General Principles
Incisions & Closures
Purpose of incision



Access
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 Incisions










Transverse: (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 closure




Edges 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 options
1. Heal by primary intention
2. Heal by secondary intention +/- VAC, large surface area wounds, large cavitating
wounds
3. Delayed primary closure
4. Steri-strips
5. Tissue glue
6. Skin staples
7. Sutures
o Subcuticular - good cosmesis, suitable for clean linear wounds
o Simple interrupted
o Vertical mattress
o Horizontal mattress
Pre-operative preparation
Pre-Induction




Identify patient, operation, site, side, starved, allergies
Check blood available
Check investigations
Check imaging
Removal of body hair




Remove from operative field
Allow for clear surface for application of dressings
Perform on morning of surgery
Care to avoid cuts/abrasions
Skin preparation


Apply to operative field with wide margin (in case need to extend incision)
Start at focus and move around
1. Chlorhexidine (0.5%)
2. Alcoholic betadine (1% povidine in 70% alcohol)
Field Draping



Sterile linen drapes
Disposable fabrics (impermeable and waterproof), expensive
Polyurethane incisible drapes (clear stuff) used in orthopaedics/vascular, general
surgery - limited by cost
Trauma / ATLS
Management of Trauma
Urgent and competent assessment of trauma
Treat life-threatening injuries first
Improve survival and outcome in "golden hour"
1. Primary Survery
o Airway
o Breathing
o Circulation
o Disability
o Exposure, temperature control
2. Monitoring
o ECG, Pulse oximetry, BP
o Urinary catheter (unless contraindicated)
o NGT
3. Radiology
o CXR
o Lateral C-spine
o AP Pelvis
4. AMPLE history -Allergies, Medications, Past medical history, Last meals, Events
surrounding injury
5. Secondary survey
o Full head-to-toe assessment
o Can be delayed until all life-threatening injuries have been dealth with
Surgical Equipment
Scalpel Blades
10 - General use
11 - Pointed, for arteriotomy
15 - Smaller minor ops
22 - Big mother
23 - Curved
Scissors
Mayo's: curved dissecting scissors
McIndoe
Pott's (for arteriotomy)
Stitch cutter
Clips
Mosquito
Dunhill
Roberts (big ones)
Spencer-Wells
Forceps
DeBakey's
McIndoe's
Babcock's
Retractors
West self-retaining
Travers
Norfolk & Norwich - Big self-retaining
Langenbeck
Devers retractor
Senn retractor (cat's paw)
Hohmann's
Breast & Endocrine
Adrenalectomy
Indications




Phaeochromocytoma
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 adrenalectomy
1. Supine + GA + Prepare/drape
2. Transverse supra-umbilical incision made with upward convexity
3. Access adrenal gland
o Mobilise right colic flexure, retract downwards, retract liver upwards
o
o
Incise posterior peritoneum above level of upper pole of right kidney
Expose IVC, right adrenal gland
4. Dissect / remove adrenal gland
o Separate from kidney and perinephric fat / fascia
o Dissect off IVC
o ligate vessels
o Dissect out
5. Ensure haemostasis
6. Close wound in layers
Post-operative considerations


30mg po hydrocortisone/day
Fludrocortisone 0.1mg/day
Breast disorders
Development / anatomy




Modified 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
1. Axillary artery (2nd part, lateral thoracic arter)
2. Internal thoracic artery
3. Intercostal arteries

Nerve supply
1. Intercostal nerves T4-T6

Lymph drainage
Axillary nodes - 75%
1. Level 1: lateral to pectoralis minor (14 nodes)
2. Level 2: posterior to pectoralis minor (5 nodes)
3. Level 3: Medial to pectoralis minor (2-3 nodes)
Internal mammary - 25%
[Anatomy of axilla]
Congenital / Developmental disroders




Athelia / 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)
Gynaecomastia

Abnormal breast enlargement
1. Female
2. Male
o
o
Physiological: neonatal, pubertal hormone imbalance
Pathological: hypogonadism, neoplasms, drugs - cimetidine, spironalactone,
ketoconazole, digitalis, oestrogens
Aberrations of normal breast development and involution (ANDI)
Tumour
Fibroadenoma
Pathology
Features


Aberation of
development;
Well
circumscribed
Management


FNA/Biopsy
Mammography /


Phylloides
Tumour

Cystic disease





Sclerosing
leions
Epithelial
hyperplasia





15-25 years
Develops from
single lobule of
breast (rather
than single cell)
Hormone
dependance
(lactating during
pregnancy,
involuting in
peri-menopausal
period)

smooth firm
lump
May be
multiple/bilat
eral


FNA / Biopsy
Rx: Complete
excision - risk of
recurrence
Discreet,
smooth lump,
may be
fluctuant (like
all cysts)


Aspirate fluid
Mammography if >
35years
Rx: Excision biopsy
Radial scars
present via
screening
Potential
underlying
breast cancer

Mammography +
excision biopsy
breast lump


FNA / NCB
Rx: Excision biopsy
+ screening
(increased risk of
breast cancer)
Arise from peristromal tissue
40-50 years
More common
in African
countries
Common 35-55
years
Macrocysts ~7%
women in West
Unknown cause

Aberration of
involution sclerosing
adenosis,
papillomatosis,
duct adenoma

Epithelial cell
increase in
terminal duct
lobular unit
Common premenopausal
women
If atypia plus
hyperplasia
increased risk of
breast cancer
Atypical ductal
or lobular cells
x4-5 greater risk
of breast cancer



ultrasonography
Rx: Reassure /
remove if large
>2cm on request

Breast pain / inflammatory lesions
Pathology
Features
Treatment
Mastalgi Cyclical Mastaliga
a
 Young women (Any age up to
menopause)
 3-7 days pre menstrual cycle
 Improves at menstruation
 Usually lateral part of breast
affected


Non-Cyclical Mastalgia





Older women (45+)
Breast Lactating
abscess
 Mastitis neonatorum - first
few weeks of life
 Infected enlarged breast bud
 Caused by s.aureus / e.coli

Non-Lactating
1. Peri-areolar
o Complication of
periductal mastitis
o More common than
lactating breast
abscess
o 35yrs
2. Peripheral
o Ass: DM, RA, Steroids,
trauma
3. Periductal mastitis
o Bacterial / cigarette
smoking / AI basis
Complications of Abscess
1. Duct ectasia: dilatation
without inflammation


Nipple
discharg
Breast pain
Retraction /
inversion
Weight loss
Supportive
bra
Evening
primrose oil
NSAIDs
Supporting
bra
Weight loss

Rx:
Antibiotics /
I&D



Antibiotics
Aspiration
I&DS
2. Duct fistula: -
Benign Neoplasms

Duct
papilloma


Common
Single / multiple

Soft lobulated
radiolucent
lesion
Lipoma

Usually small,
symptomless
Bloody
discharge if
duct
involvement


Mammography,
ductography
Rx: Microdochectomy
Nipple discharge
1.
2.
3.
4.
White = 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)
Mangement
1.
2.
3.
4.
Haemo-stix
Cytology
Mammography / USS
Ductography / ductoscopy (washings can be taken for cytology)
Breast Cancer: Aetiology & Clinical features
Risk factors: OESTROGEN EXPOSURE
1.
2.
3.
4.
Age
Early menarche, late menopause, nulliparity
Diet / obesity (fat turned into oestrogens/phyto-oestrogens)
Drugs: OCP, HRT
5. Smoking
6. Family history + Genetics: BrCa1 (17q), BrCa2(13q)
Linear increase with age
Clinical features
1. From the lesion
o Painless breast lump +/- lymph node involvment (I-III; relative to pec. minor)
o Hard lump with poorly defined margins
o Skin tethering or fixation to underlying structures
o Pain / skin ulceration "peau d'orange" - due to involvement of suspensory
ligaments of cooper
o Nipple discharge / retraction
2. Systemic features
o Weight loss
o Ascities
3. Features of spread
o Bone pain / pathological fractures
4. Paraneoplastic manifestations
Diagnosis
1. History (including risk factors)
2. Examination - "Triple assessment"
3. Investigations:
o Blood tests: Tumour markers Ca 15-3 (mucin marker)
o Imaging: Mammography, Ultrasound (if young pair of titties)
4. Tissue diagnosis
o FNA / NCB - 95% pre-operative diagnostic sensitivity
FNA
Cytology
NCB
Histology
H1 C1 Normal
Inadequate
H2 C2 - Benign
Benign
C3 H3 Equivocal
Equivocal
C4 H4 Suspicious
Suspicous
C5 H5 Malignant
Malignant
o
Excision biopsy
Pathology
1. Epithelial cell origin
1. Non-invasive
 DCIS - cured by total mastectomy
 LCIS
2. 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
2. Connective tissue origin
Prognostic indicators
1.
2.
3.
4.
5.
Node positive = <20% survival
High Grade (1-well, 3-poor)
Size
Vascular invasion
Oestrogen receptor: based on H (histochemical score) out of 300
o H Score > 50: Receptor positive
o 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% survival
NPI > 5.4 - poor: 15 8% survival
Grading
Bloom & Richardson grading system
Based on tubule formation, nuclear pleomorphism ("many different forms"), and
mitotic activity
1. Grade 1: Well differentiated
2. Grade 2
3. Grade 3: Poorly differentiated
Tissue Staging

TNM system
T - Tumour
N - Node
MMetastasis
0 Subclinical
No nodes
No mets
1 <2cm
Ipsilateral axillary
(mobile)
Distant mets
2 2-5
Ipsilateral axillary
(fixed)
3 >5
Ipsilateral mammary
4

Any size with (a) chest wall or (b) skin
extension
Manchester system / Columbia system
TNM Manchester
- T1
- N0N1
Columbia
Stage 1
o
o
Confined to breast < 5cm
With or without skin involvement
Stage A
Stage 2
T2N1b
o
o
Confined to breast <5cm
Nodes involved but not fixed
Stage B
Stage 3
T3-T4
N2-N3
o
o
Locally advanced disease >5cm
Affects underlying muscle/overlying skin or fixed lymph
nodes
Stage C
Stage 4
M1
Stage D
o
Distant metastatic disease (lung, liver, brain, bone)
Managment
1. Diagnose
o Triple assessment: high positive predicitive value and prevents erros in
diagnosis
2. Stage disease
3. Good cosmesis
1. Surgery
o
o
o
o
WLE / Quadranetectomy / Segementectomy
Remove tumour + adequate resection margins (>5mm margins)
Adequate skin flaps for cover
Breast reconstruction: pedicled flaps, free flaps (DIEP)
2. Axilla
o
Level II (up to medial border of pec minor) clearance accepted as best
balance between adequate staging and morbidity
o Sentinel node technique - finds first draining node (technetium + blue dye);
contra-indicated in pregnancy [NB also has use in melanoma and penile
cancer]
o 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
3. Hormonal therapy
o 1st Line: Tamoxifen (Selective oEstrogen Receptor Modulator (SERM)) reduce circulating oestradiol
o 2nd Line: Aromatase inhibitors (Anastrazole[Arimadex], fromenstane,
aminogluthethimide) - block oestrogen via aromatase pathway
o LHRH antagonists (Goserelinp [Zoladex] - prevents oestrogen production by
ovaries
o 3rd Line: Progesterone
4. Chemotherapy
1. Antimetabolites (impair production of DNA):5-FU, Methotrexate
2. Vinca alkaloids (inhibit microtubule formation): Vincristine, vinblastine
3. Alkylating agents (bind to and disrupt DNA): Cyclophosphamide
4. Platinum-based agents
Radiotherapy
Follow up
1. Early detection + treatment of recurrence
o Local recurrence: - single spot,
o Regional recurrence: axilla, brachial plexus, supraclavicular nodes
o Distant mets
2. Early detection of metastatic disease
3. Psychiatric morbidity
Excision of a breast lump
Indications


