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General PrinciplesIncisions & ClosuresPurpose of incisionAccess Optimise healing Good cosmesis Additional considerations:Neurovascular structures below incision line which may be injured Previous wounds which may impede blood supply to wound (parallel linear wounds render separated tissue inschaemic) Relaxed skin tension lines Avoid multiple cuts into fat (risk of fat necrosis) ?Specific IncisionsTransverse: (1) muscle cutting (2) muscle splitting Midline: "incision of indecision" rapid access, minimal blood loss, easy closure Kochers McBurney/gridiron Lanz Rooftop Paramedian: take longer to form, close, higher risk of blood loss, low complication rate Suprainguinal (Rutherford-Morrison) Inguinal Pfannenstiel ?Principles of wound closureEdges should be in good apposition (with slight gaping to allow for swelling) Wound edges should be everted Minimal suture material should be used to secure wound Knots should be secure, to one side of wound and easy to remove Closure optionsHeal by primary intention Heal by secondary intention +/- VAC, large surface area wounds, large cavitating wounds Delayed primary closure Steri-strips Tissue glue Skin staples Sutures Subcuticular - good cosmesis, suitable for clean linear wounds Simple interrupted Vertical mattress Horizontal mattress Pre-operative preparationPre-InductionIdentify patient, operation, site, side, starved, allergies Check blood available Check investigations Check imaging? ?Removal of body hairRemove from operative field Allow for clear surface for application of dressings Perform on morning of surgery Care to avoid cuts/abrasions Skin preparationApply to operative field with wide margin (in case need to extend incision) Start at focus and move around Chlorhexidine (0.5%) Alcoholic betadine (1% povidine in 70% alcohol) Field DrapingSterile linen drapes Disposable fabrics (impermeable and waterproof), expensive Polyurethane incisible drapes (clear stuff) used in orthopaedics/vascular, general surgery - limited by cost Trauma / ATLSManagement of TraumaUrgent and competent assessment of traumaTreat life-threatening injuries firstImprove survival and outcome in "golden hour"Primary Survery Airway Breathing Circulation Disability Exposure, temperature control Monitoring ECG, Pulse oximetry, BP Urinary catheter (unless contraindicated) NGT Radiology CXR Lateral C-spine AP Pelvis AMPLE history -Allergies, Medications, Past medical history, Last meals, Events surrounding injury Secondary survey Full head-to-toe assessment Can be delayed until all life-threatening injuries have been dealth with Surgical EquipmentScalpel Blades10 - General use11 - Pointed, for arteriotomy15 - Smaller minor ops22 - Big mother23 - Curved?ScissorsMayo's: curved dissecting scissorsMcIndoePott's (for arteriotomy)Stitch cutter?ClipsMosquitoDunhillRoberts (big ones)Spencer-Wells ?ForcepsDeBakey'sMcIndoe'sBabcock's ?RetractorsWest self-retainingTraversNorfolk & Norwich - Big self-retainingLangenbeckDevers retractor Senn retractor (cat's paw)Hohmann's Breast & EndocrineAdrenalectomyIndicationsPhaeochromocytoma Adrenal carcinoma / adenoma Non functioning incidentaloma > 4cm in diameters (risk of malignancy) Failure of medical therapy Considerations (if for phaeochromocytoma)- Alpha blockade (doxazosin)- Beta blockade (atenolol)?Right adrenalectomySupine + GA + Prepare/drape Transverse supra-umbilical incision made with upward convexity Access adrenal gland Mobilise right colic flexure, retract downwards, retract liver upwards Incise posterior peritoneum above level of upper pole of right kidney Expose IVC, right adrenal gland Dissect / remove adrenal gland Separate from kidney and perinephric fat / fascia Dissect off IVC ligate vessels Dissect out Ensure haemostasis Close wound in layers Post-operative considerations30mg po hydrocortisone/day Fludrocortisone 0.1mg/day? Breast disordersDevelopment / anatomyModified sweat gland 2-6 ICS; sternum to AAL 2/3 on pectoralis major, 1/3 on serratus anterior (with axillary tail of spence) Condensation of fibrous tissue forms suspensory ligament of cooper (supportive framework) Blood supply Axillary artery (2nd part, lateral thoracic arter) Internal thoracic artery Intercostal arteries Nerve supply Intercostal nerves T4-T6 Lymph drainage Axillary nodes - 75% Level 1: lateral to pectoralis minor (14 nodes) Level 2: posterior to pectoralis minor (5 nodes) Level 3: Medial to pectoralis minor (2-3 nodes) Internal mammary - 25%[Anatomy of axilla] ??Congenital / Developmental disrodersAthelia / Polytheli: absence / many nipples Amastia: Absence of breast Polymastia: accessory breast Amazia: Absent of breast with nipple present = hypoplasia of breast (90% associated absent/hypoplastic pectoral muscles; ~Poland syndrome) GynaecomastiaAbnormal breast enlargement Female Male Physiological: neonatal, pubertal hormone imbalance Pathological: hypogonadism, neoplasms, drugs - cimetidine, spironalactone, ketoconazole, digitalis, oestrogens ?Aberrations of normal breast development and involution (ANDI)TumourPathology Features Management FibroadenomaAberation of development; 15-25 years Develops from single lobule of breast (rather than single cell) Hormone dependance (lactating during pregnancy, involuting in peri-menopausal period) Well circumscribed smooth firm lump May be multiple/bilateral FNA/Biopsy Mammography / ultrasonography Rx: Reassure / remove if large >2cm on request Phylloides TumourArise from peri-stromal tissue 40-50 years More common in African countries ?FNA / Biopsy Rx: Complete excision - risk of recurrence Cystic diseaseCommon 35-55 years Macrocysts ~7% women in West Unknown cause Discreet, smooth lump, may be fluctuant (like all cysts) Aspirate fluid Mammography if > 35years Rx: Excision biopsy Sclerosing leionsAberration of involution - sclerosing adenosis, papillomatosis, duct adenoma Radial scars present via screening Potential underlying breast cancer Mammography + excision biopsy Epithelial hyperplasiaEpithelial cell increase in terminal duct lobular unit Common pre-menopausal women If atypia plus hyperplasia increased risk of breast cancer Atypical ductal or lobular cells x4-5 greater risk of breast cancer breast lump FNA / NCB Rx: Excision biopsy + screening (increased risk of breast cancer) Breast pain / inflammatory lesions?PathologyFeatures Treatment MastalgiaCyclical Mastaliga Young women (Any age up to menopause) 3-7 days pre menstrual cycle Improves at menstruation Usually lateral part of breast affected ?Weight loss Supportive bra Evening primrose oil NSAIDs ?Non-Cyclical MastalgiaOlder women (45+) ?Supporting bra Weight loss Breast abscessLactatingMastitis neonatorum - first few weeks of life Infected enlarged breast bud Caused by s.aureus / e.coli ?Rx: Antibiotics / I&D ??Non-Lactating Peri-areolar Complication of periductal mastitis More common than lactating breast abscess 35yrs Peripheral Ass: DM, RA, Steroids, trauma Periductal mastitis Bacterial / cigarette smoking / AI basis ??Complications of AbscessDuct ectasia: dilatation without inflammation Duct fistula: - Nipple discharg Breast pain Retraction / inversion Antibiotics Aspiration I&DS ?Benign NeoplasmsDuct papillomaCommon Single / multiple Usually small, symptomless Bloody discharge if duct involvement Mammography, ductography Rx: Microdochectomy Lipoma Soft lobulated radiolucent lesion ???Nipple dischargeWhite = Milk: lactating breast (physiological / prolactinoma) Yellow = Exudate: abscess Green = Cellular debris: duct ectasia Red = Blood: ductal papilloma or carcinoma Determine whether single or multiduct (not usually pathological except in hormone producing endocrine tumours)MangementHaemo-stix Cytology Mammography / USS Ductography / ductoscopy (washings can be taken for cytology) ??Breast Cancer: Aetiology & Clinical featuresRisk factors: OESTROGEN EXPOSUREAge Early menarche, late menopause, nulliparity Diet / obesity (fat turned into oestrogens/phyto-oestrogens) Drugs: OCP, HRT Smoking Family history + Genetics: BrCa1 (17q), BrCa2(13q) Linear increase with age?Clinical featuresFrom the lesion Painless breast lump +/- lymph node involvment (I-III; relative to pec. minor) Hard lump with poorly defined margins Skin tethering or fixation to underlying structures Pain / skin ulceration "peau d'orange" - due to involvement of suspensory ligaments of cooper Nipple discharge / retraction Systemic features Weight loss Ascities Features of spread Bone pain / pathological fractures Paraneoplastic manifestations ?DiagnosisHistory (including risk factors) Examination - "Triple assessment" Investigations: Blood tests: Tumour markers Ca 15-3 (mucin marker) Imaging: Mammography, Ultrasound (if young pair of titties) Tissue diagnosis FNA / NCB - 95% pre-operative diagnostic sensitivityFNA CytologyNCB Histology C1 - InadequateC2 - BenignC3 - EquivocalC4 - SuspiciousC5 - Malignant H1 - NormalH2 - BenignH3 - EquivocalH4 - SuspicousH5 - MalignantExcision biopsy ?PathologyEpithelial cell origin Non-invasive DCIS - cured by total mastectomy LCIS Invasive Ductal carcinoma: 80-90% (NB Paget's disease of nipple = Ductal carcinoma involving epidermis; starts at nipple with some evidence of destruction) Lobular carcinoma: 1-10% Mucinous 5% Medullary 1-5% Metaplastic Connective tissue origin ?Prognostic indicatorsNode positive = <20% survival High Grade (1-well, 3-poor) Size Vascular invasion Oestrogen receptor: based on H (histochemical score) out of 300 H Score > 50: Receptor positive H Score < 50: Receptor negative ?Nottingham Prognostic Index (NPI) NPI = Size (in cm) x 0.2 + Grade (1 - 3) + Stage (Lymph node)NPI < 3.4 - excellent: 15y 90% survivalNPI > 5.4 - poor: 15 8% survival?Grading Bloom & Richardson grading systemBased on tubule formation, nuclear pleomorphism ("many different forms"), and mitotic activity Grade 1: Well differentiated Grade 2 Grade 3: Poorly differentiated ?Tissue Staging TNM system ?T - TumourN - Node M - Metastasis0Subclinical No nodesNo mets 1 <2cmIpsilateral axillary (mobile)Distant mets22-5Ipsilateral axillary (fixed)?3 >5Ipsilateral mammary ?4Any size with (a) chest wall or (b) skin extension ??Manchester system / Columbia system TNMManchester Columbia - T1- N0-N1Stage 1 Confined to breast < 5cm With or without skin involvement Stage AT2N1bStage 2 Confined to breast <5cm Nodes involved but not fixed Stage BT3-T4N2-N3Stage 3 Locally advanced disease >5cm Affects underlying muscle/overlying skin or fixed lymph nodes Stage CM1Stage 4 Distant metastatic disease (lung, liver, brain, bone) Stage DManagmentDiagnose Triple assessment: high positive predicitive value and prevents erros in diagnosis Stage disease Good cosmesis ?Surgery WLE / Quadranetectomy / Segementectomy Remove tumour + adequate resection margins (>5mm margins) Adequate skin flaps for cover Breast reconstruction: pedicled flaps, free flaps (DIEP) Axilla Level II (up to medial border of pec minor) clearance accepted as best balance between adequate staging and morbidity Sentinel node technique - finds first draining node (technetium + blue dye); contra-indicated in pregnancy [NB also has use in melanoma and penile cancer] Morbidity: haematoma, wound infection, seroma, lymphoedema, intercostobrachial neuralgia, injury to thoracodorsal nerve, long thoracic nerve injury, axillary vein injury, brachial plexus injury, post-op frozen shoulder Hormonal therapy 1st Line: Tamoxifen (Selective oEstrogen Receptor Modulator (SERM)) - reduce circulating oestradiol 2nd Line: Aromatase inhibitors (Anastrazole[Arimadex], fromenstane, aminogluthethimide) - block oestrogen via aromatase pathway LHRH antagonists (Goserelinp [Zoladex] - prevents oestrogen production by ovaries 3rd Line: Progesterone Chemotherapy Antimetabolites (impair production of DNA):5-FU, Methotrexate Vinca alkaloids (inhibit microtubule formation): Vincristine, vinblastine Alkylating agents (bind to and disrupt DNA): Cyclophosphamide Platinum-based agents Radiotherapy Follow upEarly detection + treatment of recurrence Local recurrence: - single spot, Regional recurrence: axilla, brachial plexus, supraclavicular nodes Distant mets Early detection of metastatic disease Psychiatric morbidity Excision of a breast lumpIndicationsBenign lump Possibly malignant lump ProcedureFix lump between finger and thumb Incision made circumferentially if close to nipple, radially if placed distally Grasp lump with forceps and retract out of wound Expose interior of cavity and diathermy bleeding points Obliterate cavity +/- suction drain Close skin with subcuticular stitch Complications Haematoma Distortion of breast architecture Recurrence of lump Fine Needle Aspiration (FNA)ProcedureExplain to patient Sterile field 21G needle, syring + 2ml of air (for explusion of contents) Prepare slides Fix breast lump Pass needle through lesion in several directions maintaining suction Release suction, withdraw needle Air used to blow out cells to slides Label slides and send to your friendly histopathologist? MicrodochectomyIndicationsPersistent blood-stained discharge from single duct opening on nippleProcedureGA/LA Identify duct Squeeze breast until drop of discharge seen Cannulate duct Use lacrimal probe and secure in place Incise skin along line of probe, encircling duct orifice Dissect skin of areola away from breast tissue (for 1cm) Excise breast segment Secure haemostasis with diathermy + approximate breast tissue with interrupted absorbable sutures. Modified Patey MastectomyIndicationsCytologically proven breast carcinoma?PreparationGADVT prophylaxisSupine position + arm on armboard?ProcedureMark boundaries for skin incision At least 3cm from tumour Anatomical markers - medially: sternum / laterally: lat dorsi / superiorly: 2cm below clavicle / inferiorly: 1-2cm below infra-mammary fold ?? Excision should include nipple/areolar complex Dissect lump Incise skin Develop flaps (use clips/retractors) in plane corresponding to Scarpa's fascia between the subcutaneous fat and mammry fat - aim for thickness of 3-4mm medially increasing to 6-8mm laterally Approaching clavicle superiorly, dissect more deeply to pectoral fascia Raise inferior flap Dissect axilla: - obtains regional control of disease, establishes prognostic information peel breast laterally until border of lat dorsi retract pec major to expose pec minor divide pec minor (close to point of insertion onto coracoid process) Identify Long thoracic nerve of Bell, thoracodorsal nerve (and intercostobrachial nerve) Ligate all venous tributaries from axillary vein Remove lump + axillary contents en-masse Place stitch on most proximal node for pathological orientation Place one suction drain on breast bed + one in axilla Washout with antiseptic Close ?