Wounds that have no gap separating the boundaries (e.g., clean surgical wounds) will undergo “primary healing,” from the apposed edges of the tissue. Wounds that have a large gap (e.g., large debridement of infected ulcer) will undergo “secondary healing healing” which involves production of excess extracellular matrix to fill up the wound (this excess extraceullar matrix looks granular hence called granulation tissue), neo-vascularization and eventual formation of scars.
25.1 Preoperative Evaluation
25.2 Cardiac Risk Factor and Surgery
Recent myocardial infarction (MI) without percutaneous coronary intervention (PCI)
At least 2 months should lapse before considering elective noncardiac surgery
aIf risk of further delay of elective surgery is higher than cardiac risk, elective surgery can be considered earlier (after at least 3 months of DES placement, but not less than 1 month).
Additional info: Perioperatively, continuing dual-antiplatelet therapy, or discontinuing platelet-receptor blocker and giving ASA (acetylsalicylic acid) alone, is determined on a case-by-case basis. If surgery needs to be done within 4 to 6 weeks of stent placement, dual-antiplatelet therapy needs to be continued preoperatively unless the risk of bleeding is considered higher than the risk of stent thrombosis.
25.3 Neck Mass
Location: Anywhere anterior to the sternocleidomastoid muscle (yellow line in the picture)
Location: posterior lateral neck
• As it can extend into the chest, do CT scan prior to surgery.
aUsually found in children and young adults. All of them can also become infected and present with red, hot, tender cystic mass.
25.4 Inguinal and Femoral Hernias
Increased abdominal pressure: Obesity, chronic cough, constipation, etc.
Poor connective tissue strength: Smoking, diabetes, unhealthy diet, etc. Hernia anatomy:
Inguinal triangle is bordered by inguinal ligament, inferior epigastric vessels, and lateral border of rectus abdominis muscle.
Defect in the deep inguinal ring (entry to the inguinal canal)a
• Hernia may completely traverse the inguinal canal and descend into the scrotum.
Defect in fascia transversalis of the abdominal wall, which acts as the posterior wall of the inguinal canal
Defect in the femoral ring (entry to the femoral canal)a
aNeurovascular structures pass through femoral and inguinal canals. Due to the above risk factors, the ring and canal may get bigger and weaker, which allow intra-abdominal contents like mesentery or intestines to pass through.
For reducible inguinal or femoral hernias, elective repair is usually offered. These are usually asymptomatic or can be mildly tender in some cases.
Irreducible hernias are incarcerated hernias, which can be complicated by strangulation
1Irreducible hernia that is tender but shows no signs of obstruction or sepsis can be omental- or mesentery-only hernia.
As a rule in, explorative laparotomy is indicated if any of the following is present:
Generalized abdominal guarding, rigidity, or rebound tenderness
Hemodynamic instability with high suspicion for intra-abdominal source
For this chapter, these are called “abdominal danger signs.” Looking out for these during any patient encounter is very important, so remember these danger signs.
25.5 Gastrointestinal Tract
LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
25.5.1 Bowel Obstruction
Hernia, Adhesions,a Volvulus (cecal),b Intussusception,c Neoplasm, and Gallstone ileus
Hyperactive or borborygmic in early stages; hypoactive in late phase
First initial diagnostic step is X-ray. CT may be done if further information is needed.
Radiologic findings Both small and large bowels are involved (air in the distal colon and rectum typically signals a diff use pathology)
An upright view of the abdomen showing multiple air-fl uid levels in nondilated small and large bowels including the rectum (red arrow) indicating ileus.
Abdominal X-ray. Source: Abdominal pathologies and findings. In: Shi Y, Sohani Z, Tang B et al., eds. Essentials of Clinical Examination Handbook. 8th ed. Thieme; 2018.
Usually small-bowel involvement (and distal-bowel collapse)
A supine X-ray demonstrating dilated small bowel. To diff erentiate small bowel gas from colonic distention, look at the folds that extend all the way across the lumen, indicating that it is the small bowel. Also, the large bowel only has four parts: ascending, transverse, descending, and sigmoid (a square on the edges Π).
Source: Pathology. In: Gunderman R, ed. Essential Radiology. Clinical Presentation, Pathophysiology, Imaging. 2nd ed. Thieme; 2000.
aPostoperative adhesions can occur as early as within 1 week of surgery.
bVolvulus of sigmoid colon can cause large bowel obstruction. It typically occurs in an elderly patient when the sigmoid colon gets twisted on its axis. It has a “coffee bean” appearance on X-ray.
cFor intussusception, see Chapter 22 (Pediatrics). Do you remember what is the treatment?
dNG tube is most helpful in patients with pain due to stomach distention and frequent or largevolume vomiting.
25.5.2 Ogilvie’s Syndrome (Colonic Pseudo-obstruction)
Background: Acute or subacute nonobstructive dilation of large bowel due to impairment of the enteric autonomic nervous system.