Benign lump
Possibly malignant lump
Procedure
1.
2.
3.
4.
5.
6.
Fix 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)
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
Explain 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
Microdochectomy
Indications
Persistent blood-stained discharge from single duct opening on nipple
Procedure
1. GA/LA
2. Identify duct
o Squeeze breast until drop of discharge seen
3. Cannulate duct
o Use lacrimal probe and secure in place
4. Incise skin along line of probe, encircling duct orifice
5. Dissect skin of areola away from breast tissue (for 1cm)
6. Excise breast segment
7. Secure haemostasis with diathermy + approximate breast tissue with interrupted
absorbable sutures.
Modified Patey Mastectomy
Indications
Cytologically proven breast carcinoma
Preparation
GA
DVT prophylaxis
Supine position + arm on armboard
Procedure
1. Mark boundaries for skin incision
o At least 3cm from tumour
o Anatomical markers - medially: sternum / laterally: lat dorsi / superiorly:
2cm below clavicle / inferiorly: 1-2cm below infra-mammary fold
o ?? Excision should include nipple/areolar complex
2. Dissect lump
o Incise skin
o Develop flaps (use clips/retractors) in plane corresponding to Scarpa's fascia
between the subcutaneous fat and mammry fat - aim for thickness of 34mm medially increasing to 6-8mm laterally
o Approaching clavicle superiorly, dissect more deeply to pectoral fascia
o Raise inferior flap
3. Dissect axilla: - obtains regional control of disease, establishes prognostic
information
o peel breast laterally until border of lat dorsi
o retract pec major to expose pec minor
o divide pec minor (close to point of insertion onto coracoid process)
o Identify Long thoracic nerve of Bell, thoracodorsal nerve (and
intercostobrachial nerve)
o Ligate all venous tributaries from axillary vein
4. Remove lump + axillary contents en-masse
o Place stitch on most proximal node for pathological orientation
5. Place one suction drain on breast bed + one in axilla
6. Washout with antiseptic
7. Close
+ Can be combined with flap reconstruction
TRAM - transverse rectus abdominis
DIEP
Complications



Bleeding / infected haematoma
Buttonholing of skin flaps
Nerve injury - LT nerve (serratus anterior - winged scapula); thoracodorsal nerve (lat
dorsi)
Thyroid disease
Thyroid disease spectrum
1. Arteries:
o superior thyroid (external carotid)
o inferior thyroid (thyrocervical trunk of subclavian)
o Accessory thyroid ima
2. Veins:
o Superior
o Middle
o Inferior
3. Nerves:
o Recurrent laryngeal (cricoarytenoids - supply vocal cords)
o Superior laryngeal
[Thyroid hormone physiology & disease spectrum]
Thyroid Neoplasms
1.
2.
3.
4.
5.
Papillary 70% - younger population, good prognosis, TSH-dependent
Follicular 20%
Anaplastic 5% - older population
Medullary 5% - from parafollicular C-cells
Lymphoma - rare
Management of thyroid disease
1. History
o
o
o
o
Thyroid symptoms
Medications
Previous radiation exposure
Familial history
2. Examination
o Neck
o General examination: signs of thyroid disease - hands, eyes, cardiovascular
system
3. Investigations
o TSH, T4, thyroid autoantibody screen
o USS: sensitive for detecting thyroid nodules, used to guide FNA
o FNAC: Most reliable test for thyroid nodules
o Radio-isotope scans no longer routinely used ("hot" nodules were benign
and "cold" nodules were not)
Hemithyroidectomy procedure
1. GA + Supine + head-up tilt of 15'
2. Head rests on ring, sandbag in interscapular position
3. Dissect down to thyroid
o Transverse collar incision approximately 2finger breadths above
suprasternal notch
o Divide skin and platysma
o Extend superior flap to thyroid, inferior flap to suprasternal notch
o Expose strap muscles
o Divide cervical fascia in midline and retract strap muscles laterally
4. Dead with surrounding structures
o Ligate and divide middle and inferior thyroid veins
o Inferior thyroid artery identified and ligated in continuity as inferiorly as
possible
o Identify recurrent laryngeal nerve in its groove between trachea and
oesophagus (and protect)
o Identify parathyroid glands and preserve
5. Remove thyroid
o Superior vascular pedicle is ligated and divided
o thyroid lobe mobilised and excised
o oversew isthmus with absorbable sutures
6. Close
o Haemostasis completed
o Suction drain placed in subfascial space
o Fascia closed in midline with absorbable sutures
o Skin + platysma closed
o Skin closed with non-absorbable subcuticular suture
Complications
1. Haematoma - may cause respiratory embarassment
2. Recurrent laryngeal nerve palsy 1%
o Single nerve paresis results in hoarse voice
o Both nerves leads to paralysis
3. Superior laryngeal nerve palsy
4. Hypothyroidism
5. Hypoparathyroidism - causes hypocalcaemia - check calcium level post-operatively
6. Scarring
Post-op: radio-iodine scan can demonstrate remnants of thyroid tissue or distant
metastases
Remaining tissue can be ablated
Serial thyroglobulin measurement 6-12 month intervals (acts as marker for tumour
recurrence)
Wide local excision & axillary clearance
Indications


Tumours < 4cm
Mammogram excluding multifocal disease
Axillary clearance
1. Level I: Lateral to pectoralis minor
2. Level II: Up to medial border of pectoralis minor
3. Level III: Beyond medial border of pectoralis minor
Procedure
1.
2.
3.
4.
5.
6.
7.
Curvilinear 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 clearance
1.
2.
3.
4.
5.
6.
7.
8.
Incise 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.
Complications



Nerve injury (esp intercostobrachial nerve)
Secondary lymphoedema
Haematoma (avoided by diathermy + drains)
Wire-guided localisation biopsy
Indications


Radiological microcalcification suspicious of DCIS
Impalpable lesion
Workup


Radiologically guided localisation (USS/X-ray)
Barbed wire inserted
Procedure
1. Incise skin transversely over wire
2. Follow wire to substance of breast
3. Excise around wire with good margin + frozen section to identify that whole of lesion
has been taken
4. When adequate excision confirmed, ensure adequate haemostasis
5. Obliterate cavity
6. Close with subcuticular stitches
Cardiothoracic Surgery
Aortic dissection
Classification
1. Stanford
o Type A: ascending aorta only
o Type B: descending aorta with or without ascending aorta
2. BeBakey
o Type I: ascending aorta + descending
o Type II: confined to ascending aorta
o Type III: confined to descening aorta, beyond origin of subclavian artery
Pathology



Myxoid 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 factors
1.
2.
3.
4.
5.
Hypertension - leads to increased shearing forces across intima
Traumatic injury to aorta
Iatrogenic - cardiac catheterisation, aortic cannulation, AV replacement
Pregnancy
Inherited defects
o
o
o
Marfan's - 15q fibrillin defect
Ehlers-Danlos - procollagen formation
Pseudoxanthoma elasticum - fragmentation of elastic fibres in media
Effects of dissection
1. Propagation
o Aortic ring - acute aortic regurgitation
o Coronary arteries - Angina / MI
o Carotid arteries - stroke
o Abdominal aorta - gut ischaemia (if mesenteric vessels involved)
o Renal artery - ARF
o Intercostal / lumbar vessels - spinal cord ischaemia (loss of supply from
arteria radicularis magna - great spinal artery of Adamkewicz)
2. Rupture
o Pericardium - tamponade
o Pleura - haemothorax
3. Compression
o Trachea / oesophagus / SVC
4. Double-barrelled lumen (if re-enters lumen through another intimal tear)
Clinical features





Shock
New Murmur
Tamponade
Asymmetrical pulses
Neurological signs - stroke, cord features
Investigations





ECG: 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
Management
1.
2.
3.
4.
Resuscitate: fluids, maintain cardiac index (CO/BSA) and renal function
Bloods
Central line: monitor filling pressures
Pharmacological
o Labetalol - control ejection fraction and arterial pressure
o Sodium nitroprusside (can cause reflex tachycardia)
5. Transfer to cardiothoracic unit
o
o
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 bypass
Cardiopulmonary Bypass
1. 1. Expose great vessels
2. 2. Purse string inserted into ascending aorta (adventitia) + aortic perfusion cannula +
connect to bypass circuit
o Impracticalities: Aortic root surgery, dissection, severe adhesions - fem-fem
bypass can be employed
3. Purse string inserted into Rt atrium by appendage Cardiopulmonary bypass machine
takes over circulation + ventilation
o Pumped from venous reservoir
o Oxygenated in membrane oxygenator (gas exchange across silicone
membrane)
o Heat exchanger
o Filtered: remove particulate emboli
o 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. 1. Cardioplegic arrest
o Topical cooling + cardioplegic (intentional + temporary cessation of cardiac
activity) solution
o K+ - containing (arrests heart in diastole by membrane depolarisation)
o Cold isotonic crystalloid - reduce metabolic rate
o Safe cardiac arrest can be maintained for 2hours
2. Intermittent cross-clamp fibrillation
o Induce VF (by electrical voltage)
o Cross clamp aorta to render heart ischaemic
o Allow perfusion (10-20minutes) by intermittently releasing cross-clamped
aorta + electrical cardioversion
3. 3. Total circulatory arrest
Complications
1. Access
o
Infection, pulmonary injury, vascular injury
2. Bypass
o
o
Embolism
Bleeding disorder (from heparin)
3. Stress/consequences
o Tamponade
o Emboli - heart: infarction, brain: stroke, gut: ischaemia
Chest drains / Tube Thoracostomy
Indications


Diagnostic: effusion/blood/pus/lymph
Therapeutic: drainage of air/fluid (effusion, blood, pus, lymph)
Sizes


French gauge (20-32F) = external circumference in millimetres
32F used to prevent clot obstruction of tube
Technique
1. Adequately prepared / consented
2. Clinical examination + inspection of CXR: confirm side of insertion
3. Position: (1) supine + arm abducted (2) seated leaning forwards + arms outstretched
o Skin cleaned w iodine + draped
o 5th ICS / 3rd ICS (Anterior) anterior to MAL by palpation of ribs
o LA wheal w 1-2% lignocaine + deep infiltration
4. Insert over rib (avoids neurovascular bundle)
o 1.5-2cm incision w scalpel (11 blade)
5. Blunt dissection down to pleura using finger + Roberts forceps à finger sweep to
clear adhesions + widen tract
6. Drain guided into intercostal space
o Aim apically for air / basally for fluid
o Secure with drain stitch + apply dressing/tape
7. Attach to underwater seal +/- suction
o Drain bottle below level of patient at all times
o Minimise resistance: chest tube should be sufficiently wide
o End of drainage tube should not be > 5cm below level of water otherwise
resistance encountered will prevent air from escaping chest tube
8. Check CXR: accurate position + re-expansion
9. Analgesia
Complications




Laceration/puncture intrathoracic/abdominal organs (prevented by finger sweep)
Infection
Damage to intercostal nerve/artery/vein
Subcutaneous emphysema
Indications for removal



Full 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 after
1. Off suction
2. With tube clamped
Remove drain in inspiration
Coronary Artery Bypass Graft Surgery (CABG)
Operative Technique
Surgical Anatomy of the Heart
Access to heart





Harvesting of Long saphenous vein
chest opened via sternotomy + LIMA dissected from chest wall
Heart cannulated via ascending aorta + right atrium before cardiopulmonary
Longitudinal arteriotomy made beyond narrowing of coronary vessel + distal
Venous Grafts:
o Long saphenous vein (10 year patency rate 50-60%)
o short saphenous vein
o cephalic vein
Arterial Grafts:
o Left internal mammary artery (internal thoracic artery) - conduit of choice
for LAD (10 year patency rate 90%)
o Radial artery -NB Allen's test to ascertain collateral circulation
Pre-operative workup




