Surgical Obsession

The Detailing Heamorrhage

2021-07-10T00:12:00.000+06:00

Heamorrage may be defined as escape of blood from the vascular system.

· Classification of heamorrhage:

· According to vessel involved/source:

1.Arterial:Bright Red.Spurting due to increased pressure.

2.Venous:Dark red.welling up due to low pressure.

3.Capillary:Generalized oozing.

· Clinical /According to duration:

1.primary:Heamorrage occurring immediately due to injure or surgery.

2.Reactionarywithin 24 hours of (usually 6 hours),due to clot dislodgement,sliping of ligature,release of vasospasm ,rise of BP,straining ar extubation,coughing.Examples:after thyroiectomy,tonsillectomy,prostatectomy, heamorroidectomy.

3.Secondary :Within 7-14days after primary heamorrhage ,cause -infection ,pressure necrosis ,malignancy.

· According to exposure:

1.External:Bleeding that occurs during incision,massive heamatemeais from a duodenal ulcer.

2.Internal/concealed hge:E.g:Ruptured ectopic pregnancy, ruptured spleen ,intracranial, heamathorax.

· According to duration:

1.Acute:Stab injury.

2.Chronic:Hookworm infestation,hemorrhoids,menorrhagia,bleeding peptic ulcer.

Principles of treatment of heamorrhage:

Control of Bleeding:

1. Pack and pressure

2. Elevation

3. Clamp and cattery

4. Clamp and ligature.

5. Repair of blood vessel

6. Application of pharmaceutical agents. Such as adrenaline.Tranexamic acid.

7. Surgical /spongostan-helps in clotting

8. Bone wax:to stop bleeding from bones.

9. Tourniquet:to apply pressure proximal to the injury.

The pancreas

2021-06-23T15:21:00.001+06:00

The pancreas is an abdominal glandular organ with both digestive (exocrine) and hormonal (endocrine) functions.

In this article, we shall look at the anatomy of the pancreas – its structure, anatomical position and neurovascular supply.

Anatomical Position

The pancreas is an oblong-shaped organ positioned at the level of the transpyloric plane (L1). With the exception of the tail of the pancreas, it is a retroperitoneal organ, located deep within the upper abdomen in the epigastrium and left hypochondrium regions.

Within the abdomen, the pancreas has direct anatomical relations to several structures

Organs:

• Stomach – Separated from the pancreas by the lesser sac, the stomach and pylorus lie anterior and to the pancreas.

• Duodenum – The “C” shaped duodenum curves around and outlines the head of the pancreas. The first part of the duodenum lies anteriorly whereas the second part of the duodenum including the ampulla of Vater lies laterally to the right of the pancreatic head

• Transverse mesocolon – Attaches to the anterior surface of the pancreas

• Common bile duct – Descends behind the head of the pancreas before opening into the second part of the duodenum alongside the major pancreatic duct through the major duodenal papilla

• Spleen – located posteriorly and laterally. The lienorenal ligament is formed from peritoneum and connects the spleen to the tail of the pancreas.

Vessels

The pancreas lies near several major vessels and significant landmarks in vascular anatomy:

• The aorta and inferior vena cava pass posteriorly to the head of the pancreas.

• The superior mesenteric artery lies behind the neck of the pancreas and anterior to the uncinate process.

• Posterior to the neck of the pancreas, the splenic and superior mesenteric veins unite to form the hepatic portal vein.

• As it journeys from its origin at the celiac plexus to the splenic hilum, the splenic artery traverses the superior border of the pancreas.

Anatomical Structure

The pancreas is typically divided into five parts:

• Head – the widest part of the pancreas. It lies within the C-shaped curve created by the duodenum and is connected to it by connective tissue.

• Uncinate process – a projection arising from the lower part of the head and extending medially to lie beneath the body of the pancreas. It lies posterior to the superior mesenteric vessels.

• Neck – located between the head and the body of the pancreas. It overlies the superior mesenteric vessels which form a groove in its posterior aspect.

• Body – centrally located, crossing the midline of the human body to lie behind the stomach and to the left of the superior mesenteric vessels.

• Tail – the left end of the pancreas that lies within close proximity to the hilum of the spleen. It is contained within the splenorenal ligament with the splenic vessels. This is the only part of the pancreas that is intraperitoneal.

• The exocrine pancreas is classified as a lobulated, serous gland which produces digestive enzyme precursors. It is composed of approximately one million ‘berry-like’ clusters of cells called acini, connected by short intercalated ducts.

• The intercalated ducts unite with those draining adjacent lobules and drain into a network of intralobular collecting ducts, which in turn drain into the main pancreatic duct.

• The pancreatic duct runs the length of the pancreas and unites with the common bile duct, forming the hepatopancreatic ampulla of Vater. This structure then opens into the duodenum via the major duodenal papilla.

• Secretions into the duodenum are controlled by a muscular valve – the sphincter of Oddi. It surrounds the ampulla of Vater, acting as a valve.

