1
Q
Common inscision sites
A
- Midline incision = most intra-abdominal structures including retroperitoneal. Utilised avascular nature of linea alba to access abdominal contents without cutting/splitting muscle fibres. May be extended cephalad or caudally to improve access. However more pain than transverse incision and perpendicular to langers skin tension lines so poorer cosmesis .
- Commonly for emergency laparotomy (eg, faecal peritonitis secondary to malignant intestinal perforation or ischaemic bowel. Can also be used to assist laparoscopic cases.
- Layers: Skin, subcutaneous fatty layer (campers fascia), Membranous fascia (Scarpa’s), linea alba, transversalis fascia, peritoneal fat, parietal peritoneum.
- Paramedian Incision: Falciform ligament of liver common encountered when incision right of midline ad tendinous intersections must be divided on chosen side to access peritoneum. Largely now midline as poor cosmesis.
- Pararectal Incision: Largely abandoned as disruption of innervation to rectus lying medially.
2
Q
Rectus sheath
A
Rectus Sheath:
- Anteiror sheath – Ex.Ob and anterior lead of Int.Ob aponeurosises. Recti interrupted by 3 paired tendinous intersections. Posterior sheath – posterior lead internal and transversus abdominis aponeurosis. Get Linear alba.
- No posterior sheath above costal margin level and recti covered anteriorly by Ex.Ob aponeurosis and insert onto costal cartilages.
- 1/3-1/2 between umbilicus and pubic symphysis is arcuate line where posterior elements of sheath perforate to join anterior sheath and get thickened transversalis fascia in direct contact with rectus muscles.
3
Q
Identify Anatomy of inguinal canal and relate to inguinal hernia classification
A
4
Q
Requirements for General anaesthetic
A
- Through pre-anaesthetic assessment of fitness
- Patient consent
- Hypnosis or unconsciousness
- Analgesia
- Muscle relaxation
- Easy reversibility of induced state
- Maintenance of as near to normal physiology as possible
5
Q
ASA scoring- American society of anaesthesiologists
A
- Normal healthy patient
- Mild systemic disease
- Severe systemic disease that limits activity but is not incapacitating
- Incapacitating systemic disease; threat to life
- Moribund patient not expected to survive 24hours with or without surgery
- (Brain dead)
Groups 1 to 3 have no or little increased risk with normal anaesthesia. None are an absolute contraindication to anaesthesia, they are about comparing wellbeing of the patient to the important of the procedure.
6
Q
Assessment of fitness for anaesthesia
A
- History – existing Cardiorespiratory disease, intercurrent medical conditions, medications, allergies, past admissions, FH, SH
- Examination – Cardiorespiratory exam (hypertension, cough, murmurs etc)< hydration, sites for IV access, Cervical spine, loose or damaged teeth.
- Blood tests – U&Es, Hb, Haematocrit, blood glucose (supplementary are G&S, LFTs, clotting, sickle cell test, TFT, plasma cholinesterase activity).
- ECG – for those with ischaemic heart disease, hypertension, rheumatic fever, respiratory disease. Recommended over 40 in general.
- Pulmonary function tests
- Others relevant to specific medical conditions
7
Q
Gaining consent for surgery process
A
- Surgeons must establish and maintain effective relationships with patients and be honest and sensitive.
- Informed decision making with patience and clarity
- Should involve supporter if possible
- Establish they have capacity
- Involve those young in discussions and decisions
- Ensure consent obtained by person providing treatment or actively involved and they have clear knowledge of the procedure.
- Obtain consent prior to surgery and ensure sufficient time for them to make informed decisions.
- Discuss:
- Diagnosis and prognosis
- Options for treatment including non-operative and no treatment
- Purpose and expected benefit
- Likelihood of success
- Clinicians involved in treatment
- Risks inherent in the procedure
- Potential follow up treatment.
- Written information where possible
- Make patients aware of national guidelines on treatment choices
- Sign consent form and check on day of procedure nothing changed
- Record in writing the details of consent discussion with your patient
- Make sure there aware of student participation.