ECG
Echocardiography
Carotid duplex study
Pulmonary function tests


Angiography
FBC, U+Es, LFTs, Clotting, G+S

Antibiotics: Cefuroxime 1.5g +/- Vancomycin
Post-op management


Prophylactic chest drain
External cardiac pacing
Complications
Bleeding
3-5% of patients.
May develop tamponade / hypotension
Medical management first
May require emergency re-sternotomy
Management of Bleeding:
Check coagulation profile
Fibrinogen
Platelets
Specific treatments:
1. Protamine sulphate
o Directly binds to heparin and inactivates
2. Trasylol / Aprotin 2MU iv
o (Bovine) serine protease inhibitor (specifically trypsin, chymotrypsin,
plasmin, kallikrein)
o Effect on Kallikrein: inhibits formation of factor XIIa and plasmin - slows
down fibrinolysis
3. Tranexamic acid
o Inhibits activation of plasminogen into plasmin
Arrythmias
Common to develop ST / AF
Management of Tachyarrythmias
1. Correct potassium >4.5mmol/l - Potassium chloride
2. Correct magnesium: 8/10-20mmol MgSO4 IV
Atrial Flutter
1.
2.
3.
4.
Vagal manoeuvres
Adenosine 6mg/12mg/12mg
B-blocker rate control
DC synchronised cardioversion
Atrial Fibrillation
1. B-blocker iv / Digoxin 500mg iv/12'
2. Amiodarone 300mg iv/1' + 900mg iv/23'
3. DC synchronised cardioversion
Management of Bradyarrythmias
1. Atropine 500mcg iv bolus (repeat to maximum of 3mg)
2. Adrenaline 2-10mcg/min
3. Cardiac pacing
Flail chest
Flail chest injury
3 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 chest
1. High mechanism injury (one rib = 150mls blood loss)
o Possible underlying pulmonary contusion
2. Can lead to respiratory embarassement
o Exhibit paradoxical movement during respiratory cycle - moves inwards on
inspiration
o Pain from fracture leads to reduced TV
o Type II (mechanical) failure can result
3. Late complications: pneumonia, septicaemia, atelectasis
o Reduced ventilation increases risk of retained secretions and sequlae
Managment
According to ATLS principles
1. Manage flail chest
o Humified oxygen
o Analgesia - paracetamol / NSAIDS / Opiates / intercostal block / thoracic
epidural (up to T4) + splinting of injury
o Intubation / mechanical ventilation - if worsening fatigue and RR
2. Identify underlying injury
3. Prevention of secondary complications
Sucking Chest wound

Occurs 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 surgery
Requirements

Double lumen ETT (allows selective collapse of lung)
Pneumonectomy
Lobectomy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Right/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
Mediastinitis
Inflammation of the mediastium - ie. the cavity within the thorax between the pleural
cavities.
Causes




Direct mediastinal access
o Sternotomy / cardiothoracic surgery
o Mediastinoscopy
o Penetrating trauma
Per trachea
o Intubation / failed percutaneous tracheostomy
o Bronchoscopy
Per oesophagus
o Boerhaave's
o Iatrogenic oesophageal perforation
Direct extension
o
Infection from lung, pleura
Organisms: anaerobic oral flora, respiratory flora - or multi-resistant strains if
cardiothoracic surgery
Features (of general inflammation)
Pyrexia
Rigors
Surgical emphysema
Hamman's sign (crunching sound in systole)
Management



Bloods: Inflammatory markers, FBC, CRP
Imaging: CXR (enlarged mediastinum) + CT
Treatment: Surgical drainage/debridement + Antibiotics
Pericardectomy
Indications
Operative considerations


Should 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!
Pneumothorax
Types
1. Simple: air in pleural space
2. Tension: one-way valve effect
3. Open: Sucking chest wound
Causes
1. Spontaneous: rupture of blebs - asthmatics, skinny lanky
2. Trauma
3. Iatrogenic
Recognition
1. Conscious
o Tachycardia, tachypnoea, decreased sats
o Tracheal deviation, hyper-resonance
o Surgical emphysema
2. Unconcious / ventilated
o Sudden hypoxia
o Sudden increase in ventilatory pressures
o Sudden hypotension or rising CVP
o New arrythmia
Management
1.
2.
3.
4.
Early recognition (esp tension)
100% O2
Tension - needle decompression (2ICS)
Chest drain
Pleurodesis



Performed endoscopically (VATS - video assisted thoracoscopic surgery)
Chemical
Physical - 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 Heart
Median Sternotomy
1. Incision from suprasternal notch to lower end of xiphisternum
o Sternum covered by fat + pectoral muscles
o Superiorly: Suprasternal ligament from SCJ to other
o Inferiorly: rectus abdominis fibres
2. Sternum divided + retracted
o Superiorly:Thymus
o Inferiorly: Pericardium
3. Thymus divided in midline
o Highly vascular
o Care because lies anterior to innominate/brachiocephalic vein
4. Pleura dissected from pericardium laterally
5. Pericardium opened +/- cannulation (with full heparisation)
Closure of Sternotomy







Ensure 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 stitch
Thoracotomy
1. Median Sternotomy
Posterio-lateral thoracotomy

Access to hilum and pleural cavity
1.
2.
3.
4.
5.
6.
Curved incision 2cm below scapula
Dissect through skin, fat
Divide latissimus dorsi fibres
Spread off serratus anterior
Divide through intercostal muscles (at level of 5th rib - count from second rib)
Enter pleural cavity
Closure
1.
2.
3.
4.
5.
Appose ribs
Sew deep fascia onto intercostal muscles
Close serratus anterior layer
Sew latissimus dorsi
Close skin
Emergency Thoracotomy
Indications


Penetrating injury with cardiac arrest
Massive thoracic bleeding
Procedure
1.
2.
3.
4.
5.
Positioned 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 surgery
Heart valves maintain pressure gradients between cardiac chambers to ensure
unidirectional flow.
Valve leaflets supported by chordae tendinae + papillary muscles
Valve
Cusps
Description
Aortic
3
Semilunar leaflets
Attached at annulus
Coronary arteries arise from (1) Left = Left posterior sinus (2) Right =
Anterior sinus
Mitral
2
Anterior/Posterior cusps
Pulmonary 3
Tricuspid 3
Stenosis
Aortic
Mitral
Rheumatic heart disease
Calcification
Congenital
Rheumatic heart disease
Calcification of valve/chordae
Congenital
Regurgitation Rheumatic heart disease
Endocarditis
Congenital
Inflammatory - SLE, Ank spond
Dilation of aortic root - Marfan's,
dissection
Systemic disease - UC, syphilis
Rheumatic heart disease
Valve prolapse
LV dilation
Ischaemia / papillary muscle
disruption
Bacterial endocarditis
Technique of Aortic Valve replacement






Transverse 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 replacement



Severe symptoms (as classified by NYHA functional classification)
Progressive increase in LV volume leading to ventricular impairment (Ejection
fraction, end-diastolic volume)
Endocarditis
Prosthetic Valves
Type
Mechanical
Biological
Example
1. Ball & Cage
o Starr-Edwards
o Barium-impregnated silastic ball
retained in cage
2. Tilting valve disc
o Bjork-Shiley
o Single disc opens and closes with
blood flow
3. Bileaflet
o St Jude Medical valve
o Two disc occluders
Complications
Structural Valve failure
Prosthetic valve
endocarditis
Paravalvular leak


Related to
endocarditis episode
Leaflet degeneration
Autografts



Harvest patient's own pulmonary valve
into aortic position (Ross procedure)
Excellent haemodynamic function (but
technically demanding)
Autologous pericardial valves
Homografts/Allografts - Removed from
Thrombosis /
Thromboembolism


Mechanical 2.5 - 3.5
Tissue 1.5 - 2.5
cadavers



Antibiotic sterilised
Short supply
Technically difficult
Xenografts - Prepared from animal tissue


Porcine-valve
Pericardium mounted
Appendicitis / Appendicectomy
Appendicitis
Inflammation of the vermiform appendix
Most cases are idiopathic.
1. Lumen: mucosal appendicitis
o Foreign material
o Faeces
o Worms: strongyloides, ascaris lumbricoides
o Parasites: oesophagostomiasis
2. Wall: transmural appendicitis
o Infection: Viral (CMV, adenovirus), bacterial (TB, yersinia), amoebae,
schistosomes
o Inflammation: UC, crohn's, pseudomembranous colitis
o Ischaemia: ischaemic colitis, congenital stricture, iatrogeni
3. Outside wall: Serosal appendicitis
o Ovaries - salpingitis/oophritis
o Endometriosis
o Diverticular disease
Presentation
1. Clinical findings
o Periumbilical colicky pain (visceral peritoeneum)
o Migrates to RIF (parietal peritoneum)
2. Specific features
o McBurney's point pain
o 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)
o Psoas sign: flexed right hip where appendix is lying over psoas muscle
o Rectal tenderness: from pelvic appendix
Indications


Emergency - acute appendicitis
Elective - "interval" appendiciectomy after intial conservative treatment (of
appendix mass)
Open Procedure
1. GA + Antibiotics + supine position
2. Access appendix
o McBurney's incision (90' to imarginary line) / Lanz incision (cosmetically
better) / High up in RUQ in children
o Skin, fat (campers fascia), scarpa's fascia
o Incise external oblique aponeurosis in line of fibres, expose internal oblique
(if too medial will see rectus sheath)
o Split internal oblique fibres transversely, enlarge defect
o Pick up peritoneum between 2 clips, incise with scalpel - turbid fluid
indicates appendicitis (send this off to microbiology)
o Identify caecum (has teniae) and deliver into wound [enlarge incision if
difficult/impossible to deliver]
3. Remove appendix
o Hold appendix with 2 tissue forceps (Babcocks)
o Divide mesoappendix (hold up to light to see blood vessels)
o Apply purse string (buries appendix stump) with 2/O
o Crush appendix base (facilitates secure knot tying) and ligate proximally with
O suture.
o Remove appendix, bury stump by tightening purse string
o Suck out free fluid, wash out peritoneal cavity
4. Close wound in layers
Laproscopic Appendicectomy
Especially young female patients - where diagnosis uncertain, imaging has failed to
exclude gynaecological cause.
1. GA / Possible conversion to open
2. Establish pneumoperitoneum
o Trendelburg position
o Infraumbilical incision
o Open peritoneum under direct vision
o Insert trochar
o Insufflate gas
3. Inspect appendix
o
o
o
o
5mm port RIF under direct vision
5mm port LIF
Grasp caecum and move towards spleen
Aspirate free fluid (send for cytology)
4. Remove appendix
o Grasp appendix with forceps
o Dissect from mesentry using hook diathermy introduced through right port
o Ligate at base using pre-tied Vicryl ligature + second distal to first one
o Divide and remove under direct vision
5. Peritoneal lavage
6. 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
Complications

Increased risk of right hernia
Bowel obstruction
Features
1. Pain: colicky
o Epigastrium / umbilical = small bowel
o Suprapubic = large bowel
2. Vomiting
o Consequences: dehydration, metabolic alkalosis/respiratory acidosis hypoxia
o More distal lesions, later the vomiting
o Contents: pyloric = watery; high = bilious; low = faeculent
3. Distension
o Depends on level of obstruction
4. Constipation
5. Pyrexia, septicaemia
Causes
1. Luminal
o
2. Mural
Intussuception
o
o
Malignancy
Inflammatory bowel disease
3. Extra-mural
o Hernia
o Adhesions
Frequency of causes
1.
2.
3.
4.
5.
Adhesions - 60%
Herniae - 15%
Malignancy - 6%
IBD
Ischaemic bowel
Pathophysiology
1. Bowel dilatation proximal to obstruction
o Results in gas / fluid accumulation with bowel wall and lumen (proximally)
o Impairs resorption
2. Mucosal oedema impairs venous / arterial flow
o Bowel becomes strangulated
3. Ischaemia leads to haemorrhagic infarction
o Further dilation leads to bowel perforation
4. Bacterial translocation leads to sepsis
Principles of Management
1. History
o
o
o
Previous operations
Abdominal diseases
Previous obstruction
2. Examination
o Previous scars
o Presence of hernia
o Bowel sounds: tinkling / hyperactive
3. Investigations
o Plain AXR - distended bowel loops (and level of obstruction) - small plicae
circulares; large haustrae
o Plain CXR - exclude free air
o FBC: WCC, anaemia
o Electrolytes
o ABG: Lactate / acidosis
4. Resuscitation
o IV crystalloid
o Correct acid-base
o NGT
o Catherise
o Analgesia
Indications for surgery
1. Absolute
o Peritonitis
o Perforation
o Incarcerated hernia
2. Relative
o Palpable mass
o Virgin abdomen
o Failure of conservative treatment
Surgical options in Large bowel disease
1. One stage (medially optimised patient)
o resection of tumour/lesion, decompression of bowe, lavage with primary
anastamosis
2. Two stage (unwell patients who may be optimised)
o Hartmann's procedure with resection of tumour
o Later reversal of colostomy
3. Three stage (sick patients/moribund/advanced disease)
o Emergency defunctioning colostomy (until patient fit for further operation)
o resection of tumour and anastamosis in 2nd operation
o Final closure
Cholecystectomy
Indications




