia
(islands of regenerating mucosa) • It is pulsion diverticula (increased intra luminal
pressure)
Ischemic Colitis • Diverticula do not develop in the rectum
• Due to low-flow state • Asymptotic pt do not need surgical
• In watershed areas: intervention
o Splenic flexure, MC (Griffiith’s point): • Resection need IV and oral ABx preparation
Collaterals between SMA and IMA

Talal AlQaisi, MD MPH GSR 16 | P a g e

 Colocutaneous fistula ✓ IgM the earliest major Ig produced in the
• Low out-put primary immune response
• Almost spontaneously will close
• If not closed, then think about neoplasm, IBD, Pylephlebitis
TB, distal obstruction • Infectious inflammation of the portal venous
system
Diversion colitis • Tx: broad-spectrum ABx, remove the source,
• Due to absence of stool in diverted segment of antiCoag
colon (no intraluminal nutrients “short-chain
fatty acids SCFAs such as acetate, butyrate, ✓ MC worldwide intestinal parasite causing
propionate” which lead to atrophy and appendicitis is Ascaris lumbricoides
inflammation
• Tx: SCFAs enema Incidental appendectomy for:
1- Children about to undergo chemotherapy
✓ The most reproducible and reliable finding in 2- Disabled patients
appendicitis is localized tenderness at 3- Patients who cannot react normally to
McBurney’s point abdominal pain
4- CD patients
Crohn disease 5- Patients who about to travel to remote places
• MC perianal lesion in CD is skin tag followed by where no access to surgical car
fissure
• MC site of fissure is posterior Mesenteric adenitis
• CD increase the risk of perianal abscess, • Ass w Yersinia enterocolitica, Helicobacter
haemorrhoids and fistulas jejuni, Campylobacter jejuni, Salmonella,
• Perianal involvement extremely rare in UC Shigella and Sterptococcal infections of the
pharynx
Appendicitis • More commonly in children post URTI
• Vague dull periumbilical pain due to • CT scan: generalized mesenteric
stimulation of visceral peritoneum (afferent lymphadenopathy
fibres) • No need for biopsy
• RIF localized pain due to stimulation of parietal
peritoneum (somatic fibres) Pseudomyxoma peritonei
• Nausea states after the abdominal pain • Any progressive process in which the
• Luminal capacity of appendix 0.1 ml peritoneal cavity becomes filled with a thick
• Ruptured appendix drains into rectovesical gelatinous substance
pouch • Gelatinous substance arises from mucus-
• Children have higher rate of perforation secreting cells from perforated, mucus-
producing tumor
Rectovaginal fistula • MCC- benign mucinous cystadenoma of the
• MCC obstetric injury appendix
• The leading cause if colovesical fistula is • Tx: aggressive removal of all peritoneal
diverticulitis implants + appendectomy
✓ Appendix secrets IgA
✓ IgG the most abundant Ab in serum Appendiceal adenocarcinoma
✓ IgG the most perdominant Ab in the secondary • MC presentation: acute appendicitis
immune response • Ass w synchronous colon neoplasms
✓ IgE the least perdominant Ab in the secondary • Tx: Rt hemicolectomy
immune response
✓ IgE mediates hypersensitivity reactions Carcinoid tumor
✓ IgM the largest Ig • MC site in appendix: the tip
• Most commonly (in appendix) < 2 cm in size

Talal AlQaisi, MD MPH GSR 17 | P a g e

• If < 1cm, then appendectomy 5. Mobile non fixed lesion
• If > 1cm and invading the mesoappendix or the 6. No lymphatic, neural or venous invasion
base of appendix, then Rt hemicolectomy • WLE need 2 mm margin
• If > 2cm and located on the tip, then Rt
hemicolectomy Pilonidal disease
• Appendiceal adenocarcinoma regardless of the • Ingrown hair
size, then Rt hemicolectomy • Tx: acute PNS, I/D laterally to intergluteal cleft

✓ MCC of LGI bleeding: diverticulosis (Rt sided) Hidradenitis suppurativa

✓ Artriography: bleeding rate 0.5-1 mL/min • Disease of follicular epithelium (apocrine
✓ Nuclear scanning: bleeding rate 0.1 mL/min sweat glands)
• Armpits, groin, under the breast, between the
Anorectal de VIRGILIO buttocks
• Can mimic complex anal fistula or Crohn
Anatomy • Tx: warm compresses, lifestyle change,
• Presacral fascia (Waldeyer fascia) separates cessation smoking, local hygiene
the rectum from presacral venous plexus and • If failed, then, ABx + surgery
pelvic nerve
• Denonvilliers fascia: Chronic radiation proctitis
o In men separates the rectum from bladder • Surcralfate enema is the 1st line Tx
and prostate • If failed, then, endoscopic argon plasma
o In women separates the rectum from coagulation OR formalin therapy
vagina
• Livator ani marks the transition between the ✓ Post hemorrhoids sepsis is life threatening, Tx
rectum and anal canal IV ABx + EUA
• Surgical anal canal: 2-4 cm (longer in men), ✓ Nigro protocol: 5-FU + mitomycin C + radiation
from the anorectal junction to anal verge therapy
• Cancer above dentate line: adenocarcinoma ✓ Carmistine used in brain cancer
• Cancer below dentate line: squamous cell ✓ Vincristine used in testicular cancer
carcinoma ✓ Tx of thrombosed hemorrhoids: ellipse of skin
• Upper and middle rectum drain to inferior
mesenteric LN Condyloma acuminata
• Lower rectum drains to inferior mesenteric and • HPV 6 and 11 benign
internal iliac LN • HPV 16 and 18 malignancy transformation
• Distal to dentate line, drains to inguinal LN • Can be ass w SCC
• Blood supply of the rectum
o SRA arise from IMA (upper rectum) ✓ The most effective non-surgical Tx of anal
o MRA arise from internal iliac artery fissure is botulinum toxin injection
o IRA arise from pudendal artery (internal
iliac branch) Rectal prolapse
o Sudak’s point: SRA and MRA • More common in women (elderly)
o SRV drains to IMV and portal vein • Involves all layers of the rectum (Starts 6-7 cm
o MRV and IRV drains to branches of from the anal verge)
internal iliac veins then to IVC • Tx: perineal rectosegmoidectomy

Indication to wide local excision WLE Anal fistula

in anorectal adenocarcinoma: • If ass w Crohn, tend to be complex
1. Size < 3cm • MRI helps to detect the track and extension
2. T1 staging (invades only submucosa) • ABx helps in management of infection
3. < 30% involvement of bowel wall
• Immunomodulatore help in healing
4. 8 cm from anal verge
• Setone usage is recommended

Talal AlQaisi, MD MPH GSR 18 | P a g e

• Aggressive fistulotomy must be avoided Acute adrenal insufficiency
• Tx: IV fluids, then IV dexamethazone (preferred
✓ MC bacterial causing proctitis is Neisseria than 100 mg hydrocortisone), then do
gonorrhoea cosyntropin stimulation test