8
Q
Complications of surgery (Immediate, Early and Late)
A
Immediate (24h): haemorrhage, basal atelectasis (minor lung collapse), shock (reduction in BP), low urine output, broken teeth, nausea and vomiting, allergy to anaesthetic
Early (1-30): Pain, acute, confusion, nausea & vomiting, fever, secondary haemorrhage from infection, pneumonia, DVT, acute urinary retention, UTI, pressure sores. Parlytic ileus (Bowel doesn’t move for few days and get vomiting etc).
- DVT- throbbing/cramping pain in 1 leg, swelling in 1 leg, red or darkened skin around painful area, warm skin around, swollen veins
- PE- rapid or irregular heartbeat, light headedness, excessive sweating, fever, leg pain or swelling, clammy or discoloured skin
7s post operative pyrexia: chest, catheter, CVC line, cannula, cut, collections, calves.
Late (>30days): Bowel obstruction, incisional hernia, recurrence of reason for surgery, keloid formation, cosmetic appearance, osteoporosis, failure of surgery etc..,
9
Q
Explain Possible complications of abdominal surgery and identify
A
Post-op haemorrhage – assess for increase in BP, decrease HR
Basal atelectasis
For Bowel surgery:
- Delayed return of function – Temporary disruption of peristalsis (nausea, anorexia, vomiting, described as ileus)
- Early mechanical obstruction – twisted or trapped loop of bowel or adhesions. May settle with nasogastric aspiration and IV fluids
- Late mechanical obstruction – adhesions can organise and persist, commonly causing isolated episodes of small bowel obstruction months or years after surgery
- Anastomotic leakage or breakdown – small leaks are common with small localised abscesses with delayed recovery of bowel function
- Major breakdown causes generalised peritonitis and progressive sepsis needing surgery for peritoneal toilet and antibiotics. Abscess can go into fistula.
10
Q
Possible complications after vascular surgery
A
- Haemodynamic stability
- Respiratory failure e
- Myocardial ischaemia
- Bleeding and coagulopathy
- Temperature management
- Neurologic disorders
- DVT
- Acute kidney injury
*
11
Q
Surgical Sieve
A
- Congenital Acquired
- Inflammatory
- Infective / autoimmune
- Bacterial
- viral
- fungal
- Degenerative / mechanical / traumatic
- Metabolic
- Neoplastic
- Benign
- Malignant - Primary/Secondary
- Vascular
- Neurological
- Psychological
12
Q
What is anaesthesia and the types?
A
Anaesthesia – removal of sensation (1 per 100,000 GA people die)
- General anaesthesia – not conscious, no sensation, no pain.
- Endotracheal tubes (ET)or laryngeal mask tube (LMA)
- volatile anaesthetic (gas), total IV anaesthetic.
- Awake or asleep to put tubes down and secure airway
- Local anaesthetic - topical
- Neuraxial anaesthetic (anything to do with the back)- spinal, epidural, combined spinal and epidural,
- Regional anaesthesia – nerve blocks
- Sedation (Not anaesthetic but used)
13
Q
What increases the risk with General anaesthetic
A
Co-morbidities: all about bodies ability to get oxygen so we can heal and get through post-op.
- Respiratory: COPD, fibrosis (asthma), lower respiratory tract infections
- Smoking
- CV: heart failure, ischaemic heart disease, PE, arrhythmias, anaemia (Hb)
- Endocrine – diabetes (badly controlled then sugar isn’t been taken into tissues by insulin so won’t be able to increase oxygen carrying capacity)
- Malnutrition –
- Trauma: pneumothorax, hypovolemia
We need ATP to give cells energy + regenerate. To make ATP efficiently need oxygen and glucose. When you have surgery that’s a massive insult on the body and body needs a lot of ATP to heal tissues so give oxygen.
14
Q
A
15
Q
Tests to get rough idea of Patients VO2 and what to do for major operations
A
16
Q
Post-Op Haemorrhage - types
A
- Primary = during procedure
- Reactive = within 24hours
- Secondary = within 10days. More likely due to surgical site infection.