Symptomatic gallstones: biliary colic, pancreatitis
Cholecystitis
Empyema of gallbladder
Mucocoele of gallbladder
Laproscopic Procedure
1. Consent + permission to convert to open 5-10% cases
2. Establish pneumoperitoneum (open method) - 1cm incision under umbilicus,
introduce trochar, insufflate air, then laproscope
3. Insert ports 10mm epigastrium; 5mm MCL; 5mm AAL
4. Identify Calot's triangle (Liver, cystic duct, hepatic duct) - contains cystic artery
5. Dissect cystic duct, artery and GB
6. Apply x3 clips on either side of structures, divide leaving 2 clips
7. Divide gallbladder from hepatic bed using diathermy hook to maintain haemostasis
8. Remove gallbadder (collect in endobag to prevent leakage)
9. Release pneumoperitoneum, close wounds
Open Procedure
1. Upper right transver incision (over lateral border or rectus muscle)
2. Skin, campers fat, scarpas fascia, anterior rectus sheath, rectus, posterior rectus
sheath, transversalis fasicia, extraperitoneal fat, peritoneum
Complications
1.
2.
3.
4.
5.
Bile duct injury
Haemorrhage - slipping of clips
Retained stone
Biliary stricture
Duodenal injury
Colorectal cancer
Management
1. History
o
o
o
o
Characteristics of PR bleeding
Change bowel habit
Weight loss
Family history: HNPCC, p53, APC
2. Examination
o DRE: 90% palpable
o Inspect glove for blood or mucous
o Abdomen for masses
3. Investigations
o Proctoscopy: visualisation, confirmation and biopsy of any lesion
o Barium enema - identify suspicious lesions
4. Staging
o Local spread: Endoluminal USS, CT, MRI
o Metastatic spread: CXR, USS, CT Chest / Abdomen
o 2cm adequate / 5cm preferred
o Ensure tension free anastamosis by adequate mobilisation
o Consider protecting anastasmosis by proximal defunctioning loop ileostomy
Right Hemicolectomy + Primary anastamosis
1. Enter peritoneum
o Midline incision / transverse incision (less painful, slimmer patients)
2. Mobilise caecum and terminal ileum
o dividing lateral peritoneum clockwise and upwards
o Dissect off right colon
o Identify and protect the gonadal vessels, right ureter and duodenum
3. Divide bowel
o Transilluminate the mesentry; ligate vessels close to origin (as close as
possible really)
o Place non-crushing clamps on transverse colon and ileum and divide bowel
between crushing clamps
4. Form end to side anastamosis (along taeniae)
o Close distal end of colon (by hand) or stapling device
o Approximate ileum with colon and commence posterior wall by inserting
seromuscular (Lembert suture)
o Open colon along taeniae and insert full thickness absorbable suture
o Continue to midline anteriorly and tie off sutures
5. Close mesenteric defects (prevents herniaetion)
6. Close wound (mass closure etc)
Left Hemicolectomy + Primary anastamosis
1. Enter peritoneum
2. Mobilise colon
o Divide along white line of "Toldt"
o Push sigmoid mesentry medially
o Identify and protect gonadal vessels and left ureter as it crosses pelvic brim
3. Divide bowel
o Transilluminate mesentery and identify and ligate vessels close to origin
o Distally ligate vessels at bowel wall
o Place non-crushing clamps across rectum and proximal bowel
o Protect wound edges from contamination using abdominal swabs
o Excise colon
4. Form anastamosis
o Single-layer technique
o Stapled gun
5. Close mesenteric defect
6. Washout + close
Hartmann's operation / End colostomy
Indications



Obstructing lesion in sigmoid colon
Perforated lesion in sigmoid colon
Volvulus of sigmoid colon
Pre-op: marking by stoma nurse
1. Enter peritoneum
o Midline incision
2. Mobilise bowel
o
o
o
3.
4.
5.
6.
Divide along white line (avascular plane)
Sweep sigmoid off mesentry
Identify and protect gonadal vessels and left ureter
Divide bowel
o Transilluminate mesentry, identify and ligate vessels
o Place non-crushing clamps across distal and proximal bowel
o Excise diseased segment
Close distal colon with two layers of continous sutures
o Hitch bowel to presacral fascia making it easier for reversa
Formation of stoma
o Bring out proximal colon
o Circular skin incision 2cm in diameter and deepen to rectus sheath (palpate
inferior epigastric vessels to avoid damage at this stage)
o Make cruciate incision into sheat, bluntly dissect through muscle into
peritoneal cavity
o Place clamp through stoma site and capture proximal colon: manipulate
bowel through abdominal wall
o Approximate skin and bowel edge with interrupted sutures at regular
intervals (x6-8 deep: external oblique aponeurosis + superficial: skin)
o 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's


Only 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
Indications

Carcinoma of mid-rectum
1.
2.
3.
4.
5.
GA + Lloyd-Davies position + Catheter
Enter peritoneum
Mobilise bowel
Colorectal anastamosis
Defunctioning ileostomy
Abdomino-Perineal resection
Indications


Carcinoma of lower 1/3 of rectum
Anal carcinoma
Pre-op: irreversible colostomy
1. GA + Lloyd-Davis position + catheter
2. Abdominal component
o Sigmoid mobilised
o Protect other structures (ureter, gonadal vessels)
o Rectum mobilised - identify and protect pre-sacral plexus
o Divide fascia of Denonvilliers anteriorly (protect seminal vesicles)
3. Perineal component
o Elliptical incision from coccyx passing lateral to anal verge and finishing at
perineal body
o Deepen to mesorectum to meet abdominal access
o Divide posterior edge of levator ani
4. Rectum freed and delivered through perineal wound
5. Form stoma from remaining colon
6. Close abdomen
7. Close perineum
Complications





Reactionary haemorrhage
Infection - wound, pelvic abscess
Renal tract injury
Sexual dysfunction and impotence
Complications of colostomy - retraction, prolapse, herniation, stenosis, ulceration,
ischaemia/necrosis
Compartment syndrome / Fasciotomy
Compartment syndrome





Raised 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
Management
1. History
2. Examination
3. Investigations
o Classic symptoms need no further investigations
o Unclear diagnosis: compartment pressures ?30mmHg over diastolic
4. Treatment
o Double incision fasciotomy
o Daily dressings of wound
o Prophylactic antibiotics
o Re-examine in 24-48hours to debride necrotic tissue and cover wounds
Tibial Compartment fasciotomy
Compartments of the lower leg
Anterior
compartment



Tibialis
anterior
Extensor
digitorum
longus
Extensior
hallucis
longus
Lateral
compartment


Peroneus
Longus
Peroneus
brevis
Posterior
compartment
Tom-Dick-Harry


Tibialis
posterior
Flexor




digitorum
Flexor
hallucus
Plantaris
Soleus
Gastrocnemiu
s
Indication


Extensive soft tissue injury of lower leg
Compartment syndrome
Measurement of compartment pressures
1. Prepare / sterilise skin
2. Infiltrate LA
3. Insert catheter into compartment, inject small amount of saline into cannula to fill
dead space
4. 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
Procedure
1. Full length longitudinal anterolateral skin incision 2cm lateral to crest of mid-tibia
from level of tibial tuberosity to just proximal to ankle
o Anterior compartment: Incise fascia covering tibialis anterior + extend
proximally/distally
o Identify and protect superifical peroneal nerve (lies deep to intermuscular
septum)
o Lateral compartment: undermine skin to get to lateral compartment (avoid
superficial peroneal nerve)
2. Single longitudinal 1-2cm posterio-medial incision just medial to posteriomedial
border of tibia
o Identify and retract long saphenous vein
o Incise deep fascia proximally to level of tibial tuberosity and distally to 5cm
proximal to medial malleolus
o Should be anterior to posterior tibial artery to avoid damage to perforating
vessels used for later cutaneous flaps
Closure of fasciotomy
1. Wound should be left open + VAC dressing
2. Suture skin 3-5 days later (when swelling subsided) +/- split skin grafts
3. Keep leg elevated
Complications


Disruption of venous muscle pump
Poor healing
Excision of lymph node
Indications

Confirm diagnosis of lymphadenopathy
Procedure
1.
2.
3.
4.
5.
6.
Incision 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 cyst
Indications


Cosmetic
Recurrent infections, sebaceous horn
Procedure
1.
2.
3.
4.
LA
Elliptical incision over cyst (include punctum)
Grasp cyst and free from base
Close with interrupted non-absorbable sutures
Excision of toenail
Indications



Ingrowing toenail
Onychogryphosis
Nail infections
Procedure (Zadik's operation)
1.
2.
3.
4.
5.
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)
6. Suture skin flaps at side
Exicision of Skin lesions
Indications


Malignancy
Cosmesis
Procedure
1. Use small scalpel blade (10/15)
2. Make elliptical incision around lesion (along langer's lines to ensure good cosmesis)#
o BCC/SCC: excise whole of lesion
o Malignant melanoma: 1cm margin for 1mm / 2cm margin for 2mm / 3cm
margin for 3mm
3. Incise under lesion to remove
4. Close skin with undyed subcutaneous non-absorbable suture
Femoral Hernia repair
Indications

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
1. Dissect down to hernia
o Groin incision directly over inguinal ligament
o Identify, dissect superficial fascia down to sac
o Expose neck of hernia
2. Open hernia, inspect, reduce hernial contents
o If necrotic bowel, resect and perform laparotomy
3. Close hernie defect
o Carefully retract femoral vein
o close defect (suture inguinal ligament to pectineal ligament - use J-shaped
needle)
4. Close subcutaneous tissue with interrupted sutures + skin with subcuticular
High inguinal approach Extraperitoneal approach Useful if unsure hernia is
inguinal or femoral
1. Dissect down to hernia
o Supra inguinal incision (Pfannenstiel, midline)
o Skin, blunt dissect superficial tissues to gain access to hernial sac
o Open rectus sheath + retract rectus
o Open up pre-peritoneal space with blunt dissection
o Continue process down towards inguinal ligament + identify hernia
2. Identify and reduce hernia
o If sac empty, reduce back to abdomen: pull above, push below
o If bowel present, stretch femoral ring (with haemostat), transfix sac + excise
tissue
o If irreducible, open peritoneum from above + inspect contents +/- bowel
resection
3. 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 surgery
Preparation
1.
2.
3.
4.
5.
6.
Adequate 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
7. Consent
Principle
1. Perform full laparotomy - inspect everything
2. Assess *tumour for resectability + clearance margins (2cm acceptable; 5cm desired)
3. If Metastases found, should continue surgery as best "palliative" measure - resection
margins can be reduced
Complications
1.
2.
3.
4.
Surgery
Stoma
"General"
Metabolic / nutritional consequences
Haemarrhoidectomy
Haemorrhoids
1. Cushions of dilated vascular tissue at anal verge
2. Anal cushions are required for full continence
3. Straining causes the cushions to slide down and become engorged - results in
symptomatic haemarrhoids
Classification
1. First degre: small non-prolapsing
2. Second degree : prolapsing but reduce spontaneously
3. Third degre: prolapse that cannot be reduced
Treatment options
1. Asymptomatic
o No treatment required
2. First degree
o Stool-bulking agents
o Injection sclerotherapy
3. Second degree
o Banding
4. Third degree
o Haemarrhoidectomy
Haemarrhoidectomy procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
Prepared + 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 care





daily 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
complications
1.
2.
3.
4.
5.
6.
7.
Bleeding
Constipation
Anal stenosis
Faecal incontinence due to damage of sphincter mechanism
Anal fissure
Recurrence
Perianal fistula
Incisional Hernia repair
Risk factors for developing incisional herniae
1. Surgical
o
o
Careless suturing
Inappropriate material
2. Local
o
o
Haematoma
Infection
3. Patient
o
o
o
o
Malnutrition
Obesity
Jaundice
Immunosuppression
Procedure for repair
1. Optimise patient pre-operatively (repair often fails)
2. GA + supine
3. Dissect down to hernia
o Incision made over hernia
o Hernia sac dissected out
o Incision deepened around margins og hernia until healthy aponeurosis
identified
4. Reduce hernia
o Sac opened
o Contents returned to peritoneal cavity
5. Close defect
o if < 4cm can be closed with interrupted nylon
o If large: close with tension-free Prolene mesh repair sutured to anterior
rectus sheath with interrupted absorable sutures at 2cm intervals
6. Finish
Inguinal hernia repair
Indications