Pheochromocytoma
Endocrine de VIRGILIO • Rule of tens: 10% bilateral, 10% extra adrenal,
10% familial, 10% multifocal, 10% malignant
Graves’ disease • MC extra adrenal site: organ of Zuckerkandl
• MCC of hyperthyroidism is Graves’ disease (para-aortic structure at the take-off of the
• Ab against thyrotropin receptors (increase IMA or at the aortic bifurcation, small mass of
thyroid hormones) chromaffin cells)
• S&S: anxiety, tachyarrhythmia, heat • Ass w MEN IIa, MEN IIb, von-Hippel-Lindau
intolerance, weight loss, thinning hair, disease, von Recklinghausen disease
decreased libido, diarrhea, thick and shiny skin, • Malignancy determined by local invasion and
exophthalmos metastasis
• Tx: radioactive iodine ablation OR • Risk of malignancy is lower in familial type
propylthiouracil OR methimazole • Dx: increased level of catecholamines (plasma
• The only symptom resistant to antithyroid Tx is metanephrine with the highest sensitivity)
exophthalmos • Metaiodobenzylguanidine scan for localizing of
extra adrenal pheochromocytoma
Adrenal glands • Phenoxybenzamine using perOP for
• Blood supply: inferior phrenic artery, adrenal pheochromocytoma management
branch from aorta, branches from renal artery
• Lt adrenal vein drains to lt renal vein Cushing syndrome
• Rt adrenal vein drains to IVC • Dx: 24-hour urinary cortisol (sensitive and
• Cortex: Glomerulosa (aldosterone), Fasciculata specific)
(glucocorticoids), Reticularis (sex hormones) • If the above is elevated, then do low-dose
• Medulla: epinephrine, norepinephrine dexamethasone suppression test
o Suppression done: NO Cushing
Adrenocortical carcinoma o Suppression NOT done: Dx is Cushing, then
• Ass w hormonal excess do ACTH level
• CT guided biopsy not recommended ▪ Low ACTH: primary adrenal source, then
• Tx: surgical resection do Abdominal CT
▪ High ACTH: pituitary or ectopic source,
Laparoscopic adrenalectomy then do high-dose dexamethasone
• Procedure of choice for small and medium suppression test
sized functional and benign adrenal tumor • Suppression done: pituitary source,
• For uni or bilateral pheochromocytomy the do pituitary MRI
• Contraindicated in: clearly malignant invasive • Suppression NOT done: ectopic source
tumor or LN metastasis (MC bronchial tumor, SCLC), then do
• Not preferred in: size > 6cm Chest CT

Primary hyperaldosteronism Parathyroid glands

• HTN + hyperK • > 4 glands are more frequent than 3 glands
• Due to autonomous aldosterone secretion • Ectopic inferior glands: MC in thymus
which suppress renin secretion Ectopic superior glands: MC retro or
• Dx: kaliuresis, low plasma renin, high paraesophageal
aldosterone-renin ratio (>20)
• MCC idiopathic bilateral adrenal hyperplasia ✓ Sestamibi scan is the widest used and accurate
• Tx: spironolactone for controlling HTN test for parathyroid adenomas

Talal AlQaisi, MD MPH GSR 19 | P a g e

 Hyperparathyroidism 1. Nondiagnostic
• HypoPO, HyperCl, metabolic acidosis, high 2. Benign
Cl:PO ratio (> 33), high PTH, hyperCa-uria 3. Atypia of undetermined significance or
follicular lesion of undetermined significance
Secondary hyperparathyroidism 4. Follicular neoplasm or suspicious for a follicular
• Ass w chronic renal failure (decreased D3, neoplasm (risk of
elevated phosphate, low serum Ca—- this lead 5. Suspicious for malignancy
to: increased PHT) 6. Malignancy
• Tx: low phosphate diet, phosphate binders, Ca
and VitD supplementation, cinacalcet ✓ Thyroid gland arises from 1st and 2nd
pharyngeal arches
Tertiary hyperparathyroidism ✓ Superior parathyroid glands arise from 4th
• Due to long standing secondary pharyngeal pouch
hyperparathyroidism ✓ Inferior parathyroid glands arise from 3ed
• MC clinical scenario is post renal pharyngeal pouch
transplantation
• Tx: same as secondary hyperparathyroidism Hurthle cell carcinoma
• Contain sheets of eosinophilic cells packed
Pseudohypoparathyroidism with mitochondria (derived from oncocytic or
• Genetic disorder oxyphipic cells)
• Insensitivity to PTH • They are often multifucal and bilateral, more
• HypoCa, hyperPO, elevated PTH likely to metastasize to local LN and distant
• Short stature, obese, round face, short stubby sites, ass w higher mortality rate than follicular
fingers cell carcinoma
• Tx: Ca and VitD supplementation • Do not take up the radioactive iodine

Indication for surgery in symptomatic Thyroid Papillary Carcinoma

hyperparathyroid patients: • MC type of thyroid cancer
1. Serum Ca > 1 mg/dL above the upper limit • Psammoma bodies (calcified deposits: clumps
2. Reduced creatinine clearance > 30% of sloughed cells)
3. Increase urinary Ca > 400 mg/day • Orphan Annie cells are a hallmark
4. Evidence of bone mass reduction > 2.5 SD
below matched controls Follicular thyroid cancer
5. Inability to undergo continued follow up • The 2nd most common thyroid cancer
• Spreads mainly hematogenous
Thyroid cancer • FNA useless
• Age is the most important factor for staging
o < 45 y.o: Stage I (no distant mets), Stage II Hashimoto thyroiditis
(distant mets) • Autoimmune
o 45 y.o: TNM staging system • Leads to destruction of thyroid follicles (cell
• MC primary tumor to metastasize to the and Ab mediated process)
thyroid is renal cell carcinoma (also less • Ab against thyroglobulin and peroxidase
common: lung, breast, esophagus) • Increase the risk of cancer
• Serum thyroglobulin level used for recurrence • It is the leading cause of hypothyroidism
monitoring for thyroid cancer • Mostly affect young females
• Rate of malignancy in adult thyroid nodules < • Results in lymphocytic infiltration
in children • Tx: thyroid hormones replacement
• Prognosis in children is excellent • Ass w primary thyroid lymphoma (FNA may
help, Dx: flow cytometry with core needle
Bethesda system (Thyroid cytopathology biopsy)
nodules reporting)

Talal AlQaisi, MD MPH GSR 20 | P a g e

 MEN I • MC in parotid
• Hyperparathyroidism, Pituitary tumor, • MC parotid gland tumors are benign
Pancreatic tumor (pleomorphic adenoma)
• Pituitary tumor is the 3ed MC tumor in MEN I • Submandibular and sublingual glands tumors
(MC prolactinoma) 50% malignant
• Minor salivary gland tumors predominantly
MEN II malignant
• Pheochromocytoma, Hyperparathyroidism,
Medullary thyroid cancer Parotid gland tumor
• MTC is a hallmark (multifocal, bilateral, ass w • 80% benign
C-cell hyperplasia, mutation in RET proto- • 20% malignant
oncogene) • The only bilateral parotid tumor is: papillary
cystadenoma lymphatosum “Warthon tumor”,
✓ MC malignancy in thyroglossal cyst is papillary which strongly ass w smoking, and the 2nd MC
pthyroid cancer, if found, then do total benign parotid tumor
thyroidectomy • 1st MC benign parotid tumor is pleomorphic
adenoma
RLN
• RLN innervates the intrinsic muscle of larynx Tracheostomy site bleeding
EXCEPT cricothyroid muscle (external branch • First 48 Hr: secondary to local trauma (inferior
of superior laryngeal nerve) thyroid artery OR anterior jugular vein)
• Unilateral RLN injury: ipsilateral vocal cord • Tx: pressure, if not helps and SVS, then
paralysis (cord become fixed to paramedian bronchoscopy, if not SVS, then go to OR
position (weak voice), or to abducted position • >48 Hr: tracheoinnominate fistula (do
(hoarseness and ineffective cough) tracheostomy above the 3ed ring to decrease
• Internal branch of superior laryngeal nerve: the risk)
sensory input for the larynx • Tx: finger in the site of tracheostomy, pressure
• External branch of superior laryngeal nerve against sternum, then go to OR (median
injury: voice fatigue starnotomy)