+ Can be combined with flap reconstructionTRAM - transverse rectus abdominisDIEP ?ComplicationsBleeding / infected haematoma Buttonholing of skin flaps Nerve injury - LT nerve (serratus anterior - winged scapula); thoracodorsal nerve (lat dorsi)Thyroid diseaseThyroid disease spectrumArteries: superior thyroid (external carotid)inferior thyroid (thyrocervical trunk of subclavian)Accessory thyroid imaVeins:SuperiorMiddleInferiorNerves:Recurrent laryngeal (cricoarytenoids - supply vocal cords)Superior laryngeal[Thyroid hormone physiology?& disease spectrum] Thyroid NeoplasmsPapillary 70% - younger population, good prognosis, TSH-dependentFollicular 20%Anaplastic?5% - older populationMedullary 5% - from parafollicular C-cellsLymphoma - rare?Management of thyroid diseaseHistory Thyroid symptoms Medications Previous radiation exposure Familial history Examination Neck General examination: signs of thyroid disease - hands, eyes, cardiovascular system Investigations TSH, T4, thyroid autoantibody screen USS: sensitive for detecting thyroid nodules, used to guide FNA FNAC: Most reliable test for thyroid nodules Radio-isotope scans no longer routinely used ("hot" nodules were benign and "cold" nodules were not) Hemithyroidectomy procedureGA + Supine + head-up tilt of 15' Head rests on ring, sandbag in interscapular position Dissect down to thyroid Transverse collar incision approximately 2finger breadths above suprasternal notch Divide skin and platysma Extend superior flap to thyroid, inferior flap to suprasternal notch Expose strap muscles Divide cervical fascia in midline and retract strap muscles laterally Dead with surrounding structures Ligate and divide middle and inferior thyroid veins Inferior thyroid artery identified and ligated in continuity as inferiorly as possible Identify recurrent laryngeal nerve in its groove between trachea and oesophagus (and protect) Identify parathyroid glands and preserve Remove thyroid Superior vascular pedicle is ligated and divided thyroid lobe mobilised and excised oversew isthmus with absorbable sutures Close Haemostasis completed Suction drain placed in subfascial space Fascia closed in midline with absorbable sutures Skin + platysma closed Skin closed with non-absorbable subcuticular suture ComplicationsHaematoma - may cause respiratory embarassment Recurrent laryngeal nerve palsy 1% Single nerve paresis results in hoarse voice Both nerves leads to paralysis Superior laryngeal nerve palsy Hypothyroidism Hypoparathyroidism - causes hypocalcaemia - check calcium level post-operatively Scarring Post-op: radio-iodine scan can demonstrate remnants of thyroid tissue or distant metastasesRemaining tissue can be ablatedSerial thyroglobulin measurement 6-12 month intervals (acts as marker for tumour recurrence)Wide local excision & axillary clearanceIndicationsTumours < 4cm Mammogram excluding multifocal disease ??Axillary clearanceLevel I: Lateral to pectoralis minor Level II: Up to medial border of pectoralis minor Level III: Beyond medial border of pectoralis minor ProcedureCurvilinear incision (including previous biopsy sites) Incise around segment and deepen incision (maintain >1cm tumour clearance) Separate breast tissue from pectoralis fascia Remove tumour (insert silk sutures to identify parts of tumour) Haemostasis + suction drains Obliterate cavity Close skin Axillary clearanceIncise skin + elevate flaps superiorly/inferiorly Identify lateral border of pectoralis major and anterior border of latissimus dorsi Identify and divide pectoralis minor. Preserve thoracodorsal (lat dorsi) and long thoracic nerve of bell (to serratus anterior). Preserve intercostobrachial nerve (axillary sensation) Upper limit of dissection is axillary vein Dissect contents away from vital structures, remove en masse. Drain axilla with suction drain Wash wound with antiseptic betadine + close subcutaneous tissues. ComplicationsNerve injury (esp intercostobrachial nerve) Secondary lymphoedema Haematoma (avoided by diathermy + drains) Wire-guided localisation biopsyIndicationsRadiological microcalcification suspicious of DCIS Impalpable lesion Workup Radiologically guided localisation (USS/X-ray) Barbed wire inserted ProcedureIncise skin transversely over wire Follow wire to substance of breast Excise around wire with good margin + frozen section to identify that whole of lesion has been taken When adequate excision confirmed, ensure adequate haemostasis Obliterate cavity Close with subcuticular stitches? Cardiothoracic SurgeryAortic dissectionClassification?Stanford Type A: ascending aorta only Type B: descending aorta with or without ascending aorta BeBakey Type I: ascending aorta + descending Type II: confined to ascending aorta Type III: confined to descening aorta, beyond origin of subclavian artery PathologyMyxoid degeneration - loss of elastic fibres and replacement of musculo-elastic tissue with proteoglycan-rich matrix Cystic medial necrosis: may be associated with injury or occlusion of vasa vasorum Intimal tear - dissection propagates along plane that runs between inner 2/3 and outer 1/3 of media Predisposing factorsHypertension - leads to increased shearing forces across intima Traumatic injury to aorta Iatrogenic - cardiac catheterisation, aortic cannulation, AV replacement Pregnancy Inherited defects Marfan's - 15q fibrillin defect Ehlers-Danlos - procollagen formation Pseudoxanthoma elasticum - fragmentation of elastic fibres in media ?Effects of dissectionPropagation Aortic ring - acute aortic regurgitation Coronary arteries - Angina / MI Carotid arteries - stroke Abdominal aorta - gut ischaemia (if mesenteric vessels involved) Renal artery - ARF Intercostal / lumbar vessels - spinal cord ischaemia (loss of supply from arteria radicularis magna - great spinal artery of Adamkewicz) Rupture Pericardium - tamponade Pleura - haemothorax Compression Trachea / oesophagus / SVC Double-barrelled lumen (if re-enters lumen through another intimal tear) Clinical featuresShock New Murmur Tamponade Asymmetrical pulses Neurological signs - stroke, cord features InvestigationsECG: MI / exclude cardiac differentials CXR: 80% widened mediastinum Angiography: Gold standard - visualisation of ventricular valve function, permits assessment of coronary anatomy CT/MRI: 85-90% sensitivity + specificity TOE: >95%; can be used at bedside ManagementResuscitate: fluids, maintain cardiac index (CO/BSA) and renal function Bloods Central line: monitor filling pressures Pharmacological Labetalol - control ejection fraction and arterial pressure Sodium nitroprusside (can cause reflex tachycardia) Transfer to cardiothoracic unit Type A: Replacement of diseased segment of aorta with interpositional graft and re-implantation of coronary arteries if root involved +/- valve replacement Type B: Conservative managment (surgery confers no additional benefit) Cardiopulmonary bypassCardiopulmonary Bypass 1. Expose great vessels 2. Purse string inserted into ascending aorta (adventitia) + aortic perfusion cannula + connect to bypass circuit Impracticalities: Aortic root surgery, dissection, severe adhesions - fem-fem bypass can be employed Purse string inserted into Rt atrium by appendage Cardiopulmonary bypass machine takes over circulation + ventilation Pumped from venous reservoir Oxygenated in membrane oxygenator (gas exchange across silicone membrane) Heat exchanger Filtered: remove particulate emboli Infused via roller pump (achieves even arterial pressure) Post cardiopulmonary bypass Air excluded from cardiac chambers Restore beat is VF present Epicardial wires for post-op bradycardia/heart block Warm Correct acidosis Correct K When BP acceptable, CPB discontinued + Protamine to reverse effects of heparinisation +/- inotropic support +/- intra-aortic balloon pump Myocardial protection 1. Cardioplegic arrest Topical cooling + cardioplegic (intentional + temporary cessation of cardiac activity) solution K+ - containing (arrests heart in diastole by membrane depolarisation) Cold isotonic crystalloid - reduce metabolic rate Safe cardiac arrest can be maintained for 2hours Intermittent cross-clamp fibrillation Induce VF (by electrical voltage) Cross clamp aorta to render heart ischaemic Allow perfusion (10-20minutes) by intermittently releasing cross-clamped aorta + electrical cardioversion 3. Total circulatory arrest ?ComplicationsAccess Infection, pulmonary injury, vascular injury Bypass Embolism Bleeding disorder (from heparin) Stress/consequences Tamponade Emboli - heart: infarction, brain: stroke, gut: ischaemiaChest drains / Tube ThoracostomyIndicationsDiagnostic: effusion/blood/pus/lymph Therapeutic: drainage of air/fluid (effusion, blood, pus, lymph) SizesFrench gauge (20-32F) = external circumference in millimetres 32F used to prevent clot obstruction of tube TechniqueAdequately prepared / consented Clinical examination + inspection of CXR: confirm side of insertion Position: (1) supine + arm abducted (2) seated leaning forwards + arms outstretched Skin cleaned w iodine + draped 5th ICS / 3rd ICS (Anterior) anterior to MAL by palpation of ribs LA wheal w 1-2% lignocaine + deep infiltration Insert over rib (avoids neurovascular bundle) 1.5-2cm incision w scalpel (11 blade) Blunt dissection down to pleura using finger + Roberts forceps à finger sweep to clear adhesions + widen tract Drain guided into intercostal space Aim apically for air / basally for fluid Secure with drain stitch + apply dressing/tape Attach to underwater seal +/- suction Drain bottle below level of patient at all times Minimise resistance: chest tube should be sufficiently wide End of drainage tube should not be > 5cm below level of water otherwise resistance encountered will prevent air from escaping chest tube Check CXR: accurate position + re-expansion Analgesia ComplicationsLaceration/puncture intrathoracic/abdominal organs (prevented by finger sweep) Infection Damage to intercostal nerve/artery/vein Subcutaneous emphysema Indications for removalFull lung expansion Drain no longer functioning (air/fluid ceased to drain) No longer swinging (can flush drain - remove obstruction with normal saline) ?Procedure in removal X-ray afterOff suction With tube clamped Remove drain in? inspirationCoronary Artery Bypass Graft Surgery (CABG)Operative TechniqueSurgical Anatomy of the Heart Access to heartHarvesting of Long saphenous veinchest opened via sternotomy + LIMA dissected from chest wallHeart cannulated via ascending aorta + right atrium before cardiopulmonary Longitudinal arteriotomy made beyond narrowing of coronary vessel + distal Venous Grafts: Long saphenous vein (10 year patency rate 50-60%) short saphenous vein cephalic vein Arterial Grafts: Left internal mammary artery (internal thoracic artery) - conduit of choice for LAD (10 year patency rate 90%) Radial artery -NB Allen's test to ascertain collateral circulation Pre-operative workupECG Echocardiography Carotid duplex study Pulmonary function tests Angiography FBC, U+Es, LFTs, Clotting, G+S Antibiotics: Cefuroxime 1.5g +/- Vancomycin Post-op managementProphylactic chest drain External cardiac pacing ComplicationsBleeding3-5% of patients.May develop tamponade / hypotensionMedical management firstMay require emergency re-sternotomyManagement of Bleeding:Check coagulation profileFibrinogenPlateletsSpecific treatments: Protamine sulphate Directly binds to heparin and inactivates Trasylol / Aprotin 2MU iv (Bovine) serine protease inhibitor (specifically trypsin, chymotrypsin, plasmin, kallikrein) Effect on Kallikrein: inhibits formation of factor XIIa and plasmin - slows down fibrinolysis Tranexamic acid Inhibits activation of plasminogen into plasmin ArrythmiasCommon to develop ST / AFManagement of Tachyarrythmias Correct potassium >4.5mmol/l - Potassium chloride Correct magnesium: 8/10-20mmol MgSO4 IV Atrial Flutter Vagal manoeuvres Adenosine 6mg/12mg/12mg B-blocker rate control DC synchronised cardioversion Atrial Fibrillation B-blocker iv / Digoxin 500mg iv/12' Amiodarone 300mg iv/1' + 900mg iv/23' DC synchronised cardioversion Management of BradyarrythmiasAtropine 