Senior Cycle

Notes in
Surgery
RCSI Department of Surgery 1

CONTENTS

Table of Contents
CONTENTS
PREOPERATIVE ASSESSMENT 6
POST-OPERATIVE MANAGEMENT 9
(1) RESPIRATORY COMPLICATIONS 9 (2) GASTROINTESTINAL COMPLICATIONS 10 (3)HAEMORRHAGE
11 (4) URINARY COMPLICATIONS
11 (5)WOUND COMPLICATIONS
12 (6) CARDIOVASCULAR
COMPLICATIONS 12 (7) DEEP VEIN THROMBOSIS 13

SURGICAL NUTRITION 14
FLUIDS AND ELECTROLYTES 17
HYPOVOLAEMIA: 17 FLUIDS AND ELECTROLYTES 19 ELECTROLYTES 20

EPIDURAL CATHETERS 25
POST OPERATIVE COMPLICATIONS 29
PYREXIA 29 VENOUS THROMBOSIS AND THROMBOEMBOLISM 31
SURGICAL EQUIPMENT 33
TRACHEOSTOMY TUBE 33 INCENTIVE SPIROMETRY 34 NASOGASTRIC TUBE 34 JEJUNOSTOMY
TUBE 36 CENTRAL VENOUS CATHETHER (CVC) CENTRAL LINE 37 URINARY CATHETER 38 PEG
TUBE 40 TUNNELLED CENTRAL VENOUS CATHETERS (CVC) 41 PERIPHERALLY INSERTED CENTRAL
CATHETERS (PICC) 42 SURGICAL DRAINS: 42 T TUBE 46 ENDOTRACHEAL TUBE 46 STOMA BAG
47 UNDERWATER SEAL CHEST DRAIN 47 TENCKHOFF PERITONEAL CATHETER 49

SEPSIS 50
VOMITING, HAEMATEMESIS AND MALENA 52

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VOMITING 52 MALAENA 56

OESOPHAGEAL DISORDERS 59
OESOPHAGEAL
DYSPHAGIA 62

CARCINOMA

59 OESOPHAGEAL

MOTILITY

DISORDERS

60

CONSENT FOR OESOPHAGO-GASTRO-DUODENOSCOPY 65

PEPTIC ULCER DISEASE 67
GASTRIC AND PANCREATIC CARCINOMA 70
GASTRIC CARCINOMA 70 GASTRIC LYMPHOMA 72 PANCREATIC CARCINOMA 72
PANCREATITIS 74
ACUTE PANCREATITIS 74
CHRONIC PANCREATITIS 80
PANCREATITIS: HISTORY 81
GALLBLADDER DISEASE 84
CONSENT FOR A LAPAROSCOPIC CHOLECYSTECTOMY 89
JAUNDICE 90
ACUTE APPENDICITIS 94
INFLAMMATORY BOWEL DISEASE 99
ULCERATIVE COLITIS 99 CROHNS DISEASE 102
INFLAMMATORY BOWEL DISEASE HISTORY 105
SMALL BOWEL OBSTRUCTION 112
COLORECTAL CARCINOMA 113
RECTAL BLEEDING 118
INFORMED CONSENT FOR COLONOSCOPY 121 CONSENT FOR A BOWEL RESECTION 122

HERNIAS 123
(1) INGUINAL HERNIAS 123 (2) FEMORAL HERNIAS
HERNIAS 126 CONSENT FOR INGUINAL HERNIA 127

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125 (3) OTHER IMPORTANT

PERIANAL DISORDERS 129

HAEMORRHOIDAL DISEASE 129 ANAL FISSURE 131 ANORECTAL ABSCESSES

133 PILONIDIAL SINUS AND ABSCESS 136 ANAL CANCER 137

132 ANAL FISTULA

PERIPHERAL VASCULAR DISEASE 140

CHRONIC LOWER LIMB ISCHAEMIA
VASCULAR DISEASE HISTORY 146

141 ACUTE

ISCHEMIA

VENOUS DISEASE 148

LEG ULCERS 151
ANEURYSMS 153
ABDOMINAL AORTIC ANEURYSM 156
CAROTID ARTERY STENOSIS 162
CAROTID DISEASE: HISTORY 164
UROLOGICAL MALIGNANCY 166
RENAL CELL CARCINOMA 166
TRANSITIONAL CELL CARCINOMA 167
TESTICULAR MALIGNANCY 170