• Vasculature

• The pancreas is supplied by the pancreatic branches of the splenic artery. The head is additionally supplied by the superior and inferior pancreaticoduodenal arteries which are branches of the gastroduodenal (from coeliac trunk) and superior mesenteric arteries, respectively.

• Venous drainage of the head of the pancreas is into the superior mesenteric branches of the hepatic portal vein. The pancreatic veins draining the rest of the pancreas do so via the splenic vein.

Lymphatics

The pancreas is drained by lymphatic vessels that follow the arterial supply. They empty into the pancreaticosplenal nodes and the pyloric nodes, which in turn drain into the superior mesenteric and coeliac lymph nodes.

Clinical Relevance: Pancreatitis

Pancreatitis refers to inflammation of the pancreas – this is can be acute or persist over an extended period (chronic pancreatitis). The causes of pancreatitis can be remembered using the mnemonic – GET SMASHED:

Gall stones

Ethanol

Trauma

Steroids

Mumps

Autoimmune

Scorpion stings

Hypertriglyceridemia, hypercalcaemia and hyperparathyroidism

ERCP – endoscopic retrograde cholangiopancreatography

Drugs – such as sodium valproate, azathioprine and sulphonamides

Pancreatitis creates severe epigastric pain which often radiates to the back, nausea, vomiting and diarrhoea.

Treatment involves supportive measures such as IV fluids and analgesia. Antibiotics are rarely required, as most cases are not due to infection. The underlying cause will then also need to be treated

The gall bladder and surgery

2021-06-22T20:15:00.000+06:00

The gallbladder is a gastrointestinal organ located within the right hypochondrial region of the abdomen. This intraperitoneal, pear-shaped sac lies within a fossa formed between the inferior aspects of the right and quadrate lobes of the liver.

The primary function of the gallbladder is to concentrate and store bile which is produced by the liver. As part of the gustatory response, the stored bile is then released from the gallbladder in response to cholecystokinin.

In this article, we shall look at the anatomy of the gallbladder – its structure, vasculature, innervation and lymphatic supply.

Anatomical Relations

The gallbladder is entirely surrounded by peritoneum, and is in direct relation to the visceral surface of the liver.

It lies in close proximity to the following structures:

Anteriorly and superiorly – inferior border of the liver and the anterior abdominal wall.
Posteriorly – transverse colon and the proximal duodenum.
Inferiorly – biliary tree and remaining parts of the duodenum.

Anatomical Structure

The gallbladder has a storage capacity of 30-50ml and, in life, lies anterior to the first part of the duodenum. It is typically divided into three parts:

Fundus – the rounded, distal portion of the gallbladder. It projects into the inferior surface of the liver in the mid-clavicular line.
Body – the largest part of the gallbladder. It lies adjacent to the posteroinferior aspect of the liver, transverse colon and superior part of the duodenum.
Neck – the gallbladder tapers to become continuous with the cystic duct, leading into the biliary tree.

The neck contains a mucosal fold, known as Hartmann’s Pouch. This is a common location for gallstones to become lodged, causing cholestasis.

The Biliary Tree:

The biliary tree is a series of gastrointestinal ducts allowing newly synthesised bile from the liver to be concentrated and stored in the gallbladder (prior to release into the duodenum).

Bile is initially secreted from hepatocytes and drains from both lobes of the liver via canaliculi, intralobular ducts and collecting ducts into the left and right hepatic ducts. These ducts amalgamate to form the common hepatic duct, which runs alongside the hepatic vein.

As the common hepatic duct descends, it is joined by the cystic duct – which allows bile to flow in and out of the gallbladder for storage and release. At this point, the common hepatic duct and cystic duct combine to form the common bile duct.

The common bile duct descends and passes posteriorly to the first part of the duodenum and head of the pancreas. Here, it is joined by the main pancreatic duct, forming the hepatopancreatic ampulla (commonly known as the ampulla of Vater) – which then empties into the duodenum via the major duodenal papilla. This papilla is regulated by a muscular valve, the sphincter of Oddi.

CLINICAL RELEVENCE OF GALL STONES:

Cholelithiasis, commonly known as gallstones, are small lumps of cholesterol, bile salts or a mixture of the two, which may form within the gallbladder. They are relatively common and often asymptomatic.

However, they may be associated with pain, jaundice and systemic upset (depending on the location of the gallstone, and the presence or absence of associated infection or inflammation).

Different terminologies are applied to distinguish between these pathologies:

Cholelithiasis – uncomplicated gallstones

Biliary colic – typically right upper quadrant pain following a fatty meal as gallstones obstruct the cystic duct during contraction of the gallbladder. Not associated with systemic upset

Cholecystitis – inflammation of the gallbladder. Pain is often associated with nausea, vomiting or fever

Choledocholithiasis – gallstone within the common bile duct. Often causes deranged liver function tests.

