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• Definition of ACS, IAH, and APP (APP = MAP - IAP; target >60 mmHg)
• Primary / Secondary / Recurrent classification
• All risk factors and causes
• Organ-by-organ pathophysiology table
• IAP measurement technique (trans-vesical bladder pressure)
• WSACS IAH grading (Grades I-IV)
• Full non-operative management strategy + indications for decompressive laparotomy

• Detailed organ-by-organ effects (Renal, CVS, Respiratory, GIT, CNS, Abdominal wall)
• Grading table (red color-coded)
• Step-by-step IAH management algorithm

• All 6 techniques: Bogota bag, Vac-Pac/OPSITE sandwich, NPWT/ABTHERA, Wittmann patch, mesh, towel clip
• Indications (ABCDE mnemonic)
• Principles and complications

• ICU resuscitation phase (correct lethal triad)
• NPWT as current gold standard
• Planned re-look protocol at 24-72 hours
• Bjorck classification
• Definitive closure goals and complications

• Pathognomonic sign: pink serosanguineous discharge day 5-8
• Risk factors (ABCDE mnemonic)
• Jenkins rule for prevention
• Surgical management: retention sutures over bolsters

• Condition-specific table (appendicitis, PU perforation, cholecystitis, adhesions, etc.)
• Contraindications, technique, limitations
• Graham patch repair, conversion philosophy

• Principles of ultrasound
• Condition-specific findings table (10 conditions)
• FAST scan 4 windows + E-FAST
• Limitations vs CT (gold standard)

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MS GENERAL SURGERY EXAM - ACUTE ABDOMEN & ACS

Bailey & Love 28th Edition | Questions 142–148 | 15 min each

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Q142. What is Abdominal Compartment Syndrome (ACS)? Pathophysiology, Evaluation & Non-operative Management

DEFINITIONS

• IAP (Intra-Abdominal Pressure): Normal = 0–5 mmHg; Critically ill = up to 7 mmHg
• IAH (Intra-Abdominal Hypertension): Sustained IAP >12 mmHg
• ACS: Sustained IAP >20 mmHg + new organ dysfunction/failure
• APP (Abdominal Perfusion Pressure): APP = MAP − IAP. Target APP >60 mmHg

CLASSIFICATION

• Primary ACS: Abdominal/pelvic pathology (trauma, pancreatitis, AAA rupture, post-op)
• Secondary ACS: Extra-abdominal (massive fluid resuscitation, burns, sepsis)
• Recurrent ACS: After surgical decompression

CAUSES / RISK FACTORS

• Increased intraluminal content: ileus, bowel obstruction
• Increased intra-abdominal collections: haemoperitoneum, ascites, packing
• Abdominal wall non-compliance: burns, tight closure after bowel oedema
• Massive fluid resuscitation (>10 L crystalloid), damage control surgery
• Pancreatitis, ruptured AAA, liver transplant, intra-abdominal sepsis

PATHOPHYSIOLOGY - ORGAN EFFECTS

IAH GRADING (WSACS)

• Grade I: 12–15 mmHg → Medical management
• Grade II: 16–20 mmHg → Aggressive medical management
• Grade III: 21–25 mmHg → Decompression if organ dysfunction
• Grade IV: >25 mmHg → Urgent decompressive laparotomy

DIAGNOSIS

• Gold standard: Trans-vesical (bladder) pressure measurement
• Patient supine, end-expiration, zeroed at mid-axillary line, 25 mL saline instilled
• IAP >20 mmHg + organ failure = ACS

NON-OPERATIVE MANAGEMENT

1. Nasogastric decompression, rectal enemas, neostigmine (colonic pseudo-obstruction)
2. Percutaneous drainage of ascites/haematoma
3. Neuromuscular blockade (reduces abdominal wall tension)
4. Head of bed <30 degrees
5. Diuretics/ultrafiltration if fluid overloaded
6. Vasopressors to maintain MAP and APP >60 mmHg
7. Avoid excess crystalloid resuscitation

Exam Tip: APP = MAP − IAP; target >60 mmHg. Bladder pressure = gold standard. Kidney = most sensitive organ. Know WSACS grades.