UROLOGICAL SURGICAL TECHNIQUES 173

NEPHROSTOMY 173 UROSTOMY ( ILEAL CONDUIT) 174

HAEMATURIA: HISTORY 175

THYROID DISORDERS 178
DIFFUSE GOITRE 179 NODULAR GOITRE 179

NECK MASS 183

BREAST DISORDERS 188
(1) BREAST CANCER 188 (2) BENIGN BREAST DISEASE 191
SCREENING DETAILED REVIEW 193
SKIN MALIGNANCY 196
MALIGNANT MELANOMA 196

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144 PERIPHERAL

PRESENTATION 196

BASAL CELL CARCINOMA (RODENT ULCER) 199 SQUAMOUS CELL CARCINOMA 200

BURNS 202
HEAD INJURY 206
THORACIC TRAUMA 211
TRAUMA AND ORTHOPAEDIC REVIEW 215

Acknowledgements______________________________________________________
______________216
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PREOPERATIVE ASSESSMENT

Introduction
Preoperative assessment has two primary aims; firstly, to identify patients at high risk
for surgery and secondly to reduce the number of post-operative complications. The
mainstay of preoperative assessment is a thorough history and clinical examination
supported by appropriate investigations. Factors to consider include the underlying
diagnosis, the patients overall fitness for an operation, individual requirements for highrisk patients, the type of anaesthetic to be used (local or general), and the type of
operation to be performed. Informed consent is also obtained in the preoperative
assessment. The principles outlined below deal primarily with surgery under general
anaesthesia.
Assessment
A detailed clinical history and examination will highlight those patients at increased risk
of developing post- operative complications. The American Society of
Anaesthesiologists (ASA) has developed a classification system for patients undergoing
a general anaesthetic. Patients are grouped into one of five classes depending on their
associated comorbidities.
ASA Classification
Class I Healthy individual Class II Mild systemic disease Class III Limiting, but not
incapacitating, systemic disease Class IV Incapacitating systemic disease Class V
Moribund (pre-terminal)
Cardiovascular System Assessment of the cardiovascular system should include a
history of previous cardiac disease such as angina, a previous ischaemia episode (MI),
cardiac arrhythmias, previous intervention (angiogram or angioplasty) and current
cardiac medications. Clinical examination should specifically elucidate signs of cardiac
failure, arrhythmias, or cardiac murmurs.
Preoperative investigations include serum electrolytes, an ECG (all males > 40 years;
all females > 50 years) to establish a baseline of cardiac function and a chest x-ray to
assess the presence of cardiomegaly.
Patients with a significant cardiac history may require more intensive investigation. This
may include preoperative assessment by a cardiologist and further investigations such
as a cardiac stress test, an echocardiogram and in severe cases an angiogram.
Respiratory System Respiratory co-morbidities such as COAD and asthma are
common, especially in an aging population. A clinical history of previous respiratory
compromise, current medication and a smoking history must be sought. Examination of
a patients chest will give a guide to the severity of symptoms. Smoking cessation
should be advised as it improves outcome from general anaesthetic. Smoking not only
increases airway hyper-reactivity, which leads to bronchospasm but also increases
sputum production and reduces ciliary function, which leads to reduced sputum

clearance, and increases the risk of postoperative lower respiratory tract infection.
Chest x-rays are of little value in most patients without clinical evidence of respiratory
disease, but are generally performed in patients over the age of 60 years of age.
Patients with a history of chronic lung disease require pulmonary function tests and
measurement of oxygen saturation by arterial blood gas analysis pre-operatively.
Patients on steroids for lung disease may have increased steroid
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requirements in the peri-operative setting. Patients with significant respiratory

compromise should have preoperative and early post-operative chest physiotherapy.

