MSC - F. Surgery Answers 2025

1.Source control: Remove or repair the cause (e.g., perforated appendix, gangrenous bowel, perforated ulcer).

2.Debridement: Excise necrotic tissue.

3.Evacuation of pus and exudate: Reduce bacterial/toxin load.

4.Abdominal lavage: With warm saline until clear effluent.

5.Drainage: To monitor and manage residual infection.

Common Approaches

Midline laparotomy is the standard approach: gives full access.

If source control is difficult (e.g., multiple abscesses, poor patient condition), damage control surgery or planned relaparotomy may be chosen.

11.Principles of drainage of the abdominal cavity in acute peritonitis.

Proper drainage is critical to prevent recurrent infection, abscess formation, and improve outcomes.

Drainage Objectives

Remove residual pus, bile, blood, and inflammatory exudate.

Monitor ongoing infection.

Facilitate postoperative abdominal lavage if necessary.

Types of Drainage

1.Passive drainage: Via gravity (e.g., Penrose drain) – not commonly used anymore.

2.Active (closed suction) drainage: More common – e.g., Jackson-Pratt, Redon-type drains.

3.Prolonged lavage drainage:

oClosed abdominal lavage: Continuous or intermittent instillation of saline + antibiotics with suction drainage.

oLimitations: difficult to drain dependent spaces completely, risk of electrolyte imbalance.

4.Open drainage (open abdomen):

oUsed in planned relaparotomy or programmed re-exploration.

oAbdomen is temporarily closed with a vacuum-assisted dressing (e.g., VAC therapy).

Drain Placement Principles

Drains should not irritate bowel or major vessels.

Always place in dependent positions (Douglas pouch, subhepatic, paracolic gutters).

Avoid long-term dependence on drains due to infection risk and fistula formation.

Proctology

1. Methods of examination of patients with colon diseases.

1. Clinical Signs of Coloproctologic Diseases

Diagnosis begins with history taking and symptom analysis, including:

Anorectal Pain:

oAcute anal fissure, paraproctitis, hemorrhoidal thrombosis, anal canal tumors.

Abdominal Pain:

oColicky pain → bowel obstruction.

oConstant pain → inflammation (e.g., appendicitis, peritonitis).

Rectal Bleeding:

oBright red blood → anal canal/rectum (e.g., hemorrhoids, fissure).

oMucus with altered blood → rectal tumor or colitis.

Other Complaints:

o Hemorrhoidal prolapse, fistulas, polyps.

o Incontinence of gas or feces.

o Distention: May be functional or organic.

oConstipation (>3 days): Could be functional or due to obstruction (e.g., tumor).

oDiarrhea: Infectious or related to IBD (ulcerative colitis, Crohn's), tumors, polyposis.

oSystemic signs: Cachexia, anemia → suggest malignancy or severe chronic disease.

2.General & Local Physical Examination

Begin with general examination and systemic organ review.

Positioning: Preferably in gynecological chair or Sims' position.

For further rectal evaluation, knee-elbow or knee-humeral position is used.

3.Special Methods of Examination

A.Digital Rectal Examination (DRE)

First-line and highly informative.

Detects 80–90% of rectal tumors.

Evaluate sphincter tone, masses, tenderness, and structural abnormalities.

In women: Vaginal bimanual exam may be complementary.

B.Anoscopy

Short speculum inserted into anal canal.

Allows detailed inspection of anal canal walls.

C.Proctosigmoidoscopy

Mandatory in any patient with bowel symptoms.

Examines up to 30 cm of distal bowel.

Preparation: Cleansing enema or Microlax.

Used for:

o Biopsy.

o Polyp electrocoagulation.

o Drug instillation.

oForeign body removal.

Variants: With or without obturator.

D. Colonoscopy

Gold standard for full colon evaluation.

Can reach terminal ileum and ileocecal valve.

Diagnostic & therapeutic:

oPolyp removal.

o Biopsy.

oDrug delivery.

Accuracy for tumors: ~96%

Contraindications: Severe comorbidities, mental instability.

Preparation: Fortrans or enemas.

E.Radiologic Methods

Contrast X-rays: Assess mucosa, motility, strictures.

Fistulography: Especially in extrasphincteric fistulas.

Aortography (Seldinger): For ischemic colitis or bleeding.

Retropneumoperitoneum: Rarely used now.

F.Radionuclide Techniques

Assess:

oCirculating blood volume.

oColonic motility and transit.

G.Functional Tests

Sphincterometry: Evaluates anal sphincter function.

Balloonography & Electrocolography: Assess motor function of colon.

H.Imaging

Ultrasound: Useful for liver mets, pelvic abscesses.

oLiver mets: ~85% accuracy.

CT scan: Similar diagnostic value as US; better anatomical resolution.

MRI: Superior for soft-tissue and pelvic structures (not mentioned, but modern standard).

Laparoscopy: In select cases for direct visual inspection and biopsy.

I.Histologic (Morphologic) Methods

Biopsy: Critical for final diagnosis (inflammation vs malignancy).

Performed during endoscopic or surgical procedures.

2. Preparation for surgery of patients with colon diseases.

Preoperative Care (Before Surgery)

1. Correct Metabolic/Immune Issues

oFix malnutrition, anemia, electrolyte imbalance, etc.

2.Bowel Cleansing

oUse Fortrans or enemas. Combine with low-fiber diet.