Risk factors: Typically occurs in older patients after hospitalization, surgery, etc.
Presentation: Look for large-bowel distention with minimal involvement of small bowel. Patients usually appear comfortable despite significant abdominal distention. Some patients can have nausea, vomiting, and even diarrhea.
Management: Conservative, NPO + IV fluids + NG tube decompression as needed. If cecal diameter is > 12 cm or if conservative management fails, consider neostigmine. (!) If neostigmine fails, NSIM is colonoscopic decompression. If this fails, next is surgical management with cecostomy.
Complication: Ischemia and perforation (If any of the abdominal danger sign develops, NSIM is explorative laparotomy with colonic resection and ileostomy).
25.5.3 Intestinal and Gastric Perforation
Etiology: Any severe gastric or intestinal pathologycan cause perforation.
Presentation: Generalized guarding, rigidity, and/or rebound tenderness. In generalized peritonitis, even a little movement can cause significant pain.
25.5.4 Abdominal Compartment Syndrome
Background: Complicated abdominal surgery, especially requiring administration of large volume of fluids, can lead to severe edema of the abdomen and its contents, resulting in increased intra-abdominal pressure. Other risk factors include early closure of abdominal wound, severe burns, liver transplantation, etc.
Work-up: Intra-abdominal pressure can be measured by different methods. Most commonly used is intrabladder pressure measurement (look for pressure of ≥ 20-25 mmHg).
Treatment: Surgical decompression and temporary abdominal closure with mesh or plastic to protect the bowel. Primary closure is done after 48 to 72 hours.
Pathophysiology: Obstruction of appendiceal lumen can lead to inflammation ± infection. Causes of obstruction include lymphoid hyperplasia (due to viral infection), fecalith, parasites, etc.
Presentation: Classic sequence of symptom development: anorexia → vague periumbilical pain → RLQ (right upper quadrant) sharp and severe pain (localized signs of peritonitis, such as rebound tenderness and guarding in RLQ, are usually present at this stage). Other symptoms are nausea, vomiting, low-grade fever, and elevated white blood cells (WBCs).715
Clinical signs of appendicitis:
Deep palpation in LLQ elicits pain in RLQ (increased pressure in the colon is felt in the inflamed appendix)
Abbreviations: LLQ, left lower quadrant; RLQ, right lower quadrant.
No need for radiologic imaging in classic presentation. NSIM—IV antibiotics directed against GI (gastrointestinal) pathogens, followed by laparoscopic appendectomy.
In atypical presentation, abdominal CT scan can confirm the diagnosis.
During surgery, even if appendix looks grossly normal, it should be removed (microscopic appendicitis might be present).
Complication: Appendiceal abscess can develop if patient presents late (e.g., > 5 days of hx suggestive of appendicitis):
Background: Enlarged anorectal veins that commonly occur due to prolonged history of constipation and straining during defecation. Other causes include pregnancy and increased portal pressure in cirrhosis (cirrhosis patients have mostly internal hemorrhoids).
Presentation: Usually painless bleeding associated with defecation. (!) External hemorrhoids may be painful (somatic innervation), whereas internal hemorrhoids are typically painless (even when they cause bleeding).
Rx: Initial step is to prevent constipation with high-fiber diet, adequate fluid intake ± sitz baths. Use oral or topical analgesics for pain. For refractory cases, refer to colorectal surgery (rubber band ligation or surgical hemorrhoidectomy may be needed).
Complication: Vein thrombosis can cause severe pain. Management is immediate hemorrhoidectomy (simple clot removal is not recommended due to a high chance of recurrence).
25.5.7 Other Anorectal Conditions
These signs may or may not be present. Presence of obturator and psoas sign depends on the location of the appendix.
Fever + perineal pain. Look for “fluctuant mass”b
Surgical drainage. Antibiotics are indicated in all cases. (use antibiotics that cover gram +ve, gram -ve, and anaerobes, e.g., amoxicillin-clavulanate).
Most fistulas form as a result of anorectal abscess. They have internal and external openings.
Etiology: Local trauma, infection, inflammatory bowel disease, malignancy, etc.
Feature: These anal tears occur distal to the dentate line, hence are very painful. Anal area exam may require anesthesia. MC location is midline posterior wall.
First step is conservative treatment with topical vasodilators (nifedipine or nitroglycerin), topical analgesic, stool softener, sitz bath, and fiber diet.
Surgical correction is done if conservative management fails.
Abscess needs to be incised and drained. In recurrent or chronic cases, excision of cyst and sinus tract is done.
aNew-onset anorectal lesions in elderly or high-risk patients, or in atypical location (e.g., multiple anal fissures that are not in the midline), or all nonhealing lesions should be evaluated for anal cancer by proctosigmoidoscopy ± biopsy.
25.5.8 Anorectal Mass
Blunt Trauma (e.g., Motor Vehicle Accident, Skiing Accident)
25.6.1 Blunt Head Trauma
Head CT in blunt head trauma is indicated if any of the following is present: