Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
Ventral Hernia
JosephKuiper, DavidRobergeBouchard,
andPeterSantoro
80
Concept
The majority of questions will be related to either elective or
incarcerated management, typically in the form of an incisional hernia. Symptomatic ventral hernias should be
repaired in medically appropriate patients. A variety of
approaches exist to repair ventral hernias, including open
and minimally invasive techniques, and consideration should
be given to the risks and benets of each for the individual
patient.
Way Question May BeAsked?
A 62-year-old man presents to the ofce with a several-year
history of worsening bulging and discomfort at the site of a
surgical scar from a prior hand-assisted colectomy.
How toAnswer?
History
• Chronic cough, smoking, nutritional status
• Bowel function
• Change in size
• Spontaneous reducibility versus chronically incarcerated
state
• Surgical and medical history
• History of obstructions
• Prior attempted repairs, particularly if involving mesh
• Attempt to obtain previous operative reports, identify
techniques used in previous attempts at repair
J. Kuiper · D. R. Bouchard
General Surgery Residency, Christiana Care Hospital,
Newark, DE, USA
e-mail: joseph.kuiper@christianacare.org
P. Santoro (
General Surgery, Department of Surgery, Christiana Care Hospital,
Wilmington, DE, USA
e-mail: psantoro@christianacare.org
*)
History should also focus on symptoms, being sure to rule
out other possibilities:
• Abdominal wall tumors
• Small bowel obstruction
• Seromas
• Pancreatitis
• Gastritis
• Gallbladder disease
Physical Examination
• Check vital signs
• Size and reducibility of the hernia
• Overlying skin change
• Associated hernias in other common locations in the
abdominal wall (other incisions, inguinal, or umbilical)
• Surgical scars from previous surgerys
Diagnostic Tests
• The presence of a reducible bulge and a history of incision in the area are sufcient to diagnose a ventral incisional hernia.
• In the age of cross-sectional imaging, obtaining a CT scan
is helpful to aid in the diagnosis, particularly if any concern for obstruction, to characterize the size and contents
of the hernia, or in an obese patient, which could make the
diagnosis more challenging.
Treatment
• A symptomatic ventral hernia in a medically appropriate
patient should be xed in the elective setting, whereas
acutely incarcerated ventral hernias require urgent reduction of contents and repair.
• Preoperative workup and risk stratication should be
obtained as indicated based on medical comorbidities.
• Encouraging smoking cessation, advocating for weight
loss with a goal BMI of 35 or lower, and optimizing the
patient’s medical status (including glycemic control)
should be performed preoperatively (prehabilitation).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_80
261
262
J. Kuiper et al.
• Approach options differ based on surgeon preference,
surgeon training, and institutional availability but include
open, laparoscopic, robotic, and hybrid techniques.
• Hernia contents should be reduced, taking care to avoid
enterotomy during dissection.
• Defects 2 cm or larger should be repaired with mesh
whenever possible unless mesh placement is contraindicated due to contamination.
• Location of mesh placement is determined largely by the
hernia defects’ characteristics relative to abdominal wall
landmarks and include onlay, inlay, sublay, or underlay.
• Preperitoneal or retro-rectus mesh placements offers a
superior repair with lower rates of mesh complication but
only if the peritoneal lining and location of the hernia
allow for this approach.
• Complex and large defects may require more advanced
techniques, including component separations and abdominal wall reconstruction, as detailed in a separate portion
of this chapter.
• Intraperitoneal Onlay Mesh (IPOM) techniques can be
used if a patient’s abdominal wall is not amenable to preperitoneal or component separation-based repairs, or
based on the experience and/or preference of the
surgeon.
Common Curveballs
• Chronically incarcerated hernia: Can be managed less
urgently than acutely incarcerated or obstructed hernias
(which are emergencies).
• Friable peritoneal lining and multiple peritoneal tears
during dissection: IPOM repair.
• Strangulated bowel containing hernia: Should be dealt
with in an emergent fashion, and the placement of mesh
depends on bowel viability and the need for resection.
• Mesh infection or enterocutaneous stula postoperatively: Can require explantation of mesh once the stula is
controlled and EC stula takedown or conservative management depending on outputs.
• Complex, large, multiple, and loss of domain hernias:
Require more advanced techniques such as abdominal
wall reconstruction.
• Ventral hernia is a confounding feature in other oral board
scenarios that require abdominal operation.
Clean Kills
• Not ruling out other etiologies of pain.
• Not addressing an acutely incarcerated or strangulated
hernia.
• Not performing mesh repair in a large defect if
amenable.
• Placing a synthetic mesh in a grossly contaminated eld.
Bonus Points
Accurately discussing the type of mesh used for repair.
Summary
Ventral, incisional, epigastric, and umbilical hernias represent common general surgical pathologies. These hernias can be addressed operatively when symptomatic or
managed conservatively with a watchful waiting technique if asymptomatic. Diagnosis is largely clinical, but
cross-sectional imaging can aid in diagnosis and preoperative planning. Some hernias require complex repairs,
and even relatively small defects may necessitate mesh
repair. Open, laparoscopic, robotic, and even hybrid
approaches are available depending on surgeon preference, comfort, and experience.
Bibliography
Ayuso S, Elhage S, Colavita P, Heniford BT.In: Hawn M, Pryor A,
Hughes S, etal., editors. Operative techniques in surgery. 2nd ed.
Vol. 1. Lippincott Williams & Wilkins; 2022. p.208–16.
Hager M, Edgerton C, Hope WW.Primary uncomplicated ventral her-
nia repair: guidelines and practice patterns for routine hernia repairs.
Surg Clin N Am. 2023;103(5):901–15. https://doi.org/10.1016/j.
suc.2023.04.004.
Nguyen H, McDermott K.In: Cameron J, Cameron A, editors. Current
surgical therapy. 14th ed. Elsevier Health Sciences; 2023. p.671–8.
Siddiqui AA, Lyons NB, Anwoju O, et al. Mesh type with ventral
hernia repair: a systematic review and meta-analysis of randomized trials. J Surg Res. 2023;291:603–10. https://doi.org/10.1016/j.
jss.2023.07.003.
Stewart M, Poulose B.In: Dimick J, Upchurch G, Sonnenday C, Kao L,
editors. Clinical scenarios in surgery. 2nd ed. Lippincott Williams &
Wilkins; 2012. p.21–5.
Hiatal andParaesophageal Hernias
JosephMorales, AleyTohamy, andAmberBatool
81
Way Question May BeAsked?
A 62-year-old female with refractory GERD symptoms was
referred to your ofce after undergoing an EGD.At the time,
the endoscopist saw evidence of “sliding hernia” and
referred her for surgical evaluation. What are the next steps?
How toAnswer?
History
• Median age 65–75years old, 2:1 female predominance.
• Focus on symptoms and be sure to rule out other causes
– Most common: GERD and early satiety.
– Others: vague upper GI symptoms including abdomi-
nal pain, dysphagia, odynophagia, UGI bleeding,
shortness of breath, chest pain.
– Important: keep the differential broad as many diagno-
ses can present this way.
Physical Exam
• Vital signs
• HEENT if dysphagia
• Focused abdominal exam
• Peritoneal signs: can present with an acute abdomen in
the setting of gastric volvulus
Diagnosis
• Frequently found incidentally or in workup due to symp-
toms on studies including:
– Chest XR-look for a uid level behind the heart
shadow
J. Morales
TriHealth Good Samaritan Hospital, Cincinnati, OH, USA
A. Tohamy
Mercy Fitzgerald Hospital, Darby, PA, USA
e-mail: aley.tohamy@mercyhealth.org
A. Batool (
Department of Surgery, Crozer Health, Upland, PA, USA
e-mail: amber.batool@crozer.org
*)
– CT scan
– EGD—on retroexion, a portion of the stomach above
the diaphragm
Further Studies and Preoperative Workup
• Contrast esophagram.
• EGD (if not previously obtained: rule out other causes of
symptoms).
• Esophageal manometry: not required but often helpful if
fundoplication is to be performed.
• pH studies are classically ordered (sometimes as the
Bravo test in today’s world, but are not generally helpful.
Determine the Type of Hernia
• Type I: “sliding hernia”: GE junction is above the dia-
phragm with intact phrenoesophageal ligament—Makes
up 90–95% of hiatal hernias.
• Type II: GE junction in anatomic position but the portion
of stomach above GEJ.
• Type III: mixture of types I and II.
• Type IV: any other abdominal organ besides the stomach
is above the diaphragm.
Management Options
• Nonoperative:
– In general, patients who are asymptomatic can be
safely observed. Type II hernias are most susceptible
to gastric volvulus and can be considered for elective
repair although the annual probability of needing an
emergency operation is very low.
– Mild symptoms managed on acid suppressing medica-
tions (PPI or H2 blockers) without dysphagia, weight
loss, or pain.
– Patients who would otherwise not be surgical candi-
dates due to medical comorbidities.
• Elective Repair
– The concept for repairing hiatal and paraesophageal
hernias is symptom improvement, improved quality of
life, and prophylaxis to avoid complications (volvulus,
obstruction, bleeding).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_81
263
264
J. Morales et al.
– OPERATION: laparoscopic/robotic hiatal hernia
repair with fundoplication/gastropexy
Position: supine with footboard/lithotomy/split leg.
Dissection and reduction of the hernia sac: Reduce
the sac with gentle traction on the sac (not the stomach) to avoid serosal tears.
Open the gastrohepatic ligament to the Right crus
(beware of accessory L hepatic artery if present).
Identify the anterior and posterior Vagus nerves.
Dissect circumferentially from R crus anteriorly
toward the left crus and nishing with posterior
dissection.
Mobilize the stomach by taking down the short gastric arteries.
Mobilize the esophagus to obtain 3 cm of intraabdominal esophagus.
Close the hiatus posteriorly with pledgeted sutures
ensuring it is not too tight by using a 52 or 56F
bougie.
Fundoplication or gastropexy:
• Nissen fundoplication performs 360-degree
wrap and uses three sutures each 1cm apart.
• Toupet Fundoplication 240-degree repair with 3
sutures on each side for a total of 6.
– Consider laparotomy for large Type III or IV hernias or
reoperative elds.
– Thoracotomy: affords better esophageal mobilization
and performed based on surgeon preference.
• Emergency Repair
– Gastric volvulus
– Classically, Borchardt’s triad
Severe epigastric pain
Retching
Inability to pass nasogastric tube
– Orientation: organoaxial (long axis) and mesenteroax-
ial (short axis)
– If the patient is unstable
Reduce hernia and perform gastropexy.
– Emergency repair is associated with high morbidity
and mortality rates.
ever, no benet over time. Many recurrences are likely to
not be clinically signicant. Thus, mesh repair is NOT
necessary.
Complications
• Pneumothorax: In many instances, you can put a red
rubber catheter into the thoracic cavity to evacuate the
pneumothorax at the conclusion of the case and often do
not need a chest tube. If ongoing pneumothorax postoperatively, place a chest tube. Obtain a chest radiograph
postoperatively if a pneumothorax is suspected.
• Perforation: Repair in two layers: mucosal repair with
absorbable suture, muscularis layer with nonabsorbable
running suture. Leave drains in place.
Clean Kills
• Failure to take a detailed history/ruling out other causes of
symptoms.
• Failure to recognize and treat gastric volvulus.
• Not knowing the relevant anatomy in surgical repair.
Summary
Hiatal and paraesophageal hernias have a wide spectrum
of presentations. It is crucial to take a detailed history
and rule out other causes of symptoms. For diagnosis, a
contrast esophagram and an EGD should be performed.
If planning for operative repair, esophageal manometry
will guide your choice of antireux procedure.