Cholangitis – infection of the common bile duct often secondary to choledocholithiasis. Typically presents with right upper quadrant pain, fever and jaundice (Charcot’s Triad)

Once diagnosed, most symptomatic patients have surgical removal of the gallbladder (cholecystectomy); which is now often performed via laparoscopic (key-hole) surgery during the acute phase or once recovery has taken place (often at 6 weeks). In the interim, patients are prescribed analgesia and antibiotics when required

CALOT'S TRIANGLE:

Calot’s triangle (cystohepatic triangle) is a small anatomical space in the abdomen.

It is located at the porta hepatis of the liver – where the hepatic ducts and neurovascular structures enter/exit the liver.

In this article, we shall look at the borders, contents and clinical relevance of Calot’s triangle.

Borders

Calot’s triangle is orientated so that its apex is directed at the liver. The borders are as follows:

Medial – common hepatic duct.
Inferior – cystic duct.
Superior – inferior surface of the liver.

The above differ from the original description of Calot’s triangle in 1891 – where the cystic artery is given as the superior border of the triangle. The modern definition gives a more consistent border (the cystic artery has considerable variation in its anatomical course and origin).

The contents of the Calot’s triangle include:

Right hepatic artery – formed by the bifurcation of the proper hepatic artery into right and left branches.
Cystic artery – typically arises from the right hepatic artery and traverses the triangle to supply the gall bladder.
Lymph node of Lund – the first lymph node of the gallbladder.
Lymphatics

Clinical Relevance: Calot’s Triangle in Laparoscopic Cholecystectomy

The triangle of Calot is of clinical importance during laparoscopic cholecystectomy (removal of the gall bladder).

In this procedure, the triangle is carefully dissected by the surgeon, and its contents and borders identified. This allows the surgeon to take into account any anatomical variation and permits safe ligation and division of the cystic duct and cystic artery. Of particular importance is the right hepatic artery – this must be identified by the surgeon prior to ligation of the cystic artery.

If Calot’s triangle cannot be delineated (such as in cases of severe inflammation), the surgeon may elect to perform a subtotal cholecystectomy, or convert to open surgery.

Appendix-its Overview

2021-05-20T23:33:00.004+06:00

Vermiform appendix is a vestigial organ which is tubular structure. It has irregular lumen and it is a lymphoid organ.

Length:7.5-10cm

Lining epithelium:columnar epithelium.

Different Anatomical positions of appendix:

· Retroceacal 74%

· Pelvic 21%

· Subcaecal 1.5%

· Paracaecal 2%

· Preileal 1%

Structure:

· Mucosa:simple columnar epithelium.

· Submucosa:aggregated lymphatic follicle.

· Muscular layer

· Serosa

· Mc burneys point:At the junction of the lateral 1/3^rd and medial 2/3^rd of a line joining the Right anterior superior Iliad spine and umbilicus.

Parts:Base,body,tip

Artery supply:Appendicular artery branch of lower division of ileo-colic artery.

Diseases:Appendicitis :Inflammation of the vermiform appendix.

1. Classification:

1. Acute appendicitis:

1.Acute obsobstructiv

2.Acute non obstructive

2. Recurrent appendicitis

Pathological classification:

3. Catarrhal

4. Supportive

5. Gangrene

Typical presentation of Acute appendicitis:

Symptoms:1.pain in the abdomen ,which is colicky in nature.initially around the umbilicus which later shifted to the Right Iliad fossa.

2.Anorexia,nausea

3.Vomi3.Vomi.Diarrhoea,frequency,dysuria in Pelvic variety.

Sign:

1. Mc burneys point tenderness:maximum tenderness in Mc burneys point.

2. Muscle guarding and rigidity over the point of maximum tenderness.

3. Rebound tenderness

4. Rovsign's sign positive.

5. Poas sign:positive in Retroceacal appendix.

6. Obturator sign:positive in Pelvic appendix.

Treatment:

· Appendisectomy as early as possibl

· Peri operative antibiotics

· If peritonitis is suspected,antibiotics in I/V route.

· If children with Pyrexia,antibiotics, IV fluid and salicylates.

Fluid Management during surgical procedure

2020-11-16T22:22:00.005+06:00

· preoperative fluid management:

Use Ringer's lactate or Hartmann's when a crystalloid is needed for resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.

· Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It should not be used in resuscitation or replacement fluids. Adult maintenance fluid requirements are Na 50-100 mmol/day and K 40-80 mmol/day in the 1.5-2.5L fluid per day.

· Patients for elective surgery should NOT be nil by mouth for >2 hours (unless has a disorder of gastric emptying).

· Patients for elective surgery should be given carbohydrate-rich drinks 2-3h before. Ideally, this should form part of a normal pre-op plan to facilitate recovery.

· Avoid mechanical bowel preparation:

• If bowel prep is used, simultaneous administration of Hartmann's or Ringer's lactate should be considered.

• Excessive fluid losses from vomiting should be treated with a crystalloid with potassium replacement. 0.9% of N.Saline should be given if there is hypochloraemia. Otherwise, Hartmann's or Ringer lactate should be given for diarrhea/ileostomy/ileus/obstruction. Hartmann's should also be given in sodium losses secondary to diuretics.

