Absite Topic Review General 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: A. Reimplantation into the bladder. B. Trans uretero-ureterostomy C. Reanastomosis. D. 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: A. Reimplantation into the bladder. B. Trans uretero-ureterostomy C. Reanastomosis. D. 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: A. Reimplantation into the bladder. B. Trans uretero-ureterostomy C. Reanastomosis. D. 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 injuries Below 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 injuries Above 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