500mcg iv bolus (repeat to maximum of 3mg) Adrenaline 2-10mcg/min Cardiac pacing Flail chestFlail chest injury3 or more ribs fractured at 2 or more places on the rib shaft - results in area with loss of continuity with rest of rib cage and has potential to move independently during respiratory cycle?Implications of flail chestHigh mechanism injury (one rib = 150mls blood loss) Possible underlying pulmonary contusion Can lead to respiratory embarassement Exhibit paradoxical movement during respiratory cycle - moves inwards on inspiration Pain from fracture leads to reduced TV Type II (mechanical) failure can result Late complications: pneumonia, septicaemia, atelectasis Reduced ventilation increases risk of retained secretions and sequlae ManagmentAccording to ATLS principlesManage flail chest Humified oxygen Analgesia - paracetamol / NSAIDS / Opiates / intercostal block / thoracic epidural (up to T4) + splinting of injury Intubation / mechanical ventilation - if worsening fatigue and RR Identify underlying injury Prevention of secondary complications Sucking Chest woundOccurs when wall defect 2/3 size of trachea diameter Air enters chest through hole rather than trachea Can lead to tension pneumo Rx: 3-sided dressing acting as flutter valve? Lung surgeryRequirementsDouble lumen ETT (allows selective collapse of lung) ?PneumonectomyLobectomyRight/left posterio-lateral thoracotomy Spread ribs Get anaesthetist to collapse one side of lungs Enter pleural cavity Define anatomy (dissect through fissues) to hilum Dissect vein (superior), artery (inferior) and bronchus (posterior) Ligate all three Divide lung Check for air leak (fill cavity with water and ask anaesthetis to blow on lung) Insert apical chest drain Close MediastinitisInflammation of the mediastium - ie. the cavity within the thorax between the pleural cavities.?CausesDirect mediastinal access Sternotomy / cardiothoracic surgery Mediastinoscopy Penetrating trauma Per trachea Intubation / failed percutaneous tracheostomy Bronchoscopy Per oesophagus Boerhaave's Iatrogenic oesophageal perforation Direct extension Infection from lung, pleura Organisms: anaerobic oral flora, respiratory flora - or multi-resistant strains if cardiothoracic surgery?Features (of general inflammation) PyrexiaRigorsSurgical emphysemaHamman's sign (crunching sound in systole)?ManagementBloods: Inflammatory markers, FBC, CRP Imaging: CXR (enlarged mediastinum) + CT Treatment: Surgical drainage/debridement + Antibiotics PericardectomyIndicationsOperative considerationsShould release both ventricles at the same time - premature release of the right ventricle leads to increase blood flow to the lungs (with unreleased left ventriculat outflow) Result is increased pooling of blood in the lungs - pulmonary oedema!PneumothoraxTypesSimple: air in pleural space Tension: one-way valve effect Open: Sucking chest wound CausesSpontaneous: rupture of blebs - asthmatics, skinny lanky Trauma Iatrogenic? ?RecognitionConscious Tachycardia, tachypnoea, decreased sats Tracheal deviation, hyper-resonance Surgical emphysema Unconcious / ventilated Sudden hypoxia Sudden increase in ventilatory pressures Sudden hypotension or rising CVP New arrythmia ?ManagementEarly recognition (esp tension) 100% O2 Tension - needle decompression (2ICS) Chest drain? ?PleurodesisPerformed endoscopically (VATS - video assisted thoracoscopic surgery)ChemicalPhysical - by abrasive pads: used for younger patients as chemical pleurodesis carries theoretical risk of increasing malignancy?Indications for Thoracotomy in Haemopneumothorax(Persistent bleeding - usually from chest wall ~80%)Loss of >1500mls immediately into drain Loss of >200mls/hr for 2-4 hours Requirement for persistent blood transfusion Surgical Access to the HeartMedian SternotomyIncision from suprasternal notch to lower end of xiphisternum Sternum covered by fat + pectoral muscles Superiorly: Suprasternal ligament from SCJ to other Inferiorly: rectus abdominis fibres Sternum divided + retracted Superiorly:Thymus Inferiorly: Pericardium Thymus divided in midline Highly vascular Care because lies anterior to innominate/brachiocephalic vein Pleura dissected from pericardium laterally Pericardium opened +/- cannulation (with full heparisation) ?Closure of SternotomyEnsure haemostasis Insert pairs of stainless steel wires (usually 6) through sternal body Inspect for bleeding from internal thoracic vein/artery Twist wires Cross wires Suture fascia to pectoral fibres Close skin with subcuticular stitchThoracotomyMedian Sternotomy Posterio-lateral thoracotomyAccess to hilum and pleural cavityCurved incision 2cm below scapulaDissect through skin, fatDivide latissimus dorsi fibresSpread off serratus anteriorDivide through intercostal muscles (at level of 5th rib - count from second rib)Enter pleural cavity?ClosureAppose ribsSew deep fascia onto intercostal musclesClose serratus anterior layerSew latissimus dorsiClose skinEmergency ThoracotomyIndicationsPenetrating injury with cardiac arrest Massive thoracic bleeding ProcedurePositioned obliquely with ipsilateral hip and shoulder supported on sandbags Submammary incision made starting near midline and extending into axilla Pass through all layers to enter chest in 5th ICS Ribs separated with spreader Pericardium can be opened anteriorly and parallel to phrenic nerve - decompress tamponade? Valve surgeryHeart valves maintain pressure gradients between cardiac chambers to ensure unidirectional flow.Valve leaflets supported by chordae tendinae + papillary musclesValveCusps DescriptionAortic3Semilunar leafletsAttached at annulusCoronary arteries arise from (1) Left = Left posterior sinus (2) Right = Anterior sinus Mitral2Anterior/Posterior cuspsPulmonary3?Tricuspid3???AorticMitral StenosisRheumatic heart diseaseCalcificationCongenitalRheumatic heart diseaseCalcification of valve/chordaeCongenitalRegurgitationRheumatic heart diseaseEndocarditisCongenitalInflammatory - SLE, Ank spondDilation of aortic root - Marfan's, dissectionSystemic disease - UC, syphilis Rheumatic heart diseaseValve prolapseLV dilationIschaemia / papillary muscle disruptionBacterial endocarditis??Technique of Aortic Valve replacementTransverse incision across valve Dissect out / remove diseased valve Insert + secure new valve Close aorta (full thickness continous sutures) Apply tissue glue Add pro-coagulant covering ?Indications for Mitral Valve replacementSevere symptoms (as classified by NYHA functional classification) Progressive increase in LV volume leading to ventricular impairment (Ejection fraction, end-diastolic volume) Endocarditis ???Prosthetic ValvesTypeExample ComplicationsMechanical Ball & Cage Starr-Edwards Barium-impregnated silastic ball retained in cage Tilting valve disc Bjork-Shiley Single disc opens and closes with blood flow Bileaflet St Jude Medical valve Two disc occluders Structural Valve failureProsthetic valve endocarditisParavalvular leak Related to endocarditis episode Leaflet degeneration ?Thrombosis / ThromboembolismMechanical 2.5 - 3.5 Tissue 1.5 - 2.5 BiologicalAutograftsHarvest patient's own pulmonary valve into aortic position (Ross procedure) Excellent haemodynamic function (but technically demanding) Autologous pericardial valves Homografts/Allografts - Removed from cadaversAntibiotic sterilised Short supply Technically difficult Xenografts - Prepared from animal tissuePorcine-valve Pericardium mounted Appendicitis / AppendicectomyAppendicitisInflammation of the vermiform appendixMost cases are idiopathic.Lumen: mucosal appendicitis Foreign material Faeces Worms: strongyloides, ascaris lumbricoides Parasites: oesophagostomiasis Wall: transmural appendicitis Infection: Viral (CMV, adenovirus), bacterial (TB, yersinia), amoebae, schistosomes Inflammation: UC, crohn's, pseudomembranous colitis Ischaemia: ischaemic colitis, congenital stricture, iatrogeni Outside wall: Serosal appendicitis Ovaries - salpingitis/oophritis Endometriosis Diverticular disease ?PresentationClinical findings Periumbilical colicky pain (visceral peritoeneum) Migrates to RIF (parietal peritoneum) Specific features McBurney's point pain Rosving's sign: Deep palpation of RIF causes pain in RIF - confused visceral peritoneum (also positive in bladder, uterus, descending colon, fallopian tubes, ovaries inflammation) Psoas sign: flexed right hip where appendix is lying over psoas muscle Rectal tenderness: from pelvic appendix ??IndicationsEmergency - acute appendicitis Elective - "interval" appendiciectomy after intial conservative treatment (of appendix mass) Open ProcedureGA + Antibiotics + supine position Access appendix McBurney's incision (90' to imarginary line) / Lanz incision (cosmetically better) / High up in RUQ in children Skin, fat (campers fascia), scarpa's fascia Incise external oblique aponeurosis in line of fibres, expose internal oblique (if too medial will see rectus sheath) Split internal oblique fibres transversely, enlarge defect Pick up peritoneum between 2 clips, incise with scalpel - turbid fluid indicates appendicitis (send this off to microbiology) Identify caecum (has teniae) and deliver into wound [enlarge incision if difficult/impossible to deliver] Remove appendix Hold appendix with 2 tissue forceps (Babcocks) Divide mesoappendix (hold up to light to see blood vessels) Apply purse string (buries appendix stump) with 2/O Crush appendix base (facilitates secure knot tying) and ligate proximally with O suture. Remove appendix, bury stump by tightening purse string Suck out free fluid, wash out peritoneal cavity Close wound in layers ?Laproscopic AppendicectomyEspecially young female patients - where diagnosis uncertain, imaging has failed to exclude gynaecological cause. ?GA / Possible conversion to open Establish pneumoperitoneum? Trendelburg position Infraumbilical incision Open peritoneum under direct vision Insert trochar Insufflate gas Inspect appendix 5mm port RIF under direct vision 5mm port LIF Grasp caecum and move towards spleen Aspirate free fluid (send for cytology) Remove appendix Grasp appendix with forceps Dissect from mesentry using hook diathermy introduced through right port Ligate at base using pre-tied Vicryl ligature + second distal to first one Divide and remove under direct vision Peritoneal lavage Close fascial defects with absorbable sutures + steri-strips to skin ?If appendix normal - look for other causes: Gynae: ovaries, fallopian tubes, ectopic pregnancy Gut: meckel's, sigmoid diverticulitis Paediatric: look for mesenteric adenitis Insert drain if abscess present?ComplicationsIncreased risk of right hernia Bowel obstructionFeaturesPain: colicky Epigastrium / umbilical = small bowel Suprapubic = large bowel Vomiting Consequences: dehydration, metabolic alkalosis/respiratory acidosis - hypoxia More distal lesions, later the vomiting Contents: pyloric = watery; high = bilious; low = faeculent Distension Depends on level of obstruction Constipation Pyrexia, septicaemia CausesLuminal Intussuception Mural Malignancy Inflammatory bowel disease Extra-mural Hernia Adhesions Frequency of causesAdhesions - 60% Herniae - 15% Malignancy - 6% IBD Ischaemic bowel PathophysiologyBowel dilatation proximal to obstruction Results in gas / fluid accumulation with bowel wall and lumen (proximally) Impairs resorption Mucosal oedema impairs venous / arterial flow Bowel becomes strangulated Ischaemia leads to haemorrhagic infarction Further dilation leads to bowel perforation Bacterial translocation leads to sepsis ?Principles of ManagementHistory Previous operations Abdominal diseases Previous obstruction Examination Previous scars Presence of hernia Bowel sounds: tinkling / hyperactive Investigations Plain AXR - distended bowel loops (and level of obstruction) - small plicae circulares; large haustrae Plain CXR - exclude free air FBC: WCC, anaemia Electrolytes ABG: Lactate / acidosis Resuscitation IV crystalloid Correct acid-base NGT Catherise Analgesia Indications for surgeryAbsolute Peritonitis Perforation Incarcerated hernia Relative Palpable mass Virgin abdomen Failure of conservative treatment Surgical options in Large bowel diseaseOne stage (medially optimised patient) resection of tumour/lesion, decompression of bowe, lavage with primary anastamosis Two stage (unwell patients who may be optimised)Hartmann's procedure with resection of tumour Later reversal of colostomy Three stage (sick patients/moribund/advanced disease)Emergency defunctioning colostomy (until patient fit for further operation) resection of tumour and anastamosis in 2nd operation Final closure ?CholecystectomyIndicationsSymptomatic gallstones: biliary colic, pancreatitis Cholecystitis Empyema of gallbladder Mucocoele of gallbladder Laproscopic ProcedureConsent + permission to convert to open 5-10% cases Establish pneumoperitoneum (open method) - 1cm incision under umbilicus, introduce trochar, insufflate air, then laproscope Insert ports 10mm epigastrium; 5mm MCL; 5mm AAL Identify Calot's triangle (Liver, cystic duct, hepatic duct) - contains cystic artery Dissect cystic duct, artery and GB Apply x3 clips on either side of structures, divide leaving 2 clips Divide gallbladder from hepatic bed using diathermy hook to maintain haemostasis Remove gallbadder (collect in endobag to prevent leakage) Release pneumoperitoneum, close wounds Open ProcedureUpper right transver incision (over lateral border or rectus