Nonoperative management is a safe option for the asymptomatic patient or those with mild symptoms controlled
with medication. The operation of choice for elective surgical patients is laparoscopic paraesophageal hernia
repair with fundoplication or gastropexy. For large hernias or unstable patients, an open approach may be used.
Postoperative Management
• Many clinicians perform contrast esophagram on POD1
with gastrogran contrast.
• Continue full liquid diet or soft diet for 2 weeks
postoperatively.
Curveballs
• Short esophagus: Collis gastroplasty using 56F bougie
and stapler to obtain >3cm intra-abdominal esophagus.
• Mesh repair: Literature shows improved short-term
recurrence rates in the short term with mesh repair; how-
Bibliography
Beauchamp RD, etal. Gastroesophageal reux disease and hiatal her-
nias. In: Sabiston textbook of surgery: the biological basis of modern surgical practice. Philadelphia, PA: Elsevier Saunders; 2017.
p.1059–62.
Cameron JL, et al. Management of paraesophageal hernia repair. In:
Current surgical therapy. Philadelphia, PA: Elsevier; 2023. p.29–34.
Guidelines for the management of Hiatal hernia. SAGES; 2021
Oct 29. https://www.sages.org/publications/guidelines/
guidelines- for- the- management- of- hiatal- hernia/
Complex Abdominal Wall Reconstruction
FaizKhaja, ArielleBrackett, andPeterSantoro
82
Concept
The topic of complex abdominal wall reconstruction is vast
and ever-changing. There is a wide variety of pathology that
can be encountered, with importance placed on prior surgical
approaches that have been attempted. Be sure to understand
prior surgical history, pay close attention to preoperative
imaging, and understand abdominal wall anatomy when
describing repairs.
Way Question May BeAsked?
A 67-year-old gentleman presents to your ofce for evaluation of a bulge in the upper abdominal wall, with history of
multiple prior abdominal surgeries, including prior incisional hernia repair attempts. Prior operative reports and
CT scan imaging were reviewed, and the patient was found
to have large recurrent incisional hernia measuring 11cm in
maximal width. What do you do?
The case may also present as a complication of hernia
repair, including mesh infection or enterocutaneous stula.
How toAnswer?
History
• Past medical history
• Past surgical history including prior hernia repairs
• Change in hernia over time
• Weight changes, current BMI
F. Khaja · A. Brackett
General Surgery Residency, Christiana Care Hospital,
Newark, DE, USA
e-mail: Arielle.Brackett@christianacare.org
P. Santoro (
General Surgery, Department of Surgery, Christiana Care Hospital,
Wilmington, DE, USA
e-mail: psantoro@christianacare.org
*)
• Smoking
• Diabetes, current A1c level
• Activity level, lifestyle, career
• Plans for pregnancy
Physical Examination
• Abdominal scars
• Hernia defects and fascial edges, supine/standing/
valsalva
• Excess skin/soft tissue
• Any signs of abdominal wall infection or stula
• BMI
Diagnostic Tests
• Laboratory workup including CBC, BMP, and HbA1C
• CT scan imaging if no recent imaging is available
Surgical Treatment
• Patients should be optimized for elective surgical intervention, ideally with glycemic control represented by
hemoglobin A1C, smoking cessation for at least 1month
preoperatively, and BMI controlled to <35–40, depending
on the approach.
• In the patient with a complex abdominal surgical history
where minimally invasive access into the peritoneal cavity and the required adhesiolysis may prove to be difcult,
an open midline approach should be undertaken.
• Complete adhesiolysis is performed, taking care to avoid
serosal injuries and enterotomies to minimize chances of
contamination while maintaining an intact peritoneal
layer as able.
• Any former mesh material encountered along the abdominal wall should be explanted if necessary, however care
should be taken to avoid resection/debridement of the hernia sac in cases where difculty reapproximating midline
fascia may be encountered, and the hernia sac could be
utilized.