3.Antibiotic Prophylaxis

oStart day before or day of surgery. Use:

3rd/4th gen cephalosporins

Metronidazole

Carbapenems, fluoroquinolones

4. Control Existing Infections

o Treat UTI, respiratory infections, etc. beforehand.

Postoperative Care (After Surgery)

1. Feeding

o Small bowel surgery: fluids on Day 1.

oLarge bowel anastomosis: NPO till Day 5, start low-fiber food Day 3.

2.Nutritional Support (if needed)

oOral: Nutridrink.

oEnteral/Parenteral: Nutren, Lipofundin, etc.

3.Bowel Movement Management

oFirst stool after anorectal surgery: enema or purgative on Day 3–4.

4.Thrombosis Prevention (especially elderly)

oEarly mobilization, elastic stockings, LMWH (e.g., Clexane).

5.Prevent Post-op Complications

oUse early ambulation, breathing exercises, and GI stimulation to prevent ileus, pneumonia, or embolism.

6.Minor Procedures (e.g., hemorrhoidectomy)

oMobilize same or next day.

oDiet can progress to Diet No. 1 by Day 3.

3.Chronic hemorrhoids: definition, etiology, pathogenesis.

Definition:

A very common condition affecting roughly 10-12% of adults (100-120 per 1000 people). It’s a disorder of the arteriovenous (artery-vein) cavernous plexuses in the rectum that become hyperplastic and clinically present as bleeding, prolapse, thrombosis, inflammation, itching, and sometimes necrosis.

Etiology (Causes)

No single theory explains hemorrhoids completely, but three main factors contribute:

1.Congenital weakness of the vascular walls — the blood vessels themselves are structurally weak from birth.

2.Muscular and connective tissue degeneration — changes in the longitudinal muscle layer of the rectal wall and the ligament of Parks (which supports internal hemorrhoids) lead to poor support and prolapse.

3.Blood flow disturbances — impaired venous drainage causes congestion and enlargement of these vascular cushions.

Pathogenesis (Disease Development)

Hemorrhoids arise from normal vascular cushions located in the submucosal layer of the distal rectum, typically at positions corresponding to 3, 7, and 11 o’clock on a clock face.

Chronic dysfunction of the tiny arteries (intramural cochlear arteries) feeding these cavernous veins leads to their pathological enlargement and symptoms.

4.Chronic hemorrhoids: classification, clinic, diagnosis.

Classification (4 stages)

1. Stage I:

o Symptoms: Bright red bleeding during defecation, discomfort.

oOn anoscopy: Hemorrhoids visible but not prolapsed.

2.Stage II:

oSymptoms: Bleeding plus itching (pruritus).

oHemorrhoids prolapse during defecation but reduce spontaneously.

3.Stage III:

oSymptoms: Prolapsed hemorrhoids that require manual reduction after defecation.

4.Stage IV:

oSymptoms: Persistent prolapse, irreducible hemorrhoids, often with pain.

Clinical Presentation

Bright red bleeding during bowel movements is classic; blood loss can range from a few milliliters to 50-100 ml, potentially causing anemia.

Symptoms worsen with irritant foods.

Progression leads to hemorrhoid prolapse.

Consider secondary hemorrhoids from systemic conditions causing venous congestion:

o Portal hypertension (e.g., liver cirrhosis) o Cardiac or pulmonary diseases

o Retroperitoneal tumors

o Hypertension (morbus hypertonicus)

Diagnosis

Primarily clinical and straightforward.

Key steps:

o Inspection of anus during straining o Digital rectal examination

o Anoscopy and examination with rectal speculum

oMandatory: Proctosigmoidoscopy or sigmoidoscopy to exclude other pathologies

Differential diagnoses to rule out:

o Rectal cancer o Polyps

o Anal fissure

oParaproctitis

5.Treatment of hemorrhoids.

Conservative Treatment (Stages I and II)

Goal: Regulate defecation and stool consistency.

Measures:

o Diet rich in fiber (fruits, vegetables, dietary fiber supplements). o Adequate fluid intake (including juices).

oAvoid bowel irritants (spicy food, alcohol).

Medications: Phlebotropic agents (to improve venous tone and reduce symptoms).

Minimally Invasive Treatments (Early stages)

Effective in about 80% of cases if applied timely.

Common methods:

o Infrared photocoagulation

o Sclerotherapy (injection to shrink hemorrhoids) o Rubber band ligation (latex rings)

o Electrocoagulation

Surgical Treatment (Stages III and IV)

Milligan-Morgan hemorrhoidectomy: The gold standard surgery.

oExcision of external and internal hemorrhoids at classic positions (3,

7, 11 o’clock).

oVascular pedicles are ligated to prevent bleeding.

Modern techniques:

oUltrasonic scalpel

o LigaSure device

o Circular staplers for hemorrhoidectomy

o Ultrasound-guided ligation of vascular pedicles (experimental).

Postoperative and General Care

Hospital discharge usually by day 8–10 post-op, when bowel movements normalize.

Continued stool regulation and constipation prevention are essential.

Personal hygiene is critical to avoid complications.

Prognosis

Favorable overall.

Conservative + minimally invasive + surgical options achieve good results in approximately 89% of cases.

6.Complications of hemorrhoids.

1.Thrombophlebitis of Hemorrhoids

Definition: Inflammation with thrombosis of hemorrhoidal veins.

Clinical signs:

o Sudden, severe pain around hemorrhoids.

oHemorrhoids become hard, swollen, cyanotic, and very tender.

Treatment: Conservative (pain management, anti-inflammatory measures).