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0:00
Okay, so, welcome to General Surgery prep. My name is Mark Sowers, and today we're going to review some anatomy and some med term, and we're going to preview some of the terminology, and some of the procedures, that you're going to learn about during your General Surgery lecture. So, first, let's go over a little bit about what General Surgery is. Now, it used to be that General surgeons could do pretty much any kind of surgery.
0:23
But what's happened over the years is, that certain surgeons have sort of specialized in some surgeries, and they've gotten better at certain procedures. So, an Ortho surgeon is going to be doing things like total knee replacements and shoulder surgeries. Genito-urinary surgeons are going to be doing things like ureteral stents and things like that. Open heart would be done by a Cardiothoracic surgeon. Hysterectomies would be done by an Ob-Gyn surgeon.
0:49
All these specialties formed, and then anything that was, sort of, left over, is what was sort of left in General Surgery, all right? So, General Surgery, nowadays, is basically anything that doesn't fit neatly into any particular specialty, that's considered General Surgery. And about 70 percent of the surgeries that we discuss when we talk about general surgery are surgeries involving the abdominal area, mostly the digestive system.
1:18
Some hernias, the spleen is also considered General Surgery most of the time. But this can also include things like varicose veins, the thyroid, breast biopsies and lumpectomies, and the lymphatic system. So, again, it's sort of a weird mixture of anything that's left over, that didn't happen to end up in any of the several specialties that surgeons now specialize in. So, some terms for General Surgery that you're going to hear a lot in the clinical sites...
1:48
Directional terms... these are going to be important. So, you're familiar with sort of lateral and medial... that's important. 'Lateral' being sort of 'away from the body'. 'Medial' being more 'towards the center'. So, lateral being more towards the edge, medial more towards the center. Caudad and cephalad... So 'cephalad'... sort of think 'cephalo-' or 'cerebral'... the brain... that's towards the top of the body. 'Caudad' means kind of like a tail.
2:17
So, it's down towards the bottom of the body. So, directionally, upward would be cephalad, downward would be caudad. And then distal and proximal... think of an arm or a finger. The part that's closer to the body, that's going to be 'proximal'. The part that's further away from the body, here at the end of the finger, that's going to be the 'distal' end of the finger. Arms, legs, things like that, are going to have distal and proximal location. So, understanding those directions
2:46
is really important, because you're going to hear them a lot in the clinical sites. Doctors are going to say, "Hey, can you move this leg laterally?" You've got to know which way am I going to move this leg. Am I going to move it outward? or, am I going to move it towards the center? And that's going to be outward, if it's a lateral movement.
3:02
So, here's a big fun word that you're going to hear a lot: "Anastomosis" Now, an anastomosis... what this is, is essentially taking a tube... two tubes... and putting them together and sewing them together in such a way that the 'lumen'... the center of the tube... that stuff that's inside that tube... can flow from one to the other. That's an anastomosis: taking a tube and putting it together. And this you're going to see a lot in General Surgery, especially, say, colon resections,
3:31
In this case, let's say we have a tumor that we have to take out of part of the colon... part of the large intestine... and we're going to remove that. And then in order to get things to work again, we're going to sew the two ends of that together. And we're going to do that, sort of, around in a circle... around it... allowing a hole in between that's going to allow the stuff to flow from one tube into the next tube. That is an anastomosis. So that's an 'end-to-end anastomosis'.
3:58
You're taking two ends of the tube and putting them together. But sometimes you're going to have a tube that you're going to want to put the end into the side of a tube. And, in this case, this is done often in vascular surgery. So here we're going to cut a hole in the side of the tube... in the side of the artery... And we're going to attach another artery to it. That's going to take blood away, or add blood to this other tube. This is a 'side-to-end anastomosis'.
4:24
So, again, taking tubes... putting them together so this stuff can flow from one to the other... that is an anastomosis.
4:32
So '-ectomy', you're going to remember this from medical terminology, an -ectomy means you're removing something. You're surgically removing part or all of a certain organ. That may not be the whole thing, may just be part of it. But as long as you're taking something out of that organ, it's going to be considered an -ectomy. So, for example, a gastrectomy... you're going to be taking out gastro-, meaning stomach, okay? You're going to be taking out either part or all of the stomach.
5:00
Now '-ostomy' sort of sounds like '-ectomy', but it's a little bit different. An -ostomy is going to be cutting a hole, or creating an opening, in whatever it is you're doing the -ostomy on. So, creating an opening, or sometimes creating two openings and connecting them together, are called -ostomy. So, creating an opening is the general idea for an -ostomy. And I sort of remember this, because it's the letter 'o'... and it's sort
5:23
of a circle... it's got an opening in the middle of it... you're creating a hole, okay? That's an -ostomy. So, several of the -ostomies that you're going to see are going to be, say, the colostomy. That's going to be the colon. The urostomy: the ureters. And maybe a gastro-jejunostomy... there's a big fun word. In this case you're going to be taking a couple pieces of the digestive system, and putting them together. Creating an opening, and then putting them together.
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So, you can actually use this medical terminology to understand exactly what's going on in the procedure. So let me show you how this works. This is kind of cool, all right? So, take a look at this little diagram of a house. Let's say, okay, so you've got a couple of rooms along the side, and then down the middle you've got a hallway. So, when you're creating an opening between, let's say, a room and a hallway... what you're going to
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do is you're going to name the two things that you're creating the opening between. And then you're going to follow with the word or the term '-ostomy'. So, for example, in this case you're going to have a 'room-hall-ostomy'.
6:28
You're creating an opening between the room and the hall. So, say ‘room-hall-ostomy’. So, you can tell what you're creating the opening, and connecting the two things together are by looking at the word, all right? So, let's try another one... If we're going from one room to another room, or maybe we're going from one room to this different part of the same room, in this case we're going to have a 'room-room-ostomy'.
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We're going from one room to another room, and then an -ostomy means we're connecting them together, or creating an opening between those two.
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So, what happens in this case in this case? We have a room. And we're creating an opening that's going to the outside of the building... to and the outside. So essentially think of it this way... you're going out to... nothing. So, if you're going to nothing, there's not going to be a term. So, in this case we're just going to call this a 'room-ostomy'. Because we're going from a room to nothing, so there is no second term. And it's going to be followed by -ostomy.
7:27
So, a 'room-ostomy' goes from the room to the outside.
7:33
I'll give you some examples of what this would look like. So, here's again that list of terms i showed you before: Colostomy is going to go from the colon, there's no second term, so it's the colon to the outside. It's a Colostomy. Goes from the colon to the outside. And then you're going to... the patients with this will probably have a little bag, or something, that's going to catch the contents of the colon as they come out. Similar, a Urostomy is going to take the ureters
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through a little pouch, and that's going to go to the outside. So, a Urostomy is just one term, followed by -ostomy. So, it's going to the outside, because there is no second term. Now here's the fun one again. Gastro-jejunostomy Now, in this case, we do have the two terms. There we have gastro- and jejune-, okay? So, in this case gastro- means stomach Jejune- is part of the small intestine. So, we're gonna connect... we're going to create an opening... between
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the stomach and the small intestine... and that part of the small intestine. So, a gastro-jejunostomy is an opening between the stomach and that part of the small intestine. You have the two terms there. It tells you what you're creating an opening between.