• The falciform ligament and the space of Retzius should be
dissected to allow for preperitoneal plane development.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_82
265
266
F. Khaja et al.
• Retrorectus dissection should begin just lateral to the
linea alba releasing the posterior rectus sheath along the
length of the muscle, continuing until the neurovascular
bundles are encountered laterally. Extreme care should be
taken to avoid injury to these structures.
• For posterior component separation (transversus abdominis release), the posterior lamella of the internal oblique
aponeurosis should be incised, and the underlying transversus abdominus muscle should be divided and released,
developing a pretransversalis plane. This should continue
superiorly curving medially and staying below the muscle
bers of the diaphragm, and the dissection then continues
inferiorly and transitions to the preperitoneal space of
Retzius below the arcuate line. This dissection can be carried out laterally and posteriorly as far as needed for
medialization of the linea alba.
• Closure of posterior rectus sheath and recreation of the
peritoneal visceral sac after closure of any defects.
• Placement of large macroporous polypropylene mesh in
the retromuscular space along with drains.
• Reapproximation of the linea alba and anterior rectus
sheath using absorbable suture.
• Closure of skin and subcutaneous tissues with resection
of soft tissue/scar as appropriate, placement of abdominal
binder.
Common Curveballs
require explantation of mesh, although often not an emergent procedure.
• Patient has development of enterocutaneous stula: may
require nutritional support, maturation of stula, and ultimately resection of bowel and abdominal wall if unresolved. There can be one or two stages, and the primary
goal is restoring GI continuity rather than the abdominal
wall.
• Patients may develop pulmonary complications, ranging
from atelectasis, pneumonia, aspiration to pulmonary
embolism.
• Patients may develop an increase in airway pressures
intraoperatively or have postoperative changes reective
of intra-abdominal hypertension, may require intubation,
supportive care, rarely decompression is required in the
setting of abdominal wall reconstruction-induced intraabdominal hypertension.
Clean Kills
• Combining ipsilateral anterior and posterior component
separation.
• Failure to preserve neurovascular bundles or violate semilunar line during dissection.
• Failure to close all holes in the peritoneum, allowing for
intraparietal herniation and or mesh complication.
• Intraoperative contamination (enterotomy): if minimal
contamination and well controlled may be able to continue with mesh placement, but otherwise, may require
primary closure or bridged closure with planned return
for denitive hernia repair in 6–12months.
• Failure to reapproximate midline fascia: continue release
and mobilization of aps laterally. Can bridge defects
with hernia sac, omentum, or mesh.
• Patient has a postoperative seroma/hematoma formation:
can often be observed and will resolve with time.
• Patient has a postoperative surgical site infection: managed with antibiotics and drainage, which may ultimately
Summary
Abdominal wall reconstruction is a technique that can be
useful when facing challenging ventral hernia cases as
well as other pathologies affecting the abdominal wall.
Focus should be placed on preoperative workup, surgical
history, and imaging, to allow for the optimization of an
elective approach to abdominal wall reconstruction. A
thorough understanding of the anatomy of the abdominal wall is key.
Part XII
Trauma and Critical Care
Abdominal Compartment Syndrome (ACS)
MeghanMaceyko andRaduAlexandruNedelcoviciu
83
Concept
Elevated IAP has a direct effect on nearly every body system
including the pulmonary, cardiovascular, renal, neurologic,
and gastrointestinal systems. Elevation of the diaphragm
results in abnormal pulmonary mechanics with increased
pulmonary airway pressure. Increased intra-abdominal pressure leads to compression of the inferior vena cava, decreased
preload, and subsequent decreased cardiac output. Direct tissue compression and obstruction of venous outow can lead
to abdominal organ and pulmonary dysfunction.
Manifestations of ACS include progressive abdominal distention, increased peak airway ventilatory pressures, oliguria, and intracranial hypertension.
The gold standard for measuring intra-abdominal pres-
sure is by monitoring bladder pressure, typically with a urinary catheter and pressure transducer.
