CLASSIC INTRAOPERATIVE QUESTIONS

What is the difference between a McBurney’s incision and a Rocky-Davis incision?

What are the layers of the abdominal wall during a McBurney incision?

What are the steps in laparoscopic appendectomy (lap appy)?

Do you routinely get peritoneal cultures for acute appendicitis (nonperforated)?

How can you find the appendix after identifying the cecum?

Which way should your finger sweep trying to find the appendix?

How do you get to a retrocecal and

retroperitoneal appendix?

Why use electrocautery on the exposed mucosa on the appendiceal stump?

McBurney’s is angled down (follows ext oblique fibers), and Rocky-Davis is straight across (transverse)

1.Skin

2.Subcutaneous fat

3.Scarpa’s fascia

4.External oblique

5.Internal oblique

6.Transversus muscle

7.Transversalis fascia

8.Preperitoneal fat

9.Peritoneum

1.Identify the appendix

2.Staple the mesoappendix (or coagulate)

3.Staple and transect the appendix at the base (or use Endoloop® and cut between)

4.Remove the appendix from the abdomen

5.Irrigate and aspirate until clear

No

Follow the taeniae down to where they converge on the appendix

Lateral to medial along the lateral peritoneum—this way you will not tear the mesoappendix that lies medially!

Divide the lateral peritoneal attachments of the cecum

To kill the mucosal cells so they do not form a mucocele

What is a carcinoid tumor?

Tumor arising from neuroendocrine cells (APUDomas), a.k.a. Kulchitsky cells; basically, a tumor that secretes serotonin

How can you remember that Kulchitsky cells are found in carcinoid tumors?

What is the incidence?

What are the common sites of occurrence?

Think: “COOL CAR” or KULchitsky CARcinoid

Between 0.2% and 1.0% and about 25% of all small bowel tumors

“AIR”:

1.Appendix (most common)

2.Ileum

3.Rectum

4.Bronchus

Other sites: jejunum, stomach, duodenum, colon, ovary, testicle, pancreas, thymus

What is a complete memory aid for carcinoid?

Why does right-sided heart failure develop but not left-sided heart failure?

What is the incidence of carcinoid SYNDROME in patients who have a carcinoid TUMOR?

Think: B FDR CARcinoid, or “Be FDR in a cool CAR” (COOL KULchitsky cells)

Lungs act as a filter (just like the liver); thus, the left heart doesn’t see all the vasoactive compounds

10%

How does the liver prevent carcinoid syndrome?

Why does carcinoid syndrome occur in some tumors and not in others?

What tumors can produce carcinoid syndrome?

Chapter 46 / Carcinoid Tumors 303

By degradation of serotonin and the other vasoactive peptides when the tumor drains into the portal vein

Occurs when venous drainage from the tumor gains access to the systemic circulation by avoiding hepatic degradation of the vasoactive substances

Liver metastases

Retroperitoneal disease draining into paravertebral veins

Primary tumor outside the GI tract, portal venous drainage (e.g., ovary, testicular, bronchus), or both

What does the liver break down serotonin into?

What percentage of patients with a carcinoid have an elevated urine 5-HIAA level?

5-hydroxyindoleacetic acid (5-HIAA)

50%

hrf

‘07

5

4 3

2

1

304 Section II / General Surgery

How do you localize a GI carcinoid?

What are the special radiologic (scintigraphy) localization tests?

What is the surgical treatment?

What is the medical treatment?

How effective is octreotide?

Barium enema, upper GI series with small bowel follow-through, colonoscopy, enteroscopy, enteroclysis, EGD, radiology tests

131I-MIBG (131 metaiodobenzylguanidine)

111In-octreotide

PET scan utilizing 11C-labeled HTP

Excision of the primary tumor and single or feasible metastasis in the liver (liver transplant is an option with unresectable liver metastasis); chemotherapy for advanced disease

Medical therapy for palliation of the carcinoid syndrome (serotonin antagonists, somatostatin analogue [octreotide])

It relieves diarrhea and flushing in more than 85% of cases and may shrink tumor in 10% to 20% of cases

What does carcinoid tumor look like?

For appendiceal carcinoid, when is a right hemicolectomy indicated versus an appendectomy?

Which primary site has the highest rate of metastasis?

Can a carcinoid tumor be confirmed malignant by looking at the histology?

Usually intramural bowel mass; appears as yellowish tumor upon incision

If the tumor is 1.5 cm, right hemicolectomy is indicated; if there are no signs of serosal or cecal involvement and tumor is 1.5 cm, appendectomy should be performed

Ileal primary tumor

No, metastasis must be present to diagnose malignancy