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So, let's take a look at some of the pathophysiologies... the things that can go wrong... associated with general surgery. So, one of the things that can go wrong is, you can have a herniation. So, a herniation, or hernia, is when an organ, or a part of an organ, goes someplace that it doesn't really belong. Maybe they're supposed to be contained in one area, but it bulges, or squirts, out into an area where it doesn't belong.
9:08
Now, here, we show a herniation going through this little muscle wall, and it creates this little pouch, outside of where this is supposed to be contained. This, in this case it would be a really bad thing, because the contents of the bowel cannot flow through something like this, and maybe even the bowel gets strangulated a little bit... the blood flow gets cut off. So, a herniation such as this, is a bad idea.
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And because we don't want that to expand any further, we're going to go in there, intervene, do the surgical procedure to push that back into place, and to hold it back into place.
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Adhesions are something that happen often to internal organs, especially the bowel. So, you'll see this a lot in older patients, especially patients who have had previous surgeries on the intestines. Because, back in the day, there would be powder on the surgical gloves, and surgeons wouldn't wash that off. And what would happen is, the powder would get into the abdominal area, and it would cause abrasions on the intestines. And then those abrasions would sort of heal.
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But one intestine... part of the intestine... would be touching the other part of the intestine. And they would actually heal together. So, adhesions are scar tissue that, sort of, grows across, from one organ to the other. Or maybe from one part of the organ to the other. Maybe from an organ to the abdominal wall, where the scar tissue sort of attach. And now the organ that normally would flow around, and, sort of slide around,
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and be more comfortable that way, it can't do that anymore, because it's sort of stuck. And that makes for an uncomfortable situation for the patient. So often you'll go in there, and you'll break these adhesions. You'll cut these adhesions
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before you can actually perform the actual surgery that you're going to do. I was in one case where we spent over an hour just breaking and cutting the old adhesions around the small and large intestine, before we could actually get through and do the procedure that we're going to do. So, a 'volvulus' is a twisting of the bowel or the intestine somewhere. So, in this case, it sort of gets twisted around itself.
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This is a bad idea because it can cut off, again, circulation to that area and cause some problems. It could... if it stays there too long... it could cause death of that area. But also, because of that twisting, the contents of the bowel can't flow through there. So we have to go in there, and sort of untwist that, and open that up, and let the contents flow back through. And that is called a 'volvulus'. Okay, so one other term for you is an 'intussusception'. This is a fun term.
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And in this case, what you have is the bowel, or a tube, is sort of pushed in to itself. Sort of like, remember the old-time TV antennas, where you could push them down, and sort of stack inside of itself? That kind of thing? Well, this can happen to things like the intestine, the colon, inside the body where the tube, sort of, gets pushed into itself, and sort of loops around. Now the reason this is bad is because, it sort of squeezes the tube.
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That means contents of the tube have trouble getting through. It squeezes it down, and, as... the more it pushes and pushes... it actually causes this intussusception to get bigger and stronger, and sort of block that. So, think of it sort of like... Now, I've got my sock here as an example. And I've taken the sock, and I've sort of folded it into itself. So, you can sort of see here, the sock is sort of folded around and in itself. This is an intussusception.
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Now. all we have to do is reach... grab both ends... and pull it apart. That's it. So that's all we're doing when we're fixing an intussusception. We're just pulling it apart. The problem is, you can't really get to it and do that, unless you make an incision... unless you get inside the body... to reach in and grab both sides, and sort of pull it apart. So, to fix an intussusception, all you have to do is pull it apart, which is fairly easy. But it does require surgery to get in there.
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You'll see this sometimes in children. So, this is a cross section of the abdominal wall, from the inside to the outside. This outside layer, here, being the skin. And you're going to be asked about this often... the different layers that you're going to come to as you cut through the abdominal wall. Now the first layer that you're going to come to is going to be the skin, and that's this thin layer here. Underneath the skin, you have sort of a fatty layer.
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This is often referred to as sub-q or subcutaneous fat. That's kind of a fatty layer. It's very soft. Below that, is going to be a layer of 'fascia'. Fascia is very tough material. It's stuck together. Think of... if you're a carnivore... think of steak, okay? You have the fatty kind of edge of the steak. It's very soft. But then you have gristle, which is the real tough, chewy, part. It's hard to cut through. That's fascia, okay?
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That's real tough material in there that you have to... when doing the surgery... and you're going to work your way through... you've got to cut through this tougher material to get down deeper and deeper into the wound that you're creating. So below this particular layer of fascia, this one right under the sub-q, before you get to the muscles, this is known as 'Scarpa's Fascia'. Below that you have several muscle layers, as you go into the abdominal area.
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Below that you have another layer of fascia. This is the Transversalis Fascia. This fascia is right below the muscle layers. Below that you have another little layer of fat. And then you've got the 'Parietal Peritoneum'. Now the peritoneum, unlike the fascia, which is very tough to get through... peritoneum is very soft, and very thin. And what peritoneum is, it's a 'serous membrane'. It's a... it creates a lot of mucus. That's its purpose.
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And it makes the inside wall of the abdomen very slippery, okay? So, the surface of all the organs in your abdomen, and much of the body, are sort of covered with this serous membrane. They're sort of very slippery. And then, you want the wall of the abdomen to be very slippery as well, because all these organs are just going to slide around, and move around, as digestion happens... stuff moves through them... they're going to slip and slide all over the place.
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So, the parietal peritoneum creates that very slippery surface for these organs to slide across. So that's the order of layers that you're going to see: Skin, followed by a subcutaneous fatty layer, maybe the Scarpas fascia, some muscle, a transversalis fascia layer, a little bit of fat, and then the parietal peritoneum. The peritoneum being the bottom, or most innermost layer that you're going to come to.
15:40
Here we're looking at the abdominal area, and a couple of different muscles in the area. Notice that we have a couple of layers of muscles. We have the external obliques. Now 'oblique' means sort of an angle, or a diagonal. And you can see here they're moving... the lines sort of go at a diagonal here. The internal obliques, these lines go in at a diagonal as well. And then a little bit deeper, below that, we have the transversals, or transversus abdominis muscles.