Medical management of ACS includes catheter drainage
of abdominal uid/ascites, decompression of GI tract (nasogastric tube, rectal tube), and chemical paralysis. Checking
serial bladder pressures will determine if these measures are
effective. If no rapid or immediate improvement you should
move to prompt surgical decompressive laparotomy. You
will need to leave the abdomen open until the underlying
cause of ACS is mitigated.
Way Question May BeAsked?
You are called to see a 75-year-old male in the ICU who is
status post endovascular abdominal aortic repair for a ruptured AAA.The patient is now hypotensive with a decreasing
urine output. What do you want to do?
M. Maceyko (*) · R. A. Nedelcoviciu
Division of Acute Care Surgery, Thomas Jefferson University
Hospital, Philadelphia, PA, USA
e-mail: Meghan.Maceyko@jefferson.edu;
RaduAlexandru.Nedelcoviciu@jefferson.edu
An Alternate Presenting Scenario
You are called to see a patient because of high ventilatory
pressures.
In this instance, the examinee may be called upon to rule
out many causes (ARDS, pneumothorax, mucus plug) before
making the diagnosis of ACS.
How toAnswer?
• Oliguria workup: be sure to have a systematic approach
when faced with a patient with oliguria.
– Is it pre-renal?
Shock/hemorrhage/sepsis/long operation/
under-resuscitation.
Cardiogenic shock? Pump failure? Acute myocardial infarction/heart failure.
Vascular etiology? Embolism after suprarenal aortic clamp.
– Is it intrarenal?
Acute tubular necrosis from any hypotension
(perioperatively).
Nephrotoxic Medications.
– Is it post-renal/obstructive?
Ureteral occlusion/injury.
Urinary catheter kinked, clogged, clotted, etc.
• The following should be mentioned in your answer:
– Brief history and physical exam—although your
patient in the scenario will likely be ventilated and
sedated.
– Assess volume status (central venous pressure, Swan-
Ganz catheter, echocardiogram).
– Baseline renal function/trend in perioperative urine
output—is it acute onset oliguria?
– Perioperative events—did the patient receive large vol-
ume resuscitation/transfusions?
– Rule out other causes of hypotension—cardiogenic,
obstructive, or septic shock?
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_83
269
270
M. Maceyko and R. A. Nedelcoviciu
– Line placed in the operating room causing
pneumothorax?
– Review medication list for nephrotoxic agents.
– Is the urinary catheter patent?
• Briey mentioning the above will let the examiner know
you have a broad differential and are not blindly jumping
to “the obvious” diagnosis.
Diagnosis
• Diagnosis is made by conrming elevated IAP.Examinees
should have a very low threshold to check bladder pressure. Some suggest routine monitoring of IAP in all
patients in ICU with any organ dysfunction. The combination of low urine output, abnormal bladder pressure,
and increased peak pulmonary pressure on the ventilator
are highly suggestive of ACS.
Treatment
• Always start with the medical management but be prepared for abdominal surgical decompression.
• Non-surgical options include catheter drainage of abdominal uid/ascites, decompression of GI tract (nasogastric
tube, rectal tube), and paralysis.
• If no rapid or immediate improvement you should move
to prompt decompressive laparotomy.
• You will need to leave the abdomen open until the underlying etiology of ACS is resolved.
Common Curveballs
• Examiner tries to lead you away from uid resuscitation
by emphasizing the multiple liters of IVF already given
intraoperatively. (Remember insensible losses of up to
1L/h in the OR with abdomen open and/or preoperative
bowel prep put the patient behind from uid standpoint
before surgery).
• Patient has a history of renal insufciency, myocardial
infarction, or only has one kidney.
• Nothing you do will work (just testing your thinking—
make sure you follow labs.
• For electrolyte abnormalities, especially hyperkalemia,
change any medications that need renal dosing, and consider the need for dialysis).
• Not looking for other causes of renal failure (go through
the oliguria algorithm).
• Not assessing volume status (CVP or Swan-Ganz or
echocardiogram).
• Not ruling out a pneumothorax, MI, PE as a cause of
hypotension.