muscle) Skin, campers fat, scarpas fascia, anterior rectus sheath, rectus, posterior rectus sheath, transversalis fasicia, extraperitoneal fat, peritoneum ComplicationsBile duct injury Haemorrhage - slipping of clips Retained stone Biliary stricture Duodenal injury? Colorectal cancer?ManagementHistory Characteristics of PR bleeding Change bowel habit Weight loss Family history: HNPCC, p53, APC Examination DRE: 90% palpable Inspect glove for blood or mucous Abdomen for masses Investigations Proctoscopy: visualisation, confirmation and biopsy of any lesion Barium enema - identify suspicious lesions Staging Local spread: Endoluminal USS, CT, MRI Metastatic spread: CXR, USS, CT Chest / Abdomen HYPERLINK "" 2cm adequate / 5cm preferred Ensure tension free anastamosis by adequate mobilisation Consider protecting anastasmosis by proximal defunctioning loop ileostomy ??Right Hemicolectomy + Primary anastamosisEnter peritoneum Midline incision / transverse incision (less painful, slimmer patients) Mobilise caecum and terminal ileum dividing lateral peritoneum clockwise and upwards Dissect off right colon Identify and protect the gonadal vessels, right ureter and duodenum Divide bowel Transilluminate the mesentry; ligate vessels close to origin (as close as possible really) Place non-crushing clamps on transverse colon and ileum and divide bowel between crushing clamps Form end to side anastamosis (along taeniae) Close distal end of colon (by hand) or stapling device Approximate ileum with colon and commence posterior wall by inserting seromuscular (Lembert suture) Open colon along taeniae and insert full thickness absorbable suture Continue to midline anteriorly and tie off sutures Close mesenteric defects (prevents herniaetion) Close wound (mass closure etc) Left Hemicolectomy + Primary anastamosisEnter peritoneum Mobilise colon Divide along white line of "Toldt" Push sigmoid mesentry medially Identify and protect gonadal vessels and left ureter as it crosses pelvic brim Divide bowel Transilluminate mesentery and identify and ligate vessels close to origin Distally ligate vessels at bowel wall Place non-crushing clamps across rectum and proximal bowel Protect wound edges from contamination using abdominal swabs Excise colon Form anastamosis Single-layer technique Stapled gun Close mesenteric defect Washout + close ??Hartmann's operation / End colostomyIndicationsObstructing lesion in sigmoid colon Perforated lesion in sigmoid colon Volvulus of sigmoid colon Pre-op: marking by stoma nurseEnter peritoneum Midline incision Mobilise bowel Divide along white line (avascular plane) Sweep sigmoid off mesentry Identify and protect gonadal vessels and left ureter Divide bowel Transilluminate mesentry, identify and ligate vessels Place non-crushing clamps across distal and proximal bowel Excise diseased segment Close distal colon with two layers of continous sutures Hitch bowel to presacral fascia making it easier for reversa Formation of stoma Bring out proximal colon Circular skin incision 2cm in diameter and deepen to rectus sheath (palpate inferior epigastric vessels to avoid damage at this stage) Make cruciate incision into sheat, bluntly dissect through muscle into peritoneal cavity Place clamp through stoma site and capture proximal colon: manipulate bowel through abdominal wall Approximate skin and bowel edge with interrupted sutures at regular intervals (x6-8 deep: external oblique aponeurosis + superficial: skin) Good practice to pass colon through peritoneum at point lateral to intended stoma site as this creates a tunnel which should reduce the incidence of stomal herniation Washout peritoneal cavity with tetracycline throughout procedure (very high risk of wound infection) ?Reversal of Hartmann'sOnly attempt once patient has fully recovered + stoma has matured (3-6 months) ~60% are reversed due to persisting morbidity in the patient? ??Anterior Resection + defunctioning ileostomy IndicationsCarcinoma of mid-rectum GA + Lloyd-Davies position + Catheter Enter peritoneum Mobilise bowel Colorectal anastamosis Defunctioning ileostomy ?Abdomino-Perineal resection IndicationsCarcinoma of lower 1/3 of rectum Anal carcinoma Pre-op: irreversible colostomy GA + Lloyd-Davis position + catheter Abdominal component Sigmoid mobilised Protect other structures (ureter, gonadal vessels) Rectum mobilised - identify and protect pre-sacral plexus Divide fascia of Denonvilliers anteriorly (protect seminal vesicles) Perineal component Elliptical incision from coccyx passing lateral to anal verge and finishing at perineal body Deepen to mesorectum to meet abdominal access Divide posterior edge of levator ani Rectum freed and delivered through perineal wound Form stoma from remaining colon Close abdomen Close perineum ComplicationsReactionary haemorrhage Infection - wound, pelvic abscess Renal tract injury Sexual dysfunction and impotence Complications of colostomy - retraction, prolapse, herniation, stenosis, ulceration, ischaemia/necrosis Compartment syndrome / FasciotomyCompartment syndromeRaised pressure in osteofascial compartment Elevation of pressure prevents tissue capillary perfusion: causes muscle and nerve damage Features: severe pain out of proportion to injury aggravate by muscle stretch and parasthesia Causes: trauma, reperfusion, burns, exercise Complications of missed compartment: muscle necrosis, myoglobinuria, renal failure, infection, amputation, foot drop from peroneal nerve palsy, volkmann's ischaemic contracture ?ManagementHistory Examination Investigations Classic symptoms need no further investigations Unclear diagnosis: compartment pressures ?30mmHg over diastolic Treatment Double incision fasciotomy Daily dressings of wound Prophylactic antibiotics Re-examine in 24-48hours to debride necrotic tissue and cover wounds ??Tibial Compartment fasciotomyCompartments of the lower leg?Anterior compartmentTibialis anterior Extensor digitorum longus Extensior hallucis longus Lateral compartmentPeroneus Longus Peroneus brevis Posterior compartmentTom-Dick-HarryTibialis posterior Flexor digitorum Flexor hallucus Plantaris Soleus Gastrocnemius ??IndicationExtensive soft tissue injury of lower leg Compartment syndrome ?Measurement of compartment pressuresPrepare / sterilise skin Infiltrate LA Insert catheter into compartment, inject small amount of saline into cannula to fill dead space Fill manometer tubing with saline + connect to catheter + pressure monitor (ensure no bubbles/other dampening influence) 10-30mmHg < diastolic: Impending ischaemia>30mmHg < diastolic: Impending/established compartment syndrome - Need urgent fasciotomy?ProcedureFull length longitudinal anterolateral skin incision 2cm lateral to crest of mid-tibia from level of tibial tuberosity to just proximal to ankle Anterior compartment: Incise fascia covering tibialis anterior + extend proximally/distally Identify and protect superifical peroneal nerve (lies deep to intermuscular septum) Lateral compartment: undermine skin to get to lateral compartment (avoid superficial peroneal nerve) Single longitudinal 1-2cm posterio-medial incision just medial to posteriomedial border of tibia Identify and retract long saphenous vein Incise deep fascia proximally to level of tibial tuberosity and distally to 5cm proximal to medial malleolus Should be anterior to posterior tibial artery to avoid damage to perforating vessels used for later cutaneous flaps Closure of fasciotomyWound should be left open + VAC dressing Suture skin 3-5 days later (when swelling subsided) +/- split skin grafts Keep leg elevated ?ComplicationsDisruption of venous muscle pump Poor healing Excision of lymph nodeIndicationsConfirm diagnosis of lymphadenopathy ProcedureIncision should be able to convert to a radical procedure should this be necessary Deepen incision Identify lymph node Dissect node (+ vascular pedicle) Diathermy / tie pedicle, excise node Ensure haemostasis, close wound? Excision of sebaceous cystIndicationsCosmetic Recurrent infections, sebaceous horn ?Procedure LA Elliptical incision over cyst (include punctum) Grasp cyst and free from base Close with interrupted non-absorbable sutures Excision of toenailIndicationsIngrowing toenail Onychogryphosis Nail infections Procedure (Zadik's operation)LA ring block Apply rubber tourniquet Incise nail bed (transversely) + elevate flaps Remove nail plate with heavy scissors Cut across nail bed down to bone and continue to nail fold, remove nail bed (get all of germinal matrix) Suture skin flaps at side Exicision of Skin lesionsIndicationsMalignancy Cosmesis ?ProcedureUse small scalpel blade (10/15) Make elliptical incision around lesion (along langer's lines to ensure good cosmesis)# BCC/SCC: excise whole of lesion Malignant melanoma: 1cm margin for 1mm / 2cm margin for 2mm / 3cm margin for 3mm Incise under lesion to remove Close skin with undyed subcutaneous non-absorbable suture Femoral Hernia repairIndications All femoral hernias (high risk of strangulation) ?Landmarks: inguinal ligament (anteriorly), pectineal ligament (posteriorly), lacunar ligament (medially), femoral vein???Procedure: Low / crural approach?If any doubt as to bowel viability, laparotomy recommended Dissect down to hernia Groin incision directly over inguinal ligament Identify, dissect superficial fascia down to sac Expose neck of hernia Open hernia, inspect, reduce hernial contents If necrotic bowel, resect and perform laparotomy Close hernie defect Carefully retract femoral vein close defect (suture inguinal ligament to pectineal ligament - use J-shaped needle) Close subcutaneous tissue with interrupted sutures + skin with subcuticular ??High inguinal approach??Extraperitoneal approach?Useful if unsure hernia is inguinal or femoral Dissect down to hernia Supra inguinal incision (Pfannenstiel, midline) Skin, blunt dissect superficial tissues to gain access to hernial sac Open rectus sheath + retract rectus Open up pre-peritoneal space with blunt dissection Continue process down towards inguinal ligament + identify hernia Identify and reduce hernia If sac empty, reduce back to abdomen: pull above, push below If bowel present, stretch femoral ring (with haemostat), transfix sac + excise tissue If irreducible, open peritoneum from above + inspect contents +/- bowel resection Close femoral canal with interrupted non-absorbable sutures between pectineal + inguinal ligament Intestinal Stenosis of Garre Strangulated hernia causes mucosal ulcer Intestinal mucosa more vulnerable to ischaemia rather than overlying seromuscular layer - heals by fibrosis Annular stenotic stricture of small bowel Causes small bowel obstruction Gut surgeryPreparationAdequate bowel prep - fluid restriction 48 hours prior + picolax 24 hours prior DVT prophylaxis IV antibiotic prophylaxis - metronidazole / cefotaxime Catherise NGT Seen by stoma nurse / "stomatherapist" - marks stoma in 3 positions of standing, sitting and lying Consent ?PrinciplePerform full laparotomy - inspect everything Assess *tumour for resectability + clearance margins (2cm acceptable; 5cm desired) If Metastases found, should continue surgery as best "palliative" measure - resection margins can be reduced ComplicationsSurgery Stoma "General" Metabolic / nutritional consequences? HaemarrhoidectomyHaemorrhoidsCushions of dilated vascular tissue at anal verge Anal cushions are required for full continence Straining causes the cushions to slide down and become engorged - results in symptomatic haemarrhoids ClassificationFirst degre: small non-prolapsing Second degree : prolapsing but reduce spontaneously Third degre: prolapse that cannot be reduced Treatment optionsAsymptomatic No treatment required First degree Stool-bulking agents Injection sclerotherapy Second degree Banding Third degree Haemarrhoidectomy Haemarrhoidectomy procedurePrepared + consented + phosphate enema Lithotomy position + GA Skin or anus/perineum prepared + Parkes proctoscope passed PR Gently draw haemorrhoid towards surgeon and then make V-shaped incision in anal skin at base of haemorrhoid Raise haemorrhoid towards lumen away from sphincter fibres + transfixed and ligated with vicryl suture Divide haemorrhoid 5mm distal to ligation and removed Repeat for other haemorrhoids (3,7,11 position) Pack anal canal with gauze or spone to keep mucocutaneous bridges flat against the internal sphincter (prevents an anal stricture forming) Apply perineal pad and firm T-bandage Post-op caredaily bulking agents glycerin suppositories for faecal retnetion Analgesia 30 minutes before bowel movements and change of dressings External wounds managed with twice daily baths, irrigation and dressings 4 week outpatient review complicationsBleeding Constipation Anal stenosis Faecal incontinence due to damage of sphincter mechanism Anal fissure Recurrence Perianal fistula ?Incisional Hernia repairRisk factors for developing incisional herniaeSurgical Careless suturing Inappropriate material Local Haematoma Infection Patient Malnutrition Obesity Jaundice Immunosuppression Procedure for repairOptimise patient pre-operatively (repair often fails) GA + supine Dissect down to hernia Incision made over hernia Hernia sac dissected out Incision deepened around margins og hernia until healthy aponeurosis identified Reduce hernia Sac opened Contents returned to peritoneal cavity Close defect if < 4cm can be closed with interrupted nylon If large: close with tension-free Prolene