• High-risk patients should receive fluids and inotropes.

• An attempt should be made to detect pre or operative hypovolaemia using flow-based measurements. If this is not available, then clinical evaluation is needed i.e. JVP, pulse volume, etc. Blood loss or an infection causing hypovolaemia should be treated with a balanced crystalloid or colloid (or until blood available in blood loss). A critically ill patient is unable to excrete Na or H20 leading to a 5% risk of interstitial edema. Therefore 5% dextrose, as well as a colloid, should be given.

• If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes (NICE Guidance CG 174).

Intra-operative fluid management:

Recommendation:

The latest set of NICE guidelines produced in 2013 relating to intravenous fluids did not specifically address the requirements of intraoperative fluid administration. The reason for this is that administration of fluids in this specific situation does not lend itself to rigid algorithms. With the introduction of enhanced recovery programs 10 years ago there was an increasing emphasis on the concept of fluid restriction. Historically, patients received very large volumes of saline rich solutions peri-operatively. Clearing the sodium load of a single liter of saline may take up to 36 hours or more. This can have deleterious effects on the tissues including the development of edema. This results in poor perfusion, increased risk of ileus, and wound breakdown. A tailored approach to fluid administration is now practiced and far greater usage is made of cardiac output monitors in providing goal-directed fluid therapy.

Intra-operative fluid management:

Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -
Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28
Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -	Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -	0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -	Dextrose / saline 30.6 - 30.6 - -
Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28	Hartmann’s 130 4 110 - 28

Post-operative fluid management:

In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post-operative patients received enormous quantities of IV fluids. As a result, they developed hyperchloraemic acidosis. With a greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hartmans) is now favored over normal saline.

The other guidance includes:

• Fluids given should be documented clearly and easily available

• Assess the patient's fluid status when they leave the theatre

• If a patient is hemodynamically stable and euvolemic, aim to restart oral fluid intake as soon as possible

• Review patients whose urinary sodium is < 20

• If a patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored using urine Na excretion levels

• Solutions such as Dextran 70 should be used with caution in patients with sepsis as there is a risk of developing an

acute renal injury.

Surgical microbiology

2020-09-17T21:51:00.002+06:00

Staphylococcus aureus

• Facultative anaerobe

• Gram positive coccus

• Haemolysis on blood agar plates

• Catalase positive

• 20% population are long term carriers

• Exo and enterotoxin may result in toxic shock syndrome

and gastroenteritis respectively (enterotoxin is pre-formed → rapid onset of symptoms.)

• Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicillin.

• Resistance to methicillin (and other antibiotics) is mediated by the mec operon, essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues

• Common cause of cutaneous infections, abscesses, surgical site infections. Common cause of lactational mastitis

• Most common cause of septic arthritis.

Streptococcus pyogenes

• Gram positive, forms chain like colonies, Lancefield Group A Streptococcus

• Produces beta haemolysis on blood agar plates

• Rarely part of normal skin microflora

• Catalase negative

• Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction

• Releases superantigens such as pyogenic exotoxin A which results in scarlet fever

• Remains sensitive to penicillin, macrolides may be used as an alternative.

Helicobacter pylori

• Gram negative, helix shaped rod, microaerophilic

• Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria

• Flagellated and mobile

• Those carrying the cag A gene may cause ulcers

• It secretes urease that breaks down gastric urea → CO2 & NH3→ Ammonium → Bicarbonate (simplified!). The bicarbonate can neutralise the gastric acid.

• Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylori- these patients get gastric ulcers.

• Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive.

• In patients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma.

Actinomycosis spp

• Gram positive bacilli.

• Facultative anaerobes.

• May be difficult to culture. Direct visualisation of organisms and sulphur granules from lesions themselves is the easiest way to make a diagnosis.

• It remains a differential of conditions such as hydradenitis suppurativa, particularly if it is occurring in odd locations and with deeper abscesses than usual.

Skin malignancies

2020-09-14T22:34:00.001+06:00

Non melanoma skin cancer (BCC and SCC) are some of the commonest types of human malignancy. Up to 80% of these are BCC's with approximately 20% comprising SCC's. The incidence of NMSC's increases with age and whilst there is a female preponderance in those under 40 years of age, in later life the sex incidence is roughly equal.

The vast majority of NMSC's are related to UV light exposure. For SCC's the major pattern is chronic long term exposure.

For BCC's, the pattern of sporadic exposure with episodes of burning is more important. Organ transplant recipients have a markedly increased incidence of SCC, risk factors include length of immunosuppression, ethnic origin and associated sunlight exposure. Human papilloma virus DNA is found in the majority of transplant recipient SCC's. In addition to this increased risk, transplant recipients are also more likely to develop locoregional recurrences following treatment.