Sites bleeding (trauma) = intraabdominal, intra-pelvic, bleeding in to chest, bleeding into long bones. (compartment)
Signs: tachycardia, hypotension, tachypnoea, cool peripheries, presyncpe…
17
Q
Haemorrhagic shock classes
A
18
Q
Pulmonary embolism, RFs and symptoms
A
RFs = Pregnancy, cancer, HRT, pill, obesity, smoking, infection, recent fractures/surgery, recent immobility.
Symptoms: SOB, Chest pain, pain in calves, tachycardic, tachypnoea, haemoptysis, swelling/redness in calves, pleural rub.
19
Q
Wells score
A
20
Q
ECG Changes in PE
A
Most commonly sinus tachycardia.
S1Q3T3 of acute cor pulmonale is a classic – McGinn-White sign
- A large S wave in Lead I
- Q wave in lead III
- Inverted T wave in Lead III
These indicate right heart strain.
21
Q
Post Op Sepsis
A
Post Op sepsis: Pyrexia, confusion, tachycardic, low BP, cold + clammy, low urine output, localising signs, non blanching rash, malaise, dizziness…
Red flags:
SEPSIS 6
22
Q
Types consent forms
A
- Consent form 1: Patient agreement to investigation, treatment or procedure. Adults or competent young adults
- CF2: Parental agreement to investigation, treatment or procedure for a child or young person
- CF3: Patient parental agreement to investigation, treatment or procedure where consciousness not impaired.
- CF4: Adults unable to consent to investigation or treatment.
23
Q
AMPLE hsitory taking in surgery
A
Allergies, Medications, PMH, Last meal or intake, Events leading to presentation
24
Q
Goals of a wound dressing
A
Goals of a Wound dressing:
- Protecting a wound form microorganisms
- Aiding hemostasis – pressure dsg prevents bleedings and eliminates dead space
- Promoting healing by absorbing drainage and debriding a wound
- Patients comfort.
25
Types wound dressings
* Woven gauze dressings
* Wet to dry – used in treating wound that requires debridement. Moistened gauez placed in or on wound, left until dry then removed.
* Self adhesive-temporary, acts as a second skin, traps the wounds moisture (Acu-derm, Op-site, Tegaderm)
* VAC dressing – for big wounds. Negative pressure wound therapy/ Special foam or gauze dressing placed directly into wound.
26
Pre-OP things to do
27
Emergency surgery - things to do
Emergency surgery - things to do
28
intra vs post operative care
29
Body composition
* 67% water: 33% ECF (20% blood plasma, 80%interstitial(, 66% ICF
* Solids 33%
30
Starling Forces
* Happens in ECF from blood plasma through capillary membrane to interstitial fluid
* Hydrostatic pressure= force generated by plasma or interstitial fluid on capillary walls
* Osmotic pressure = proteins displace water molecules leading to lower water concentration. This draws water molecules from opposite compartment by osmosis.
31
Types iV fluids
* Crystalloids: Contain simple ions. Crystalloids that easily pass across semi-permeable membrane from plasma to interstitium. Normla saline, hartmanns, 5% glucose.
* Colloids: Contain larger molecules eg, proteins that cant easily pass across semi permeable membrane (increase plasma oncotic pressure and expand plasma volume). Human albumin (Low protein levels due to cirrhotic), blood products (When blood loss)
32
Fluid Balance
* Input = oral fluid intake from drinking (60%) and food and metabolism (40%). In surgical patients nil by mouth (cant maintain oral fluid intake so replace by IV)
* Output – urine (60%), insensible losses (40% - faeces, sweat, breathing). In surgical patients – increased bowel output, sweating due to pyrexia, tachypnoea.
33
Daily fluid requirements
* Water 25-30ml/kg/day
* Glucose 50-100 g per day
* Potassium 1mmol/kg/day
* Sodium 1mmol/kg/day
* Chloride 1mmol/kg/day
34
Changes in fluid requiremenys - Decreased Input and Increased Output
* Decreased input – nil by mouth, poor oral intake, reduced consciousness
* Increased output – GI losses (often high in potassium). Third space losses-losses you cant see in the body (eg, bowel obstruction-fluid leaks into interstitium in bowel, acute pancreatitis- loss fluid in to retroperitoneum), intra operative blood loss.