Symptomatic 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 ligament
Superficial Ring: Above pubic tubercle
Ilioinguinal nerve
Position: Prone
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
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
o If bowel present, check viability (wrap in warm saline-soaked abdominal
pack)
o If necrotic, must be resected
9. Reinforce wall with mesh
o In children, repair is usually satisfactory, and don't need mes
o Tension-free repair: Liechtenstein (lateralises cord)
o Bassini repair
o Shouldice repair
10. Ensure haemostasis, ensure testis in scrotum.
Laparoscopy
Advantages

Smaller incisions, reduced tissue
trauma
Disadvantages


Absent tactile feedback
Difficult haemorrhage control





Reduced post-op pain
Decreased incidence of wound
complications
Decreased physiological insult to
patient
Reduced inpatient stay
Improved cosmesis


Learning curve
May need consersion to open
Contraindications (things that really need open procedures being done)
1. General
o
o
Coagulopathy
Shock
2. Specific
o
o
Peritonitis
Obstruction
Essential components
1.
2.
3.
4.
Establish pneumoperitoneum
Insertion of trocar
Inpection of cavity
Removal of trocar and closure of wounds
Pneumoperitoneum
1. Trendelenburg position (head down) - position bowel away from pelvis
2. 1-2cm infraumbilical incision (transverse or vertical), deepen down to rectus sheath
o Closed laparoscopy - Veress needle
1. Hold up abdominal wall, insert Veress needle perpendicular to skin
until "give", then point needle towards pelvis at 45'
2. Confirm satisfactory insertion - saline drop test or aspiration
o Open laparoscopy - Hassan cannula
1. Pick up / incise rectus sheath. Place sutures on each side of linea
alba
2. Incise peritoneum and enter peritoneal cavity under direct vision
3. Insert finger, sweep away adhesions
4. Insert port + stay sutures
3. CO2 insufflation (aim pressure 0-5mmHg)
4. Percuss abdomen to ensure symmetrical abdominal distension
5. Maintain pressures of 13-15mmHg, volume of gas 4-5L
Insertion of trochar
1. Introduce cannula using corkscrew technique (aim towards pelvis) - check position
by releasing gas tap/vavle (hearing air)
2. Attach camera
3. (Bleeding can be controlled by inserting a foley catheter to achieve compression)
Insert other ports under direct vision
Position of ports
1. Infra-umbilical pneumoperitoneum (veress/hassan)
2. Epigastric trochar / camera
3. Epigastric cannula
Finishing
1.
2.
3.
4.
5.
Remove 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 complications
1. Rectus sheath insufflation, gives high pressures - stop
2. Misting of equipment (if not adequately pre-warmed)
3. Blood on lens can be wiped on omentum
Laparotomy
Midline incision
Closure of Midline Laparotomy
1. Divide skin in midline, divide
Jenkin's rule: decreases the risk of
subcutaneous tissue
dehiscence
2. Divide linea alba for full length of skin
incision
 Mass closure technique (include
3. Pick up peritoneum between clips,
peritoneum + rectus sheath in
confirm no bowel adherent, nick
closure)
peritoneum between clips
 Continous suture (0 or 1 loop PDS) on
4. Insert finger beneath wound to
a blunt needle
ensure no underlying adhesions, then
 Suture should be FOUR times the
divide peritoneum with scissors for
full lenght of incision
5. Ensure no adherent viscera, avoid
bladder in lower midline
lenght of the incision and bites should
be taken 1cm from the wound edge
at 1cm intervals
Exploratory laparotomy







Oesophageal 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
Paramedian incision
1. Incise skin 4cm from midline (over
rectus)
2. Incise anterior rectus sheath
3. Divide sheath from muscle at points
of intersections
4. Reflect rectus laterally to expose
posterior sheath
5. Incise posterior sheath for full length
of wound and then divide peritoneum
Subcostal incision
1. Keep parallel + 2cm from costal
margin
2. Divide anterior rectus sheath
3. Pass long forceps underneath
meuscle to emerge in midline
4. Pull swab back under muscle to
protect underlying structures from
cutting diathermy (superior epigastric
artery br. int thoracic) as muscle is
being divided
5. Small incision made into peritoneum,
allows protection of viscera as
transversus abdominis muscle is
divided
Closure of Paramedian incision


Close peritoneum using over and over
technique
Anterior rectus sheath closed as for
midline incision (applying Jenkins'
rule)
Management of Abdominal wound dehiscence
Surgical 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 disorders
Hiatus Hernia
Acquired form of diaphragmatic hernia
Types:
1. Sliding: GOJ slides through the oesophageal opening of the diaphragm
2. Rolling / paraoesophageal: GOJ remains in position but area of stomachad
peritoneum rolls up alongside oesophagus into thorax
Gastro-Oesophageal Reflux Disease
Management
1. History
o Burning pain
2. Examination
3. Investigations
o Upper GI endoscopy + biopsy to detect oesophagitis and Barrett's
oesophagus
o 24h pH manometry
4. Treatment
o Lifestyle changes: weight loss, avoid alcohol and smoking, avoid large meals
at night
o Medical: antacids, H2 antagonists, PPIs
o Surgery in: severe persistent regurgitation, severe reflux symptoms, patient
choice
Nissen Fundoplication
Other options - Belsey Mark IV: fundoplication through thoracotomy - Hill
gastropexy (securing cardia to pre-aortic fascia
1. Laparscopic / Midline incision
2. GA + elevate head end of table
3. Create pneumoperitoneum / access oesophagus
o Divide lesser omentum
o Retract right lobe of liver
o Dissect oesophageal hiatus
4. Repair crural defect
o Identify crura
o Dissect 3-4cm of abdominal oesophagus and mobilise
o Retract oesophagus to right
o Repair crural defect with interrupted non-absorbable sutures
5. Free fundus and greater curvature
o Divide short gastric vessels
o Freed fundus passed behind and then to the left of the oesophagus
6. Fundoplicate
o Fundal wrap held with 3 interrupted non-absorbable sutures, taking bites of
both fundal folds and the oesophagus
7. Finish
o Irrigate operative field + ensure haemostasis
o Close fascial defects
Paraumbilical hernia repair
Indications
Procedure (Mayo repair)
1. GA + Supine
2. Dissect down to hernia sac
o curved infraumbilical incisio
o Dissect subcutaneous tissue, dissect from rectus sheath
o identify hernia sac
3. Excise hernia
o open sac, reduce contents (usually omentum)
o Ligate sac and excise to level of fascia
4. Close defect
o Grab edges of fascia with Allis clamps
o Superior fold of fascia overlapped on top of inferior fold (double breasted
manner) using non-absorbable interrupted mattress sutures
5. Close
o
Close in layers
Peptic ulcers
[Peptic ulcer disease]
Perforated peptic ulcer
Indications

Acute duodenal perforation - prevents sepsis and shit like that
Procedure: Oversew
1.
2.
3.
4.
GA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + supine position
Upper midline laparotomy
Identify stomach + work distally to duodenum
Identify perforation
o Usually found on anterior surface of 1st part of duodenum
o 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)
5. Close perforation
o Insert x3 absorbable sutures through duodenum on each side of perforation
o Find mobile piece of omentum that can be mobilised into position
o Lay across perforation and loosely tie stures over the top of omentum (do
not tie tightly - may necrose omentum)
6. Wash out peritoneal cavity (remove food and shit)
7. Close as for laparotomy
Laproscopic procedure
1. Pneumoperitoneum via open method (1cm infra-umbilical incision), enter
peritoneum under direct vision
2. Introduce trochar, insufflate CO2, introduce laproscope
3. 11mm port under xiphisternum
4. 5mm port in MCL R hypochondrium
5. 5mm port AAL R hypochondrium
6. Irrigate / suction peritoneal cavity
7. Repair as above
8. Close port sites
Post-op care
1. Proton-pump inhibitor
2. H.pylori eradication - (urease breath test C13): Metronidazole + clarithromycin + PPI
3. 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
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
GA + 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
o Pass sucker into duodenam lumen to identify bleeding point (usually
posterior wall)
o Stuff swab into pylorus to prevent blood from being expelled from stomach
o 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
o Take good bites (can miss artery otherwise)
o Don't go too deep as will hit CBD
o Tie sutures firmly
Remove swabs, evacuate blood from stomach
Depending on degree of ulcer-related duodenal scarring proceed to
o pyloroplasty (close duodenum transversely with interrupted sutures)
o gastroenterostomy
Close wound
Perianal abscess / fistula / fissure in ano / Pilonidal sinus
Peri-anal abscess
Usually painful in anal region
Swinging pyrexia
Treatment is drainage with appropriate antibiotics
Classification of Perianal abscess
1. Peri-anal 60%- suppuration of anal gland (can also occur as result of thrombosed
external pile)
2. Ischio-rectal 30% (IR fossa communicates with opposite side via the post-sphincteric
space; involvement of contralateral fossa not uncommon)
3. Sub-mucous 5%; usually resolves (result of injection of haemarrhoids)
4. Pelvi-rectal 5% (supralevator) - usually secondary to appendicitis, salpingitis,
diverticulitis, parametritis
Procedure
1. Cruciate incision over abscess + excise skin over abscess (de-roof)
2. (Take microbiological cultures - if enteroccocci, high incidence of fistula; up to 40%
risk)
3. As soon as infection subsided, wound explored under anaesthesia + careful search
for fistulous opening
4. If no fistula found, cavity should be lightly packed with gauze + apply T-bandage
Fistula in Ano
Track lined by granulation tissue that connects deeply in anal canal/rectum and
superficially on the skin around the anus
Usually results from an anorectal abscess which bursts spontaneously
Associated with underlying diseases - eg TB, Crohns
Gives recurrent discharge
Goodsall's rule: fistulae with external opening anterior to anus have a direct (straight)
opening. Fistulae with posterior opening have curved tracks.
Classification of Perianal fistula
1. Simple or complex - associated or not with abscess cavity
2. High or Low - above or below anorectal (puborectalis) ring
o Subcutaneous
o Submucous
o Low anal
o High anal
o Pelvirectal
3. Park's Classification - by origin of fistula track
o
o
o
o
Intersphincteric (between internal/external sphincters) 70%
Transphincteric (across external sphincters) 25%
Suprasphincteric (over sphincters)
Extrasphincteric (above and through levator ani)
Procedure
1. Decide whether fistula is low or high
2. Proctoscopy - reveals internal opening
3. Endoluminal ultrasonography / MRI to map complex fistulae (may have multiple
openings)
o Low: Lay open
1. Prep cleaning enema
2. Lithotomy position
3. Identify the fistula: protoscopy + retrograde probe + dilute
methylene blue dye
4. Track opened along director and bleeding controlled
5. Trim edges of track
o High: (risk of incontinence if laid open) - staged procedure + protective
diverting colostomy to prevent septic complications and to shorten healing
time between procedures
1. Treat the cause: TB, Crohns
2. Insertion of a seton
1. (a heavy ligature of silk, nylon, silastic or linen) used when
internal opening near anorectal ring
2. acts as wick/drain to allow acute inflammatory reaction
around track to subside
3. Can be serially tightened to cut through sphincter (allows
healing) to maintain sphincter integrity
4. Acts to drain fistula
3. + Covering colostomy
[Levator ani = Pubo-rectalis + Pubo-coccygeus + Ilio-coccygeus]
Fissure in Ano