mesh repair sutured to anterior rectus sheath with interrupted absorable sutures at 2cm intervals Finish? Inguinal hernia repairIndicationsSymptomatic herniae Irreducible herniae Patent processus vaginalis ?Landmarks:Inguinal Ligament (Gimbernaut):Formed from reflection of the aponeurosis of the external oblique muscle Runs from the Anterior Superial Iliac Spine (ASIS) to the pubic tubercle Deep Ring: Midpoint of inguinal ligamentSuperficial Ring: Above pubic tubercleIlioinguinal nerve?Position: ProneProcedure Incise skin 2cm above inguinal ligament from deep ring to superficial ring Pass through superficial fascia/fat (Camper's) Pass through deep fascia (Scarpa's) Expose extern oblique apneurosis Enter inguinal canal, identify and protect ilioinguinal nerve Identify and protect the spermatic cord Dissect hernia sac (anterior + superior to cord) Open sac, inspect contents (may contain ovary in female), reduce hernia, close defect If bowel present, check viability (wrap in warm saline-soaked abdominal pack) If necrotic, must be resected Reinforce wall with mesh In children, repair is usually satisfactory, and don't need mes Tension-free repair: Liechtenstein (lateralises cord) Bassini repair Shouldice repair Ensure haemostasis, ensure testis in scrotum. LaparoscopyAdvantagesDisadvantages?Smaller incisions, reduced tissue trauma Reduced post-op pain Decreased incidence of wound complications Decreased physiological insult to patient Reduced inpatient stay Improved cosmesis Absent tactile feedback Difficult haemorrhage control Learning curve May need consersion to open ?Contraindications (things that really need open procedures being done)General Coagulopathy Shock Specific Peritonitis Obstruction ?Essential componentsEstablish pneumoperitoneum Insertion of trocar Inpection of cavity Removal of trocar and closure of wounds ?PneumoperitoneumTrendelenburg position (head down) - position bowel away from pelvis 1-2cm infraumbilical incision (transverse or vertical), deepen down to rectus sheath Closed laparoscopy - Veress needle Hold up abdominal wall, insert Veress needle perpendicular to skin until "give", then point needle towards pelvis at 45' Confirm satisfactory insertion - saline drop test or aspiration Open laparoscopy - Hassan cannula Pick up / incise rectus sheath. Place sutures on each side of linea alba Incise peritoneum and enter peritoneal cavity under direct vision Insert finger, sweep away adhesions Insert port + stay sutures CO2 insufflation (aim pressure 0-5mmHg) Percuss abdomen to ensure symmetrical abdominal distension Maintain pressures of 13-15mmHg, volume of gas 4-5L ?Insertion of trocharIntroduce cannula using corkscrew technique (aim towards pelvis) - check position by releasing gas tap/vavle (hearing air) Attach camera (Bleeding can be controlled by inserting a foley catheter to achieve compression) Insert other ports under direct visionPosition of ports1. Infra-umbilical pneumoperitoneum (veress/hassan)2. Epigastric trochar / camera3. Epigastric cannula?FinishingRemove under direct vision Check port site for haemostasis Umbilical/epigastric ports should be closed formally Skin closure by tapes/sutures + wound infiltration with bupivacaine for analgesia ??Common complicationsRectus sheath insufflation, gives high pressures - stop Misting of equipment (if not adequately pre-warmed) Blood on lens can be wiped on omentum LaparotomyMidline incisionDivide skin in midline, divide subcutaneous tissue Divide linea alba for full length of skin incision Pick up peritoneum between clips, confirm no bowel adherent, nick peritoneum between clips Insert finger beneath wound to ensure no underlying adhesions, then divide peritoneum with scissors for full lenght of incision Ensure no adherent viscera, avoid bladder in lower midline ?Exploratory laparotomyOesophageal hiatus > stomach > duodenum Palpate liver, GB, Rt kidney Right colon > caecum Pelvis Sigmoid > ascending colon, spleen, left kidney Transverse colon, pancreas, aorta Small bowel, (from ligament of Treitz) to jejunum, ileum and caecum Closure of Midline LaparotomyJenkin's rule: decreases the risk of dehiscenceMass closure technique (include peritoneum + rectus sheath in closure) Continous suture (0 or 1 loop PDS) on a blunt needle Suture should be FOUR times the lenght of the incision and bites should be taken 1cm from the wound edge at 1cm intervals Paramedian incision Incise skin 4cm from midline (over rectus) Incise anterior rectus sheath Divide sheath from muscle at points of intersections Reflect rectus laterally to expose posterior sheath Incise posterior sheath for full length of wound and then divide peritoneum ?Closure of Paramedian incisionClose peritoneum using over and over technique Anterior rectus sheath closed as for midline incision (applying Jenkins' rule)? ?Subcostal incision Keep parallel + 2cm from costal margin Divide anterior rectus sheath Pass long forceps underneath meuscle to emerge in midline Pull swab back under muscle to protect underlying structures from cutting diathermy (superior epigastric artery br. int thoracic) as muscle is being divided Small incision made into peritoneum, allows protection of viscera as transversus abdominis muscle is divided ???Management of Abdominal wound dehiscenceSurgical emergency with 30-40% mortality Resuscitation with IV fluids Protection abdominal contents with sterile soaked towels (saline/betadine) Immediate closure in theatre with deep tension sutures ITU backup for post-op management Oesophagus disordersHiatus HerniaAcquired form of diaphragmatic herniaTypes:Sliding: GOJ slides through the oesophageal opening of the diaphragm Rolling / paraoesophageal: GOJ remains in position but area of stomachad peritoneum rolls up alongside oesophagus into thorax ??Gastro-Oesophageal Reflux DiseaseManagementHistory Burning pain Examination Investigations Upper GI endoscopy + biopsy to detect oesophagitis and Barrett's oesophagus 24h pH manometry Treatment Lifestyle changes: weight loss, avoid alcohol and smoking, avoid large meals at night Medical: antacids, H2 antagonists, PPIs Surgery in: severe persistent regurgitation, severe reflux symptoms, patient choice ?Nissen FundoplicationOther options - Belsey Mark IV: fundoplication through thoracotomy - Hill gastropexy (securing cardia to pre-aortic fasciaLaparscopic / Midline incision GA + elevate head end of table Create pneumoperitoneum / access oesophagus Divide lesser omentum Retract right lobe of liver Dissect oesophageal hiatus Repair crural defect Identify crura Dissect 3-4cm of abdominal oesophagus and mobilise Retract oesophagus to right Repair crural defect with interrupted non-absorbable sutures Free fundus and greater curvature Divide short gastric vessels Freed fundus passed behind and then to the left of the oesophagus Fundoplicate Fundal wrap held with 3 interrupted non-absorbable sutures, taking bites of both fundal folds and the oesophagus Finish Irrigate operative field + ensure haemostasis Close fascial defects ?Paraumbilical hernia repairIndications???Procedure (Mayo repair)GA + Supine Dissect down to hernia sac curved infraumbilical incisio Dissect subcutaneous tissue, dissect from rectus sheath identify hernia sac Excise hernia open sac, reduce contents (usually omentum) Ligate sac and excise to level of fascia Close defect Grab edges of fascia with Allis clamps Superior fold of fascia overlapped on top of inferior fold (double breasted manner) using non-absorbable interrupted mattress sutures Close Close in layers Peptic ulcers[Peptic ulcer disease]??Perforated peptic ulcerIndicationsAcute duodenal perforation - prevents sepsis and shit like that ?Procedure: OversewGA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + supine position Upper midline laparotomy Identify stomach + work distally to duodenum Identify perforation Usually found on anterior surface of 1st part of duodenum If not present there - look on posterior surface of stomach - if perforated stomach ulcer is found biospy it cause it's probably going to be a fat cancer, innit? If ulcer is large and friable, will need partial gastrectomy (as omentum just isn't man enough to do it) Close perforation Insert x3 absorbable sutures through duodenum on each side of perforation Find mobile piece of omentum that can be mobilised into position Lay across perforation and loosely tie stures over the top of omentum (do not tie tightly - may necrose omentum) Wash out peritoneal cavity (remove food and shit) Close as for laparotomy ?Laproscopic procedurePneumoperitoneum via open method (1cm infra-umbilical incision), enter peritoneum under direct vision Introduce trochar, insufflate CO2, introduce laproscope 11mm port under xiphisternum 5mm port in MCL R hypochondrium 5mm port AAL R hypochondrium Irrigate / suction peritoneal cavity Repair as above Close port sites Post-op careProton-pump inhibitor H.pylori eradication - (urease breath test C13): Metronidazole + clarithromycin + PPI Oral fluids once flatus passed ??Bleeding peptic ulcer: Under-running Indications Bleeding from an ulcer that has failed to respond to conservative managment (prevents bleeding to death and shit like that) - including endoscopy + injection of sclerosants or adrenaline Haemorrhage requiring more than 6 units blood/24hours Haemorrhage unresponsive to intensive resuscitation High risk of re-bleeding: (1) spurting/oozing vessel on endoscopy (2) visible vessel at base of ulcer on endoscopy (3) fresh or adherent clot on endoscopy ProcedureGA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + Supine position Upper midline laparotomy Identify stomach (distended with blood) with grey small bowel (cause of blood) Insert two stay sutures on duodenum and open duodenum longitudinally (will be closed transversely - prevents stenosis) Identify point of bleeding Pass sucker into duodenam lumen to identify bleeding point (usually posterior wall) Stuff swab into pylorus to prevent blood from being expelled from stomach If cannot find blood in duodenum, look in the stomach - gastic ulcer, erosions, varices Under-run gastroduodenal artery as it passess behind duodenum using 1/O absorbable suture Take good bites (can miss artery otherwise) Don't go too deep as will hit CBD Tie sutures firmly Remove swabs, evacuate blood from stomach Depending on degree of ulcer-related duodenal scarring proceed to pyloroplasty (close duodenum transversely with interrupted sutures) gastroenterostomy Close wound ?Perianal abscess / fistula / fissure in ano / Pilonidal sinusPeri-anal abscessUsually painful in anal regionSwinging pyrexiaTreatment is drainage with appropriate antibioticsClassification of Perianal abscessPeri-anal 60%- suppuration of anal gland (can also occur as result of thrombosed external pile) Ischio-rectal 30% (IR fossa communicates with opposite side via the post-sphincteric space; involvement of contralateral fossa not uncommon) Sub-mucous 5%; usually resolves (result of injection of haemarrhoids) Pelvi-rectal 5% (supralevator) - usually secondary to appendicitis, salpingitis, diverticulitis, parametritis ProcedureCruciate incision over abscess + excise skin over abscess (de-roof) (Take microbiological cultures - if enteroccocci, high incidence of fistula; up to 40% risk) As soon as infection subsided, wound explored under anaesthesia + careful search for fistulous opening If no fistula found, cavity should be lightly packed with gauze + apply T-bandage Fistula in AnoTrack lined by granulation tissue that connects deeply in anal canal/rectum and superficially on the skin around the anusUsually results from an anorectal abscess which bursts spontaneouslyAssociated with underlying diseases - eg TB, CrohnsGives recurrent dischargeGoodsall's rule: fistulae with external opening anterior to anus have a direct (straight) opening. Fistulae with posterior opening have curved tracks. Classification of Perianal fistulaSimple or complex - associated or not with abscess cavity High or Low - above or below anorectal (puborectalis) ring Subcutaneous Submucous Low anal High anal Pelvirectal Park's Classification - by origin of fistula track Intersphincteric (between internal/external sphincters) 70% Transphincteric (across external sphincters) 25% Suprasphincteric (over sphincters) Extrasphincteric (above and through levator ani) ProcedureDecide whether fistula is low or high Proctoscopy - reveals internal opening Endoluminal ultrasonography / MRI to map complex fistulae (may have multiple openings) Low: Lay open Prep cleaning enema Lithotomy position Identify the fistula: protoscopy + retrograde probe + dilute methylene blue dye Track opened along director and bleeding controlled Trim edges of track High: (risk of incontinence if laid open) - staged procedure + protective diverting colostomy to prevent septic complications and to shorten healing time between procedures Treat the cause: TB, Crohns Insertion of a seton (a heavy ligature of silk, nylon, silastic or linen) used when internal opening near anorectal ring acts as wick/drain to allow acute inflammatory reaction around track to subside Can be serially tightened to cut through sphincter (allows healing) to maintain sphincter integrity Acts to drain fistula + Covering colostomy [Levator ani = Pubo-rectalis + Pubo-coccygeus + Ilio-coccygeus]Fissure in AnoLongitudinal tear in anal canal (90% posterior midline) ?Constipation / large stools primary