Actinic keratosis and SCC

Actinic keratosis is viewed as a premalignant lesion because there are atypical keratinocytes present in the epidermis. In a person with 7 actinic keratosis the risks of subsequent SCC is of the order of 10% at 10 years. The primary lesion is a rough erythematous papule with a white to yellow scale. Lesions are typically clustered at sites of chronic sun exposure.

Squamous cell carcinoma in situ

Also known as Bowens disease the commonest presentation of in situ SCC is with an erythematous scaling patch or elevated plaque arising on sun exposed skin in an elderly patient. Lesions may arise de novo or from pre-existing actinic keratosis.

Pathologically there is full thickness atypia of dermal keratinocytes over a broad zone. Nuclear pleomorphism, apoptosis and abnormal mitoses are all seen.

Invasive SCC

The commonest clinical presentation of SCC is with an erythematous keratotic papule or nodule on a background of sun exposure. Ulceration may occur and both exophytic and endophytic areas may be seen. Regional lymphadenopathy may be present.

Pathologically there is downward proliferation of malignant cells and invasion of the basement membrane. Poorly differentiated lesions may show perineural invasion and require immunohistochemistry with S100 to distinguish them from melanomas (which stain strongly positive with this marker).

various types of hernia

2020-09-13T17:09:00.002+06:00

Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias are covered under their designated titles the remainder are addressed here.

Spigelian hernia

• Interparietal hernia occurring at the level of the arcuate line

• Rare

• May lie beneath internal oblique muscle. Usually between internal and external oblique

• Equal sex distribution

• Position is lateral to rectus abdominis

• Both open and laparoscopic repair are possible, the former in cases of strangulation

Lumbar hernia

The lumbar triangle (through which these may occur) is bounded by:

Crest of ilium (inferiorly), External oblique (laterally), Latissimus dorsi (medially)

Primary lumbar herniae are rare, most are incisional hernias following renal surgery

Direct anatomical repair with or without mesh re-enforcement is the procedure of choice

Obturator hernia

• Herniation through the obturator canal

• Commoner in females

• Usually lies behind pectineus muscle

• Elective diagnosis is unusual most will present acutely with obstruction

• When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if

indicated)

Richters hernia

• Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within

a hernia (of any type)

• They do not present with typical features of intestinal obstruction as lumenal patency is preserved

• Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may

perforate)

Incisional hernia

• Occur through sites of surgical access into the abdominal cavity

• Most common following surgical wound infection

• To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length

4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge

• Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are

described

Bochdalek hernia

• Typically congenital diaphragmatic hernia

• 85% cases are located in the left hemi diaphragm

• Associated with lung hypoplasia on the affected side

• More common in males

• Associated with other birth defects

• May contain stomach

• May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory

compromise mechanical ventilation may be needed and mortality rate is high

Morgagni Hernia

• Rare type of diaphragmatic hernia (approx 2% cases)

• Herniation through foramen of Morgagni

• Usually located on the right and tend to be less symptomatic

• More advanced cases may contain transverse colon

• As defects are small pulmonary hypoplasia is less common

• Direct anatomical repair is performed

Umbilical hernia

• Hernia through weak umbilicus

• Usually presents in childhood

• Often symptomatic

• Equal sex incidence

• 95% will resolve by the age of 2 years

• Surgery performed after the third birthday

Paraumbilical hernia

• Usually a condition of adulthood

• Defect is in the linea alba

• More common in females

• Multiparity and obesity are risk factors

• Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel

resection is required owing to acute strangulation

suture materials

2020-09-13T17:05:00.003+06:00

Agent Classification Durability Uses Special points

Silk:

· Braided

· Biological

· Theoretically

· permanent

· although strength

· not preserved

· Anchoring devices, skin

· closure

· Knots easily, poor

· cosmesis

Catgut:

· Braided

· Biological

· 5-7 days Short term wound

· approximation

· Poor cosmesis

· Degrades rapidly

· Not available in UK

Chromic catgut:

· Braided

· Biological

· Up to 12 weeks Apposition of deeply sited

· tissues

· Unpredictable

· degradation pattern

· Not in use in UK

Polydioxanone

(PDS)

· Synthetic

· Monofilament

· Up to 3 months

· (longer with thicker

· sutures)

· Widespread surgical

· applications including visceral

· anastomoses, dermal closure,

· mass closure of abdominal

· wall*

· Used in most surgical

· specialties (avoid dyed

· form in dermal closure)

Polyglycolic acid

(Vicryl, Dexon)

· Braided

· Synthetic

· Up to 6 weeks Most tissues can be apposed

· using polyglycolic acid

· It has good handling

· properties, the dyed form

· of this suture should not

· be used for skin closure

Polypropylene

(Prolene)

· Synthetic

· Monofilament

· Permanent Widely used, agent of choice

· for vascular anastomoses

· Poor handling properties

· Polyester

(Ethibond)

· Synthetic

· Braided

· Permanent Its combination of

· permanency and braiding

· makes it useful for

· laparoscopic surgery

· It is more expensive and

· has considerable tissue

· drag

· *PDS or polydioxanone is the ideal suture material. Non absorbable sutures have higher incidence of incisional herniae.