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These... transverse means going across... so these lines... you can see the muscles are going across. These large white areas... now the muscles, say, for the external oblique... they end at some tendinous kind of material. That... this is the part of the muscle that doesn't really contract. It's just a tendon. It's just there to connect the muscle to whatever it's connecting to. And when you have a very wide flat tendon... the fancy term for this,
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like you have here... a wide flat tendon is called an 'aponeurosis'. This kind of sounds like a medical, you know, like a disease or something. It's really not. It's just the fancy name for a wide flat tendon. So, you see these wide flat tendons across the abdominal area, this is called an aponeurosis.
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Now the vertical muscles that you see here... this is the rectus abdominis muscle. And you can see this broken into little sections. This is where the six pack abs come from, when you see people who do a lot of bodybuilding, and that kind of thing. You're going to get a muscle... then you have this little tendinous area... then another muscle... and a little tendinous area. That's what creates those six-pack abs.
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Now, down the middle of the rectus abdominis... right down the middle of the body... you have this, again, this white area shown here. This tendinous area this is known as the 'linea alba'. You're going to hear about this a lot, because this is actually a good place to make incisions when we're getting into the abdomen. Why? Well, generally, we want to try to avoid cutting into muscle, if we can, because muscle is a little bit harder to heal. It's a little harder to suture together,
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and then have it stay together, because it keeps pulling, right? So, we cut into this tendinous material, if we can, because it's not it's pulling... but it's constantly kind of pulling... so we can suture that better It's a little bit tougher... we can suture that more easily, and it heals a little bit faster. So, the linea alba is a good place to make your midline incision, straight down the middle of the abdomen. And notice that the linea alba goes right through the 'belly button'.
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Sorry. That's the low-class term. The navel... wait, that's a middle-class term. The umbilicus! There's the high-class term for the belly button: the umbilicus. So, the umbilicus is located right in the middle of the linea alba.
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So, let's go over a little bit of the anatomy of the digestive system. The digestive system itself starts at the mouth, goes through the throat, or the high-class term for that is the pharynx. It goes down through the esophagus, into the stomach. Then from the stomach, the food goes into the small intestine, which is a very long tubular organ. Followed by the large intestine, which is a larger organ that goes around the abdomen.
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Eventually to the rectum, and then to the anus. So, let's break down some of those sections a little bit more closely. So, let's look at parts of the stomach first. Now, first we have the 'cardia', which is the part where the esophagus leads into the stomach. It's up there. It's called the 'cardia', I think, is because it's right next to the heart, so that kind of makes sense. Then this top bulge of the stomach... that's called the 'fundus'. The fundus is the top bulge.
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The body of the stomach, which is the larger portion of the stomach. And the body of the stomach has some curve. The stomach's sort of a weird-shaped organ. But it has this large outside curve, and the small inside curve. So, this is called the lesser curvature and the greater curvature. And those are the curvatures around the edges of the stomach, around the body of the stomach. Then down towards the bottom of the stomach, we have the pylorus area.
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And right at the very end, there's a pyloric sphincter. And in this area is where the stomach sort of squirts its contents... a little bit, one bit at a time... into the small intestine. So, there is a little sphincter here that squirts the contents into the small intestine. That's called the pyloric sphincter, leading from the stomach into the small intestine. The small intestine itself is divided into three sections: The first section, the smallest section, is called the 'duodenum'.
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That's shown in purple, here. Now, I pronounce it doo-odd'-en-um. You'll hear some people pronounce it duo-de'num. I pronounce it doo-odd'-en-um. So, the smallest section of the small intestine... the first section… is called the duodenum. Then it goes into a larger section, called the jejunum. And then finally, the third section of the small intestine, is the ilium. So, duodenum, jejunum, and ilium are the three parts of the small intestine.
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From the small intestine, the contents there go into the large intestine, and it starts down here, near the appendix. So, the very first part of the large intestine is actually this little tail sticking off here, called the appendix. Now what is... the appendix... well, I think of it this way... Remember during COVID, when a lot of people were making bread at home, because that was a thing to do... they could make bread?
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I don't know if you did it or not, but a lot of people were doing it. So, when you make bread, you need to add the ingredients, plus you need to add some yeast. And the yeast is what makes the bread rise. And different yeasts give different flavors to the bread. So, what will happen is, people will often take a little piece of yeast from a piece of bread that they made previously, store it, and save it. Because that's maybe some really good tasting yeast.
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And then when they put it into a new batch of bread. They'll mix it in the yeast... then grows and expands in there, adding that same flavor to this new batch of bread. Then they'll save this one, and continue on, and put it into the next batch of bread that they make. So, it's sort of a 'starter'. It makes... it gives it a little hint of flavor... especially sourdough bread is really good at this. So, you save this yeast, these microbes, this
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fungus, basically, that gives the bread a flavor... And you use it over and over to start the rising... to start the process of rising the bread, okay? So, I think of the appendix as working the same way. Not with yeast, so much, but with bacteria. And the main bacteria in the colon is going to be e-coli. So, the appendix, sort of, stores a little bit of bacteria... e-coli and a few other things... and it uses it as a 'starter'. So, as new material comes into the colon, the appendix,
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sort of, injects a little bit of new bacteria: it starts it. So, the bacteria can sort of grow and expand and do the things that the bacteria has to do in this large intestine. So, the appendix acts as a little starter area. Now, when you're making bread, you don't necessarily have to start with this very special yeast. Just any old yeast will do. You're still going to get bread out of it. But if you start with that special yeast, the bread is going to have a better flavor.
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But again, you're still going to get bread no matter what. So, the same thing is going to happen with the appendix. You don't necessarily need it. You're still going to get the digestion to happen in the large intestine that would otherwise happen. The appendix just makes it a little bit better, it makes it a little bit faster, it gives it a better 'taste'. Let's put it that way, all right? So, leading from the appendix, and leading from the ilium of the small intestine,
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both of these lead into the 'cecum', which is this very first bulge in the large intestine. The first bulge here is called the 'cecum'. And that's where this contents of the large intestine begin their journey. From there, they move up the large intestine. This is called the 'ascending colon'. It makes sense... you're ascending... you're going up this part of the colon. Then you go across. or transverse. So, this section of the colon is called the 'transverse colon'.
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Followed by going down, you're going through the 'descending colon'. Then you go through this little, sort of, s-shape in the colon, here, towards the end. This is called the 'sigmoid colon'. The s-shape... the sigmoid colon... that empties into the rectum, and then finally to the anus.
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Now, up here at the top of the colon, you have these two, kind of, sharp bends. These are kind of landmarks that... especially when you're doing a colonoscopy... you're sending the tube through there to look around... you're going to notice these landmarks. Now, these two landmarks are known as the 'hepatic flexure' and the 'splenic flexure'. And the reason they're called that... a flexure is a 'bending', okay? Anywhere that the colon sort of bends real sharply... that's a flexure.
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So, sort of like flexing your arm... think of it that way.