cause or result of them Combination of local trauma to epithelium + ischaemia preventing adequate healing Also seen in STDs and IBD Symptoms: pain, bleeding, itching, pruritis ani TreatmentConservative High fibre diet, stool bulking Topical LA Topical GTN (controls anal spasm) Surgical Lateral sphincterotomy: divide distal internal sphincter to dentate line with incision lateral and away from fissure (complications - transient flatus incontinence) Ramstedt's pyloromyotomyIndicationsPyloric stenosis??ProcedureGA Access pylorus 3-4cm transverse incision made in right upper quadrant over palpable pyloric tumour advanced through rectus sheath, sheath, into peritoneum Deliver greater curvature of stomach into woun Split pyloric muscles Rotate pylorus Incise visceral peritoneum over lenght of tumour Using blunt forceps, longitudinal and circular muscles are split down to submucosa Finish Identify any inadvertant leaks (and repair with omental patch) Close abdominal wound with interrupted absorbable sutures Close skin with subcuticular sutures PeritonitisCausesUpper GI Perforated peptic ulcer Lower GI Appendicitis Perforation sigmoid diverticulitis Perforation Hepatobiliary Perforation of Gallbladder Acute pancreatitis Gynaecological Rupture ectopic pregancy Organisms: Bacteroides, E.coli, clostridium, pseudomonas, klebsiella???PeritonismGuarding / rebound suggests strangulation or perforation Continous pain (rather than colic) Tachycardia Dehydration WCC Pyrexia? Rectal prolapsePredispositionAnatomy - continence maintained by 120' pubo-rectalis sling Children; direct downward course of rectum (undeveloped sacral curve) Maldevelopment of pelvis Female - torn perineum (pregnancy) Weak pelvic floor Constipation / straining Diarrhoea (in children) Straining Haemarrhoids ?Classification ??PathologyTreatmentCompleteFull thickness prolapse of rectum through anusWeakness of levator ani Starts at weak anterior wall Protrudes 10-15cm in lenght Contains pouch of peritoneum anteriorly (which can sometimes contain small intestine) Perineal approach Delorme's operation - rectal mucosa removed circumferentially from prolapsed rectum; sutured in "concertina" fashion to reduce prolapse and create ring of muscle within anal canal - narrows orifice and prevents recurrence Abdominal approach Wells operation - rectum fixed firmly to sacrum by inserting sheet of polypropelene mesh between them Suture rectopexy - 4-6 interrupted sutures used to fix rectum to sacrum Incomplete/partial (mucosal)Mucous membrane + submucosa of rectum protrude outside of anusDigital repositioning Phenol submucous injections Excision of prolapsed mucosa Concealed Intersusseption of upper anus into rectumLaxatives / stool bulking agents Dietary modifications Small bowel resectionSmall bowel resectionIndicationsIschaemia, infarction, necrosis Tumour ProcedureGA + NGT + Antibiotics / Supine position Midline incision Deliver diseased segment into wound Protect wound edges (with swabs - minimise sepsis) Apply 2 non-crushing clamps to occlude bowel either side of disease segment Incise peritoneum of mesentery along chosen line for division of vessels (transilluminate, then tie with absorbable sutures) Place crushing clamps at 30' angle to bowel and divide close to clamp - allows better perfusion of anti-mesenteric border Cut across bowel with knife, remove diseased section Cover cut ends with antiseptic soaked swabs If bowel ends do not bleed (usually poor blood supply) - resect until health tissue reached Perform anastamosis (two layers - inner including submucosa + outer lembert stitch) Posterior wall first: seromuscular continous Full thickness suture (double ended) Check anastamosis - if looks dusky; wait, observe Close defect (including mesentry - prevents gut herniation) with interrupted sutrues Close abdominal walSplenectomyIndicationsElective Haematological disorders Part of radical upper abdominal surgery Splenic tumours (Previously - staging of lymphoma) Emergency Trauma PreparationGA NGT Antibiotics DVT prophylaxis Supine position Vaccination against streptococcus pneumoniae 6/52 before elective surgery and ASAP post-operatively in emergency splenectomy + Long-term prophylaxis against pneumococcal sepsis (with PenV - 250mg bd) Elective Procedure(remove spleen and look for speniculi)Incision Left paramedian Midline: for trauma Transverse Left subcostal Divide lienorenal ligament - attaches spleen to kidney (stand on right of patient) Pass hand over spleen onto lienorenal ligament Retract spleen and divide - start from lower end and move towards apex/upper pole using long scissors (obviously!) Deliver spleen up into wound (sweep away peritoneum with swab on a stick) Detach omentum from lower pole of spleen Divide left gastroepiploic vessles between artey forceps + ligation with ties Ligate main splenic vessels Pass fingers around hilum and palpate branches of splenic artery as they pass into spleen; clip + divide branches Remove artery before the vein (if you don't - blood can enter but not leave and you end up in a bloody mess from an exploded spleen) - removing artery "deflates" the spleen (Protect tail of pancreas), left colic flexure and diaphragm Detach gastrosplenic ligament Remove spleen + place suction drain in subphrenic space Close abdominal wall in layers Emergency splenectomy(Aim to preserve spleen if possible - prevents post op splenic sepsis)IV access, resuscitateCorrect coagulopathyCross match lots of blood (4+ units)Evacuate clots (manually + suction) Pass hand down to hilum to control bleeding Assess degree of splenic damage Minor decapsulating injury - managed by application of topical haemostatic agents + wrapping spleen in absorbable mesh Single laceration: suture (splenorrhapy) Complete/partial avulsed fragment: partial splenectomy - divide splenic vessels supplying pole in question, resect the fragment and oversew edge with absorbable mattress sutures Massive irreprable damage: splenectomy Close abdomen Complications of splenectomyGeneral Bleeding Atelectasis of lower lobe Ischaemic perforation of greater curvature of stomach Wound infection / subphrenic abscess Damage to organs causing gastric fistula, pancreatitis, pancreatic fistula Specific Thromobcythaemia (strokes, clots) + leucocytosis - commence aspirin 300mg daily if platelets >750 Infection from encapsulated organisms ?Umbilical hernia repairIndicationSymptomatic hernia (rare) ProcedureStab incision below umbilicus Develop plane Identify hernia sac Divide sac from skin, open sac, reduce hernia Close defect transversely Close defect with interrupted absorbable sutures Orthopaedic SurgeryAnatomy of WalkingHeel strike Stance phase Push off Swing Ankle fracturesWeber classificationCarpal Tunnel syndromeThe Carpal Tunnel???Attachments of flexor retinaculum (palmaris longus inserts into it; proximal edge is at distal wrist crease)tubercle of Scaphoid ridge of Trapezium Hook of hamate Pisiform Superficial:Ulnar nerve and artery (runs in Guyon's canal) ?Deep structures: 4FDS, 4FDP, FPL Median nerve (Flexor carpi radialis runs underneath the flexor retinaculum but lies outside the carpal tunnel CausesIdiopathic Pregnancy Obesity Trauma Systemic disease: myxodema, rheumatoid arthritis, acromegaly, diabetes ManagementHistory Risk factors (above) Examination Tinels tap test positive Phalen's test Investigations Nerve conduction studies Surgical decompression ??Surgical decompression procedureInformed consent, mark correct side LA / Regional / GA Limb exsanguinated + tourniquet, note inflation time Exposure of flexor retinaculum 3cm incision from distal flexor crease (from line ring finger ------) expose flexor retinaculum ?Cut retinaculum Place MacDonald's elevator underneath retinaculum Incise longitudinally down to instrument Median nerve identified (paler in colour, has visible blood vessels called vasa vasorum on surface) Protect motor branch to thenar muscles / palmar cutaneous branch that provides sensation to skin [by staying medially...] Close skin with interrupted nylon sutures Apply light splint DislocationsShoulderElbowHipAnteriorPosteriorKnee?Femoral Neck fracturesConsiderations in Hip anatomyFemoral neck anteverted 10-15', angled approximately 125' Coxa valga > 125; Coxa vara <125' ??Blood supply to Femoral headNutrient artery (profunda femoris) Artery of ligamentum teres (from obturator artery) Retinacular branches of medial (most important) and lateral circumflex femoral arteries (from profunda) ?Attachments of femoral capsule?Femoral Musculature?Movements of the HipFlexion Psoas, iliacus (femoral nerve) Assisted by rectus femoris, sartorius, pectineus Extension Gluteus maximus [inserts iliotibial tract, into gluteal tuberosity of femur // inferior gluteal nerve] Hamstrings (semimembranosus, semitendinosis, biceps femoris // tibial nerve) Abduction Gluteus medius, gluteus minimus (superior gluteal nerve) Adduction Adductor longus, magnus, brevis (obturator nerve) Internal rotation Anterior fibres of gluteus medius and minimus (Weakest) External rotation Gluteus maximus Obturators Gemelli Pyriformis Quadratus femoris ?ClassificationIntracapsular / extracapsular Intracapsular - Garden: based on AP of hip Extracapsular - intertrochanteric, pertrochanteric, subtrochanteric Angulation / alignment Oblique / spiral / transverse Displacement Parts Comminuted Aetiology: trauma, pathological ?Complications of fracturesFrom fracture Avascular necrosis Non-union Malunion Secondary osteoarthritis Damage to surrounding tissues Bleeding - can loose 1-2litres of blood Nerve injury Loss of function DVT / PE Chest infection Pressure sores Surgical Treatment optionsIntracapsular Aim to preserve femoral head if undisplaced, otherwise remove Internal fixation - cannulated screws Replacement of femoral head - hemiarthroplasty Extracapsular Internal fixation ?Surgical Approaches to the HipLateral approach Split tensor fascia lata, gluteus medius, gluteus minimus Detaching greater trochanter [ends up with really bad trendelenburg!] Anterior approach Passess between gluteus medius and minimus laterally + sartorius medially Divide reflected head of rectus femoris to expose anterior aspect of hip joint More room may be provided by detaching gluteii Posterior approach Angled incision commencing at posterior superior iliac spine to greater trochanter split gluteus maximus Detach gluteus medius and minimus from insertion at greater trochanter (or trochanter detached and then re-wired into place) ?Dynamic Hip screw FixationIndications: Extracapsular fractures of #NOF, Garden I-IIMark, consent, X-rays, Image intensifer // GA or regional block Traction table, ensure adequate reduction of fracture (traction + internal rotation) Access bone 15cm incision 2cm from greater trochanter Split fascia lata Expose vastus lateralis; retract or split fibres + lift from bone with periosteal elevator Insert internal fixation Use 135' guide to place guidewire into femoral neck (aim to get into femoral head, just "inferiorly") - tip of wire should sit in subchondral bone of femoral head Measure lenght of insertion Ream with reamer -5mm of measured Insert screw + 4-hole plate to femoral shaft Confirm position with image intensifier Finish Close fascia lata with absorbable sutures Clips to skin Check X-rays post-operatively ?Trendelenburg sign / gaitFailure of contralateral pelvis to rise when weight is taken on the the affected sideCauses:Mechanical Short femoral neck Medial migration of femoral head Neuromuscular Pain Neuropathy Myopathy ?Eponymous fractures??FractureX-ray MechanismTreatment Bennett'sIntra-articular fracture dislocation of base of thumb?MonteggiaFracture proximal ulna + dislocation of radial head?GaleazziFracture distal radius + dislocation of ulna?Colles'?Fracture distal radius through metaphysis (4cm proximal to articular surfaceDistal dorsal angulationUlna styloid?Jones'?Base of 5th MT (insertion of peroneus tertius)??Open fracturesOpen FractureFracture (discontinuity in bone) that is in communication with an epithelial-lined surfaceSkin GIT ?Gustilo-Anderson ClassificationType I: <1cm (inside-out mechanism) wound Type II: <10cm; no soft tissue loss, no periosteal stripping Type III >10cm or with contamination IIIa: extensive soft tissue damage / gross contamination irrespective of wound size (farmyard, GSW) IIIb: soft tissue loss resulting in inadequate amounts of tissue to cover the bone IIIc: neurovascular injury that requires repair to maintain limb viability ?ManagmentATLS principles Airway Breathing Circulation Assess limb Assess neurological function of limb Assess vascular status Examine wound Photograph wound prior to dressing it and attach photo to notes Treatment Cover wound with betadine-soaked dressing Immobilise limb (in POP, gutter splint, cricket pad splint) +/- manipulation of fracture Systemic antibiotics with broad-spectrum cover + tetanus prophylaxis Adequate analgesia Debride within 6-8 hours; should never be closed primarily; re-examine 48h after; close wound when clean with no evidence of necrotic tissue (primary suture, second intention or flapsReplacement ArthroplastyFeatures of an ideal replacement arthroplastyPatient Good range of movement Complete pain relief Implant Mechanical stability Low coefficient of friction Low wear Biocompatible Surgery Secure fixation to skeleton Revisable in event of component failure ?Materials used for manufacturing