· NB: Stainless steel clips for skin following thyroidectomy.

· NB: For closure of sternum following CABG, a stainless steel wire is typically used.

· Absorbable vs Non absorbable

• Time taken to degrade absorbable materials varies

• Usually by macrophages hydrolysing material

• Consider absorbable sutures in situations where long term tissue apposition is not required. In cardiac and

· vascular surgery non-absorbable sutures are usually used.

· Suture size

• The higher the index number the smaller the suture i.e.: 6/0 Prolene is finer than 2/0 Prolene.

• Finer sutures have less tensile strength. For example, 6/0 Prolene would not be a suture suitable for abdominal

· mass closure but would be ideal for small Prolene distal arterial anastomoses.

· Braided vs monofilament

· Generally speaking braided sutures have better handling characteristics than non-braided. However, they are associated

· with higher bacterial counts. Braided materials are unsuitable for use in vascular surgery as they are potentially

· thrombogenic.

Suture Sizes

USP Suture size and corresponding suture diameter

USP Size Diameter in mm

· 11-0 0.01

· 10-0 0.02

· 6-0 0.07

· 3-0 0.2

· 0 0.35

· 1 0.4

colorectal cancer:screening & diagnosis

2020-09-13T00:11:00.003+06:00

Overview

• Most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16%

• The NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 69 years. Patients aged over 70 years may request screening

• Eligible patients are sent faecal occult blood (FOB) tests through the post

• Patients with abnormal results are offered a colonoscopy

At colonoscopy, approximately:

• 5 out of 10 patients will have a normal exam

• 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential

• 1 out of 10 patients will be found to have cancer

Diagnosis

Essentially the following patients need referral:

• Altered bowel habit for more than six weeks

• New onset of rectal bleeding

• Symptoms of tenesmus

Colonoscopy is the gold standard, provided it is complete and good mucosal visualisation is achieved. Other options

include double contrast barium enema and CT colonography.

Staging

Once a malignant diagnosis is made patients with colonic cancer will be staged using chest / abdomen and pelvic CT.

Patients with rectal cancer will also undergo evaluation of the mesorectum with pelvic MRI scanning.

For examination purposes the Dukes and TNM systems are preferred.

Tumour markers

Carcinoembryonic antigen (CEA) is the main tumour marker in colorectal cancer. Not all tumours secrete this, and it may be raised in conditions such as IBD. However, absolute levels do correlate (roughly) with disease burden and it is once again being used routinely in follow up.

Dukes Classification

Gives the extent of spread of colorectal cancer

Dukes A Tumour confined to the bowel but not extending beyond it, without nodal metastasis (95%)

Dukes B Tumour invading bowel wall, but without nodal metastasis (75%)

Dukes C Lymph node metastases (50%)

Dukes D Distant metastases (6%) (25% if resectable)

Lung carcer

2020-09-13T00:01:00.003+06:00

Lung cancers may be classified according to histological subtypes. The main distinction is between small cell and non- small cell lung cancer. Non-small cell lung cancer is the most common variant and accounts for 80% of all lung cancers.

Non-small cell lung cancer

These share common features of prognosis and management. Paraneoplastic features and early disease dissemination are less likely than with small cell lung carcinoma. They comprise the following tumours:

• Adenocarcinoma (40% cases) most common lung

cancer type encountered in never smokers.

• Squamous cell carcinoma (25% cases) more slow

growing and are typically centrally located

• Large cell carcinoma (10% cases)

Small cell lung carcinoma

Small cell lung carcinomas are comprised of cells with a neuro endocrine differentiation. The neuroendocrine hormones may be released from these cells with a wide range of paraneoplastic associations. These tumours are strongly associated with smoking and will typically arise in the larger airways. They disseminate early in the course of the disease and although they are usually chemosensitive this seldom results in long lasting remissions.

Management of non small cell carcinoma:

Management

• Only 20% suitable for surgery

• Mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement

• Curative or palliative radiotherapy

• Poor response to chemotherapy

Surgery contraindications

• Assess general health

• Stage IIIb or IV (i.e. metastases present)

• FEV1 < 1.5 litres is considered a general cut-off point*

• Malignant pleural effusion

• Tumour near hilum

• Vocal cord paralysis

• SVC obstruction

infection in Surgeries

2020-09-11T22:29:00.004+06:00

Surgical site infections may occur following a breach in tissue surfaces and allow normal commensals and other

pathogens to initiate infection. They are a major cause of morbidity and mortality.

• Surgical site infections (SSI) comprise up to 20% of all healthcare associated infections and at least 5% of patients

undergoing surgery will develop an SSI as a result.

• In many cases the organisms are derived from the patient's own body.