Longitudinal 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
Treatment
1. Conservative
o High fibre diet, stool bulking
o Topical LA
o Topical GTN (controls anal spasm)
2. Surgical
o Lateral sphincterotomy: divide distal internal sphincter to dentate line with
incision lateral and away from fissure (complications - transient flatus
incontinence)
Ramstedt's pyloromyotomy
Indications
Pyloric stenosis
Procedure
1. GA
2. Access pylorus
o 3-4cm transverse incision made in right upper quadrant over palpable
pyloric tumour
o advanced through rectus sheath, sheath, into peritoneum
o Deliver greater curvature of stomach into woun
3. Split pyloric muscles
o Rotate pylorus
o Incise visceral peritoneum over lenght of tumour
o Using blunt forceps, longitudinal and circular muscles are split down to
submucosa
4. Finish
o Identify any inadvertant leaks (and repair with omental patch)
o Close abdominal wound with interrupted absorbable sutures
o Close skin with subcuticular sutures
Peritonitis
Causes
1. Upper GI
o Perforated peptic ulcer
2. Lower GI
o Appendicitis
o Perforation sigmoid diverticulitis
o Perforation
3. Hepatobiliary
o Perforation of Gallbladder
o Acute pancreatitis
4. Gynaecological
o Rupture ectopic pregancy
Organisms: Bacteroides, E.coli, clostridium, pseudomonas, klebsiella
Peritonism
1.
2.
3.
4.
5.
6.
Guarding / rebound suggests strangulation or perforation
Continous pain (rather than colic)
Tachycardia
Dehydration
WCC
Pyrexia
Rectal prolapse
Predisposition
1. Anatomy - continence maintained by 120' pubo-rectalis sling
o Children; direct downward course of rectum (undeveloped sacral curve)
o Maldevelopment of pelvis
o Female - torn perineum (pregnancy)
o Weak pelvic floor
2. Constipation / straining
o Diarrhoea (in children)
o Straining
o Haemarrhoids
Classification
Pathology
Complete
Full thickness prolapse
of rectum through anus




Weakness of
levator ani
Starts at weak
anterior wall
Protrudes 1015cm in lenght
Contains pouch
of peritoneum
anteriorly (which
can sometimes
contain small
intestine)
Incomplete/partial Mucous membrane +
Treatment
1. Perineal approach
o 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
2. Abdominal approach
o Wells operation - rectum fixed
firmly to sacrum by inserting
sheet of polypropelene mesh
between them
o Suture rectopexy - 4-6
interrupted sutures used to fix
rectum to sacrum
1. Digital repositioning
(mucosal)
submucosa of rectum
protrude outside of anus
2. Phenol submucous injections
3. Excision of prolapsed mucosa
Concealed
Intersusseption of upper
anus into rectum
1. Laxatives / stool bulking agents
2. Dietary modifications
Small bowel resection
Small bowel resection
Indications


Ischaemia, infarction, necrosis
Tumour
Procedure
1. GA + NGT + Antibiotics / Supine position
2. Midline incision
3. Deliver diseased segment into wound
o Protect wound edges (with swabs - minimise sepsis)
o Apply 2 non-crushing clamps to occlude bowel either side of disease
segment
4. Incise peritoneum of mesentery along chosen line for division of vessels
(transilluminate, then tie with absorbable sutures)
5. Place crushing clamps at 30' angle to bowel and divide close to clamp - allows better
perfusion of anti-mesenteric border
o Cut across bowel with knife, remove diseased section
o Cover cut ends with antiseptic soaked swabs
o If bowel ends do not bleed (usually poor blood supply) - resect until health
tissue reached
6. Perform anastamosis (two layers - inner including submucosa + outer lembert stitch)
o Posterior wall first: seromuscular continous
o Full thickness suture (double ended)
o Check anastamosis - if looks dusky; wait, observe
7. Close defect (including mesentry - prevents gut herniation) with interrupted sutrues
8. Close abdominal wal
Splenectomy
Indications
1. Elective
o
o
o
o
Haematological disorders
Part of radical upper abdominal surgery
Splenic tumours
(Previously - staging of lymphoma)
2. Emergency
o Trauma
Preparation
1.
2.
3.
4.
5.
6.
GA
NGT
Antibiotics
DVT prophylaxis
Supine position
Vaccination against streptococcus pneumoniae 6/52 before elective surgery and
ASAP post-operatively in emergency splenectomy
7. + Long-term prophylaxis against pneumococcal sepsis (with PenV - 250mg bd)
Elective Procedure
(remove spleen and look for speniculi)
1. Incision
o
o
o
o
2.
3.
4.
5.
6.
7.
Left paramedian
Midline: for trauma
Transverse
Left subcostal
Divide lienorenal ligament - attaches spleen to kidney
o (stand on right of patient)
o Pass hand over spleen onto lienorenal ligament
o Retract spleen and divide - start from lower end and move towards
apex/upper pole using long scissors (obviously!)
o Deliver spleen up into wound (sweep away peritoneum with swab on a stick)
Detach omentum from lower pole of spleen
o Divide left gastroepiploic vessles between artey forceps + ligation with ties
Ligate main splenic vessels
o Pass fingers around hilum and palpate branches of splenic artery as they
pass into spleen; clip + divide branches
o 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
o (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, resuscitate
Correct coagulopathy
Cross match lots of blood (4+ units)
1. Evacuate clots (manually + suction)
2. Pass hand down to hilum to control bleeding
3. Assess degree of splenic damage
o
Minor decapsulating injury - managed by application of topical haemostatic
agents + wrapping spleen in absorbable mesh
o Single laceration: suture (splenorrhapy)
o Complete/partial avulsed fragment: partial splenectomy - divide splenic
vessels supplying pole in question, resect the fragment and oversew edge
with absorbable mattress sutures
o Massive irreprable damage: splenectomy
4. Close abdomen
Complications of splenectomy
1. General
o
o
o
o
o
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
2. Specific
o
o
Thromobcythaemia (strokes, clots) + leucocytosis - commence aspirin
300mg daily if platelets >750
Infection from encapsulated organisms
Umbilical hernia repair
Indication

Symptomatic hernia (rare)
Procedure
1.
2.
3.
4.
5.
6.
Stab 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 Surgery
Anatomy of Walking
1.
2.
3.
4.
Heel strike
Stance phase
Push off
Swing
Ankle fractures
Weber classification
Carpal Tunnel syndrome
The Carpal Tunnel
Attachments of flexor retinaculum (palmaris longus inserts into it; proximal edge is at
distal wrist crease)
1.
2.
3.
4.
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
Causes
1.
2.
3.
4.
5.
Idiopathic
Pregnancy
Obesity
Trauma
Systemic disease: myxodema, rheumatoid arthritis, acromegaly, diabetes
Management
1. History
o
Risk factors (above)
2. Examination
o Tinels tap test positive
o Phalen's test
3. Investigations
o Nerve conduction studies
4. Surgical decompression
Surgical decompression procedure
1.
2.
3.
4.
Informed consent, mark correct side
LA / Regional / GA
Limb exsanguinated + tourniquet, note inflation time
Exposure of flexor retinaculum
o 3cm incision from distal flexor crease (from line ring finger ------)
o expose flexor retinaculum
5. Cut retinaculum
o Place MacDonald's elevator underneath retinaculum
o Incise longitudinally down to instrument
o Median nerve identified (paler in colour, has visible blood vessels called vasa
vasorum on surface)
o Protect motor branch to thenar muscles / palmar cutaneous branch that
provides sensation to skin [by staying medially...]
6. Close skin with interrupted nylon sutures
7. Apply light splint
Dislocations
Shoulder
Elbow
Hip
Anterior
Posterior
Knee
Femoral Neck fractures
Considerations in Hip anatomy
1. Femoral neck anteverted 10-15', angled approximately 125'
2. Coxa valga > 125; Coxa vara <125'
Blood supply to Femoral head
1. Nutrient artery (profunda femoris)
2. Artery of ligamentum teres (from obturator artery)
3. Retinacular branches of medial (most important) and lateral circumflex femoral
arteries (from profunda)
Attachments of femoral capsule
Femoral Musculature
Movements of the Hip
1. Flexion
o
o
Psoas, iliacus (femoral nerve)
Assisted by rectus femoris, sartorius, pectineus
2. Extension
o Gluteus maximus [inserts iliotibial tract, into gluteal tuberosity of femur //
inferior gluteal nerve]
o Hamstrings (semimembranosus, semitendinosis, biceps femoris // tibial
nerve)
3. Abduction
o Gluteus medius, gluteus minimus (superior gluteal nerve)
4. Adduction
o Adductor longus, magnus, brevis (obturator nerve)
5. Internal rotation
o Anterior fibres of gluteus medius and minimus (Weakest)
6. External rotation
o Gluteus maximus
o Obturators
o Gemelli
o Pyriformis
o Quadratus femoris
Classification
1. Intracapsular / extracapsular
o Intracapsular - Garden: based on AP of hip
o
2.
3.
4.
5.
Extracapsular - intertrochanteric, pertrochanteric, subtrochanteric
Angulation / alignment
o Oblique / spiral / transverse
Displacement
Parts
o Comminuted
Aetiology: trauma, pathological
Complications of fractures
1. From fracture
o Avascular necrosis
o Non-union
o Malunion
o Secondary osteoarthritis
2. Damage to surrounding tissues
o Bleeding - can loose 1-2litres of blood
o Nerve injury
3. Loss of function
o DVT / PE
o Chest infection
o Pressure sores
Surgical Treatment options
1. Intracapsular
o Aim to preserve femoral head if undisplaced, otherwise remove
o Internal fixation - cannulated screws
o Replacement of femoral head - hemiarthroplasty
2. Extracapsular
o Internal fixation
Surgical Approaches to the Hip
1. Lateral approach
o Split tensor fascia lata, gluteus medius, gluteus minimus
o Detaching greater trochanter [ends up with really bad trendelenburg!]
2. Anterior approach
o Passess between gluteus medius and minimus laterally + sartorius medially
o Divide reflected head of rectus femoris to expose anterior aspect of hip joint
o More room may be provided by detaching gluteii
3. Posterior approach
o Angled incision commencing at posterior superior iliac spine to greater
trochanter
o split gluteus maximus
o Detach gluteus medius and minimus from insertion at greater trochanter (or
trochanter detached and then re-wired into place)
Dynamic Hip screw Fixation
Indications: Extracapsular fractures of #NOF, Garden I-II
1. Mark, consent, X-rays, Image intensifer // GA or regional block
2. Traction table, ensure adequate reduction of fracture (traction + internal rotation)
3. Access bone
o 15cm incision 2cm from greater trochanter
o Split fascia lata
o Expose vastus lateralis; retract or split fibres + lift from bone with periosteal
elevator
4. Insert internal fixation
o
o
o
o
o
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
5. Finish
o
o
o
Close fascia lata with absorbable sutures
Clips to skin
Check X-rays post-operatively
Trendelenburg sign / gait
Failure of contralateral pelvis to rise when weight is taken on the the affected side
Causes:
1. Mechanical
o Short femoral neck
o Medial migration of femoral head
2. Neuromuscular
o Pain
o Neuropathy
o Myopathy
Eponymous fractures
Fracture
X-ray
Mechanism
Treatment
Bennett's
Intra-articular fracture dislocation
of base of thumb
Monteggia
Fracture proximal ulna +
dislocation of radial head
Galeazzi
Fracture distal radius + dislocation
of ulna
Colles'
Fracture distal radius through
metaphysis (4cm proximal to
articular surface
Distal dorsal angulation
Ulna styloid
Jones'
Open fractures
Open Fracture
Base of 5th MT (insertion of
peroneus tertius)
Fracture (discontinuity in bone) that is in communication with an epithelial-lined
surface