Neuroblastoma Juvenile nasal angiofibroma

• MC abdominal malignancy in children • Highly vascular benign neoplasm arising from
• From neural crest origin around the pterygopalantine fossa
• Abdominal mass that cross the midline • Recurrent epistaxis
• Amplification of N-myc oncogene has • If air way compares is bending due to bleeding,
unfavourable prognosis then intubate the patient
• Dx: CT scan (look for sinus extension)
• Biopsy contraindicated
Head and Neck de VIRGILIO • If nasal packs do not help, then do angio-
embolization of internal maxillary artery
Thyroglossal duct cyst
• Definitive Tx: surgical excision
• Remnant of thyroid gland
• Anterior neck, midline mass, that moves with Hearing loss
swallowing or sticking out the tongue
• Conductive: more common with cerumen (ear
• Tx: Sistrunk procedure (removing the cyst, wax). Otosclerosis.
tract, central portion of hyoid bone, portion of
• Sensorineural: persbycusis
tongue base up to foramen cecum)
• Ear wax should not be removed always
• NB! Always do neck U/S, because the cyst
could contain the only available thyroid tissue
Sialolithiasis (salivary gland stones)
• MC from submandibular salivary gland
Salivary gland tumors

Talal AlQaisi, MD MPH GSR 21 | P a g e

• 2nd MC parotid gland • Anaerobic, gram +ve, branching filamentous
• Stensen duct drains parotid gland bacteria
• Rivinus duct drains sublingual gland • Can case infection post trauma of face or neck
• Whaeton’s duct drains submandibular gland • Microscopic: sulfur granules
• Tx: penicillin
Branchial cleft cysts
• 1st: sinus from submandibular area to external
auditory canal Breast de VIRGILIO
o Tx: includes superficial parotidectomy
• 2nd: MC. Anteriorly to SCM muscle Anatomy
• 3ed: Lt side, on the lateral neck • Breast extends from 2nd to 6th ribs, and from
• 4th: lateral neck, can lead to swelling and lateral border of sternum to the anterior
airway compression axillary line
• Mammary tissue extends from clavicle to the
Brachial plexus 7-8th ribs, and from midline to the edge of
• Posterior to the anterior scalene muscle and latissimus dorsi
anterior to the middle scalene muscle • Each breast contains 10-100 lobules which
open into lactiferous ducts (15-20 ducts)
✓ MC nerve injured in cervical LN dissection: • Ligaments of Cooper if involved in the cancer
spinal accessory nerve CN IX (trapezius palsy, the skin dimpling will be seen
shoulder weakness and pain) • Lymphatics drainage predominantly to axillary
✓ MC nerve injured in temporal bone Fx: facial LN
nerve CN VII
✓ MC nerve injured in parotid surgery: greater ✓ Sentinel node is the first LN draining the
auricular nerve tumor-bearing area of the breast

Nasopharyngeal carcinoma Mammography

• Ass w EpsteinBarr virus • Low voltage, high amperage X-Rays
• Alcohol increase the risk • Dose: 0.1 cGy (safe investigation)
• Initial presentation: middle ear effusion
• 90% have mets MRI
• Distinguish scar from recurrence
Epistaxis • Assess multifocality and multicentricity in
• MC is anterior (Kiesselbach plexus), Tx: lobular cancer
compression or anterior packing • Assess extent of high-grade DCIS
• Posterior is more dangerous (branch of • For breast with implants
sphenopalatine artery), ass w HTN and • Screening tool in high risk women
atherosclerosis
Nipple
Cystic hygroma • Amazia: absence of the nipple (more common
• Lymphatic malformation in males)
• Ass w trisomy 21 and Turner syndrome • Polymazia: Accessory nipple may be on the
• MC site is posterior neck milk line (anterior fold of axilla to the fold of
• 2nd MC site is axilla groin)
• MC presentation at birth • Slit-like nipple retraction may be ass w duct
• Tx: if in neck, then conservative excision ectasia
• Circumferential retraction may well indicate
Actinomyces israelii carcinoma
• Is normal flora of the mouth and tonsillar • Cracked nipple: stop feeding for 24-48 hr
crypts • Pappiloma of the nipple should be excised or
ligated

Talal AlQaisi, MD MPH GSR 22 | P a g e

 Poland syndrome Breast cyst
• Sporadic congenital disorder • Benign
• Affect unilateral breast, chest wall, upper • 35-50 y.o.
extremity • Painful, smooth, mobile, firm mass, changing
• More at Rt side size with menstrual cycle
• More in men • Tx: aspiration, if bloody, then send to cytology
• Undeveloped or absence of pectoralis, and do core needle biopsy of cyst wall
serratus, latissimus dorsi muscles, • If complicated cyst (thickened wall, septation,
symbrachydactyly, short forearm, intracystic mass), then do core needle biopsy
dextracardia, rib abnormalities, absent axillary
hair, thin subcutaneous fat tissue localized Nipple discharge
over ipsilateral chest wall, renal agenasis • Pathologic if: serous, bloody, unilateral, from
• Due to interruption in the vascular supply to single duct, copious in amount, spontaneous
the affected side • Physiological: brown, green, milky, yellow,
blue, multiple ducts, bilateral
Axillary LN (6 groups)
• Lateral, pectoral, scapular, central, Tamoxifen
subclavicular, intrapectoral • Selective estrogen-receptor modulator (halt
• Levels (according to pectoralis minor muscle) cell division)
o I: Lateral, most inferior • To reduce cancer risk in high-risk patients
o II: Behind “Rotter nodes: intrapectoral • As cancer therapy for estrogen +ve non-
(between pectoralis major and minor)” invasive and invasive breast cancer
o III: Medial • Side effects: endometrial adenocarcinoma,
• Sappy lymphatics: subareolar lymphatic DVT, cataract, steatosis
system
• Batson plexus: avalvular veins, that make the ✓ Taller-than-wide is an U/S character of
root of spine mets malignancy

Gynecomastia BRCA
• Abnormal benign proliferation of glandular • Are tumor suppressor genes
breast tissue in men • BRCA 1 on long arm of chromosome 17
• No risk of breast cancer • BRCA 2 on short arm of chromosome 13
• More common in infancy, puberty, after 50 y.o. • BRCA 1 more risky than BRCA 2
• Due to imbalance of the effect of estrogen VS • BRCA 2 ass w ovarian cancer
testosterone • BRCA 1 mostly triple -ve
• Causes: • Male breast cancer more risky with BRCA 2
o Spironolactone: increase metabolism and
clearance of testosterone ✓ Proto-oncogenes are coding for protein
o Marijuana: alerts hypothalamic-pituitary- production regulation
gonadal axis
o Uremia due to ESKD: increases half-life of Invasive lobular carcinoma
LH, which leads to decreased secretion of • Arise from the terminal lobular components of
LH and decreased testosterone levels the lactiferous ducts
o Cimetidine: increase plasma prolactin • Typically hormonal receptor +ve
• Tx: antiestrogen (tamoxifen) • More in postmenopausal period
• Linear infiltration
Non-lactational breast infection
• Due to obstruction or pseudo-obstruction of Radiotherapy
lactiferous duct • Works by direct DNA damage
• MC organism Staph aureus
• No risk from alcohol