hip joint prosthesesUltra high molecular weight polyethylene Cobalt-chromium-molybdenum alloys Cobalt-chromium alloys Ceramic? ?Surgical OptionsTotal hip replacement Hip resurfacing ComplicationsInfection Minimised by pre-operative antibiotics Anti-microbial loaded cememnt Laminar airflow ventilation in operating room Thorough scrubbing, use of disposable gowns, changing gloves and good skin preparation Gentle handling of tissues, adequate haemostasis and good suturing techniques Optimisation of tissue oxygenation Component failure Dislocation Mechanical loosening Minimised by dry operative field with adequate haemostasis Pressurised cement (tighter fit) Cement restrictors Lavage systems Aseptic loosening Microfracture of components Leads to small particulate matter in joint Incites inflammatory reaction leading to cysts and loosening Metal sensitivity? Plastic SurgeryReconstructive surgerySurgical reconstructive ladderSecondary intention Direct closure Skin graft Flap: local / distant / composite / island flaps Tissue transfer ?Factors affecting reconstructionPatient Motivation Health Healing factors - nutrition, vitamins Donor site cost vs benefit Wound / defect Size and complexity Anatomy and blood supply/vascularity Availability of local tissue Timeframe (ie. open tibias should be closed pretty quickly - innit?) ??Skin graftSkin transferred from one location to another on same individual Consists of epidermis + variable amounts of dermis "Takes" by acquiring blood supply from health donor bed Independent of blood supply (see skin graft - which needs it's blood supply) ?Split thickness (STSG)Full thickness (FTSG)AnatomyEpidermis + variable amount of dermis Harvested using dermatome (Watson & braithwaite modifications of Humby knife) or gas-powered dermatomes Epidermis regenerates from "adnexal elements of skin" - hair follicles, sebacous glands and sweat glands Dermis does not regenerate ?Epidermis + dermis Preserved skin characteristics (more collagen content, dermal vascular plexuses, epithelial appendages) (Skin cannot grow back and donor site needs to be closed primarily) AdvantagesLarge areas can be covered (skin can be put through mesh) Less likely to fail Less contraction at graft site (important for hands and joints - that need movement) Better cosmesis DisadvantagesIncreased graft contraction at donor site Poor cosmesis Creates second wound at donor site which needs caring for Donor site must be primarily closed More likely to fail because of greater amount of tissue requiring vascularisation Recipient sitesAny large wound Line cavities Resurface mucosal defects Close flap donor sites Resurface muscle flaps ?Donor siteAny part of body but in particular areasEasily concealed by clothing Position of easy post-operative care Capable of providing adequate tissue ?Upper thigh, upper inner arm, scalp, buttock ?Skin FlapTissue/tissues transferred from one site to another maintaining a vascular pedicle Classification of skin flapsSite Local Distant: Free flap Contents Tissue capable of transfer Random / axial Not based on an artery Based on an artery ?Renal transplantIndications?TypesCadavericLive-donor Needs HLA matching (as does pancreas) ?ProcedureCurved muscle-splitting incision in contralateral iliac fossa where donor kidney is implanted Donor vein anastamosed to external iliac vein (end to side) Donor artery anastamosed to external iliac artery (end to side) including patch of donor aorta (Carrel patch) Ureter anastamosed to dome of bladder + JJ stent Complications90-95% survival rate for living related donors 85% for cadaveric donor kidneys at 12 months 75% total graft survival rate at 5 years?Liver transplantIndications??ProcedureBilateral subcostal incision madef with upward extension to xiphoid process Diseased liver mobilised, IVC clamped and liver removed (Patient on veno-venous bypass - IVC blood directed back to heart via cannula in axillary/internal jugular vein) Portal veins anastamosed end to end Common hepatic arteries anastamosed end to end CBD anastamosed end to end UrologyCircumcisionIndicationsMedical Phimosis (intractable foreskin) - congential adhesions, poor hygeine, balanitis causing foreskin to become thickened and tight Paraphimosis (trapped foreskin behing the glans) Recurrent UTIs Non-medical Contraindications?Hypospadius ProcedureInformed consent, prepared Supine position, GA / LA dorsal penile block Free foreskin from glans with forceps Pull foreskin down over glans; apply straight forceps, divide between forceps to ~5mm of corona Incise laterally, circumferentially towards frenulum Excise Transfix frenulum Two layers of skin brought together with interrupted absorbable sutures Loose vaseline dressing + "sporan" Plastibell (Hollister) technique ?ComplicationsImmediate Bleeding / haematoma Infection Urine retention Glans injury Ischaemia / necrosis of penis Late Poor cosmesis Urethrocutaneous fistula Meatal stenosis Psychological morbidity Hydrocoele(Canal of Nuck = female equivalent of processus vaginalis, projecting into labium majora)??IndicationsSymptomatic swelling in adults?ProcedureGA + supine position Access tunica Stretch scrotal skin Incise between visible vessels using either knife or cutting diathermy Evacuate fluid Make small incision in tunica vaginalis Evacuate the fluid Repair hydrocoele Jaboulay [tie off sac at apex]: using absorbable sutures, stitch edges of tunica behind cord and subsequently return testis to scrotum Lords [tie off sac around testis]: using series of interrupted catgut sutures bunching up remaining sac around testis before tying sutures and returning the testis to the scrotum. Close wound with interrupted absorbable sutures NephrectomyIndicationsMalignancy [renal cell carcinoma] TCC of ureter requiring nephro-ureterectomy Non-functioning kidney Chronic pyelonephritis Possible approachesOpen Anterior/Transperitoneal Posterio-lateral/Retroperitoneal Laparoscopic Transperitoneal Retroperitoneal? Procedure (Right nephrectomy - Anterior/peritoneal approach)CT scan + confirm presence of opposite kidney (otherwise you're in big shit) + mark side + consent GA + supine Kocher's subcostal incision identify hepatic flexure, duodenum, gonadal vessels Mobilise colon medially: display perinephric fat Identify kidney (surrounded by paranephric fat), ligate vascular pedicle (prevents dislodging of tumour cells into circulation) Identify vascular pedicle Clamp renal artery Palpate renal vein; ligate and divide Divide renal artery Mobilise kidney within fascia (Gerota's, surrounds perinephric fat) Divide ureter at accessible point Remove kidney with perinephric fascia intact Place suction drain Close wound in layers ?Procedure - Posterio-lateral approachLateral decubitus position + renal bridge on operating table under contralateral loin. Subcostal incision along line of 12th rib: Midline -> posterior axillary line (ie, quite large) Divide layers: skin / lat dorsi / ext obl / int obl / quad lumb / > kidney ?Laproscopic nephrectomyDissect out Bring to surface Make skin incision to deliver ComplicationsEarly Wound infection Bleeding Haemorrhage General - DVT, Chest infection, PE Late Tumour reccurrence OrchidectomyIndicationsMalignancy Suspected malignancy Orchidectomy ProcedureConsent + marked + GA Access testicle via inguinal route (reduced risk of scrotal seeding) Inguinal incision 2cm above and parallel to medial 2/3 of inguinal ligament Incise through campers fatty fascia, scarpa's fascia to external oblique Split external oblique Free spermatic cord Apply 2 artery forceps to cord at deep ring (to prevent tumour dissemination) Remove testicle Divide cord between clamps, tie with non-absorbable sutures Manipulate testis into inguinal region,free from gaubernaculum by blunt dissection Remove and send for histological analysis Finish Close external oblique aponeurosis with absorbable sutures Close skin with subcuticular suture Apply scrotal support Prostate??Treatment options for prostatic hypertrophyConservative measures: fluid restriction, reduction caffeine intake Pharmacotherapy: alpha blockers (alfuzosin, doxzosin) - inhibit smooth muscle contraction 5-alpha-reductase inhibitor (finasteride) - block conversion of testosterone to DHT which limits size of prostate Surgical intervention Transurethral resection of the prostate (TURP) Transurethral incision of prostate for BOO Open retropubic prostatectomy - prostates > 80g in weight Transurethral microwave thermotherapy (TUMT) Transurethral needle ablation of the prostate (TUNA) Indications for prostatic surgeryAcute retention (where there is no other cause) / Chronic retention with evidence of renal failure Recurrent haematuria, urinary tract infection Voiding difficulties (hesitancy, poor flow, dribbling, incontinence) instability (frequency, urgency, incontinence) Principles of Prostate surgeryProstatectomy = removal of hyperplastic mass of glandular tissue from surrounding prostatic gland which is compressed into a thin rim around itApproaches: (1) transvesically across bladder (2) retropubically?through prostatic capsule (3) transurethrallyin TURP, surgeon keeps proximal to verumontanum (colliculus seminalis) in order not to damage the urethral sphincter mechanism???Complications90% success rate 1/6 require re-operation in 6 years Retrograde ejaculation (70%), impotence 20%, erectile dysfunction 5-10% Urethral strictures may be secondary to prolonged catheterisation / infection Incontinence normally up to 3 months Bleeding / infection common TUR syndrome - dilutional hyponatraemia secondary to excessive absorption of irrigation fluid intra-operatively TUR syndromePathogenesis: 20ml/minute fluid (isotonic glycine) can be absorbed with 1/3 absorbed into venous system directly (from exposed ends)Risk factors (1) large prostate (2) long operation (3) high pressure irrigation (4) pre-operative hyponatraemia Features: (hyponatraemia - swollen brain cells) - confusion, nausea, vomiting Fluid overload - pulmonary oedema Convulsions, coma Symptoms occur generally when Na < 125 mmol/l Up to 50% mortality rate Treatment: support - O2, IV access, oral diuretics, fluid restrict Suprapubic catheter / cystotomyIndications?ProcedureTesticular TorsionDifferential DiagnosisTesticular torsion Torsion of testicular/epididymal appendage Orchitis - mumps / epididymo- Incarcerated hernia Hydrocoele ManagementHistory Examination Investigations Scrotal USS: can demonstrate flow of blood in testicular artery. Poor negative predictive value Treatment When suspected immediate exploration is indicated within 8 hours (after 8 hours, infarcted testis is unlikely to recover Surgical ApproachAccess scrotum Skin, dartos, external spermatic fascia, cremasteric fascia, internal spermatic fascia, tunica vaginalis/albuingea, testis ("Some damn Englishman called it the testis") Assess testicle for viability Release torted testis Wrap in warm soaked gauze for 10minutes Fix other testicle Explore contralateral hemiscrotum Insert 3point fixation for testis to tunica vaginalis Close with non-absorable sutures If viable, fix; if not viable clamp, ligate and remove UreterRepair of damaged ureterDirect spatulated ends (plus JJ stent insertion) Implant onto contralateral ureter Boari procedure VaricocoeleVaricocoeleAcute onset often due to left renal vein compression from renal cell tumour More common on the left Associated with oligospermia ?IndicationsMale infertility Scrotal discomfort Treatment optionsRadiological embolisation Laproscopic division of varicocole from within peritoneal cavity Surgical approach at level of internal ring Surgical ProcedureGA + supine Dissect down to testicular vein Make incision over internal ring parallel to inguinal ligament Divide external oblique aponeurosis, visualise cord and split spermatic fascia longitudinally to expose testicular veins (from pampiniform plexus) Isolate and divide vein Separate vein from vas and testicular artery Ligate and divide with absorbable sutures Close Repair external oblique aponeurosis with absorbable subcuticular suture close skin incision with subcuticular non-absorbable suture VasectomyIndicationsMale sterilisation (between 28-45) with stable marriage with family of 2+ children Considerations - Irreversible (reversal can be attempted in first 5 years but cannot always restore fertility - production of antisperm autoantibodies) Sterilisation not immediate - must provide x2 post op negative counts (at 3 and 4 months), so must continue with barrier contraceptives Recanalisation can occur; unpredictable fertility 1/1000 cases ?