Absite Topic ReviewGeneral Surgery

Nir Hus, MD, PhD.

Mount Sinai Medical Center

Miami Beach

A 25 yo man comes to the office 3 months post an MVC w/ L chest pain. A CXR shows air-fluid levels in the chest. Yhe most appropriate next step in management is:

A. Exploration through the abdomen.

B. Exploration through the chest.

C. Chest tube

D. Percutaneous drain

Nir Hus

Diaphragm injuries

The acute management of a diaphragmatic injury is to go through the abd.

In Pt. w/ delayed presentation >1 week, go through the chest because the pt. will have adhesions which you must take down through a chest incision.

Nir Hus

Ureteral injuries

A 25 yo man sufferes a GSW to the lower abd. On exploration, the ureter above the pelvic brim is transected w/ a 1cm segment missing. The most appropriate management of this injury is:

B. Reimplantation into the bladder.C. Trans uretero-ureterostomyD. Reanastomosis.E. Percutaneous drainage.

Nir Hus

Ureteral injuries

A 25 yo man sufferes a GSW to the lower abd. On exploration, the ureter below the pelvic brim is transected w/ a 1cm segment missing. The most appropriate management of this injury is:

B. Reimplantation into the bladder.C. Trans uretero-ureterostomyD. Reanastomosis.E. Percutaneous drainage.

Nir Hus

Ureteral injuries

A 25 yo man sufferes a GSW to the lower abd. On exploration, the ureter above the pelvic brim is transected w/ a 2.5cm segment missing. The most appropriate management of this injury is:

B. Reimplantation into the bladder.C. Trans uretero-ureterostomyD. Reanastomosis.E. Percutaneous drainage.

Nir Hus

Ureteral injuries

Full transsection ureteral injuries can be divided into: high/middle injuries (above the pelvic brim).Lower injuries (below the pelvic brim).

Nir Hus

Ureteral injuriesBelow the pelvic brim

Complete transections below the pelvic brim are always treated w/ reimplantation into bladder.

This is because a cysto-ureteral anastomosis has a much higher success rate than a uretero-ureteral anastomosis, especially after trauma.

Nir Hus

Ureteral injuriesAbove the pelvic brim

Injuires above the pelvic brim (in the trauma setting) are handled in one of two ways. If there is just a short segment missing (<2cm) then

mobilize as much ureter as possible without devascularizing it and perform re-anastomosis.

Consider placing a stent in this situation.

If more than 2 cm are missing, place a percutaneous nephrostomy tube and tie off both ends of the ureter.

At a later date, a urologist can perform a uretro-ureter anastomosis or an ileal conduit.

Nir Hus