Talal AlQaisi, MD MPH GSR 23 | P a g e

• More effect in M phase of cell cycle (free O2 • Fast growing, firm, mobile mass
radical formation) • Large sized, makes a teardrop shape of
• More effective with small tumors affected breast
• Higher energy has more skin preserving effect • Dx: core needle biopsy
• More effective if used post chemotherapy • Tx: excision with clear margins (> 1cm)
• Used post lumpectomy • Mets hematogenous (MC to lungs)
• Used post mastectomy if: locally advanced • No radio or chemotherapy
disease (=> 4 cm tumor, => 4 +ve LN)
✓ Radial scars < 1cm and complex sclerosing
Chemotherapy lesions > 1cm are benign
• Important role in treating occult distant mets
• Type of gene mutation is important Intraductal papilloma
• Benign intraepithelial tumor
MRM • It is a nonproliferative lesion of the breast
• Excision of entire breast parenchyma and level • Can grow up to a few cm
I+II LN • Has a risk of cancer
✓ Longe thoracic nerve innervates serratus • Presented w bloody or serosanguinous nipple
anterior muscle (abduction, lateral rotation of discharge
scapula), if injured: winged scapula • Tx: duct excision
✓ Thoracodorsal nerve innervates latissimus
dorsi muscle (adduction, extending, medially BI-RADS (Breast Imaging Reporting and Data
rotation of the upper are), if injured: difficulty System)
in arm adduction and medial rotation • 0: assessment in complete and additional
✓ Medial pectoral nerve innervates pectoralis imaging required (should obtain additional
minor and major muscles, if injured: atrophy of studies)
clavicular portion of pectoralis muscles • 1: negative (continue routine screening)
✓ Anterior branches of supraclavicular nerve • 2: benign findings (continue routine screening)
(sensory) innervates the upper aspect of the • 3: probably benign findings (short-term follow
skin of the breast up mammogram in 6 months)
• 4: suspicious abnormalities (preferred needle
Mondor disease biopsy)
• Thrombophlebitis of one or more of the • 5: highly suspicious of malignancy (biopsy and
superficial anterior chest wall veins (lateral treatment)
thoracic, thoracoepigastric, superficial • 6: known biopsy-proven malignancy (continue
epigastric) with treatment plan)
• Palpable cord like structure, painful
• Risk factors: trauma, surgery, heavy lifting, Breast MRI
tight clothing, malignancy • Indications:
• Tx: NSAID, warm compresses o Evaluating primary breast cancer in patients
with nodal mets and no obvious lesion in
Mastitis the breast
• Breast tissue infection o Assess the extent of disease in patients with
• Due to ascending infection from the nipple dense breasts
• Tx: ABx covering Staph aureus, hot
compresses, breast massage, continuation of LCIS
breast feeding • Non-invasive
• Originates from the terminal lobular region of
Phyllodes tumor lactiferous ducts
• Rare • Subtypes: classic, pleomorphic
• Leaflike structure
• Mostly benign, but has a malignancy risk

Talal AlQaisi, MD MPH GSR 24 | P a g e

• Not considered to be malignant by itself, but it • Grade II: dissection or intra luminal hematoma
is a marker for the subsequent development of with =>25% luminal narrowing
invasive cancer in either ipsilateral or • Grade III: pseudoaneurysm
contralateral side • Grade IV: occlusion
• Tx: excision and chemotherapy • Grade V: transection with free extravasation
• First to do is to give heparin in stable patients
Vascular - Arterial de
VIRGILIO Sudden ICA occlusion
• In younger highly suggestive for spontaneous
Carotid endarterectomy CEA dissection
• The goal is to prevent further damage to the • Tx: antiCoag
ipsilateral motor cortex
• Best time to do is 2 weeks after primary stroke Thromboangiitis obliterans (Buerger disease)
• CEA in asymptomatic women has less benefits • Progressive non-atherosclerotic segmental
• No benefit if the stenosis is 100% (no embolic inflammatory disease of small and medium
risk) sized arteries, veins and nerves of upper
extremity
• Neurological deficit within first 12hr post CEA:
thromboembolic phenomena from the site of • More in smoker men
CEA. Tx: immediate heparinization and re- • Has corkscrew collaterals
exploration (check the ECA and ICA pulses) • Not involved the coronary and aortoiliac
• Do not do Fogarty balloon embolectomy of
cephalad ICA (risk of carotid-cavernous sinus Ankle brachial index ABI
fistula) • Normally 1-1.2
• MC injured nerve during CEA: hypoglossal o ABI < 0.9: claudication
nerve CN XII o ABI < 0.5: rest pain
o ABI < 0.4: ulcer
Post CEA hyperperfusion o ABI < 0.3: gangrene
• Long standing stenosis leads to dilation of • Ankle pressure in supine position can be as
cerebral vessels distally to the stenosis. After same as 20% higher than in arm
CEA the blood flow restored, but the dilation • DM and ESKD cause false elevation in ABI
still, leading to increased blood flow to brain
• Risk factors: recent stroke, CEA for very tight Thrombolytic therapy
ICA stenosis, concomitant contralateral ICA • Absolute C/I: resent stroke, TIA, active or
occlusion, chronic ipsilateral hypoperfusion, resent bleeding, coagulopathy
staged bilateral CEA performed within 2 • Relative C/I: resent major surgery (> 2 weeks),
months of each other, poorly controlled pre resent trauma, uncontrolled HTN, intra renal
and post OP HTN tumor, pregnancy
• Leads to: brain edema, petechial hemorrhage, • More effective if the ischemia < 2 weeks
intracerebral hemorrhage duration
• Sx: severe ipsilateral frontal headache
(POD#5), seizures Acute limb ischemia ALI
• Tx: controlling BP • Types: embolic, thrombotic
• MCC of emboli is heart (A fib)
✓ Carotid bifurcation at the level of C3-C4 • MCC of thrombus is atherosclerosis
✓ High carotid bifurcation is contraindication for • Severity of ALI depend on motor and sensation
CEA • Classes:
o I: non-threatened extremity,
Carotid blunt trauma revascularization may/may not be needed
• Grade I: luminal irregularity or dissection with o II: threatened extremity, revascularization
< 25% luminal narrowing is indicated
o III: infarction, salvage surgery is not possible

Talal AlQaisi, MD MPH GSR 25 | P a g e

• Irreversible ischemia: absence of arterial or Popliteal artery aneurysm
venous Doppler signals for 6-8 hr, mottling of • MC peripheral artery aneurysm
the skin, absence of capillary refill, complete • 50% bilateral
anesthesia and paralysis • 30% ass w AAA
• Most frequent complication: leg ischemia
Revers saphenous vein femoral-to-popliteal • MC symptom: thrombosis
artery bypass • Repair if:
• Early failure (within 30 days): technical error o 2cm
• Intermediate failure (30 days to 2 years): o Any with intraluminal thrombus
myointimal hyperplasia o Symptomatic or with previous embolization
• Late failure (> 2 years): progression of • Tx: surgical (medical or posterior approach)
atherosclerotic occlusive disease • Saphenous vein bypass with interval ligation of
• Leg edema most commonly due to lymphatic the popliteal artery
distribution (groin and popliteal regions)
Indication for surgical repair in aneurysm
Acute mesenteric ischemia • Thoracic aorta: > 6.5cm
• MCC embolization form cardiac source (A fib) • Abdominal aorta: > 5.5cm
• MC site SMA (due to angle from aorta) • Iliac artery: > 4cm
• 1st to do is heparin therapy, then do • Femoral artery: > 2.5cm
embolectomy (transverse arteriotomy), • Popliteal artery: > 2cm
borderline bowel status indicates a second
look within 24-48 hr to prevent massive bowel
resection Vascular - Venous de
Cilostazole
VIRGILIO
• Inhibit PLT aggregation, inhibit smooth muscle
proliferation, increase vasodilation, lowering Internal jugular vein IJV
HDL anD TG • Rt IJV is more accessible for cannulation
• Increase the walking distance in patients with • 70% lies anterolateral to the carotid artery
claudication • May lies anteriorly or posteriorly to carotid
artery
✓ MC artery to do coronary bypass is Lt internal • If carotid artery wrongly cannulated:
mammary artery o By probe needle, then remove the needle
✓ MC visceral artery aneurysm is splenic artery and apply pressure for 10 minutes
✓ 2nd common visceral artery aneurysm is o By dilator or catheter, then remove under
hepatic artery direct exploration, and repair the artery