[Contents of spermatic Cord]3 Nerves: genitofemoral, autonomics, cremasteric [NB ilioinguinal nerve lies on outside] 3 Arteries: Testicular, ductus, cremasteric 3 Other: Vas, pampinoform plexus, lymphatics ProcedureLA, supine position Locate and fix vas (grab scrotum and roll between fingers) Infiltrate local anaesthetic 1cm incision into scrotum (Skin, Dartos, ExtSpFasc, Cremaster, IntSpFasc, Tunica, Testis) in direction of vas Dissect out vas with tissue forceps, pass forceps under vas to separate from coverings Divide vas, turn ends backwards and tie ends Bury lower end deep in scrotum to minimise risk of re-joining Close with interrupted stitches ?Vascular SurgeryAmputationsIndicationsDead: ischaemia (atherosclerosis), gangrene, infection (clostridium), trauma Deadly: tumours of bone (osteosarcoma) / soft tissue (malignant melanoma) Dead weight (excess fingers/toes) Aim is to produce most practical/functional limb for prosthetics - therefore through knee (Gritti-stokes) are not favoured.Through knee - when previous orthopaedic surgery precludes it (ie, long intramedullary femoral nail)?Can be performed under GA / LADouble check side of operation Isolate areas of gangreneGenerous flaps can be trimmed laterIf tissue does not bleed (it will not heal properly) - therefore move proximally with amputationMobilise early to avoid contractures ?WorkupPatient Condition and mobility of patient (AKA more easy to transfer bed-bound patient) Ability for patient to be rehabilitated Psychological counselling Disease Pathology / severity of disease Viability of flaps Health-care related OT / Physiotherapy Limb fitting / prosthetics (end-bearing amputation may be suitable to allow simple prosthesis) Deciding level of amputationJoint contractures - AKA Severely reduced mobility - AKA affords better transfer, less risk of stump pressure sores Knee OA - AKA Infection Viability of distal limb? Types of AmputationUpper limb Upper arm Supracondylar (above elbow) Extraarticulation (thorugh elbow) Proximal forearm (below elbow) Distal forearm Wrist Metacarpophalangeal Proximal interphalangeal Distal interphalangeal Lower limb Hindquarter Above knee - equal anterior-posterior flap Supracondylar Through knee (Gritti-stokes) Below knee - long posterior flap Symes (Tibia/Talus) Chopart (Talus/Navicular) Lisfranc (Navicular/Metatarsal) - posterior plantar flap Transmetatarsal Ray Above knee amputationOne hand's breadth (8-10cm) above upper border or patella: site of femur division Equal length flaps Divide skin + tissues along planned lines Divide soft tissue Ligate veins using2/O absorbable suture Deepen incision to bone Divide quadriceps tendon (to patella) Divide hamstrings posteriorly Double-Ligate femoral artery Apply tension to nerves before ligating so they retract (femoral/sciatic) Retract thigh muscles Divide Bone Divide femur, remove lower leg, place clean towel under stsump Smooth edges of femur using a rasp + bone wax (stop bleeding) Close defect Bring anterior-posterior muscles together using 1/O interrupted sutures Place suction drain under muscle layer Place second layer of sutures in superfical muscles Suture skin edges with interrupted 2/O sutures Cover stump with gauze + crepe bandage ?Below knee amputation14cm from tibial plateau: tibial division / 12cm from tibial plateau: fibular division 2cm proximal Burgess Long posterior myocutaneous gastrocnemius flap (extending down to achilles tendon) Robinson skew flap when posterior flap area compromised Incise along marked lines Divide soft tissue Divide achilles tendon posteriorly Divide posterior muscles Ligate vessels, divide (ie. don't tie them) nerves Divide Bone Cut fibula obliquely (with Gigli saw) + divide tibia 2cm distal to this Clear muscle off bone with periosteal elevator Close defects Oppose muscle flaps + suture Unite skin edges with 2/O interrupted Trim edges Apply crepe/cotton-wool bandaging Allows for pressure to be put on stump with smaller risk of dehiscence?ComplicationsEarly Haematoma Wound infection Dehiscence, flap necrosis DVT / PE Phantom limb pain Late Neuroma Bone spurs Stump ulceration Psychological distress AneurysmAneurysmD: Abnormal localised dilation of a blood vessel ?ClassificationCongenital / Acquired: Berry aneurysm (art. circle of Willis) hypertension True / False: Full thickness (all three layers) partial (outpouching of intima) Shape: Fusiform (entire circumference) saccular (part of circumference) dissecting Cause: Atheroma, syphillis, trauma, inflammatory (PAN, Ank Spond), Iatrogenic, ischaemic, congenital, mycotic (following low grade infection), hypertension (Charcot-Bouchard aneurysm) Anatomy: Ascending aortic aneurysm Descending - supra-renal (blood supply to gut, spinal cord), infra-renal ComplicationsThrombosis Embolus Haemorhage Pressure effects - nerve, vertebral column Fistulation Indications for screeningAll patients with risk factors should have USS at 65 years Small aneurysms (4-5.5cm) should undergo ultrasound surveillance at 6 month intervals Indications for surgeryEmergency Rupture Elective Symptomatic aneurysm Rapidly expanding > 5.5cm ?Elective mortality is 2-5%?Management of Ruptured aneurysmResuscitation / stabilisation Large bore cannulae, IV crystalloid, maintain relative hypotension (90-100 systolic) Urinary catheter - UO Adequate analgesia Bloods: FBC, U/Es, LFTs, Amylase, Cross match 8 units of blood + FFP + platelets Contact most senior surgeon / dedicated vascular team + anaesthetist Arrange ITU bed Surgery if unstable, imaging if stable (CT) Risk of death - 50% survive to hospital, 25% die before operation Operative complications - limb loss, ischaemic gut, renal failure Aneurysm repair procedureGA, supine, exposed groins (for embolectomy) Access aorta Long midline incision from xiphisternum to pubis, skirt left of umbilicus Omentum, large bowel displaced superiorly Pack small bowel to right Duodenum displaced Peritoneum dissected off aorta Give IV heparin Repair aneurysm Clamp across neck and lower end of aneurysm sac Incise sac longitudinally Scoop out thrombus, atheromatous material End-to-end anastamosis with prosthetic graft using prolene sutures Test repair Soft clamp applied below sleeve, release upper clamp Repair lower end of anastamosis Closure Remove clamps (warn anaesthesist - may get hypotension) Ensure haemostasis Close aneurysm sac around repair Close posterior peritoneum (avoids fistulation) Mass closure of wound using looped 0-nylon/PDS Close skin with clips Go to intensive care - watch for complications Vascular: haemorrahge, graft thrombosis, false aneurysm, distal embolism Neurological: CVA, spinal ischaemia GIT: ischaemic gut, aorto-enteric fistula, pancreatitis Renal: ARF Respiratory: ARDS Cardiovascular: MI Haematological: DIC Endovascular stentingMinimally invasive interventional radiology Catheter places metal stent inside aorta Indications: Patients unsuitable for open surgery Infra-renal aneurysms Anatomy: proximal and distal neck of arteries must allow complete exclusion of aneurysm Endovascular stenting procedureGA / regional Access femoral artery Pass graft over guidewire Deploy graft once in position Graft achieves final shape through elasticity / thermal memory ComplicationsInfection Leakage Fracture of graft Graft migration Graft occlusion? Arterial bypass surgeryExamplesFemoral-popliteal Femoral-distal Axillo-femoral Femoral-femoral Types of graftNative Reverese autologous long saphenous vein graft Insitu long saphenous vein graft (disrupted with valvulotome) Synthetic PTFE Dacron ComplicationsBleeding Infection: wound, graft Suture line aneurysm Graft failure: thrombosis Carotid endarterectomyIndicationsTIAs in distribution of artery (middle/anterior cerebral territory) ?PreparationCarotid duplex: extent of stenosis Carotid angiogram Echo, cholesterol, ECG, CT brain (previous CVA) ??ProcedureLocal anaesthetic block / intercostal block (allows monitoring of neurological status intra-operatively) - enables operation without a shunt GA allows for better airway control, requires shunt + EEG Incision over sternocleidomastoid (oblique) Dissect down to common carotid, external, internal carotid Tape looped around external carotid for control Heparin infused, longitudinal arteriotomy into carotid distal to site of stenosis Plaque removed distal to proximal in one piece Close arteriotomy with graft/patch (avoid problems of stenosis) with full thickness sutures (+ removal of shunt) + irrigate with heparinised saline ComplicationsNerve injury - recurrent laryngeal, hyoglossal (12) nerve Haematoma Hypertension / hypotension (carotid body effects) Stroke (1-5%) Follow up6 month surveillance scans Femoral EmbolectomyIndicationsAcute limb ischaemia WorkupCoagulation screen Test foley catheter beforehand Performed under LA/GA??ProcedurePalpate femoral artery (mid inguinal point) Longitudinal incision over skin Deepen down to femoral artery Sling around CFA, SFA, Profunda Angled vascular clamp on each of three main vessels Transverse (risk of dissection) or Longitudinal (risk of stenosis) arteriotomy into femoral artery Pass catheter proximally up aortic bifurcation; inflate balloon (avoid overdistension - damages intima), withdraw any clot (assistant tightens tape to prevent bleeding) Send clot / embolus for histology - never know what is is! When good inflow, inject heparinized saline up vessel + reapply clamp If unable to achieve good back bleeding - do on-table angiogram If unable to achieve good inflow - get help Repeat on SFA, PFA Repair arteriotomy (5/O non-absorbable) Remove clamps, tapes, check haemostasis Insert suction drain Close wound Check + document pulse / clinical condition of limb ComplicationsDissection Perforation of vessel Amputation? Varicose veinIndicationsSymptomatic veins Cosmesis Varicose ulceration Lipodermatosclerosis ?Pre-operative workupHand-held doppler - confirm superficial reflux Venous duplex imaging +/- junction marking - demonstrates incompetent perforators, deep veins Mark veins pre-operatively with indelible marker ?TributariesSuperficial inferior epigastric Superficial circumflex iliac Superficial / deep external pudendal Lateral / anterior cutaneous vein of thigh? ?Risk factors - any cause of obstruction: DVT, pregnancy, running, malignancy, smoker??Trendelenburg operationGA, supine 1.5cm incision lateral and below pubic tubercle (site of SFJ) - 4cm in groin crease Dissect tributaries of SFJ (superficial inferior epigastric, superficial circumflex iliac, deep/superficial external pudendal) Ligate and divide tributarie Ligate SFJ Pass stripper down LSV to knee Stab incision over stripper and deliver Strip vein back to groin Close incision Avulse local varicosities in lower calf Apply compression bandaging ComplicationsHaematoma Recurrence (up to 20%) Saphenous nerve injury - loss of sensation medial thigh Short saphenous vein?Transverse skin crease incision Dissect down to SSVJ Tie off junction (avoid sural nerve lateral to SPJ) ?Other surgical optionsEndovenous laser ablation Ultrasound guided foam sclerotherapy (risk of thrombosisParotid gland surgery??IndicationsBenign tumours confined to superifical part of parotid gland Superficial parotidectomy ProcedureGA + supine + slight head-up tilt Dissect down to parotid S-shaped pre-auricular incision (as close to ear as possible to avoid facial nerve) extending unde the ear and down anterior border of SCM Incision curved around ear lobe to extend for 2-3cm into postauricular groove Angled acutely over mastoid to be continous with cervical part of incision Deepen incision down to bony external auditory meatus Deepen through subcutaneous fat, platysma to stylohyoid muscle (anterior branch of great auricular nerve usually sacrificed - causes parasthesia of earlobe) Identify branches of facial nerve Reflect parotid forwards Dissect divisions and branches of facial nerve (TZBMC) Dissect out parotid duct, ligate Raise skin flaps superiorly to just above zygomatic arch, anteriorly to anterior border of masseter muscle and inferiorly to anterior border of SCM Parotid duct dissected forwards as far as anterior border of masseter muscle, then ligate and divide [normally opens 2nd molar] Remove superficial parotid Close Ensure haemostasis Close skin with subcuticular suture ComplicationsBleeding / haematoma Infection Damage to facial nerve Salivary fistula Frey's syndrome: gustatory sweating, hyperhidrosis, pain, flushing in distribution of auriculotemporal nerve. Thought to be due to disorganised post-ganglionic sympathetic fibres and preganglionic parasympathetic fibres following trauma Parotid duct stomatoplastyIndicationsObstructive parotitis GA + supine position Nasophryngeal ETT Mouth kept open with dental prop, tongue retracted to contralateral side by assistant Identify parotid papilla (opposite upper 2nd molar) Insert 2 stay sutures above and below papilla Pass dilator through parotid duct and then incise longitudinally down to dilator Surgical airwayTracheostomyIndicationAirways obstruction Protection from aspiration (decreased consciousness, GBS, tetanus) Prolonged intubation / long-term ventilation Facilitate airways suction ?Types of TubingMetal / plastic Cuffed (reduces risk of aspiration) / uncuffed (used in children - as risk of mucosal ulceration) Windowed - permits speech ?Open ProcedureETT intubation + GA Sandbag beneath shoulders to maintain neck extension Transverse skin incision midway between cricoid cartilate and suprasternal notch Separate pretracheal muscles Divide thyroid isthmus between clamps + oversew Tracheostomy between 2nd and 4th rings: (1) Bjork flap opens inferiorly (2) vertical slit Insert tube, secure ??Percutaneous procedureMore rapid, less traumatic, doesn't need surgeon/anaethestistLA + fibre-optic bronchscopy to aid insertion Small skin incision between cricoid / sternal notch 14G cannula Guide wire through Remove cannula Ram Rhino dilator over guidewire to make a big hole Pass tracheostomy over guidewire Secure in place, get a CXR Complications:Nerve, vessel damage, pleural injury Stenosis if incision too high Tracheo-inominate fistula if too low Bleeding Displacement Blockage Infection Mucosal ulceration ................
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