Problem solving : a quiz in general surgerypptx

questions and answers. surgical cases, anatomy, operations.

1. Problem solving Dr K arrar A dil Team E

2. Question 1

3. T his is an intra operative image of laparoscopic cholecystectomy. 1- Identify the structures ( A,B,C,D,and E). 2- Describe the anomaly . What is it called ? 3- Why is it important to recognize this anomaly? 4- What are the critical view of safety principles?

4. Answer : 1- A : Infundibulum of gallbladder. B : cystic duct. C : common bile duct. D : RHA. E : Cystic Artery and proximal clip ligation. 2- long tortuous right hepatic artery in front of the origin of the cystic duct is called as Moynihan's or caterpillar hump . It is important cause of bleeding in cholecystectomy .

5. 3- If such a hump is present , the cystic artery in turn is very short. In this situation right hepatic artery is either liable to be mistakenly identified as cystic artery or torn in attempts to ligate the cystic artery. Injury to right hepatic artery leads to ischemic necrosis of right functional lobe of the liver. 4- Strasberg’s method, known as Critical View of Safety , is based on three criteria : First : only two structures can be clearly seen connected to the gallbladder. Second : the lower one third of the gallbladder is separated from the liver to expose the cystic plate. Third : the calot’s triangle must be completely clear of tissue allowing proper visibility of all cystic structures.

6. Question 2

7. A 26-year-old dark skinned female complains of swelling on right ear lobe since 3 years when she had got her ear pierced. 1- What is the diagnosis ? 2- How to differentiate it from other closely related conditions? 3- How to treat this condition?

8. Answer : 1- K eloid scar. 2- Hypertrophic scar usually show a rapid growth phase for up to 6 months, and then gradually regresses over a period of a few years. but keloid typically persist for long periods of time, and do not regress spontaneously. the incidence of keloid scar formation is much higher in black-skinned individuals than in whites. More common in females .

9. The histology of both hypertrophic and keloid scars shows excess collagen with hypervascularity , but this is more marked in keloids where there is more type III collagen. Keloids typically extend beyond the original wound margins. while it will not happen with hypertrophic scars. The most common sites for hypertrophic scar are shoulders, neck, presternum , knees, and ankles whereas; keloids are frequently seen on anterior chest, earlobes , upper arms, and cheeks. Keloids have a higher tendency to recur following excision , whereas new hypertrophic scar formation is rare after its excision.

10. 3 - Treatment : I ntra-marginal surgical excision of keloid tissue is recommended to prevent the stimulation of additional collagen synthesis. O ther most commonly used treatment modalities include : Intra- lesional steroid injection (triamcinolone). Cryotherapy . L aser removal. Radiotherapy. S ilicon gel sheeting.

11. Question 3

12. 6 year old child presented with Lt upper arm pain , swelling , and limitation of movement following a minor fall. X-ray was done. 1- What are the x-ray findings? 2- What is the diagnosis? 3- What are the most common sites for this pathology? 4- Mention the treatment options.

13. Answer : 1- lucent lytic lesion at the upper humeral metaphysis and shaft with symmetrical thinning of cortices. pathological fracture and a displaced bone chip in its cavity giving fallen leaf sign . 2- Unicameral Bone Cyst (also called simple bone cyst). Is a non-neoplastic , serous fluid-filled bone lesion typically presents in patients < 20 years of age with a pathological fracture through the lesion.

14. Fallen leaf sign

15. 3- location : Most common site is the proximal humerus (60%). other locations including proximal femur, distal tibia, calcaneus , and occasionally metacarpals, phalanges, and distal radius 4- Treatment : Non-operative : Immobilization. methylprednisolone acetate injection. Operative : curettage and bone grafting +/- internal fixation based on tumor location.

16. Question 4

17. A 40-year old farmer experienced right upper abdominal pain for one week, radiating to the right shoulder, associated with fever of (39 C), chills, and malaise . He had a history of diarrhea 3 months ago. Abdominal CT scan was done.

18. 1- Describe the image. 2- What is the diagnosis ? 3- Mention the risk factors of this condition. 4- What are the treatment options?

19. Answer : 1- Contrast enhanced abdominal CT scan (Axial view) showing round hypodense lesion in the Rt lobe of the liver displaying double-target sign consisting of an inner enhancing ring (white arrowhead) and outer hypodense ring (black arrowhead ). 2- Amoebic liver abscess.

20. 3- Risk factors associated with amebic liver abscess: Immigrants from endemic areas. or short-term travelers to endemic countries. Institutionalized persons. Crowding and poor hygiene. Homosexuality . Presence of immunosuppression : (ex: HIV infection, malnutrition with hypoalbuminemia , alcohol abuse, chronic infections, steroid use, malignancy, extremes of age, and pregnancy).

21. 4- Medical treatment : Metronidazole ( Tinidazole is an alternative). luminal agent : is used for removing any intraluminal cysts. Paromomycin , diiodohydroxyquin , or diloxanide furoate .

22. Percutaneous drainage of abscess : Indications : high risk of rupture (size >5 cm). failure to observe a clinical response to therapy within 5-7 days. abscess in pregnancy where drug therapy cannot be used. Pyogenic superinfection . Can’t differentiate from a pyogenic liver abscess.

23. Surgical treatment : (open surgical approach or laparoscopic surgery) Indications : for patients whom medical and percutaneous treatment failed. when there are large, multilocular or dense content abscesses. Left lobe abscess. imminence of rupture or development of serious complications such as peritonitis.

24. Question 5

25. This is an image of a 2-week-old female seen in the Emergency Department. she was born at 34 weeks gestational age due to maternal pre- eclampsia . 1- What is the diagnosis? 2- What are the predisposing factors for this condition? 3- Which micro organisms cause this condition? 4- What are the main complications?

26. Answer : 1- Omphalitis . 2- predisposing factors for omphalitis include : Prematurity. Complicated delivery. Poor hygienic practices during the neonatal period. maternal infection. umbilical catheterization. home birth.

27. 3- causative micro organisms : S . aureus . Streptococcus pyogenes . Gram-negative organisms (i.e., E. coli, Klebsiella species ). anaerobes ( Bacteroides fragilis and Clostridium). 4- main complications : Suppurative thrombophlebitis of the umbilical or portal veins (resulting in portal vein thrombosis). Abscess. Abdominal wall necrotizing fasciitis. Peritonitis. Intestinal gangrene. Pyourachus (infection of the urachal remnant ).

28. Question 6

29. 1- Name the devise in the image below. 2- What do the digital screen readings stand for ? 3- W hat is the preferred gas for establishing pneumoperitoneum ? Why ? Mention other gases than can be used.

30. Answer : 1- Laparoscopic Insufflator. 2- Quadro manometric Indicators: are the four important readings of the insufflator. These are : Preset Insufflation pressure. Actual Pressure. Gas flow rate (liter/minute). Volume of gas consumed.

31. 3- Carbon dioxide (CO2) is the most commonly used gas for insufflation during laparoscopic surgery because it is colorless , inexpensive , non-flammable , and has higher blood solubility than air , which reduces the risk of complications. Other used gases include Nitrous Oxide , Helium and argon .

32. Thank you …