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Q143. ACS - Effects on Individual Organs, Grading, IAH Management Algorithm

IAH/ACS MANAGEMENT ALGORITHM

1. Measure IAP every 4 hours in at-risk ICU patients
2. If IAP >12 mmHg → Begin medical measures:
   • Evacuate intraluminal contents (NG tube, enema, colonoscopic decompression)
   • Drain intraperitoneal collections (ultrasound-guided)
   • Improve wall compliance (sedation, NMB, positioning)
   • Optimize fluids (avoid excess), diuretics/CVVH
3. If IAP >20 mmHg + organ failure despite above → Decompressive laparotomy
4. Post-decompression: plan delayed fascial closure (24–72 h), use Vac-Pac / NPWT / ABTHERA

Exam Tip: "Serial bladder pressure → stepwise non-op measures → decompressive laparotomy if failing."

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Q144. Temporary Closure of the Abdominal Cavity

INDICATIONS (ABCDE)

• A - ACS / prevention of ACS
• B - Bowel oedema (can't close without tension)
• C - Contamination (planned re-look for faecal peritonitis)
• D - Damage control surgery
• E - Enterocutaneous fistula / staged procedures

TECHNIQUES

• Rapid emergency use; fascia left open, skin clips only

• Sterile 3L IV bag or silastic sheet sutured to skin edges
• Simple, inexpensive, widely available

• Fenestrated plastic sheet over bowel (non-adherent layer)
• Surgical swabs as intermediate absorptive layer
• OPSITE® drape to skin creating watertight seal
• Suction drains collect fluid
• Creates airtight, watertight seal; easy to change

• Polyurethane foam in paracolic gutters
• Continuous negative pressure −75 to −125 mmHg
• Reduces fluid, maintains fascial domain, aids closure

• Velcro-like device sutured to fascial edges
• Progressive fascial approximation at each re-look

• Polyglycolic acid mesh sutured to fascia
• For when closure is impossible; allows eventual skin grafting

COMPLICATIONS

• Enterocutaneous fistula (most feared - 10–25%)
• Loss of abdominal domain → planned ventral hernia
• Wound infection, bowel desiccation
• Fluid and protein loss

Exam Tip: Know OPSITE/Vac-Pac technique in detail. NPWT = current preferred. Goal = fascial closure within 7 days. Fistula = most feared complication.

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Q145. Management of Patients with Open Abdomen (2015)

DEFINITION

BJORCK CLASSIFICATION

• 1A: Clean, no fixity | 1B: Contaminated, no fixity
• 2A: Developing fixity (clean) | 2B: Developing fixity (contaminated)
• 3: Enteroatmospheric fistula | 4: Frozen abdomen

PHASE 1 - ICU RESUSCITATION

• Correct lethal triad: hypothermia, coagulopathy, acidosis
• Target: Temp >36°C, pH >7.35, INR <1.5, lactate <2 mmol/L
• Damage control resuscitation: 1:1:1 (PRBC:FFP:Platelets), avoid crystalloid excess
• Vasopressors: MAP >65, APP >60 mmHg
• Lung-protective ventilation
• Nasojejunal enteral feeding if tolerated
• IAP monitoring every 4 hours
• NPWT dressing (ABTHERA preferred)

PHASE 2 - PLANNED RE-LOOK (24–72 hours)

• Peritoneal washout
• Reassess bowel viability; anastomosis if safe
• Progressive fascial closure attempt at each sitting
• Wittmann patch for serial closure

PHASE 3 - DEFINITIVE CLOSURE

• Primary fascial closure within 7 days (ideal)
• Component separation if needed
• If fails → skin graft over granulating bowel → delayed reconstruction

COMPLICATIONS

• Enteroatmospheric fistula (10–25%)
• Wound infection, bacteraemia
• Fluid/protein loss (>2 L/day replacement needed)
• Loss of abdominal domain, adhesions

Exam Tip: "DCR runs concurrently with DCS." Primary fascial closure within 7 days. NPWT = gold standard for temporary closure.