Skin
GIT
Gustilo-Anderson Classification
1. Type I: <1cm (inside-out mechanism) wound
2. Type II: <10cm; no soft tissue loss, no periosteal stripping
3. Type III >10cm or with contamination
o IIIa: extensive soft tissue damage / gross contamination irrespective of
wound size (farmyard, GSW)
o IIIb: soft tissue loss resulting in inadequate amounts of tissue to cover the
bone
o IIIc: neurovascular injury that requires repair to maintain limb viability
Managment
1. ATLS principles
o Airway
o Breathing
o Circulation
2. Assess limb
o Assess neurological function of limb
o Assess vascular status
o Examine wound
o Photograph wound prior to dressing it and attach photo to notes
3. Treatment
o Cover wound with betadine-soaked dressing
o Immobilise limb (in POP, gutter splint, cricket pad splint) +/- manipulation of
fracture
o Systemic antibiotics with broad-spectrum cover + tetanus prophylaxis
o Adequate analgesia
o 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 flaps
Replacement Arthroplasty
Features of an ideal replacement arthroplasty
1. Patient
o
Good range of movement
o
Complete pain relief
2. Implant
o
o
o
o
Mechanical stability
Low coefficient of friction
Low wear
Biocompatible
3. Surgery
o
o
Secure fixation to skeleton
Revisable in event of component failure
Materials used for manufacturing hip joint prostheses




Ultra high molecular weight polyethylene
Cobalt-chromium-molybdenum alloys
Cobalt-chromium alloys
Ceramic
Surgical Options
1. Total hip replacement
2. Hip resurfacing
Complications
1. Infection
o Minimised by pre-operative antibiotics
o Anti-microbial loaded cememnt
o Laminar airflow ventilation in operating room
o Thorough scrubbing, use of disposable gowns, changing gloves and good
skin preparation
o Gentle handling of tissues, adequate haemostasis and good suturing
techniques
o Optimisation of tissue oxygenation
2. Component failure
3. Dislocation
4. Mechanical loosening
o Minimised by dry operative field with adequate haemostasis
o Pressurised cement (tighter fit)
o Cement restrictors
o Lavage systems
5. Aseptic loosening
o Microfracture of components
o Leads to small particulate matter in joint
o Incites inflammatory reaction leading to cysts and loosening
6. Metal sensitivity
Plastic Surgery
Reconstructive surgery
Surgical reconstructive ladder
1.
2.
3.
4.
5.
Secondary intention
Direct closure
Skin graft
Flap: local / distant / composite / island flaps
Tissue transfer
Factors affecting reconstruction
1. Patient
o
o
o
o
Motivation
Health
Healing factors - nutrition, vitamins
Donor site cost vs benefit
2. Wound / defect
o Size and complexity
o Anatomy and blood supply/vascularity
o Availability of local tissue
o Timeframe (ie. open tibias should be closed pretty quickly - innit?)
Skin graft




Skin 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)
Anatomy




Advantages


Disadvantages

Full thickness (FTSG)
Epidermis + variable amount
 Epidermis + dermis
of dermis
 Preserved skin
Harvested using dermatome
characteristics (more
(Watson & braithwaite
collagen content, dermal
modifications of Humby knife)
vascular plexuses, epithelial
or gas-powered dermatomes
appendages)
Epidermis regenerates from
"adnexal elements of skin" - (Skin cannot grow back and donor
hair follicles, sebacous glands site needs to be closed primarily)
and sweat glands
Dermis does not regenerate
Large areas can be covered
(skin can be put through
mesh)
Less likely to fail

Increased graft contraction at
donor site


Less contraction at graft site
(important for hands and
joints - that need movement)
Better cosmesis
Donor site must be primarily
closed
Recipient sites
Donor site


Poor cosmesis
Creates second wound at
donor site which needs caring
for





Any large wound
Line cavities
Resurface mucosal defects
Close flap donor sites
Resurface muscle flaps

More likely to fail because of
greater amount of tissue
requiring vascularisation
Any part of body but in particular
areas



Easily concealed by clothing
Position of easy postoperative care
Capable of providing adequate
tissue
Upper thigh, upper inner arm, scalp,
buttock
Skin Flap

Tissue/tissues transferred from one site to another maintaining a vascular pedicle
Classification of skin flaps
1. Site
o
o
Local
Distant: Free flap
2. Contents
o Tissue capable of transfer
3. Random / axial
o Not based on an artery
o Based on an artery
Renal transplant
Indications
Types
Cadaveric
Live-donor
Needs HLA matching (as does pancreas)
Procedure
1. Curved muscle-splitting incision in contralateral iliac fossa where donor kidney is
implanted
2. Donor vein anastamosed to external iliac vein (end to side)
3. Donor artery anastamosed to external iliac artery (end to side) including patch of
donor aorta (Carrel patch)
4. Ureter anastamosed to dome of bladder + JJ stent
Complications



90-95% survival rate for living related donors
85% for cadaveric donor kidneys at 12 months
75% total graft survival rate at 5 years
Liver transplant
Indications
Procedure
1. Bilateral subcostal incision madef with upward extension to xiphoid process
2. Diseased liver mobilised, IVC clamped and liver removed
3. (Patient on veno-venous bypass - IVC blood directed back to heart via cannula in
axillary/internal jugular vein)
4. Portal veins anastamosed end to end
5. Common hepatic arteries anastamosed end to end
6. CBD anastamosed end to end
Urology
Circumcision
Indications
1. Medical
o
Phimosis (intractable foreskin) - congential adhesions, poor hygeine,
balanitis causing foreskin to become thickened and tight
o Paraphimosis (trapped foreskin behing the glans)
o Recurrent UTIs
2. Non-medical
Contraindications

Hypospadius
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
Informed 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
Complications
1. Immediate
o Bleeding / haematoma
o Infection
o Urine retention
o Glans injury
o Ischaemia / necrosis of penis
2. Late
o Poor cosmesis
o Urethrocutaneous fistula
o Meatal stenosis
o Psychological morbidity
Hydrocoele
(Canal of Nuck = female equivalent of processus vaginalis, projecting into labium
majora)
Indications
Symptomatic swelling in adults
Procedure
1. GA + supine position
2. Access tunica
o Stretch scrotal skin
o Incise between visible vessels using either knife or cutting diathermy
3. Evacuate fluid
o Make small incision in tunica vaginalis
o Evacuate the fluid
4. Repair hydrocoele
o Jaboulay [tie off sac at apex]: using absorbable sutures, stitch edges of
tunica behind cord and subsequently return testis to scrotum
o 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.
5. Close wound with interrupted absorbable sutures
Nephrectomy
Indications




Malignancy [renal cell carcinoma]
TCC of ureter requiring nephro-ureterectomy
Non-functioning kidney
Chronic pyelonephritis
Possible approaches
1. Open
o
o
Anterior/Transperitoneal
Posterio-lateral/Retroperitoneal
2. Laparoscopic
o Transperitoneal
o Retroperitoneal
Procedure (Right nephrectomy - Anterior/peritoneal approach)
1. CT scan + confirm presence of opposite kidney (otherwise you're in big shit) + mark
side + consent
2. GA + supine
3. Kocher's subcostal incision
o identify hepatic flexure, duodenum, gonadal vessels
o Mobilise colon medially: display perinephric fat
4. Identify kidney (surrounded by paranephric fat), ligate vascular pedicle (prevents
dislodging of tumour cells into circulation)
o Identify vascular pedicle
o Clamp renal artery
o Palpate renal vein; ligate and divide
o Divide renal artery
5. Mobilise kidney within fascia (Gerota's, surrounds perinephric fat)
6. Divide ureter at accessible point
7. Remove kidney with perinephric fascia intact
8. Place suction drain
9. Close wound in layers
Procedure - Posterio-lateral approach
1. Lateral decubitus position + renal bridge on operating table under contralateral loin.
2. Subcostal incision along line of 12th rib: Midline -> posterior axillary line (ie, quite
large)
3. Divide layers: skin / lat dorsi / ext obl / int obl / quad lumb / > kidney
Laproscopic nephrectomy



Dissect out
Bring to surface
Make skin incision to deliver
Complications
1. Early
o
o
o
o
Wound infection
Bleeding
Haemorrhage
General - DVT, Chest infection, PE
2. Late
o
Tumour reccurrence
Orchidectomy
Indications


Malignancy
Suspected malignancy
Orchidectomy Procedure
1. Consent + marked + GA
2. Access testicle via inguinal route (reduced risk of scrotal seeding)
o Inguinal incision 2cm above and parallel to medial 2/3 of inguinal ligament
o Incise through campers fatty fascia, scarpa's fascia to external oblique
o Split external oblique
o Free spermatic cord
o Apply 2 artery forceps to cord at deep ring (to prevent tumour
dissemination)
3. Remove testicle
o Divide cord between clamps, tie with non-absorbable sutures
o Manipulate testis into inguinal region,free from gaubernaculum by blunt
dissection
o Remove and send for histological analysis
4. Finish
o Close external oblique aponeurosis with absorbable sutures
o Close skin with subcuticular suture
o
Apply scrotal support
Prostate
Treatment options for prostatic hypertrophy
1. Conservative measures: fluid restriction, reduction caffeine intake
2. Pharmacotherapy:
o alpha blockers (alfuzosin, doxzosin) - inhibit smooth muscle contraction
o 5-alpha-reductase inhibitor (finasteride) - block conversion of testosterone
to DHT which limits size of prostate
3. Surgical intervention
o Transurethral resection of the prostate (TURP)
o Transurethral incision of prostate for BOO
o Open retropubic prostatectomy - prostates > 80g in weight
o Transurethral microwave thermotherapy (TUMT)
o Transurethral needle ablation of the prostate (TUNA)
Indications for prostatic surgery


Acute 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 surgery



Prostatectomy = removal of hyperplastic mass of glandular tissue from surrounding
prostatic gland which is compressed into a thin rim around it
Approaches: (1) transvesically across bladder (2) retropubically through prostatic
capsule (3) transurethrally
in TURP, surgeon keeps proximal to verumontanum (colliculus seminalis) in order
not to damage the urethral sphincter mechanism
Complications







90% 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 syndrome
Pathogenesis: 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) preoperative 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 / cystotomy
Indications
Procedure
Testicular Torsion
Differential Diagnosis
1.
2.
3.
4.
5.
Testicular torsion
Torsion of testicular/epididymal appendage
Orchitis - mumps / epididymoIncarcerated hernia
Hydrocoele
Management
1. History
2. Examination
3. Investigations
o Scrotal USS: can demonstrate flow of blood in testicular artery. Poor
negative predictive value
4. Treatment
o When suspected immediate exploration is indicated within 8 hours (after 8
hours, infarcted testis is unlikely to recover
Surgical Approach
1. Access scrotum
o Skin, dartos, external spermatic fascia, cremasteric fascia, internal spermatic
fascia, tunica vaginalis/albuingea, testis ("Some damn Englishman called it
the testis")
2. Assess testicle for viability
o Release torted testis
o Wrap in warm soaked gauze for 10minutes
3. Fix other testicle
o Explore contralateral hemiscrotum
o Insert 3point fixation for testis to tunica vaginalis
o Close with non-absorable sutures
4. If viable, fix; if not viable clamp, ligate and remove
Ureter
Repair of damaged ureter



Direct spatulated ends (plus JJ stent insertion)
Implant onto contralateral ureter
Boari procedure
Varicocoele
Varicocoele



Acute onset often due to left renal vein compression from renal cell tumour
More common on the left
Associated with oligospermia
Indications
1. Male infertility
2. Scrotal discomfort
Treatment options
1. Radiological embolisation
2. Laproscopic division of varicocole from within peritoneal cavity
3. Surgical approach at level of internal ring
Surgical Procedure
1. GA + supine
2. Dissect down to testicular vein
o Make incision over internal ring parallel to inguinal ligament
o Divide external oblique aponeurosis, visualise cord and split spermatic fascia
longitudinally to expose testicular veins (from pampiniform plexus)
3. Isolate and divide vein
o Separate vein from vas and testicular artery
o Ligate and divide with absorbable sutures
4. Close
o Repair external oblique aponeurosis with absorbable subcuticular suture
o close skin incision with subcuticular non-absorbable suture
Vasectomy
Indications

Male sterilisation (between 28-45) with stable marriage with family of 2+ children
Considerations 1. Irreversible (reversal can be attempted in first 5 years but cannot always restore
fertility - production of antisperm autoantibodies)
2. Sterilisation not immediate - must provide x2 post op negative counts (at 3 and 4
months), so must continue with barrier contraceptives
3. 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
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
LA, 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 Surgery
Amputations
Indications