Pseudoaneurysm Chronic venous insufficiency

• < 2cm, higher likelihood of spontaneous • Ulcer located at the medial malleolus
thrombosis with compression • Due to increased venous pressure, which leads
• Tx: U/S guided thrombin injection to WBC trapping, which release free O2
radicals and proteolytic enzymes, leading to
AAA local inflammation
• Stable: do CT scan • Tx: compression therapy
• Unstable: go to OR
• Mortality same with endovascular or open DVT
repair • Virchow triad: stasis, vascular injury,
• Endoleak is common complication after EVAR hypercoagulability
• MC type is type II • Tx:
• Type I need immediate repair • Provoked: proximal, give antiCoag for 3
months.

Talal AlQaisi, MD MPH GSR 26 | P a g e

• Unprovoked: >12 months antiCoag • Manifestation of thoracic outlet syndrome
(muscle compression on the axillary-subclavian
Heparin therapy vein between 1st rib and clavicle)
• Bolus 80 units/ kg • In men more than women
• Maintenance 18 units/ kg / hr • Tx: IV heparin + 1st rib resection
• PTT follow up 6-12 hourly (aim 60-90 min)
• HIT appears at the day 5 of administration ✓ MC finding on ECG in PE is sinus tachycardia
(50% drop in PLT) ✓ S1 Q3 T3 also can be seen in PE

Lower extremity veins Thoracic de VIRGILIO

• Superficial: greater saphenous vein, lesser
saphenous vein Superior vena cava syndrome
• Deep: follow the arteries (popliteal vein • Facial swelling, dyspnea, headache, chest pain,
becomes femoral vein, which connects with hoarseness, stridor
greater saphenous vein to become common • MCC is secondary to malignancy (MC
femoral veins malignancy is SCLC)
• Perforators veins: connecting the superficial • It is a C/I for tumor excision (do endovascular
and deep systems “flow from superficial to stenting of SVC)
deep” (Cockett perforators: drains the lower
part of the leg medially. Boyd perforators: Chylothorax
connect the greater saphenous vein to deep • MCC esophageal dissection (2-7 days after
veins higher up in the medial lower leg 10 cm injury of thoracic duct)
below the knee) • Thoracic duct originates from cisterna chyle
• No valves in: portal, SVC, IVC, common iliac (posterior to abdominal aorta, entering
veins thoracic cavity at T12, crossing to Lt side at T5-
• Calf muscle acting as a pump to return blood to 6
the heart • Sudan stain used to detect chyle in plural
• Normally the venous pressure drops by effusion
walking
✓ Upper airway dead space volume is 150 mL
✓ MC congenital case of hypercoagulbailty:
factor V Leiden deficiency Pulmonary sequestration
✓ MC acquired case of hypercoagulbailty: • Types:
smoking o Intralobar: MC, within the visceral pleura,
✓ Provoked Superficial thrombophlebitis Tx: blood supply from thoracic aorta
NSAID + warm compresses o Extralobar: has separate pleura, blood
✓ Unprovoked Superficial thrombophlebitis Tx: supply from abdominal aorta
(think about malignancy) and give antiCoag • No connection with tracheobronchal tree
• MC involvement is Lt lower lobe
IVC filter • In man more than in women
• Increase the risk of DVT • Dx: pulmonary angiography (gold standard), CT
• Decrease the risk of PE angio (tool of choice)
• Indications: • Tx: surgical resection
o DVT or PE in patients who contraindicated
gor antCoag therapy SCLC
o New PE in patients who already on antiCoag • For limited type, Tx is chemo-rediotherapy
therapy • PET scan the best for M-status

Paget-Schroetter syndrome ✓ Paraparesis can occur after bronchial artery

• Spontaneous thrombosis of axillary-subclavian embolization
vein

Talal AlQaisi, MD MPH GSR 27 | P a g e

 Aortic stenosis • Ass w pulmonary hypoplasia (hypercarbia)
• Angina, syncope, CHF (swollen legs, elevated • Bochalek hernia: Lt posterolateral
brain natriuretic peptide) • Morgagni hernia: anteromedial
• Symptoms start when aortic valve area < 1cm2
Congenital lobar emphysema
Intra-aortic balloon pump • Excessive hyper expansion of one or more
• Indications: high-risk percutaneous coronary lobes (due to bronchial cartilage abnormalities
intervention, acute MI, cardiogenic shock which creates one way valve, or external
• Increases the diastolic coronary blood flow compression from enlarged Lt atrium)
• MC in upper lobes
✓ FEV1 if: • Bronchoscope is contraindicated
o 2L, patient can tolerate pneumoectomy • Tx: urgent thoracotomy and resection
o 1.5L, patient can tolerate lobectomy
Tracheoesophageal fistula TEF
Thoracic anatomy • MC type: C (proximal esophageal atresia +
• Rt lung has 3 lobs distal TEF)
• Lt lung has 2 lobs
• Azygous vein runs at the Lt side, drains into SVC Pyloric stenosis
• Vagus nerve runs posterior to the lung hilum • Non-bilious projectile vomiting (3-6 weeks of
• Phrenic nerve runs anterior to lung hilum age)
• Palpable olive shape epigastric mass
Mediastinal neurogenic tumors • Dehydration
• MC mediastinal tumor in children • HypoCL, hypoK metabolic alkalosis with
• Often in posterior mediastinum paradoxic aciduria
• Arise from sympathetic ganglia • 1st to do: rehydration with 20 mL/kg boluses
• MC type neurofibromas (NaCl)
• Tx: pyloromyotomy
✓ MC mediastinal tumor in adult is thymomas
Necrotizing enterocolitis NEC
Trachea • Pathogenesis: intestinal hypoperfusion
• 10-13 cm • Bell criteria:
• 18-22 rings o I: suspicious for NEC (NPO, NG tube, ABx for
• Carotid cartilage is the 1st complete cartilage 3-7 days)
• Blood supply: inferior thyroid artery, bronchial o II: definite NEC (NPO, NG tube, ABx, close
arteries observation for 7-14 day)
• Tracheostomy between 2-3 or 3-4 rings o III: advanced NEC or definite intestinal
perforation or no response for
Catamenial pneumothorax nonoperative therapy (surgery)
• Pneumothorax in women that occurs around
the time of menstruation Malrotation of the bowel
• Ladd procedure: reduce volvulus, division of
✓ MCC of lung abscess: aspiration Ladd bands (between cecum and abdominal
✓ MC primary chest wall malignancy: wall, duodenum and terminal ileum) cecum
chondrosarcoma will be in the LLQ and the duodenum in RLQ,
✓ Lung adenocarcinoma is peripherally appendectomy
✓ Rasmussen aneurysm: pulmonary artery
aneurysm ass w TB Intussusception
• Telescoping of the bowel into itself
Pediatric de VIRGILIO • More common in boys
Congenital diaphragmatic hernia • Currant jelly is a late finding
• MC al Lt side