Diabetes Diabetic surgical patients are at increased risk of unrecognised hypoglycaemia
and ketoacidosis. Diabetes, which is uncontrolled, predisposes to infection and as a
result of the small vessel disease in diabetes, there is an increased risk of gangrene
and ulceration. The age of onset of the disease and the method of blood sugar control
should be enquired after. How well controlled the diabetes should be established. If the
diabetes is poorly controlled or brittle the advise of an endocrinologist should be
sought. The use of more than 40 units of insulin a day indicates moderate disease and
increases the post-operative risk. Therefore, all diabetic patients should be admitted 48
hours prior to surgery and have a full haematological screen (FBC, U&E, glucose), an
ECG and a chest x-ray performed. All diabetic patients should be done first on the list.
The morning dose of insulin should be omitted and an infusion of 5% dextrose with
15units / litre soluble insulin should be commenced two hours prior to the surgery. The
blood glucose level should be checked prior to surgery.
Rheumatoid Arthritis Patients with rheumatoid arthritis should have not only a chest xray performed, but also should have a lateral cervical spine x-ray preoperatively to
assess for any atlanto-axial subluxation, which may compromise vertebral blood flow or
compress the spinal cord with neck manipulation during the induction of anaesthetic.
General Preoperative Measures
Blood Tests All patients should have a full blood count, a renal profile and a coagulation
screen performed routinely. For all major surgery blood should be cross-matched or
serum grouped. If the patient is anaemic (Hb <10g/dL) this should be investigated
preoperatively. Patients may require supplementation with oral iron for elective
procedures. For emergency procedures blood should be cross-matched and the
anaemia corrected. Patients from Africa may have sickle-cell problems and may require
a sickle test to be performed. If the patients has liver disease or is jaundiced they may
have a prolonged prothrombin time. This can be corrected with vitamin K.
DVT Prophylaxis Deep vein thrombosis prophylaxis must be considered in all patients
but especially in those undergoing pelvic or hip surgery, obese patients, those with
malignant disease, older patients, diabetic patients and those with a previous history of
a DVT or a PE. All patients who have been on the OCP or HRT also require DVT
prophylaxis. DVT prophylaxis consists of thromboembolic deterrent stockings (TEDs)
and subcutaneous low molecular weight heparin.
Discontinuing Medications Patients who are taking aspirin and/or clopidogrel should, as
a general rule, discontinue these 10 days prior to admission for elective surgery. This
reduces the amount of intra-operative bleeding. If the indication for anti-platelet
medication is stent patency, consultation with cardiology and anesthesia is warranted.
Ideally women on the OCP should discontinue it one month prior to surgery, and
alternative contraception should be advised. This reduces the risk of DVT. Patients

taking -blockers should have these continued, including the morning of surgery. Abrupt
discontinuation may lead to rebound hypertension and tachycardia causing cardiac
morbidity.
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Preoperative measures Patients undergoing a general anaesthetic are required to fast

for 6 hours preoperatively. This ensures that the stomach is empty at the time of
induction of anaesthesia, which reduces the risk of aspiration. Factors that may delay
gastric emptying include a hiatus hernia, pyloric outlet obstruction, autonomic
neuropathy, pain and opiates. Fasting overnight for surgery does not have
consequences for most healthy patients, however delays during the operating list may
predispose patients to dehydration and thus patients who are not being operated on at
the start of a list should be kept on maintenance fluids overnight.
Patients undergoing elective large bowel surgery generally require bowel preparation
with oral and/or retrograde purgatives such as sodium picosulphate (picolax).
Additionally, these patients require peri- operative prophylactic antibiotics to reduce the
incidence of wound infection. Patients who require a stoma should have the place of
their stoma marked preoperatively.
All patients undergoing an operation should have the side of the operation marked by
the surgeon doing the operation.
Patients who have a prosthetic metal heart value may require early admission in order
to effectively anticoagulate them with IV heparin following discontinuation of their
warfarin. Intravenous heparin is discontinued four hours prior to the anticipated
operative time. All patients with prosthetic values will require antibiotic prophylaxis.
Consent All patients undergoing surgery should have informed consent obtained. It
must be recognised that the informed patient of sound mind has every right to withdraw
consent. It is not possible to inform the patient of every possible complication of an
operation however there are two types of complications that must be discussed with the
patient. The first type is a complication that occurs relatively frequently such as wound
infection, DVT or lower respiratory tract infection. The second is a rare complication that
has potentially catastrophic consequences, such as recurrent laryngeal nerve injury
after thyroidectomy or common bile duct injury after cholecystectomy.
Children under the age of 16 and patients who are mentally unfit cannot provide their
own consent and this is carried out by their next of kin. In an emergency situation where
a patient is unconscious and a next of kin is unavailable the surgeon is expected to
provide treatment in the patients best interest (such as surgery) without consent.
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POST-OPERATIVE MANAGEMENT