24:38
So, these are two flexures in the colon, the hepatic... hepatic is a fancy medical term for the liver. So, you know, that this flexure the hepatic flexure, is on the liver-side, or the right side of the body, okay? Also called the right-colic flexure, but usually the hepatic flexure. Now on the splenic, or the spleen-side of the body, okay? This flexure happens to be near the spleen. This is called the 'splenic flexure'. And that's where the colon bends to go downwards.
25:09
It's sharp bending, a sharp flexure, in the area of the spleen, so it's the 'splenic flexure'.
25:16
So, let's look at the rectum and the anus a little bit more closely, and there actually is a difference between the two. So, most people would think of the anus as the opening of the large intestine to the outside. But actually, the anus goes into the body, about an inch or two, before it turns into the rectum, all right? So, there's actually a little fold here... a little line called the 'anorectal line' that separates the rectum from the anus.
25:41
So that's a little landmark that differentiates between those two areas: the rectum above that, the anus below that is, again, only about an inch or two deep, and then it goes to the outside of the body. So that's the main tube of the digestive system, where food flows in from the mouth, all the way out to the anus. But beside, and going along with the digestive system, you have a couple of other very important organs. You have the liver, the gallbladder, and the pancreas.
26:08
Now, the pancreas is really important because of what it does. What the pancreas does is, it provides the juices... the enzymes... that help digestion happen.
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So, the pancreas itself is divided into a couple of sections, and these... they're not any real landmarks here... it's not real obvious... it's just sort of sections of the pancreas... You have the 'head' of the pancreas, which is the larger area, closer to the duodenum. You have the 'body' of the pancreas, sort of in the middle. And then the 'tail' where the pancreas gets a little bit thin. That's known as the tail of the pancreas. And through the pancreas, you have this
26:44
tube... the pancreatic duct... that runs down the pancreas. And that's how the pancreatic juices make their way into the duodenum.
26:54
So, the pancreas itself actually does a couple of different things. It's kind of a cool organ. It has 'endocrine' cells and it has 'exocrine' cells, and there's a difference. They're endocrine and exocrine. Now, I think of it this way... 'endocrine' cells create stuff that goes 'into' the body, and it's going to stay in the body. So endocrine... kind of 'endo'... kind of sounds like 'into'... So endocrine cells secrete stuff that goes into the body.
27:24
Now, a good example of this is something called the 'Eyelets of Langerhans'. Now, whenever you hear a big fancy term like, 'Eyelets of Langerhans', you know it's going to appear on a test somewhere, so make sure you know what this is. The 'Eyelets of Langerhans' are a little area of cells... of endocrine cells... that secrete and produce hormones. Specifically, the main hormone that they produce is insulin. So. insulin is important for controlling blood sugar in the body.
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So, the insulin goes from these cells, into the bloodstream. So, it's an endocrine system. It creates stuff that goes into the body. Now, if you don't have insulin... if your pancreas doesn't produce enough insulin... that creates a disease, and you've probably heard of this. It's called diabetes. Now. specifically. if your pancreas doesn't create enough insulin, that's diabetes type 1. Now, if your pancreas creates a whole lot of insulin, but your body has gotten so used to
28:22
that insulin that it just doesn't handle it anymore, that's known as diabetes type 2. And that's different. So, often, children will come in, they'll have a viral infection or something like that, the insulin isn't being produced in the pancreas. They'll have diabetes type 1. Usually older folks, larger folks, folks like me, for example, will often become diabetic. And that will be diabetes type 2, because their pancreas has been producing so much insulin,
28:48
for so long, that the body's sort of gotten used to it, and it's gotten immune to it, and the insulin just doesn't work anymore. And you're going to see that in older, larger patients especially. Again, endocrine cells produce stuff that goes into... endo... into the body. Exocrine cells produce stuff that will eventually exit the body... exocrine... *exit* the body. You can sort of remember it that way. Now, in this case, the exocrine cells are called Aciner cells,
29:15
and these are the cells that produce the pancreatic juices that help digestion. And these digestive enzymes will flow down through some ducts, eventually to the duodenum. And they'll exit into the duodenum through something called the 'Ampulla of Vater'. There's a big fun word! Again, when you have these big, fun terms, you know they're going to appear on a test somewhere. So 'Ampulla of Vater' is the duct where the pancreatic juices exit the pancreas, and go into the duodenum.
29:47
So, what are these pancreatic juices? What do they do? Well, think about the food that you eat. The food can sort of be described into three main categories known as macronutrients. We have carbohydrates, proteins, and fats; those are the three main types of things that you can eat. So, to digest carbohydrates, the pancreas produces amylase. To digest proteins, trypsin. And to digest fats, it produces lipase.
30:11
Now you don't need to necessarily know those fancy terms for all these enzymes that the pancreas produces. Just know that the pancreas produces these enzymes, and together they're sort of considered the pancreatic juices. And these pancreatic juices, these enzymes, are produced by Aciner cells. Those are the exocrine cells in the pancreas. Now, another organ that helps in digestion is the liver. The liver is, like, a really cool organ!
30:38
It does a whole lot of neat stuff, and I could talk about that for ages. I'm not going to bore you with that, but I am going to tell you the one thing that it does for digestion. And in this case, what it does is, it produces something called bile. So, right here you see the bile duct, and you see the gallbladder. Now, what the gallbladder... is another bladder. Yeah, your body has a couple of bladders in it.
30:59
It has, you know, your regular bladder that what you think of... that's the urinary bladder. It's a bladder that stores urine. Well, you also have a gallbladder. It stores bile, or 'gall'. 'Gall' is another name for bile. So, it's another little bladder, that sits right under the liver, and it stores the bile that the liver produces. So, what is bile? What does it do? Well, I think of it this way... Bile is essentially soap. It's soap. That's what it is.
31:27
The liver produces soap, that it's going to inject into the duodenum to help digestion. Now, why would you want soap in your small intestine? Well, think of it this way... You have lipase, remember lipase? That's one of the enzymes that the pancreas produces, and it helps digest fat. Well, fat... when you put fat together... it tends to sort of... clump together. Think of when you put some oil in a pot of water... The oil sort of bubbles up and it sort of forms together in this big glob
31:56
sitting at the top of the pot of the water.
31:59
What soap does is, it attaches to that oil, and breaks it up into smaller pieces. So that one large glob of fat, it breaks it up into smaller and smaller pieces. It's still fat, okay? But they're just smaller bubbles of it. And eventually, if you have enough soap in there, the water will sort of turn cloudy. But that big glob of fat will go away, because the soap has sort of broken it up into all these tiny little bubbles of oil. And that's what bile does in your small intestine...
32:27
It takes big globs of fat, and breaks it up into tiny little bubbles of fat. Now, the advantage to this is, if you have a big glob of fat, and you have the lipase trying to attack it... It's working its way in from the edges, and it takes forever... and it takes forever because it's trying to work its way into that big bubble, and it's going to take a long time, and you're never going to digest that whole big glob of fat.