35
Assessing fluid status
* Dehydration: conc urine, reduced urine output, dryness (mucous membranes), sunken eyes, reduced skin turgor. Check for prolonged capillary refill time \>2, tachycardia, hypotension
* Overload: Hypertension, peripheral oedema (lower limb or sacral), elevated JVP, bilateral basal crackles, displaced apex beat, third heart sounds, ascites.
36
Steps in Fluid status
**Quick ABCDE:**
Red flags: CRT\>2, SBP\<100, HR\>90, RR\>@0, cool peripheries, News\>5. NEED IV fluid resuscitation. Passive leg raise: improvement after raising legs to 45degrees suggests fluid responsiveness.
**History**: Have they managed to eat and drink do they feel thirsty, is their mouth dry.
**Exam:**
General inspection (patient – alert, tachypnoea, pyrexia, wounds, drains) (Bed – IV fluids, catheter, stoma, nasogastric tube, vomit/sputum)
Hands and arms – pulse, CRT, turgor
Face and neck – sunken eyes, mucous membranes, JV
Chest – CRT, apex beat, heart sounds, lung bases
Abdomen – ascites
Legs/sacrum- peripheral oedema.
**Charts:**
Obs: RR, BP,HR, temp
Stool chart – diarrhoea (high output), constipation (may be secondary to dehydration)
Fluid balance chart – inout and output
Drain charts
Drug chart – IV fluids, diuretics, oral electrolyte replacement.
**Bloods + imaging:**
FBC&U&Es :
Dehydration dry – high urea, high urea to creatinine ratio, high packe cell volume
Comiting – low potassium, low chloride, metabolic alkalosis
Diarrhea – low potassium and metabolic acidosis
Acute kidney injury
CXR: pulmonary overload
37
Indications of fluid
Needs cannot be met via oral or enteral routes due to:
* Resuscitation – hypovalaemia
* Miantainence – nil by mouth or reduced oral intake
* Replaceent – excessive losses eg, vomiting, diarrhea, third space losses, bleeding
* Redistribution – gross oedema, severe sepsis, hyper/hyponatraemia, renal, liver, or cardiac impairment, post op fluid retention and redistribution, mlnutritiona nd refeeding issues
REASS REGULARLY
38
Shock - types
Poor tissue perfusion leads to ischaemia and organ failure:
* Hypovolaemic
* Distributive
* Cardiogenic
* Obstructive
39
Resusitation
* Indicates: CRT\>2s, SystolicBP\<100, HR\>90, RR\>20, cool peripheries, NEWS\>5
* Ai to improve intravascular volume to maintain BP leading to improved tissue perfusion
* Prescribing: STAT (0ver 15mins), 500ml bolus or crystalloid (reduce to 250ml in HF or elderly/frail), keep reassessing with a-e, can give up to 2000ml, if no improvement seek specialist support (likely to require critical care input for inotropes or vasopressors).
40
Routine Maintenance of fluid
Indications – nil by mouth or not able to meet full fluid requirements orally
Calculate requirements per 24hours from those stated in NICE guidelines:
* 25-30ml/kg (less if HF/frail)
* 1mmol/kg each of sodium, potassium, chloride
* 50-100g gucose if not eating.
41
Replacement fluids
* Indications: ongoing losses
* Prescribing: replace losses on top of maintenance fluid requirement
* Urine output: \<0,5ml/kg/hour-\> fluid challenge
42
omplications of fluid
* Hypovolaemia
* Pulmonary oedema
* Hyponatremia
* Hypernatraemia
* Peripheral oedema
* Hyperkalaemia
* Hypokalaemia
* Cannula associated complication eg, phlebitis
43
screenign bias
**Lead-time bias**
* Screening detects earlier (pre-symptomatic) individuals
* In comparison to symptomatic individuals, survival can appear prolonged
* Even though treatment does not change
* Due to length of time between diagnosis and death increasing
**Length-time bias**
* Screening detects more indolent disease
* So the compared to the non-screened population
* Same amount of aggressive tumours
* But improved survival through the pick of indolent tumours
* Which would have been picked up at a later date when symptoms arise
44
cancer screenign principles
Placement blocks
flashcards
Decks in class (13)
# Cards