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Q146. Management of Burst Abdomen (2006)

DEFINITION

RISK FACTORS (ABCDE)

• A - Age (elderly), Albumin low (<30 g/L)
• B - BMI (obesity/cachexia), Bowel disease (IBD, malignancy)
• C - Corticosteroids, Chemotherapy, Coughing (raised IAP)
• D - Diabetes, Drug immunosuppression
• E - Emergency surgery, Extensive contamination, anaemia
• Technical: poor closure, haematoma, wound infection

PATHOGNOMONIC SIGN

PREVENTION

• Jenkins Rule: Suture length: wound length ratio >4:1
• Mass closure with No.1 loop PDS or nylon
• Retention sutures in high-risk patients
• Correct malnutrition pre-operatively

MANAGEMENT

• Reassure, lay supine
• Cover with warm moist sterile saline packs
• Do NOT reduce bowel at ward level
• IV access, fluid resuscitation, NBM, analgesia
• Broad-spectrum antibiotics
• Urgent return to operating theatre

• Examine bowel viability, reduce contents, peritoneal lavage
• Re-suture: mass closure with interrupted No.1 nylon
• Retention sutures through ALL layers, 2–3 cm from edge, 2–3 cm apart
• Tied over plastic/rubber bolsters (prevents cutting through)
• Leave in situ for 3 weeks
• If contaminated: leave skin open, delayed primary closure

COMPLICATIONS

• Incisional hernia (30–50%, most common late complication)
• Wound infection, sepsis
• Enterocutaneous fistula
• Recurrent dehiscence

Exam Tip: Pink discharge day 5–8 = pathognomonic. Jenkins rule ratio >4:1. Retention sutures over bolsters, remove at 3 weeks. Incisional hernia = most common sequel.

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Q147. Laparoscopic Management of Acute Abdomen (2010)

INTRODUCTION

ADVANTAGES

• Diagnostic accuracy (direct peritoneal visualization)
• Reduced wound complications, less SSI
• Faster recovery, shorter stay
• Less pain, reduced ileus, better cosmesis
• Avoids negative laparotomy

CONDITIONS & APPROACH

CONTRAINDICATIONS

• Haemodynamic instability → open laparotomy
• Gross bowel distension (perforation risk with trocar)
• Dense adhesions from prior surgery
• Inability to tolerate pneumoperitoneum
• Known intra-abdominal malignancy

TECHNIQUE

• Open (Hasson) entry preferred in acute abdomen
• CO₂ insufflation 12–15 mmHg
• Systematic inspection from RUQ → LUQ → pelvis
• Peritoneal lavage with warm saline for peritonitis
• Low conversion threshold - not a failure

Exam Tip: List 4–5 specific conditions. Graham patch for PU, 3-port appendicectomy, early lap cholecystectomy. Conversion is not a failure.

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Q148. USG Imaging - Principles and Role in Acute Abdomen

PRINCIPLES OF ULTRASOUND

• High-frequency sound waves (2–15 MHz) reflected from tissue interfaces
• Real-time, dynamic; Doppler for vascular assessment
• No ionising radiation - safe in pregnancy
• Excellent for fluid, gallstones, solid organ, vascular structures
• Limitations: obesity, bowel gas, operator-dependent

ROLE IN SPECIFIC CONDITIONS

FAST SCAN (Focused Assessment with Sonography in Trauma)

1. Subxiphoid (pericardial)
2. Right upper quadrant - Morison's pouch (hepatorenal)
3. Left upper quadrant - splenorenal recess
4. Suprapubic (Douglas pouch)

• Takes <3 minutes in A&E resus
• Positive = free fluid → guides laparotomy in unstable patients

LIMITATIONS

• Operator-dependent
• Bowel gas obscures retroperitoneum/pancreas
• Poor for mesenteric ischaemia, retroperitoneal injury
• CT is gold standard for most acute abdominal pathology

OTHER IMAGING

• Erect CXR / AXR: Free air under diaphragm (perforation), Rigler's sign, Sentinel loop
• CT abdomen/pelvis: Gold standard - highest sensitivity/specificity for most conditions
• MRI: Pregnancy, appendicitis (2nd line)
• CT angiography: Mesenteric ischaemia, GI bleeding

Exam Tip: FAST = 4 windows + E-FAST for thorax. USG is first-line, CT is gold standard. Always mention: no radiation, bedside, real-time Doppler as advantages; operator-dependent and bowel gas as limitations.

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