32:48
But with soap... with bile... you break it down into little tiny pieces. And now the lipase can attack it from all these little angles, and it can dissolve that fat, and digest that fat very quickly.
33:00
So, now, let's take a look at some of the surgeries that fall under the "General Surgery" category that you might see during your clinical experience. Esophageal dilation Now in this case you have the esophagus of the patient, where you have sort of a narrowing. And whenever you have a narrowing of any tube... in this case the esophagus is a tube... whenever you have a little narrowing of that tube... that's known as a 'stricture'.
33:26
So 'stricture' is the big, fancy word for a narrowing of the tube. And sometimes patients will have this little narrowing in their esophagus, and food will have difficulty passing past the stricture, and moving on through. So, the patient has trouble eating. So, in order to help this situation, we're going to insert, down the esophagus, something called a 'Maloney Dilator'... actually a series of several of these... or another term for it is 'bougies'.
33:51
So, these bougies, or Maloney dilators, are going to be inserted through the esophagus, push through that stricture, and then, one after the other, each one's a little bit bigger than the next one... It's going to make that stricture... it's going to expand that structure a little bit more, and more, and more, as you insert the next, and the next, and the next dilator in there. And it will eventually stretch that stricture out enough,
34:13
that hopefully it's not going to collapse back on itself. It'll stay open. Food will be able to pass, and the patient's going to feel a lot better when they eat. So, the esophagus, then, enters the stomach but it does so... where it does so is... it passes through the diaphragm. The diaphragm, being the muscle across the top of the abdomen, that moves up and down as you breathe, all right? That's what helps you breathe... is that muscle moving up and down.
34:38
And in order to get from the thoracic area, down to the abdominal area, the esophagus has to pass through this diaphragm... through this muscle. And it at that point it enters the stomach. Well, sometimes that opening in that muscle... the opening in the diaphragm... can get a little bit large. And part of the stomach can actually bulge through into the thoracic area... into the area where your lungs and your heart are.
35:01
And that's a bad idea, partially because it's really uncomfortable, but also because the opening the diaphragm sort of creates a little sphincter at the end of the esophagus, and that holds all the stomach contents in the stomach. So, the stomach produces a whole lot of acid, and that sphincter sort of keeps that acid down, out of the esophagus. And the reason for that is, because, although the stomach is lined with this special lining,
35:28
it can stand that acid, the esophagus... not so much. So, if you get acid back into your esophagus, it's going to burn. It's going to hurt. And that's called heartburn, or GERD. GERD is the fancier term for a continuous sort of heartburn situation where acid from the stomach flows up into the esophagus. And one of the reasons... one of the things that can cause this... is something called a hiatal hernia.
35:52
Now, again, a hernia is when a part of an organ pushes through a wall, or somewhere, into a place that it doesn't belong. So, a hiatal hernia is where the top of the stomach pushes through the diaphragm, into an area... into the thoracic cavity where it doesn't really belong. Now you've got acid now, above the diaphragm, and there's not really much of a sphincter there. So, this acid very easily flows up into the esophagus... creates a lot of burns, and can cause a lot of problems.
36:21
So, we want to fix this situation. Now, the way we're going to do this is, first, we're going to push the stomach back down to where it belongs. And then we're going to do something called a 'Nissen Fundoplication'... there's a big fun word... a 'Nissen Fundoplication', all right? Now, here's the hint of what's going on. See fundo- or fund-? Remember the sections of the stomach? What's the fundus of the stomach?
36:47
Well, that's that top bulge... that top bulge that comes off the very top of the stomach. So, in a Nissen Fundoplication, what we're going to do is we're going to grab that top bulge... And we're going to loop it around, and then suture it to itself. So, we're just grabbing the fundus, the top of the stomach, looping it around, suturing it together, going around the esophagus, going around that area where the esophagus enters the stomach. Now, what does this do?
37:13
Well, it creates kind of a knot, okay? it creates this really tough knot, or bulge there, at the end of the esophagus. Now, hopefully, this knot is going to be bigger than the hole in the diaphragm. So, it's not going to fit through that diaphragm anymore. And it's going to keep the stomach down where it's supposed to be, in the abdominal cavity. So, that's the whole goal of a Nissen Fundoplication, to create this knot
37:39
at the very top of the stomach, to keep it from moving back up and preventing those hiatal hernias from happening. Now, a 'Nissen Fundoplication' is a little bit of an older procedure. You're seeing that less, and less nowadays. Nowadays there's newer ways of doing this. This would have to be done through incisions into the abdominal area. Nowadays, they're able to do that by sending a scope and a special probe down the throat.
38:03
It sort of reaches in through the esophagus... grabs the side of the stomach... and sort of pinches it together and creates a knot that way. So, you're not actually having to do incisions into the abdominal area, you can all do this through a scope going down through the esophagus. That's a little bit easier on the patient in many cases. But it creates the same idea. It creates this kind of bulge or knot at the very top of the stomach.
38:26
So, a gastrostomy is a procedure that you'll see often. A -ostomy, again remember, -ostomy has got that 'o', it's creating an opening, all right? So, what are we creating an opening between? Well, we have only one term: gastro-. Remember, if we had two terms, we'll be creating and opening between two things. We have only one term. That means we're creating an opening between the thing, and the outside of the body. So, in this case, gastrostomy... gastro-... meaning the stomach...
38:53
means we're creating an opening from the stomach to the outside of the body. See how you can break that term down and figure out what's going on? We're creating an opening from the stomach to the outside of the body. And what does this look like?
39:04
Well, in this case, we're going to create a little tube that's going to go through the skin, and into the stomach, creating this opening between the stomach and the outside of the body. This is a gastrostomy. And notice the tube has a little bubble here. That sort of keeps the tube from pulling back out. Now, one type of gastrostomy is known as a PEG Tube. Now, this is a particular way of doing a gastrostomy, and if you break the word
39:28
PEG... P-E-G... down, you see that it stands for Percutaneous Endoscopic Gastrostomy. That's a big fancy term. let's break it down a little bit. 'Percutaneous', that means you're going through the skin. 'Endoscopic', that means you're using an endoscope. You're going down through the esophagus and looking around from the the inside that way... And you're going to use that endoscope to sort of grab and guide the tube as it's guided into the stomach from the outside.
39:56
And then the 'gastrostomy', meaning you're creating that opening from the stomach to the outside. So, a Percutaneous Endoscopic Gastrostomy, or a PEG tube, is inserted into patient. And this also helps for feeding. So, if a patient needs a feeding tube, and for some reason you can't send it down through the esophagus, you can do a PEG tube, and that way you can feed material directly into the stomach.