• Measures that may increase the risk of SSI include:

o Shaving the wound using a razor (disposable clipper preferred)

o Using a non-iodine impregnated incise drape if one is deemed to be necessary

o Tissue hypoxia

o Delayed administration of prophylactic antibiotics in tourniquet surgery

Preoperatively

• Don't remove body hair routinely

• If hair needs removal, use electrical clippers with single use head (razors increase infection risk)

• Antibiotic prophylaxis if:

o Placement of prosthesis or valve

o Clean-contaminated surgery

o Contaminated surgery

• Use local formulary

• Aim to give single dose IV antibiotic on anaesthesia

• If a tourniquet is to be used, give prophylactic antibiotics earlier

Intraoperatively

• Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)

• Cover surgical site with dressing

• A recent meta-analysis has confirmed that administration of supplementary oxygen does not reduce the risk of

wound infection. In contrast to previous individual RCTs

• Wound edge protectors do not appear to confer benefit

Post operatively

Tissue viability advice for management of surgical wounds healing by secondary intention

Use of diathermy for skin incisions

In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials

have been undertaken and demonstrated no increase in risk of SSI when diathermy is used.

Gall stones

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Introduction

· Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The etiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East, a far higher proportion arises in the CBD de novo. The classical symptoms are of colicky right upper quadrant pain that occurs postprandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.

Investigation

· function tests Of In almost all suspected cases the standard diagnostic workup consists of abdominal ultrasound and liver patients who have stones within the bile duct, 60% will have at least one abnormal result on LFTs. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intraoperative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances preoperative MRCP is

Specific gallstone and gallbladder related disease

Disease Features Management

Biliary colic Colicky abdominal pain, worse postprandially,

worse after fatty foods

If imaging shows gallstones and history compatible

then laparoscopic cholecystectomy

Acute

cholecystitis

• Right upper quadrant pain

• Fever

• Murphys sign on examination

• Occasionally mildly deranged LFT's (especially

if Mirizzi syndrome)

Imaging (USS) and cholecystectomy (ideally within

48 hours of presentation) (2)

Gallbladder

abscess

• Usually prodromal illness and right upper

quadrant pain

• Swinging pyrexia

• Patient may be systemically unwell

• Generalised peritonism not present

Imaging with USS +/- CT Scanning

Ideally surgery, subtotal cholecystectomy maybe

needed if the Calots triangle is hostile

In unfit patients, percutaneous drainage maybe

considered

Cholangitis • Patient severely septic and unwell

• Jaundice

• Right upper quadrant pain

• Fluid resuscitation

• Broad-spectrum intravenous antibiotics• Correct any coagulopathy

• Early ERCP

Gallstone

ileus• Patients may have a history of previous

cholecystitis and known gallstones

• Small bowel obstruction (may be intermittent) Laparotomy and removal of a gallstone from small

bowel, the enterotomy must be made proximal to

the site of obstruction and not at the site of

obstruction. The fistula between the gallbladder

and duodenum should not be interfered with.

Acalculous

cholecystitis

• Patients with intercurrent illness (e.g.

diabetes, organ failure)

• Patient of systemically unwell

• Gallbladder inflammation in the absence of

stones

• High fever

If the patient fits then cholecystectomy, if unfit then

percutaneous cholecystostomy

Treatment

Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones, the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient, there is sometimes a role for selective use of ultrasound-guided cholecystostomy. During the procedure, some surgeons will routinely perform either intraoperative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by the use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where trans-cystic exploration fails the alternative strategy is that of formal choledocholithotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously.

Compartment syndrome as a complication of fracture

2020-09-10T23:17:00.000+06:00

Compartment syndrome:

This is a particular complication that may occur following fractures (or following ischemia reperfusion injury in vascular patients. It is characterized by raised pressure within a closed anatomical space.

• The raised pressure within the compartment will eventually compromise tissue perfusion resulting in necrosis. The two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries.

Symptoms and signs

• Pain, especially on movement (even passive)

• Parasthesiae

• Pallor may be present

• Arterial pulsation may still be felt as the necrosis occurs as a result of a microvascular compromise

• Paralysis of the muscle group may occur

Diagnosis

• Is made by measurement of intracompartmental pressure measurements. Pressures over 20mmHg are

abnormal and >40mmHg is diagnostic.

Treatment

• This is essentially prompt and extensive fasciotomies

• In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when

smaller incisions are performed

• Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients

require aggressive IV fluids

• Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to

be considered

• Death of muscle groups may occur within 4-6 hours

Emergency medicine in surgery

2020-09-10T00:03:00.002+06:00

Management of addisionian crisis

hydrocortisone 100mg IM or IV
• 1-liter normal saline infused over 30-60 min or with dextrose if hypoglycaemic
• Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol
exerts weak mineralocorticoid action
• Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

Management of anaphylactic shock

Remove allergen
• ABCD
• Drugs:
o Adrenaline 1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 min if no response.
o Then Chlorpheniramine 10mg IV
o Then Hydrocortisone 100-200mg IV

Management of Acute coronary syndrome

NICE produced guidelines in 2010 on the management of unstable angina and non-ST elevation myocardial infarction

(NSTEMI). They advocate managing patients based on the early risk assessment using a recognized scoring system such

as GRACE (Global Registry of Acute Cardiac Events) to calculate predicted 6-month mortality.