Talal AlQaisi, MD MPH GSR 28 | P a g e

• Tx: trial of radiographic or pneumo-reduction Omphalocele
of the intussuception, if failed, then surgical • Congenital defect of the abdominal wall at the
reduction midline, covered by amniotic membrane
• Ass w cardiac and musculoskeletal anomalies
Hirschsprung disease • Ass w premature and IUGR
• Absence of ganglion cells in the Auerbach • Higher mortality than gastroschisis
plexus and hypertrophy of associated nerve
trunk Gastroschisis
• MC affected part: rectosegmoid junction • Congenital defect of the abdominal wall at the
• MCC of death in uncorrected Hirschsprung Rt of umbilicus, not covered by membrane
disease is enterocolitis • It is a surgical emergency
• MC associated anomaly is malrotation
Imperforate anus • Ass w intrauterine rupture of umbilical vein
• Rectum fails to descend through the external • Ass w intestinal atresia
sphincter complex Biliary atresia
• Ass w VACTERL anomalies (vertebral defects, • MCC of neonatal jaundice that need surgery is
anal atresia, cardiac defects, TEF, renal biliary atresia
anomalies, limb abnormalities) • Dx: radionuclide study
• Tx: high lesion, then primary sigmoid • Bx: bile plugging and periportal fibrosis
colostomy, then definitive surgery at 3-6 • Tx: portoenterostomy
months of life. Low lesion, then repair with
perianal procedure Transplant de VIRGILIO
Neuroblastoma ✓ Allograft: between members of the same
• Embryonal tumor of neural crest origin species
• Mostly asymptomatic abdominal mass ✓ Xenograft: between members of different
• Mass may cross the midline species
• 3ed MC pediatric malignancy ✓ Orthotopic graft: placed in the usual
• MC solid abdominal malignancy in children < 2 anatomical location
years of age ✓ Hetrotopic graft: placed in non-anatomical
• MC in adrenal medulla position
• Age and tumor biology is predicting factors for ✓ Rh antigen compatibility is of little concern in
prognosis organ transplantation
o < 1 years of age has best prognosis ✓ HLA antigens active CD4 T cells
o 3 copies of N-myc amplification has poor
prognosis Acute rejection
• Occurs up to 6 months
Sacrococcygeal teratoma • Due to HLA mismatch and subsequent T-cell
• Large mass extending off of the sacrum in mediated graft injury
neonatal period
• MC teratoma in neonates Chronic rejection
• Tx: excision and coccyx removal • Occurs after 6 months
• Major cause of allograft loss
Intestinal atresia • Risk factors: previous acute rejection, poor HLA
• Due to in utero mesenteric vascular accident mismatch, long cold ischemic time
• Duodenal atresia
• Due to in utero failure of recanalization of the Hyperacute rejection
bowel • Within minutes to hours
• Ass w prematurity, Dawn syndrome, • Due to ABO mismatch or presence of
malrotation, annular pancreas, biliary atresia performed anti-HLA Ab

Talal AlQaisi, MD MPH GSR 29 | P a g e

 Pancreatic transplantation mediators including IL-1, IL-2 (1-2 months after
• Improves survival and quality of life transplantation), need biopsy to confirm
• May halt complications of DM (retinopathy) ✓ MC clinically important viral infection in
and may reverse neuropathy and automatic transplant recipients is CMV
dysfunction
• Do not reverse vascular disease
Trauma de VIRGILIO
• Indications:
• DM with imminent or established ESKD who Role of nine (TSBA)
have had or plan to have a kidney transplant • Each upper extremity: 9% (anterior aspect
• Patients meeting all of the following: 4.5%)
• Frequent episodes of metabolic complications • Each lower extremity: 18% (anterior aspect
related to DM 9%)
• Emotional problems with insulin therapy • Anterior trunk: 18% (9% for anterior chest and
9% for anterior abdomen)
• Failure to manage the complications
• Posterior trunk: 18% (9% for posterior chest
• Transplantation should be avoided in 45-65
and 9% for back)
years old patients
• Head and neck: 9%
Renal transplantation • Perineum: 1%
• The highest risk of death in patients awaiting • Hands: 1%
renal transplantation is COPD
• Donors must have GRF > 80mL / min Parkland formula:
• MC complication for donors postOP is SSI • 4 x TSBA x kg (fluids resuscitation over 24 hr)
• C/I for donation: • One-half over first 8hr
o HIV • One-half over the next 16hr
o Hepatitis • Fluid of choice: R/L
o Cirrhosis
o Active systematic infection with +ve blood ✓ Preferred method of cannulation in trauma is
culture peripheral cannulation (median antecubital
o Urosepsis fossa)
• Peritoneum is poor choice for implantation ✓ Central line not preferred in trauma settings
• Retroperitoneum and pelvic fossa good for ✓ MCC of death in trauma patients reaching the
implantation (Rt side more easy) hospital alive is: head injury
✓ MCC of death within the first hour in trauma
• First end-to-side arterial anastomosis, then
patients is: hemorrhagic shock
venous anastomosis, then ureteral
✓ In traumatic brain injury avoid the secondary
anastomosis (external iliac vein and artery)
brain injury by avoiding hypotension and
• DO NOT remove the native kidney
hypoxia
• MCC of post transplantation oliguria is ATN
Abdominal stab wounds
Liver transplantation
• If unstable, then do immediate exploratory
• The best test for follow up the liver function
laparotomy
post transplantation is INR
• If stable, then do local wound exploration:
o If anterior fascia not penetrated, then
✓ MC cancer affecting patients with solid organ
discharge to home
transplant is SCC (occurs 8 years post-
o If anterior fascia penetrated, then:
transplant)
▪ FAST or CT scan or serial abdominal
✓ 2nd MC cancer affecting patients with solid
examinations
organ transplant is post-transplant
lymphoprliferative disorder (occurs in the 1st
Abdominal compartment syndrome
year)
✓ Acute transplant rejection is T-cell mediated
with activated monocytes secreting soluble

Talal AlQaisi, MD MPH GSR 30 | P a g e

• Triad: oliguria, rise in peak airway pressure, • Electrical or chemical burns
increased intra-abdominal pressure (> 12 • Co-existing inhalation injury or multiple
mmHg) trauma
• The above lead to
o Increased intra thoracic pressure Electrical shock
o Decreased venous return • AC leads to repetitive, tetanic muscle
o Increased pulmonary vascular resistance contraction
o Increased pulmonary capillary wedge • DC leads to single, large muscle contraction
pressure (will be thrown away)
• Tx: abdominal decompression • Fat tissue has high resistance to electricity
(more heat, more damage)
Burn • MCC of death in early post electrical shock:
• 1st degree: epidermis; redness, pain, no cardiac arrhythmia
blisters • Immediate complications: posterior shoulder
• 2nd degree - superficial partial-thickness: dislocation, spinal cord injury
papillary; blisters, pain, blanching, intact hair • Long term complications: cataract,
follicles. No need for grafting polyneuritis, ototoxicity
• 2nd degree - deep partial-thickness: retrcular, • Red urine means rhabdomyolysis (check
blisters, less painful (may be painless), loss of creatinine)
hair follicles, non-blanching. Need grafting • Tx: admission, cardiac monitoring, IV fluids
• 3ed degree: all layers, white leathery
appearance Frostbite
• 4th degree: all layers + underlying tissues • Temperature < -2
(muscles, fascia, bone) • 1st degree: hyperemic, no necrosis, yellow
plaque
Topical ABx in burn • 2nd degree: superficial vesicles with
• Silver sulfadiazine: broad spectrum, poor hyperemia and partial-thickness necrosis
coverage for Pseudomonas, poor eschar • 3ed degree: hemorrhagic bullae, full-thickness
penetration, painless necrosis
o S/E: neutropenia, thrombocytopenia • 4th degree: frank gangrene with involvement
o Avoid in patients with sulfa allergy of underlying muscles and bone
• Silver nitrate: broad spectrum, no effect on • Management: rapid rewarming (T: 40-42)
Pseudomonas, painful, poor eschar • Avoid early debridement or amputation
penetration • Pathogenesis: extra cellular space
o S/E: tissue discoloration, hypoNa, hypoK, crystallization—- increased extra cellular
hypoCl oncotic pressure—- cellular dehydration and
o Can be used in sulfa allergy impaired metabolism—- inflammatory process
• Bacitran and neomycin: painless, limited leads to thrombosis, tissue ischemia,
eschar penetration, poor gram -ve coverage endothelial injury
• Mafenide acetate: broad spectrum, active • Thrombolytic therapy limits microvascular
against Pseudomonas and Enterococcus spp., thrombosis
good eschar penetration • Poor response to thrombolytic therapy (tPA):
o S/E: metabolic acidosis o Warm ischemia time > 6hr
o Cold exposure > 24 hr
Burn centre transfer criteria (admission) o Multiple freeze-thaw cycles
• 2nd or 3ed degree > 20% TBSA, age 10-50 y.o
• 2nd or 3ed degree > 10% TBSA, age < 10 or > Chance Fx (seat-belt Fx)
50 y.o • In children due to wearing of only the lap belt
• 3ed degree > 5% TBSA, any age • L1 Fx
• 2nd or 3ed degree to hands, feet, face, eyes, • Flexion-distraction mechanism
genitalia, perineum, skin over major joints