40:20
Now, that's a little bit different from a gastr-ectomy. Now, again, -ectomy... what does that mean? That means the cutting out, or cutting away, of part or all of an organ. And, again, we're still have gastro-, so we're still talking about the stomach. So, we're going to be cutting away part or all of the stomach in a gastrectomy. So, let's take a look at a couple of different ways that we can do this, So, let's say there's a tumor that forms in the stomach... maybe down
40:45
towards the bottom of the stomach... down towards the pylorus area of the stomach... And we want to cut this section of the stomach away. So, when we do that, we're going to be left with the stomach and the duodenum, and we have to sew those together. So, for a gastrectomy, we're going to cut away... and then we're going to sew them together. So, we're creating an ostomy, as well. So, we're doing a gastro-duodenostomy, okay? So, we're sewing together the gastro-, the stomach,
41:10
and the duodenum, after we cut the section away. This is what it looks like at the end, where we attach the stomach... what's left of the stomach... to the beginning part of the duodenum. This surgery... instead of calling it a gastroduodenostomy, which is really what it is... that's the fancy term for it. Some surgeons will use a little bit shorter term. They call this a 'Billroth 1'. So, a Billroth 1 is just a little bit easier way of saying a gastroduodenostomy,
41:39
where you're attaching the stomach to the duodenum.
41:43
So, if there's a Billroth 1, you can assume that there is a Billroth 2, and you would be right. Now, in this case, we're taking away a little bit more of the stomach. So, we've cut the stomach down a little bit more. It's hard to see in this graphic, but we've taken a little more of the stomach away. And in this case, we've attached the stomach then to the jejunum. A little bit further down the duodenum, past the duodenum, to the jejunum itself. So, this would be a gastro-jejunostomy.
42:09
We're attaching the stomach to the jejunum. And in this case, we're going to call this a Billroth 2. So, you're probably wondering, why don't we just move the duodenum over, or just cut it off completely, and attach directly to the jejunum? Why do we have this little tail that we leave here in a Billroth 2? Well, again, think about what's in this area. Because the digestive system is not just the stomach and the intestines. It is all these extra organs that are around it.
42:38
And these extra organs, the pancreas, and the liver, and the gallbladder, feed into the duodenum. So, if you cut away the duodenum, and just take that away, Well, now all these juices from the pancreas, and all the bile from the liver, can't get into the digestive system to do the digesting that it needs to do. So, we have to leave this part of the duodenum here, to collect all those juices. Bring it down where it eventually meets the contents of the stomach.
43:06
And that's where the two come together, and the digestion begins down here, in the jejunum, as it continues on down.
43:14
So, then, there's a third type of gastrectomy. And in this case, we're going to take the entire stomach away. Now this one leaves something that looks like this. And, here, what we're going to do is, we're going to take the jejunum... stretch it all the way up, and connect it to the esophagus. We're going to do an anastomosis... again, connecting those tubes together, connecting the jejunum to the esophagus.
43:37
We've taken the stomach away completely, but we still left the duodenum, because the duodenum is going to attach to the liver and the pancreas... Bring those juices down, and eventually dump those juices into the jejunum, here. And that's where the digestion process can begin. So, I would have called this a Billroth 3, but they decided they didn't want to do it that way. They called this, instead, a 'Roux-en-Y'. That's the fancy term for this particular
44:03
procedure, where the entire stomach is taken away: Roux-en-Y. And notice the 'y'. Kind of looks like the intestines are left in sort of a 'y'-shape. You have to really use your imagination to see that, but it's there. So, a Roux-en-Y is taking the entire stomach out... pulling the jejunum up... and attaching it to the esophagus. Now this procedure is actually becoming more and more common, because a version of this procedure,
44:27
a version of the Roux-en-Y, is actually the number one treatment for obesity. It works better than any other treatment that we've developed so far, and essentially what you're doing is making the stomach smaller, or in this case removing the stomach completely. So that what happens here the patient ends up eating less food, because there's no stomach to, sort of, hold that. And the patient will feel full very quickly.
44:52
And, because, now the intestines are a little bit shorter... the food's going past the duodenum... it's not going through the duodenum... It's not getting absorbed as readily... the body's not taking in quite as many calories... so the patient actually ends up losing weight after a Roux-en-Y. Their diabetes goes away. It's really impressive the results that patients see by having their stomach removed, and having the food go directly from the esophagus, into the jejunum.
45:20
This would be known as a gastric-bypass. So, a gastric-bypass... certain types of gastric-bypass surgeries, are also a Roux-en-Y surgery.
45:31
Now another large, upper-abdominal surgery that you'll see… and this is a really major surgery... this is called a Whipple procedure. Now a Whipple procedure is done usually with patients that have pancreatic cancer. Pancreatic cancer is a nasty, nasty disease that can spread very quickly. It is a very deadly, serious disease, and we want to treat this as quickly as possible, and as thoroughly as possible. And because, for some reason, pancreatic cancer spreads
46:02
very easily, it spreads very quickly, we're not just going to remove the tumor, but we're going to remove everything, even sort of near this thing. We want to get it all out of there, to make sure that we get as much of that cancer cells out of there as we can. So, during a Whipple procedure, usually what you have is a tumor at the head of the pancreas, and we're going to remove the head of the pancreas. We want to leave as much of the tail of the pancreas as we can,
46:27
because we still want the insulin produced. We still want those digestive enzymes produced. So, we're going to leave as much of the pancreas as we can. If we're lucky enough, we'll be able to save a lot of that, all right? But we're going to remove, as well, the entire duodenum. We're going to move the common bile duct and the gallbladder. So, we want to get all of this stuff out of here, because it's very easy for that tumor to metastasize into these other areas.
46:53
So, we're just going to remove everything. This is a long procedure. There's a lot of attaching you have to redo. So, you're going to pull the jejunum back up... we're going to attach it to different places, and the end is going to look something like this. And, here, we've taken the jejunum... pulled it up... attached it to the tail of the pancreas. We've attached the bile duct to the jejunum, here. And then, we've attached the stomach down here, a little bit lower in the jejunum,
47:19
where it's going to feed into the small intestine. That's a Whipple procedure.
47:25
A little bit lower in the intestine... if we have to anastomose some area because we have a cancerous tumor in the area... We could do a Colon Resection. Now, in this case, if the colon resection that we're going to do... we're taking out a section of the colon... happens to be down near the rectum, we can use something called an EEA stapler. And this is kind of cool. What you do here is, you're going to cut out the section of the colon that has the tumor in it,
47:50
and now you have to anastomose... you have to reattach the tube so that stuff can flow through. So, you start at the proximal end... You're going to create what's called a 'purse string' suture. Now, purse string suture... It's not the suture itself; it's the way you do the suture. You're going to suture around the opening of a tube, and then this is called... sort of like... Think of your gym bag... where you have that string in the middle... and you take your gym bag...