Introduction
Regardless of the degree of surgery performed, the management of patients in the
immediate postoperative period follows the same basic principles. Three systems are
monitored
1. Cardiac function
a. Heart rate, rhythm, volume b. Non-invasive BP monitoring
c. Invasive haemodynamic monitoring
i. Central Venous Catheter measures Central Venous Pressure (CVP)
ii. Swan-Ganz Pulmonary Artery Catheter measures Pulmonary Capillary Wedge
Pressure and thus Left Atrial Pressure
2. Respiratory function
a. Respiratory Rate, Work of breathing
b. Non-invasive SpO2 monitoring, End tidal CO2 c. Invasive monitoring through arterial
blood gas analysis (ABG) and ventilator feedback and
settings for intubated patients 3. Fluid balance
a. Strict input and output monitoring b. Invasive Arterial waveform, CVP
.
(1) Respiratory Complications
Atelectasis
Basal atelectasis is the commonest cause of a post-operative temperature within the
first 48 hours. It describes a collapse of the alveoli, which occurs as a result of
inadequate alveolar expansion. There are a number of causes including poor ventilation
of the lungs during surgery, inability to fully inspire secondary to pain or excessive
sputum retarding airflow. Patients with COAD, smokers, those who are over-sedated,
have poor pain control or are obese are especially at risk. Basal atelectasis presents
with fever, tachypnoea, tachycardia, decreased oxygen saturation and reduced air entry
at the lung bases. It is treated with post- operative chest physiotherapy, incentive
spirometry and suctioning. Saline nebulisation and humidified oxygen will prevent
secretions becoming dry and difficult to expectorate. Importantly, adequate pain relief
will allow deep inspiration and good compliance with physiotherapy.
Pneumonia
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Pneumonia may develop secondary to basal atelectasis or may arise as a result of

aspiration. Factors predisposing to aspiration pneumonia include the supine position

and decreased airway protective responses. Patients who are obese or pregnant
patients, elderly patients, patients with a depressed level of consciousness or who are
over-sedated or those with a bowel obstruction are at particular risk. Patients develop a
pyrexia, tachypnoea, tachycardia and decreased air entry with associated crepitations.
A chest x-ray, along with a leucocytosis and increased inflammatory markers, (eg) CRP,
will confirm the diagnosis. In severe cases patients may develop respiratory failure
requiring ventilatory support, either invasive or non-invasive. Treatment is with oxygen,
bronchodilator nebulizers, chest physiotherapy, incentive spirometry and intravenous
antibiotics.
Pulmonary embolism
A pulmonary embolism arises when a blood clot, typically originating in the lower limb
venous system, migrates to the pulmonary arterial system. Risk factors include postoperative status, immobility, obesity, use of oral contraceptives, malignancy, and
advanced age, myocardial infarction and hypercoagulable status. Patients develop a
sudden shortness of breath and associated pleuritic chest pain. Occasionally patients
may have haemoptysis. On examination they may be hypotensive and tachycardic,
tachypnoic with a loud second heart sound.
An ABG, ECG and chest x-ray should be performed. Patients have a low PO2 and
PCO2. More than 50% of ECGs will be abnormal; sinus tachycardia is the most
common abnormality, but inverted T waves, ST segment depression or the classical
pattern of S1, Q3, T3 may all be seen. The chest x-ray will be normal in the vast
majority of cases but may demonstrate a wedge-shaped area of decreased pulmonary
vasculature, indicating an area of lung infarction. Further investigations include a CTPA
(Computed Tomography Pulmonary Angiogram). The definitive investigation is
pulmonary angiography but is rarely used due to its invasive nature.
The usefuleness of D-Domer assay in the post operative patient is questionable. D
Dimer is useful when used in conjunction with a clinical prediction rule such as the Wells
Score for PE and the Geneva Score for PE. However, prediction tools are generally
designed to be sensitive and useful to rule out the condition in question, Given that
the Wells Score and Geneva Score use a NEGATIVE ddimer in low risk patients as a
PE rule out criteria, they are not useful in a ward setting. Post operative patients are by
their nature high- risk thus, a d dimer is not a useful test.
The management of patients with a pulmonary embolism depends on whether they are
clinically stable. A stable patient is anticoagulated with subcutaneous low molecular
weight heparin, and subsequently with warfarin for at least six months. If there is a
contra-indication to anticoagulation, or repeated PEs, while on warfarin the insertion of a
Greenfield filter should be considered. If the patient is unstable a cardiothoracic opinion
should be sought regarding possible embolectomy and thrombolysis should be

considered.
(2) Gastrointestinal Complications
Paralytic Ileus
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