All patients should receive

• Aspirin 300mg

• Nitrates or morphine to relieve chest pain if required

Whilst, commonly, non-hypoxic patients receive oxygen therapy there is little evidence to support this approach.

The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic.

Antithrombin treatment. Low molecular weight heparin should be offered to patients who are not at a high risk of

bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a

patient’s creatinine is > 265 mmol/l unfractionated heparin should be given.

Clopidogrel 300mg should be given to patients with a predicted 6-month mortality of more than 1.5% of patients who

may undergo percutaneous coronary intervention within 24 hours of admission to the hospital. Clopidogrel should be

continued for 12 months.

Intravenous glycoprotein IIb/IIIa receptor antagonists(eptifibatide or tirofiban) should be given to patients who have an

intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are

scheduled to undergo angiography within 96 hours of hospital admission.

Coronary angiography should be considered within 96 hours of the first admission

to the hospital to patients who have predicted 6-month mortality above 3.0%. It should also be performed as soon as

possible in clinically unstable patients.

Ventricular Tachycardia: Management

Whilst a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, the European

Resuscitation Council advise that in a peri-arrest situation it is assumed to be ventricular in origin

If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min) then immediate

cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical

cardioversion may be needed with synchronised DC shocks

Drug therapy

• Amiodarone: ideally administered through a central line

• Lidocaine: use with caution in severe left ventricular impairment

• Procainamide

Verapamil should NOT be used in VT

If drug therapy fails

• Electrophysiological study (EPS)

• Implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired

LV function

investigations that are used in vascular surgery

2020-09-04T23:41:00.001+06:00

Venous Doppler
The simplest investigation for assessment of venous junctional incompetence is a Doppler assessment. This involves the
patient standing and manual compression of the limb distal to the junction of interest. Flow should normally occur in one
direction only. Where junctional incompetence is present reverse flow will occur and is relatively easy to identify.
Venograms and duplex scans
Structural venous information is historically obtained using a venogram. This is an invasive test and is rarely required in
modern clinical practice. The most helpful test is a venous duplex scan which will provide information relating to flow and
vessel characteristics. Duplex is also useful in providing vein maps for bypass surgery.
Arterial disease
Ankle-brachial pressure
The ankle-brachial pressure index measurement is an important investigation as it will allow the classification of the severity
of the flow compromise present. False readings may occur in those with calcified vessels such as diabetics and results in
such settings should be interpreted with caution. When auscultating the vessel note should be made of the character of
the signal. Monophasic signals are associated with proximal stenosis and reduction inflow. Triphasic signals provide
reassurance of a healthy vessel.
Arterial Duplex
As with the vein, the duplex scan can provide a substantial amount of information about arterial patency and flow
patterns. In skilled hands, they can provide insight as to the state of proximal vessels that are anatomically inaccessible to
duplex (e.g. Iliacs). Through assessment of distal flow patterns. It is an operator-dependent test.
An arterial duplex should be performed first, before progression to an angiography.
Conventional angiogram
Vessel puncture and catheter angiography is the gold standard method of assessing arteries. High-quality information can
usually be obtained. Limitations of the technique include the risk of contrast toxicity and risks of vessel damage. Severely
calcified vessels may be difficult to puncture and in this situation, a remote access site (e.g. brachial) may be used. This

technique is particularly useful in providing a distal arterial roadmap before femoro-distal bypass.
CT angiography
These tests provide a considerable amount of structural and flow information. They require contrast and thus carry the
risks associated with this. They are particularly useful in the setting of GI bleeding as they are rapidly available and can be
performed by a non-vascular radiologist. However, they lack the facility for endovascular intervention. In general, they do
not provide high enough resolution for distal arterial surgery.

Magnetic resonance angiography

This has the advantage of being non-invasive and not using nephrotoxic contrast. Movement artifact remains a problem
in some sites and distal arterial resolution is imperfect.

performing 9_ incisions during_ surgeries

2020-09-03T22:57:00.003+06:00

9_ incisions are performed during surgeries such as..

Midline incision
Paramedian incision
Kocher's
Lanz
gridiron
gable
Pfannenstiel's
McEvedy's
Rutherford Morrison etc

Surgical Obsession

The Detailing Heamorrhage

The pancreas

The gall bladder and surgery

Anatomical Relations

Anatomical Structure

The Biliary Tree:

Borders

Contents

Appendix-its Overview

Fluid Management during surgical procedure

Surgical microbiology

Skin malignancies

various types of hernia

suture materials

colorectal cancer:screening & diagnosis

Lung carcer

infection in Surgeries

Gall stones

Compartment syndrome as a complication of fracture

Emergency medicine in surgery

investigations that are used in vascular surgery

performing 9_ incisions during_ surgeries