48:17
You put your clothes in it. And then you, sort of, pull it. And you cinch it together. And it creates a nice, little, tight closing there. That's what a purse string suture is going to do. This method of suturing... you're going to suture all the way around... and then you're going to pull it tight... And it's going to close it off real tight. That's a purse string suture. So, to use an EEA stapler, we're going to take this little anvil... We're going to insert it to the upper part of the
48:39
colon... purse string suture around it, leaving this little tail, here. We're going to take the rest of our EEA stapler... Insert it through the rectum... Hook it through this little staple line that we have here... Connect the two pieces... And when we pull them together, it's going to do two things at once: One, is going to staple all the way around, and create a nice circle with those staples. And then, it's going to cut out the middle, in between those staples.
49:06
So, it's going to cut through the middle, create an opening between these two tubes, create an anastomosis, that's going to allow the contents of tube #1 to pass into tube #2, while sealing off all the edges around that.
49:21
So, an appendectomy is where we're gonna go in and remove an appendix. We don't necessarily need an appendix to live. It just sort of seeds the colon with a little bit of extra bacteria... helps digestion a little bit better. But we don't need it. Digestion will still happen without it. So, usually, when the appendix becomes inflamed... Maybe it gets a little bit of bacteria in there it shouldn't have... We're going to go in there, and we're just going to cut it out.
49:44
Because, if that thing bursts, that can be a real bad situation. So, we go in and we cut out... an inflamed appendix. The old way of doing it would be to, again, take that purse string suture where... because the appendix is a little tube, we're going to suture all the way around the appendix... And then we're going to pull that suture tight, making it seal it off right there. And then we can cut the appendix off. So, we would use a purse string suture.
50:08
The newer sort of modern way of doing this, is to do it laparoscopically. Which means we're going to make a little incision... Extend a linear stapler into the abdomen... Grab the appendix... very delicately, because the appendix is inflamed... we don't want to burst it. And then we're going to, sort of, pinch around the very end of the appendix. We're going to put staples across both sides, and then cut right down the middle, sealing off both ends.
50:34
So that we can then grab the appendix and remove it.
50:38
That's the more modern way of doing an appendectomy, nowadays.
50:43
A colostomy... which we mentioned at the beginning of this lecture... A colostomy... again -ostomy... creating an opening... There's only one term, so we're going from the colon to nothing... the colon to outside. Now, in this case, if we can't anastomose, if we can't put the colon back together after we take a certain section of it out for whatever reason... We can, sort of, invert the colon a little bit... take it out through the skin... invert it around the skin...
51:10
And create a little opening to the outside, so that the contents of the colon are now... instead of flowing all the way around like it would normally do, into the rectum... It's going to go flowing out through this little hole. And the patient is going to wear a colostomy bag to capture the contents of the colon.
51:27
A hemorrhoidectomy has the word -ectomy in it. So, what does -ectomy mean? That means 'removal of'. So, a hemorrhoidectomy is the removal of hemorrhoids.
51:38
So, what exactly are hemorrhoids? Well, hemorrhoids are basically varicose veins in the anus. Now what are varicose veins? So, let me sort of describe it this way... You have... they're blood vessels that swell up. Now, the reason for this is, maybe you have a massive constipation or something. Or just a lot of pressure of blood flowing into that area through the arteries. Now, the blood is at higher pressure in the arteries, okay?
52:03
But maybe you have a mass, or something, there that's blocking, and putting pressure on those blood vessels. So, veins, which have lower pressure, it can't quite push past that mass. So, you have arteries where the blood's flowing in... but veins where the blood's not quite flowing out the way it should. So, what happens is the vessels... the veins especially... they start to balloon up. They get bigger, and bigger, and bigger.
52:26
And they expand to the point where they cause pain, and they cause problems. And that is what a hemorrhoid is. And that's what varicose veins are, wherever varicose veins form anywhere else in the body. There is a blood vessel... a vein... that is expanded past its normal capacity.
52:43
So, to remove a hemorrhoid, one way of doing it is to use a rectal speculum, like this guy. I've sort of referred to this as the silver bullet.
52:52
But, basically, it's a rectal speculum. You insert it... remove the obturator... the obturator makes it go in nice and smoothly... You remove the obturator, and then you can, sort of, twist it around to get to that part of the rectum that... part of the anus where the hemorrhoid is. And you grab it, and then you'll cut it off, and then suture it back together. And then you move around to a different location... you'll grab that hemorrhoid... cut it off... and suture it together
53:16
So, that's, sort of, the direct way of doing a hemorrhoidectomy... of removing those hemorrhoids. But using sutures like this can cause some problems. They sort of pull against each other. They can become a little bit infected. So, there's a more modern way of doing it, and that's using the ligator. And what it's going to do is... it has these little rubber bands around it... And we'll grab the hemorrhoid, and put the rubber bands over the hemorrhoid,
53:41
and release the rubber bands at the top of the hemorrhoid, where it attaches to the anus. And that's going to strangulate, and cut off the blood flow, to that hemorrhoid. So, what will happen is, that will eventually heal over under those rubber bands. It'll seal off. And because the blood flow has been cut off, the hemorrhoids going to die, and will, in a week or so's time, fall away. So, there we... without doing actually any surgery... without doing any suturing...
54:08
we put these rubber bands on there. It seals it off in a couple of days or weeks. That's going to fall away, and sort of fix the problem with that hemorrhoid.
54:17
Now another way of doing it, if you have a lot of hemorrhoids going on, is, you can use, again, the EEA stapler... The End-to-End Anastomosis stapler. But you use this little cone kind-of-thing... a little speculum. You're going to insert the anvil into the anus... into the rectum... and attach the EEA stapler to it, together, pulling all of the hemorrhoids into this little cone. And then, when you close... when you staple it together...
54:44
it's going to cut away all the hemorrhoids at one time. It's going to staple all around them, so sealing those blood vessels so they don't bleed, and taking, and removing all the hemorrhoids through that cone.
54:57
Now, General Surgeons also work on the liver, oftentimes Now, to give a little anatomy of the liver... The liver is divided into two lobes: the right lobe a little larger, the left lobe a little bit smaller. And then, underneath the liver, is the gallbladder. This is what stores the bile as the liver produces it. The bile... the liver sort of produces a steady stream of bile. It's stored in the gallbladder until it's needed.
55:21
The liver itself is surrounded by something called the 'Glisson's Capsule'. And, again, there's one of those fancy terms. If you see a term like that, it's probably going to show up on a test somewhere. So the liver is surrounded by Glisson's Capsule. But, sometimes, we can get problems in our gallbladder. And what will happen is, we're creating bile... we're creating soap... but you know how soap will, sort of, dry on the end of a soap dispenser? It sort of gets hard?
55:48
Well, that can kind of happen inside the gallbladder as well. The soap can crystallize... it can form stones... inside the gallbladder... and we need to get those stones out of there. Because if they get... because they can cause inflammation. They can cause a lot of pain. And if they get too large, they can actually move down... blocking the common bile duct... which is a really bad situation... where nothing... where everything sort of backs up... and nothing can get through.