• Not ruling out PTX, mucus plug, endotracheal tube kink
as cause of high airway pressures.
• Not checking the urinary catheter (is it kinked?).
• Diurese with no objective assessment of volume status.
• Not reassessing the patient frequently (labs/physical
exam).
Bonus Points
Be able to describe the operative techniques to assist with
delayed primary closure of the open abdomen after decompressive laparotomy once the underlying etiology of ACS
has resolved. Options include primary fascial closure, bridging mesh, skin closure only or use of absorbable mesh with
negative pressure wound therapy until ready for skin
grafting.
Words ofWisdom
Have a low threshold for checking bladder pressures in
critically ill patients who exhibit signs of end organ damage after large volume resuscitation. However, be sure to
rule out other causes of renal failure, hypotension, and
elevated airway pressures before jumping to the obvious
diagnosis.
Bibliography
Łagosz P, etal. Elevated intra-abdominal pressure: a review of current
knowledge. World J Clin Cases. 2022;10(10):3005–13. https://doi.
org/10.12998/wjcc.v10.i10.3005.
Further Reading
Score. Available from: https://www.surgicalcore.org/modulecontent.
aspx?id=168371
Clean Kills
• Not ruling out compartment syndrome (check bladder
pressures).
Colon Trauma
LindsayWeil
84
Generally, colon injuries can be categorized as penetrating,
blunt, or iatrogenic injuries and treatment methods differ
depending on the mechanism of injury. Most traumatic colon
injuries result from penetrating trauma, and that is the likely
context in which examiners will ask these questions
• AAST Colon Injury Scale:
– Grade 1: Contusion or hematoma without devascular-
ization or partial thickness laceration with no
perforation.
– Grade 2: Laceration <50% of circumference.
– Grade 3: Laceration ≥50% of circumference without
transection.
– Grade 4: Transection of the colon.
– Grade 5: Transection of the colon with segmental tis-
sue loss or devascularized segment.
Management is based on the Grade of injury. Class I evidence for primary repair in all Grade I and II injuries. For
any trauma question, always start with the ABCs, and don’t
forget the secondary survey.
Way Question May BeAsked?
Example 1: A 32-year-old male is brought in by EMS after a
high-speed motor vehicle collision. On examination, he is
hemodynamically unstable and has signs of a seatbelt injury
with lower abdominal tenderness. What do you want to do
next?
Example 2: A 25-year-old male presents with multiple
gunshot wounds to the lower abdomen. He is hemodynamically stable upon arrival. What do you want to do next?
L. Weil (*)
Department of General Surgery, Thomas Jefferson University
Hospital, Philadelphia, PA, USA
How toAnswer?
• For trauma patients, always start with ABCs.
– Airway: Does the patient need to be intubated?
– Breathing: Does the patient need a chest tube?
– Circulation: Make sure the patient has two large-bore
IVs.
– Disability: What is the patient’s GCS and neuro
status?
• Do not skip the secondary survey.
• After primary and secondary surveys, determine if the
patient is stable enough for CT or if the patient is going
straight to the OR.
• Once in the OR, deal with bleeding rst. Evaluate and
control major vascular injury, solid organs, and mesenteric. Evaluation for a hollow viscus injury, including
colon injury, occurs last in the operative evaluation.
• Once colon injury has been established, one needs to
decide on operative management: primary repair, resection and primary anastomosis, resection and diversion, or
damage control procedure.
• Primary repair
– Indicated for injuries involving <50% of the bowel
lumen circumference.
– Must be sure that the surrounding tissue is viable.
– Patient must be stable.
– Can close in one or two layers.
• Resection and primary anastomosis:
– Indicated for injuries involving ≥50% of the bowel
lumen circumference or if there is a signicant mesenteric injury that would compromise a primary repair.
– Patient must be stable.
• Resection and end colostomy:
– Can consider for patients with signicant contamina-
tion, signicant blood loss, hemodynamic instability,
multiple concomitant injuries, or prolonged operative
time.
• Damage control procedure:
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_84
271