Dead: 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 / LA
Double check side of operation
Isolate areas of gangrene
Generous flaps can be trimmed later
If tissue does not bleed (it will not heal properly) - therefore move proximally with
amputation
Mobilise early to avoid contractures
Workup
1. Patient
o
o
o
Condition and mobility of patient (AKA more easy to transfer bed-bound
patient)
Ability for patient to be rehabilitated
Psychological counselling
2. Disease
o
o
Pathology / severity of disease
Viability of flaps
3. Health-care related
o OT / Physiotherapy
o Limb fitting / prosthetics (end-bearing amputation may be suitable to allow
simple prosthesis)
Deciding level of amputation
1. Joint contractures - AKA
2. Severely reduced mobility - AKA affords better transfer, less risk of stump pressure
sores
3. Knee OA - AKA
4. Infection
5. Viability of distal limb
Types of Amputation
1. Upper limb
o Upper arm
o Supracondylar (above elbow)
o Extraarticulation (thorugh elbow)
o Proximal forearm (below elbow)
o Distal forearm
o Wrist
o Metacarpophalangeal
o Proximal interphalangeal
o Distal interphalangeal
2. Lower limb
o Hindquarter
o Above knee - equal anterior-posterior flap
o Supracondylar
o Through knee (Gritti-stokes)
o Below knee - long posterior flap
o Symes (Tibia/Talus)
o Chopart (Talus/Navicular)
o Lisfranc (Navicular/Metatarsal) - posterior plantar flap
o Transmetatarsal
o Ray
Above knee amputation

One hand's breadth (8-10cm) above upper border or patella: site of femur division

Equal length flaps
1. Divide skin + tissues along planned lines
2. Divide soft tissue
o Ligate veins using2/O absorbable suture
o Deepen incision to bone
o Divide quadriceps tendon (to patella)
o Divide hamstrings posteriorly
o Double-Ligate femoral artery
o Apply tension to nerves before ligating so they retract (femoral/sciatic)
o Retract thigh muscles
3. Divide Bone
o Divide femur, remove lower leg, place clean towel under stsump
o Smooth edges of femur using a rasp + bone wax (stop bleeding)
4. Close defect
o Bring anterior-posterior muscles together using 1/O interrupted sutures
o Place suction drain under muscle layer
o Place second layer of sutures in superfical muscles
o Suture skin edges with interrupted 2/O sutures
5. Cover stump with gauze + crepe bandage
Below knee amputation



14cm 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
1. Incise along marked lines
2. Divide soft tissue
o Divide achilles tendon posteriorly
o Divide posterior muscles
o Ligate vessels, divide (ie. don't tie them) nerves
3. Divide Bone
o Cut fibula obliquely (with Gigli saw) + divide tibia 2cm distal to this
o Clear muscle off bone with periosteal elevator
4. Close defects
o Oppose muscle flaps + suture
o Unite skin edges with 2/O interrupted
o Trim edges
5. Apply crepe/cotton-wool bandaging
Allows for pressure to be put on stump with smaller risk of dehiscence
Complications
1. Early
o
o
o
o
o
Haematoma
Wound infection
Dehiscence, flap necrosis
DVT / PE
Phantom limb pain
2. Late
o
o
o
o
Neuroma
Bone spurs
Stump ulceration
Psychological distress
Aneurysm
Aneurysm

D: Abnormal localised dilation of a blood vessel
Classification
1. Congenital / Acquired:
o Berry aneurysm (art. circle of Willis)
o hypertension
2. True / False:
o Full thickness (all three layers)
o partial (outpouching of intima)
3. Shape:
o Fusiform (entire circumference)
o saccular (part of circumference)
o dissecting
4. Cause: Atheroma, syphillis, trauma, inflammatory (PAN, Ank Spond), Iatrogenic,
ischaemic, congenital, mycotic (following low grade infection), hypertension
(Charcot-Bouchard aneurysm)
5. Anatomy:
o Ascending aortic aneurysm
o Descending - supra-renal (blood supply to gut, spinal cord), infra-renal
Complications
1.
2.
3.
4.
5.
Thrombosis
Embolus
Haemorhage
Pressure effects - nerve, vertebral column
Fistulation
Indications for screening
1. All patients with risk factors should have USS at 65 years
2. Small aneurysms (4-5.5cm) should undergo ultrasound surveillance at 6 month
intervals
Indications for surgery
1. Emergency
o Rupture
2. Elective
o Symptomatic aneurysm
o Rapidly expanding
o > 5.5cm
Elective mortality is 2-5%
Management of Ruptured aneurysm
1. Resuscitation / stabilisation
o Large bore cannulae, IV crystalloid, maintain relative hypotension (90-100
systolic)
o Urinary catheter - UO
o Adequate analgesia
o Bloods: FBC, U/Es, LFTs, Amylase, Cross match 8 units of blood + FFP +
platelets
2. Contact most senior surgeon / dedicated vascular team + anaesthetist
3. Arrange ITU bed
4. Surgery if unstable, imaging if stable (CT)
o Risk of death - 50% survive to hospital, 25% die before operation
o Operative complications - limb loss, ischaemic gut, renal failure
Aneurysm repair procedure
1. GA, supine, exposed groins (for embolectomy)
2. Access aorta
o Long midline incision from xiphisternum to pubis, skirt left of umbilicus
o Omentum, large bowel displaced superiorly
o Pack small bowel to right
o Duodenum displaced
o Peritoneum dissected off aorta
3. Give IV heparin
4. Repair aneurysm
o Clamp across neck and lower end of aneurysm sac
o Incise sac longitudinally
o Scoop out thrombus, atheromatous material
o End-to-end anastamosis with prosthetic graft using prolene sutures
5. Test repair
o Soft clamp applied below sleeve, release upper clamp
o Repair lower end of anastamosis
6. Closure
o Remove clamps (warn anaesthesist - may get hypotension)
o
o
o
o
o
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
7. Go to intensive care - watch for complications
o Vascular: haemorrahge, graft thrombosis, false aneurysm, distal embolism
o Neurological: CVA, spinal ischaemia
o GIT: ischaemic gut, aorto-enteric fistula, pancreatitis
o Renal: ARF
o Respiratory: ARDS
o Cardiovascular: MI
o Haematological: DIC
Endovascular stenting
1. Minimally invasive interventional radiology
2. Catheter places metal stent inside aorta
3. Indications:
o Patients unsuitable for open surgery
o Infra-renal aneurysms
o Anatomy: proximal and distal neck of arteries must allow complete
exclusion of aneurysm
Endovascular stenting procedure
1.
2.
3.
4.
GA / regional
Access femoral artery
Pass graft over guidewire
Deploy graft once in position
o Graft achieves final shape through elasticity / thermal memory
Complications





Infection
Leakage
Fracture of graft
Graft migration
Graft occlusion
Arterial bypass surgery
Examples




Femoral-popliteal
Femoral-distal
Axillo-femoral
Femoral-femoral
Types of graft
1. Native
o
o
Reverese autologous long saphenous vein graft
Insitu long saphenous vein graft (disrupted with valvulotome)
2. Synthetic
o PTFE
o Dacron
Complications
1.
2.
3.
4.
Bleeding
Infection: wound, graft
Suture line aneurysm
Graft failure: thrombosis
Carotid endarterectomy
Indications

TIAs in distribution of artery (middle/anterior cerebral territory)
Preparation



Carotid duplex: extent of stenosis
Carotid angiogram
Echo, cholesterol, ECG, CT brain (previous CVA)
Procedure
1. Local anaesthetic block / intercostal block (allows monitoring of neurological status
intra-operatively) - enables operation without a shunt
2. GA allows for better airway control, requires shunt + EEG
3.
4.
5.
6.
7.
8.
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
Complications




Nerve injury - recurrent laryngeal, hyoglossal (12) nerve
Haematoma
Hypertension / hypotension (carotid body effects)
Stroke (1-5%)
Follow up

6 month surveillance scans
Femoral Embolectomy
Indications

Acute limb ischaemia
Workup


Coagulation screen
Test foley catheter beforehand
Performed under LA/GA
Procedure
1.
2.
3.
4.
5.
6.
Palpate 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
7. Pass catheter proximally up aortic bifurcation; inflate balloon (avoid overdistension damages intima), withdraw any clot (assistant tightens tape to prevent bleeding)
o Send clot / embolus for histology - never know what is is!
8. When good inflow, inject heparinized saline up vessel + reapply clamp
o If unable to achieve good back bleeding - do on-table angiogram
o If unable to achieve good inflow - get help
9. Repeat on SFA, PFA
10.
11.
12.
13.
14.
Repair arteriotomy (5/O non-absorbable)
Remove clamps, tapes, check haemostasis
Insert suction drain
Close wound
Check + document pulse / clinical condition of limb
Complications



Dissection
Perforation of vessel
Amputation
Varicose vein
Indications




Symptomatic veins
Cosmesis
Varicose ulceration
Lipodermatosclerosis
Pre-operative workup



Hand-held doppler - confirm superficial reflux
Venous duplex imaging +/- junction marking - demonstrates incompetent
perforators, deep veins
Mark veins pre-operatively with indelible marker
Tributaries




Superficial 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 operation
1. GA, supine
2. 1.5cm incision lateral and below pubic tubercle (site of SFJ) - 4cm in groin crease
3. Dissect tributaries of SFJ (superficial inferior epigastric, superficial circumflex iliac,
deep/superficial external pudendal)
4. Ligate and divide tributarie
5. Ligate SFJ
6.
7.
8.
9.
10.
11.
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
Complications



Haematoma
Recurrence (up to 20%)
Saphenous nerve injury - loss of sensation medial thigh
Short saphenous vein
1. Transverse
skin crease
incision
2. Dissect down
to SSVJ
3. Tie off
junction
(avoid sural
nerve lateral
to SPJ)
Other surgical options
1. Endovenous laser ablation
2. Ultrasound guided foam sclerotherapy (risk of thrombosis
Parotid gland surgery
Indications

Benign tumours confined to superifical part of parotid gland
Superficial parotidectomy Procedure
1. GA + supine + slight head-up tilt
2. Dissect down to parotid
o 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
o Incision curved around ear lobe to extend for 2-3cm into postauricular
groove
o Angled acutely over mastoid to be continous with cervical part of incision
o Deepen incision down to bony external auditory meatus
o Deepen through subcutaneous fat, platysma to stylohyoid muscle
o (anterior branch of great auricular nerve usually sacrificed - causes
parasthesia of earlobe)
3. Identify branches of facial nerve
o Reflect parotid forwards
o Dissect divisions and branches of facial nerve (TZBMC)
4. Dissect out parotid duct, ligate
o Raise skin flaps superiorly to just above zygomatic arch, anteriorly to
anterior border of masseter muscle and inferiorly to anterior border of SCM
o Parotid duct dissected forwards as far as anterior border of masseter
muscle, then ligate and divide [normally opens 2nd molar]
5. Remove superficial parotid
6. Close
o Ensure haemostasis
o Close skin with subcuticular suture
Complications
1.
2.
3.
4.
5.
Bleeding / 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 stomatoplasty
Indications

Obstructive parotitis
1. GA + supine position
2. Nasophryngeal ETT
3. Mouth kept open with dental prop, tongue retracted to contralateral side by
assistant
4. Identify parotid papilla (opposite upper 2nd molar)
5. Insert 2 stay sutures above and below papilla
6. Pass dilator through parotid duct and then incise longitudinally down to dilator
Surgical airway
Tracheostomy
Indication




Airways obstruction
Protection from aspiration (decreased consciousness, GBS, tetanus)
Prolonged intubation / long-term ventilation
Facilitate airways suction
Types of Tubing



Metal / plastic
Cuffed (reduces risk of aspiration) / uncuffed (used in children - as risk of mucosal
ulceration)
Windowed - permits speech
Open Procedure
1. ETT intubation + GA
2.
3.
4.
5.
6.
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
7. Insert tube, secure
Percutaneous procedure
More rapid, less traumatic, doesn't need surgeon/anaethestist
1.
2.
3.
4.
5.
6.
7.
8.
LA + 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