General Surgery

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    • 1. Kocher
    • 2. Midline
    • 3. Muscle splitting (ureter)
    • 4. Pfannenstiel
    • 4. Thoraco-abdominal (oesophagectomy 9th or 10th ICS)
  1. 1?
    • 1. Paramedian
    • 2. Mc Burney
    • 3. Lanz
    • 4. Muscle-cutting transverse
    • 5. Rooftop
    • 6. McEvedy (femoral hernia)
    • 7. Inguinal hernia incision
  2. Suture classification, broadest & structure
    • Broadest:
    • - absorbable or non-absorbable
    • - natural or synthetic

    • Structure:
    • - monofilament, twisted or braided
  3. Monofilament sutures properties
    • -: quite slippery
    • +: minimize infection, produce less reaction
  4. Braided sutures + & -
    • +: secure knots (plaited strands)
    • -: infection to occur between strands
  5. Best size of sutures for skin closure
    3-0 or 4-0
  6. Timing of suture removal
    a. depends on?
    b. face and neck
    c. scalp and back of neck
    d. abdominal incisions and proximal limbs (including clips)
    e. distal extremities
    f. pt with poor wound healing
    • a. depends on site and general health of pt
    • b. face & neck: 5d (earlier in children)
    • c. scalp and back of neck: 5d
    • d. abdominal incisions and proximal limbs (including clips): 10d
    • e. distal extremities: 14d
    • f. pt with poor wound healing 14d
  7. Pt with poor wound healing
    steroids, malignancy, infection, cachexia, elderly, smokers
  8. 3 types of Surgical drains in the post-operative period
    to do what, e.g., drain what, removed when?
    • 1. in area of surgery, put under suction or -ve pressure
    • - protect against collection, haematoma and seroma formation (in breast surgery -> overlying skin necrosis)
    • - e.g. Redivac - high vacuum
    • - Removed when stop draining

    • 2. protect sites where leakage may occur
    • - e.g. bowel anatomoses
    • - These form a tract and are removed after ~1 week

    • 3. collect red blood cells from site of op -> autotransfused within 6h (protect fm hazards of allotransfusion, common in orthopedics)
    • e.g. Bellovac
  9. Meaning of 'shortening a drain'
    withdrawing it (eg by 2cm/d) to allow the tract to seal, bit by bit
  10. General principles of anaesthesia
    • Centre on triad of
    • hypnosis, analgesia, muscle relaxation
  11. Complications of anaesthesia are due to loss of:
    • 1. Pain sensation
    • 2. Consciousness
    • 3. Muscle power
  12. Complications of anaesthesia: 
    1. loss of pain sensation
    urinary retention, diathermy burns, pressure necrosis, local nerve injuries (e.g. radial nerve palsy from arm hanging over a table)
  13. Complications of anaesthesia: 
    2. loss of consciousness
    • retained consciousness
    • -> ill-defined, delayed neuroses, post traumatic stress disorder
  14. Complications of anaesthesia: 
    1. loss of muscle power
    • - corneal abrasion (-> so tape eye closed)
    • - no respiration, 
    • - no cough (pneumonia and atelecstasis partial lung collapse -> shunting and impaired gas exchange)
  15. Post-op complications
    divide up and for each: immediate, early and late

    1. From the anaesthetic: eg respiratory depression from induction agents.

    2. From surgery in general: eg wound infection, haemorrhage, neurovascular damage, dvt/pe.

    3. From the specific procedure: eg saphenous nerve damage in stripping of the long varicose vein.
  16. General post-op complications
    • - Pyrexia 
    • - Confusion
    • - Dyspnoea or hypoxia
    • - BP ↑ or ↓
    • - Urine output ↓ (oliguria)
    • - Nausea/vomitting
    • - ↓Na+
    • - Haemorrhage
    • - DVT
    • - Swollen legs: bilateral or unilateral
  17. General post-op complications (with details) - Pyrexia
    • - Pyrexia (from atelectasis (needs prompt physio, not antibiotics), tissue damage/necrosis or even from blood transfusions, but still have a low threshold for infection screen, also DVT)
  18. General post-op complications: confusion
    - Confusion (Common causes :• Hypoxia (pneumonia, atelectasis, lvf, pe)• Drugs (opiates, sedatives, and many others)• Urinary retention• MI or stroke• Infection (see above)• Alcohol withdrawal ([link])• Liver/renal failure)
  19. General post-op complications: dyspnoea or hypoxia
    • Any previous lung disease? Sit patient up and give O2, monitor peripheral O2 sats by pulse oximetry.
    • Examine for evidence of:
    • • Pneumonia, pulmonary collapse or aspiration
    • • lvf (MI; fluid overload)
    • • Pulmonary embolism
    • • Pneumothorax; due to cvp line, intercostal block or mechanical ventilation).
  20. General post-op complications: BP ↓
    • Check pulse and BP and compare w/ pre-op; 
    • - hypoV fm inadequate fluid input -> monitor urine output or CVP line;
    • haemorrhage -> review wounds and abdomen
    • - beware cardiogenic & neurogenic cause, MI, PE, sepsis, anaphylaxis
  21. General post-op complications: BP↑
    • pain, urinary retention, idiopathic hypertension (eg missed medication) or inotropic drugs.
    • Oral cardiac medications (including antihypertensives) should be continued throughout the perioperative period even if nbm)
  22. General post-op complications: Urine output decreases
    - Urine output ↓ (oliguria) 

    • - Aim for output of >30mL/h in adults (or >0.5mL/kg/h).
    • - Anuria often: blocked or malsited catheter, others: AKI, both ureter tied.
    • - Oligouria: too little fluid replacement
  23. General complications: nausea/vomitting
    Any mechanical obstruction, ileus, or emetic drugs (opiates, digoxin, anaesthetics)
  24. General complications: Na
    • - ↓Na+
    • compare w/ pre-op; over-administration of iv fluids may exacerbate the situation. Correct slowly. siadh can be precipitated by perioperative pain, nausea, and opioids as well as chest infection
  25. General complication: Haemorrhage
    - Haemorrhage (primary: cont bleeding, staring during surgery, reactive: secure until BP↑, 2dary: 1-2/52 post-op)
  26. General complications: DVT DDx
    - ΔΔ:Cellulitis; ruptured Baker’s cyst
  27. General complications: swollen legs bilateral
    + bilateral (systemic disease with ↑venous pressure (eg right heart failure) or ↓intravascular oncotic pressure (any cause of ↓albumin, so test the urine for protein). It is dependent (distributed by gravity). Causes: RHF, albumin↓, venous insufficiency: acute or chronic, vasodilators e.g. nifedipine, amlodipine, pelvic mass, pregnancy)
  28. General complications: unilateral swollen leg
    Pain ± redness implies dvt or inflammation, eg cellulitis or insect bites (any blisters?). Bone or muscle may be to blame, eg tumours; necrotizing fasciitis ; trauma (check for sensation, pulses and severe pain esp. on passive movement: acompartment syndrome with ischaemic necrosis needs prompt fasciotomy). Impaired mobility suggests trauma, arthritis, or a Baker’s cyst. Non-pitting oedema is oedema you cannot indent.
  29. Post-op: Looking for infection:
    • Surgery
    • - Wound infection
    • - Cannula site erythema
    • Tren xuong
    • Rarer
    • - Menigism
    • - Endocarditis
    • Common
    • - Chest infection
    • - Peritonisim
    • - UTI

Card Set Information

General Surgery
2015-02-02 16:57:50
Incisions, Sutures
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