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Diagnosis
Diagnosis
29-year-old female who presents to the ED with left lower quadrant abdominal pain and diarrhea. A CT scan shows complicated diverticulitis with a 3.8 x 4.3-cm pelvic abscess.
Hinchey II Diverticulitis
Main blood supply of the appendix
(feeder artery needed as well)
Appendiceal artery (terminal branch of the ileocolic)
This bacteria is most commonly isolated in perforated appendicitis
E. coli
Common patient positioning for laparoscopic appendectomy
Trendelenburg and right side up
This is the safest intraoperative strategy for a patient undergoing emergent laparotomy due to diffuse peritonitis/hemodynamic instability from perforated diverticulitis
Abdominal washout, partial colectomy, and end colostomy creation I.e. Hartmann Procedure
63-year-old woman presenting to the ED with a 2-day history of left lower quadrant abdominal pain. White count of 11,800/µL and CT scan shows a 2-cm fluid collection adjacent to the distal sigmoid colon with rim-enhancement and pericolic stranding.
Hinchey I Diverticulitis
These are the layers of the colonic wall
Mucosa, submucosa, muscular layer, serosa
Sigmoid colon
Useful landmark used to identify the appendix with regards to the cecum
Convergence of the taeniae coli
These two commonly named incisions can be used in an open appendectomy
(Need name and description)
Rocky-Davis: transverse incision at McBurney's point
McBurney's incision: Oblique incision at McBurney's point
55-year-old man with history of multiple episodes of LLQ, now presenting with abdominal pain, fever, dysuria, and pneumaturia. UA with evidence of UTI
(Diagnosis and confirmation modality)
Colovesical fistula. Confirmed with a CTAP
"Classic" location of tenderness on exam for a patient with suspected appendicitis
McBurney's Point: 1/3 of the distance between the ASIS and umbilicus
Presence of Dunphy's sign can suggest this
34-year-old male with 4-days of persistent abdominal pain, nausea, and vomiting. Leukocytosis of 21K, BP 130/72, HR 92. PE with focal rebound tenderness in the RLQ and this on CTAP
Percutaneous drainage, IV abx, and bowel rest
47-year-old female undergoing chemotherapy for lymphoma presents with several days of RLQ. White count of 1.4 and a CTAP demonstrating fat stranding and wall thickening of the cecum and appendix
(Diagnosis and treatment)
Dx: Neutropenic enterocolitis (typhlitis)
Tx: Bowel rest and broad-spectrum antibiotics
Proximal anastomosis between the SMA and IMA
Meandering mesenteric artery
Severity of complicated diverticulitis can be described via this staging system
(Include stages)
I: Pericolic or mesenteric abscess/plegmon
II: Walled off pelvic/retroperitoneal abscess
III: Purulent peritonitis (does not communicate with bowel lumen
IV: Feculent peritonitis (free perforation)
Surgical management of Grade II mucinous adenocarcinoma confined to the base of the appendix
Right hemicolectomy with oncologic resection of the ileocolic mesentery
Typically recommended after an episode of complicated diverticulitis at this time interval
(Two answers)
Colonoscopy, 6 weeks
27-year-old female with a history of intermittent abdominal pain currently on steroid eye drops for some eye irritation now presenting with anorexia, diarrhea, and lower abdominal pain. Leukocytosis of 15 and CTAP with some periappendiceal stranding concerning for acute appendicitis. Taken to the operating for a laparoscopic appendectomy - appendix appears normal but the terminal ileum proximal to the base appears inflamed.
(Likely diagnosis and management)
Dx: Crohn's terminal ileitis
Tx: Proceed with appendectomy
Most common places to find the appendiceal tip
1. Right lower quadrant
2. Pelvis
3. Posterior to the cecum
Conversion rate from laparoscopic to open in the setting of diverticular disease
20%
Management of a 1.5cm well-differentiated appendiceal neuroendocrine neoplasm (NEN)
Appendectomy
You proceed with this during a planned laparoscopic appendectomy in which the appendix was found to be completely normal but this was noted to be projecting from the antimesenteric border of the ileum and appeared quite edematous and inflamed
1. Appendectomy
2. Segmental small bowel resection and primary anastomosis