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• Associated with hollow viscus and pancreas • Grade III: laceration > 1 cm without urinary
injury extravasation (conservative or surgical if
• If no solid organ injury and there is FFC in the laparotomy done for another issue)
abdomen, then: • Grade IV: laceration involving collecting system
o CAO, non-ventilated patient: serial with urinary extravasation, any segmental
abdominal examination renal vascular injury, renal infarction, renal
o Ventilated patient: exploratory laparotomy pelvis laceration and/or ureteropelvic
disruption (conservative if stable)
NEXUS criteria for spinal precautions • Grade V: completely shattered kidney or an
• If any is exist, keep neck collar and perform C- avulsion of the renal hilum (surgical)
spine CT scan (NSAID) • If blunt trauma and stable, no expansion in the
1. Neurologic deficit perirenal hematoma, then DO NOT explore it
2. Spinal (cervical) tenderness • If penetrated trauma, and perirenal
3. Altered mental status hematoma, then DO exploration
4. Intoxicated • Do nephrectomy if vascular or renal pedicle
5. Distracting injury injury, or in completely shattered kidney
• If CT is -ve, then remove the collar • Before nephrectomy, PALPATE the other
kidney
Occult pneumothorax
• Pneumothorax that is not seen on initial Human bite wound
radiography, but may be demonstrated on CT • MC organism found in human bite wound:
• If asymptomatic and the patient stable, then streptococcus
just observation “even if he undergoing GA, or • Other organisms may be found in human bite
on mechanical ventilation” (1.25% of the wound: Eikenella, Fusobacterium, Prevotella,
volume will be absorbed in 24hr), 100% O2 Porphyromonas
usage is controversial (O2 toxicity?)
• If persistent air leak on post injury day #3, then Chest tube
perform VATS • Preform thoracotomy or VATS if:
o Initially > 1500 cc blood
Electrolytes in burn o 250 cc blood per hour, for 3 hours
• MC electrolytes abnormalities in burn is: o 2500 cc blood over 24 hours
hyperNa (due to insensible water loss through o Bleeding in unstable patient
the burn)
• HyperNa is independent predictor of mortality Surgical cricothyroidotomy
in burn • Do if patient cannot be intubated
• Hyperglycemia due to increased glucose o #15 blade
production and insulin resistance o Transverse or vertical incision over the
• HypoCa due to Ca sequestration in the burned cricothyroid membrane
skin o Transverse incision through the
• HypoMg cricothyroid membrane
o Dilation by finger
✓ Most likely muscle to be compressed in supine o Insertion of 6 Fr or smaller
position is: gluteal area (buttocks) cricothyroidotomy tube
• Needle cricothyroidotomy in children < 12 y.o
Kidney injury
• Grade I: contusion or subcapsular, non- Tranexamic acid TXA
expanding hematoma (conservative) • Anti-fibrinolytic agent
• Grade II: laceration <= 1 cm in depth without • In blunt trauma reduce all-case mortality
urinary extravasation, perirenal hematoma • Beneficial if given within the 1st hr of trauma
confound within the perirenal fascia • Not administered after 3hr of trauma
(conservative)

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 Bleeding
• Hard signs: shock, pulsatile bleeding, Trauma in pregnancy
expanding or pulsatile hematoma, palpable • Blood volume increased more than RBCs in
thrill or bruit, absent distal pulses pregnancy (50%:30%): functional
• Soft signs: diminished pulse, proximity of hemodilution
wound to vessels, hematoma, reports of • Pregnant less likely to manifest tachycardia
significant blood loss and hypotension
• ABI < 0.9 suggests vascular injury and • Pregnant has:
promotes CT angiogram o Increased TV, minute ventilation (mild
• Arterial pressure index API: is a bilateral respiratory alkalosis)
comparison of SBP distally to injury o Decreased functional residual capacity
o Increased 2,3-diphosphoglycerate
Urethral injury o Increased GFR
• MC site is: prostatic urethra o Decreased serum creatinine
• MC sign: blood per meatus • Uterus compresses the IVC, decreasing the
• Dx: retrograde urethrogram venous back flow
• Early NG tube decompression is recommended
Prothrombin complex concentrate PCC • Radiology studies seems to be safe after 20
• Must be given in potentially life-threatening weeks GA
hemorrhage
• 4-factors PCC: protein C and S, factors II, IX, X + Flail chest
normal amount of factor VII • Two or more ribs Fx, in at least two locations
• 3-factors PCC: protein C and S, factors II, IX, X + • Paradoxical movement of free-floating
low amount of factor VII segment
• PCC has clotting factors 25 times higher • Initial CXR underestimates the degree of
concentration from plasma pulmonary contusion
• Over resuscitation with IV fluids can result in
Hemorrhagic shock blossoming of pulmonary contusion
• Class I: < 750 mL blood loss (<15%) • Pain control is vital for Tx
• Class II: 750-1500 mL blood loss (15-30%) • Surgical fixation in non-contusion patients can
• Class III: 1500-2000 mL blood loss (30-40%) decrease intubation time, complications and
• Class IV: > 2000 mL blood loss (>40%) improve cosmetic and functional results
• The earliest sign of blood loss: tachycardia
(class II) Blunt cardiac injury BCI
• Suspect in patients with severe blunt chest
Resuscitative thoracotomy trauma
• Do if: • MC recommended tool for initial diagnosis:
o Blunt chest trauma, loss of BP or Pulse in ECG
ED • Norma ECG, then 95% no BCI
o Penetrated chest trauma, loss of BP or • Normal ECG and normal cardiac troponin, the
pulse on the way to ED (with CPR) or in ED 100% no BCI
• If patient unstable, the do Echo
Resuscitation access • If cardiac tamponade and cardiac rupture is
• Preferred access for IV resuscitation is suspected, the do emergent sternotomy
peripheral IV cannulation (anticubital or
saphenous veins) Cardiac tamponade
• If failed then IO cannulation (Pediatrics; • Beck’s triad: hypotension, DJV, muffled heart
proximal tibia: 2-3 cm below tibial tuberosity, sound (but not reliably present)
distal femur: above femoral condyles. Adults; • If Beck’s triad +ve, then do FAST
sternal, proximal tibial) • If FAST +ve for tamponade, then do
• IO access must be removed within 42 hours decompression