56:13
So, we're going to go in, and do a cholecystectomy. So, the -ectomy means we're removing the cholecyst. In this case 'chole' means bile, and 'cyst' means bladder. So, the bile-bladder, or the gallbladder, is what we're removing in a cholecystectomy. Now, here we have the gallbladder, sort of attached under the liver. Now, a couple of landmarks here... We have... feeding into the gallbladder... we have the 'cystic artery'.
56:39
And then we have the 'cystic duct', which feeds the bile out of the gallbladder, and into the common bile duct. And this, along with the hepatic duct, creates this triangle. You can see it here. This is known as the 'Triangle of Calot'. And, again, whenever you have a fancy term like that, you're probably going to see it on a test... The Triangle of Calot is an important landmark when it comes to removing the gallbladder.
57:05
And the way we remove the gallbladder, is by putting a couple of staples on these tubes. Again, one of the tubes is the cystic artery... We're going to staple that closed, so that the blood cannot flow into the gallbladder that we're about to remove. And we're going to staple the cystic duct, which is where the bile would flow out. But if we remove the gallbladder now, you're going to have bile flowing back in, through this tube, and we don't want that either.
57:29
So, we're going to staple that. At that point, we're going to remove the gallbladder. When we have a hernia, we have to repair that hernia, And, again, a hernia is when an organ bulges into an area that it doesn't belong. And sometimes that'll be through the skin, as shown here, where it, sort of, bulges through the muscle, and sort of pushes the skin out into this big bulge. And that'll, sort of, strangulate the intestine a little bit. So, we want to push that back in.
57:54
But, then, we want to seal it off, so this hernia doesn't happen again... so that the intestine doesn't bulge back out. And the way we're going to do that is, not just by suturing the muscle back together... Because sometimes that muscle will pull apart again... But we can also strengthen that muscle. Because sometimes the muscle will be a little bit thin, we can strengthen it by applying a layer of mesh. And that mesh is going to stay in there.
58:17
We're going to suture the mesh to the muscle wall, and that's going to hold... And it's going to strengthen that muscle, and prevent the organs from pushing back through there.
58:27
Now a couple of different ways... a couple of different methods of doing this you're going to hear... So, we have the 'TAP', which is the 'TransAbdominal Pre-peritoneal' method. And that's where the mesh is going to be placed under, or through, the peritoneum. It's going to go on the underside of the peritoneum... The peritoneum being that smooth layer that lines the abdominal wall... A 'TEP', or a 'Totally Extra-Peritoneal' mesh is slightly different.
58:53
Only that the mesh is placed *above* the peritoneum. So away from the organs a little bit. So, the organs still slide across the peritoneum. The mesh is then placed between the peritoneum and the muscle.
59:06
Hernias in the groin-area, especially in men, can come in a couple of different types. We have 'direct hernias' and 'indirect hernias'. Now, in this case, the hernia is the small intestine. Its pushing down towards the scrotum, and sometimes even into the scrotum area, and that can cause, obviously, a lot of pain. So, you think... "Okay, which one's which?" Well, normally we think a 'direct' hernia is going to go into the scrotum, but it's actually reversed.
59:32
And the reason for that is because of the landmarks that are used to describe what is a direct hernia and what is an indirect hernia. So, the landmark that we use, is something known as Hesselbach's Triangle. And, again, there's one of those words that you're going to see a lot in the test: Hesselbach's Triangle. And this triangle is formed by the rectus abdominis muscle, the inguinal ligament, and the inferior epigastric vessels. So, why is this important?
1:00:02
Well, this is what tells us what kind of hernia we have. If the hernia... if the small intestine... goes, again, where it's not supposed to... If it goes *through* this space, through this triangle, through Hesselbach's Triangle... That is known as a 'direct hernia'. If it goes anywhere *outside* of this triangle... Let's say, over the inferior epigastric muscles, or somewhere else. Maybe through the inguinal canal... Then it's going to be an 'indirect hernia'.
1:00:30
So, a direct hernia goes directly through Hesselbach's Triangle. That's where the definition comes from. So, in order to do the hernia repair, again, just like we did before with the abdomen... We're going to use a piece of mesh, and we're going to place the mesh over where the hernia happened... Pull the intestines back up to where they belong... put the mesh in place... staple it into place. And hopefully that mesh will be strong enough to keep that hernia from happening again.
1:00:57
This is a view of that region... the bottom of the pelvic cavity... you're inside the abdomen looking down, towards the feet of the patient. And, again, we can identify Hesselbach's Triangle, where we have the inguinal ligament, the inferior epigastric vessels, and the rectus abdominis muscle... This area right here ...Section B... is Hesselbach's Triangle. If the hernia goes through this area, that's going to be a direct hernia.
1:01:21
If, however, it goes through Area A, which is right here... which is where you can see the vas deferens here... That leads down to the scrotum... If the hernia goes through this area, that's going to be an indirect hernia. It goes directly to the scrotum, but it's an indirect hernia because it doesn't go through Hesselbach's Triangle. Now, a third location where a hernia could happen, is down here, where the iliac vessels lead into the leg. This would be known as a 'femoral hernia'.
1:01:49
And this can happen in both men and women. The hernia... the intestines... can sort of bulge down the leg a little ways. It causes a lot of pain. So. usually. when we do a hernia repair... Not only will repair wherever the hernia actually went... But we'll apply the mesh all across all three of these areas, to try to prevent any future hernias in that area. And then, one last surgery, not quite associated with the digestive system...
1:02:14
But one last surgery that I'll cover for General Surgery would be Thyroid Surgery. Now, the thyroid is a little, sort of, butterfly-shaped organ, that's a place just in front of the trachea, in the throat area. And the thyroid produces hormones. It produces thyroxine. And what that does, it helps to regulate metabolism. It increases and decreases metabolism throughout the body. So, the thyroid controls metabolism in that way... by producing thyroxine.
1:02:43
And sometimes you can get a tumor, or something like that, in the thyroid, and we need to remove it. On the back side of the thyroid, we actually have these four little nodules, called parathyroid glands. Now, parathyroids produce a different hormone called PTH (parathyroid hormone). And that helps regulate calcium levels in the blood. So, if we have to remove the thyroid, thyroxine is pretty easy to take,
1:03:08
and people can take thyroxine for the rest of their lives, and that happens very often. But we want to try to save the parathyroid... we want to save these four little nodules... we don't want to have the patient having to take additional hormones to regulate their calcium levels. So, a thyroid cancer can take a little bit longer because we want to try to save as many of these parathyroid glands as we can.
1:03:29
So, that's just a quick review of the anatomy, and a broad introduction to General Surgery. I hope you find this helpful, as your teacher describes more in depth the details of each of the surgeries that we've talked about today.
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