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✓ Cattell maneuver: Rt medial visceral rotation o 50% of lumen, then evacuation
(cecum and ascending colon), by incising the • Full-thickness duodenal injury >50% of lumen,
line of Toldt (access to Rt retroperitoneum: then:
IVC, Rt ureter) o 1st, 3ed, 4th portion, do resection and
✓ Kocher maneuver: cephald mobilization and duodenoduodenostomy or
medial rotation of duodenum (access to duodenojejunostomy
suprarenal IVC) o 2nd, 3ed portion and intact ampulla, then
✓ Mattox maneuver: Lt medial rotation of Roux-en-Y duodenojejunostomy
descending colon, spleen and/or kidney to
midline (Lt ureter, distal IVC) Plastic de VIRGILIO
Veins that cannot tolerate ligation Skin graft
• SVC (SVC syndrome) • Suspected to immediate shrinkage, primary
• Renal veins close to parenchyma (inadequate contraction (FTSG), secondary contraction
out flow) (STSG)
• IVC above the renal veins (impair renal out • Graft survival:
flow) o 1st 3 days: imbibition, passive absorption
• IVC at diaphragm (Budd-Chiari syndrome) o 3ed-4th day: inosculation, direct
• Portal vein (supplies 75% of liver) connection of the skin graft to vessels in
• Lt renal vein can be ligated close to IVC (out wound bed
flow can be via adrenal, gonadal iliolumber o 5th+ day: neovascularization and
veins) angiogenesis
• Graft failure:
Extremity compartment syndrome o MCC: Hematoma, seroma
• MC features: severe pain out of proportion o Infection
• Pain on passive motion o Poor wound bed
• Tense edema o Sheer forces
Split-thickness skin graft STSG
• Tenderness
• Contains all epidermis and some dermis
• Anterior compartment is the first to be
involved in lower extremity (early finding: • Has higher chance for survival (thin)
numbness in the 1st web space of the toe, due • Meshing increase the coverage, drains the
to deep peroneal nerve compression) fluids and blood, but increases scarring
• Deep posterior compartment is the MC
inadequately decompressed (contains tibial Full-thickness skin graft FTSG
nerve, soleus muscle must be detached to do • Contains all epidermis and dermis
decompression) • Appropriate for face and hands
• Has lower chance for survival
Duodenal injury
• Grade I: single hematoma or partial-thickness ✓ Most important principle in lip repair is re-
injury approximation of vermilion-cutaneous
• Grade II: hematoma in more than one portion junction
or laceration < 50% of lumen
• Grade III: laceration 50-75% in D2, or, 50-100% Negative pressure wound therapy NPWT
in D1, 3, 4 • MOA: reduction of edema, removal of wound
• Grade IV: laceration > 75% in D2, involvement fluids rich in distractive enzymes, increasing
of ampulla or distal CBD growth factor by cyclic compression mode
• Grade V: massive disruption of • C/I: malignancy, ischemia, infected wound
pancreticoduodenal complex or complete
duodenal devascularization Reconstructive ladder
1. Secondary intention
• Duodenal hematoma (intraOP finding), then:
2. Primary closure
o < 2cm, nothing to do

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 3. Skin graft • Superior orbital fissure syndrome:
4. Tissue transfer compression of CN III, IV, VI (eye ptosis, globe
5. Free tissue transfer proptosis, paralysis of extraocular muscles)
• Orbital apex syndrome: superior orbital fissure
Cleft lip syndrome + compression of optic nerve (+
• Rule of 10s: Hb > 10, age > 10 weeks, body blindness)
weight > 10 pounds
• C/I for repair: severe malnutrition, concurrent Skin and soft tissue
cardiac anomalies that require repair
Basal Cell Carcinoma
✓ O2, iron, VitC, alpha-ketogutarate are needed • Arise for basal layer of non keriatinocytes
for hydroxylation and cross-linking in collagen • Risk factor: UV-B exposure
✓ VitA is needed for epithelalization • More local invasion than distant metastasis
• MC subtype: nodular variant (rodent ulcer)
Rectus muscle blood supply • Other subtypes: morpheaform,
• Superior epigastric artery from internal fibroepithelioma of Pinkus
thoracic artery • Histologic subtypes:
• Inferior epigastric artery from external iliac o Nodular
artery (most dominant) o Micro-nodular
o Superficial (on the trunk)
✓ Superficial epigastric artery from femoral o Infiltrative (on head and neck)
artery • Tx: Moh’s microsurgery
✓ Deep circumflex artery from external iliac
artery supplies the iliac crest Squamous Cell Carcinoma
✓ Microvascular free flap survival is > 95% • 2nd MC skin cancer
✓ The gold standard for postOP flap assessment • Risk factor: UV-A, HPV-16, HPV-18, smoking
is clinical examination • Subtypes: adenoid, adenosquamos,
Deep inferior epigastric perforator flap DIEP desmoplastic
• Higher rate of flap necrosis • Factors for high risk: size >2 cm, subcutaneous
• Reduce the morbidity at the donor site tissue involvement
• Minimum nerve dysfunction • Tx: < 2cm, WLE with 4mm margins for low-
• Reduce pain grade and 6mm margins for high-grade lesions
• Reduce the risk of hernia
Melanoma
Gynecomastia surgery • Arise from melanocytes at the epidermal-
• MC early complication: hematoma dermal junction
• MC long-term complication: under-resection • Subtypes: lentigo maligna (in elderly, on head
and neck), superficial spreading (MC), acral
Facial Fx lentiginous, mucosal, nodular (worst
• MC site is nasal Fx prognosis), polypoid, desmoplastic,
• Mandibular Fx mostly multiple amelanotic, soft tissue
• Any septal hematoma must be drained to • Localized anywhere on the body except hand
prevent pressure necrosis and feet
• Nasal examination is mandatory in nasal bone • Growth starts radically then become vertically,
Fx except in nodular (vertical growth then radical)
• MC isolated orbital Fx: orbital floor Fx • Asymmetric outlines, changing irregular
(maxillary bone Fx) borders, color variation, diameter > 6mm,
• MC complication after orbital floor Fx: elevation
entrapment of extraocular muscles • Prognostic indicators: thickness, ulceration,
mitotic rate

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• MC non cutaneous site: ocular melanoma
(mets to liver)

Merkel cell carcinoma

• Aggressive neuroendocrine tumor of the skin
• Risk factor: UV-A
• Rapid growing, flesh-colored papule or plaque

Kaposi’s sarcoma
• Proliferation and inflammation of endothelial-
derived spindle cell lesions
• Multifocal, rubbery blue nodules

Sarcoma
• The most common site of sarcoma is lower
extremities
• The most common subtype overall of sarcoma
is malignant fibrous histiocytoma
• The most common retroperotoneal type is
Liposarcoma
• Most common type in children is
rhabdomyosarcoma
• Most common subtype of rhabdomyosarcoma
is embryonal
• Worst prognosis subtype of
rhabdomyosarcoma alveolar
• Primary treatment for all sarcomas is surgical
resection
• The most important factor in overall survival is
complete surgical resection at the time of
diagnosis
• Most common cause of death in
retroperitoneal sarcomas is local recurrence
• Most common site of mets (extremity
sarcoma) lung
• Most common site for mets (retroperitoneal
sarcoma) lungs and liver equally

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