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					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  Incise posterior peritoneum above level of upper pole of right kidney
           o  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   Physiological: neonatal, pubertal hormone imbalance
            o   Pathological: hypogonadism, neoplasms, drugs - cimetidine, spironalactone,
                ketoconazole, digitalis, oestrogens




Aberrations of normal breast development and involution (ANDI)

Tumour          Pathology                 Features                Management

Fibroadenoma           Aberation of             Well                 FNA/Biopsy
                        development;              circumscribed        Mammography /
                     15-25 years             smooth firm           ultrasonography
                    Develops from           lump                 Rx: Reassure /
                     single lobule of       May be                remove if large
                     breast (rather          multiple/bilat        >2cm on request
                     than single cell)       eral
                    Hormone
                     dependance
                     (lactating during
                     pregnancy,
                     involuting in
                     peri-menopausal
                     period)

Phylloides          Arise from peri-                             FNA / Biopsy
Tumour               stromal tissue                               Rx: Complete
                    40-50 years                                   excision - risk of
                    More common                                   recurrence
                     in African
                     countries

Cystic disease      Common 35-55           Discreet,            Aspirate fluid
                     years                   smooth lump,         Mammography if >
                    Macrocysts ~7%          may be                35years
                     women in West           fluctuant (like      Rx: Excision biopsy
                    Unknown cause           all cysts)

Sclerosing          Aberration of          Radial scars         Mammography +
leions               involution -            present via           excision biopsy
                     sclerosing              screening
                     adenosis,              Potential
                     papillomatosis,         underlying
                     duct adenoma            breast cancer

Epithelial          Epithelial cell        breast lump          FNA / NCB
hyperplasia          increase in                                  Rx: Excision biopsy
                     terminal duct                                 + screening
                     lobular unit                                  (increased risk of
                    Common pre-                                   breast cancer)
                     menopausal
                     women
                    If atypia plus
                     hyperplasia
                     increased risk of
                     breast cancer
                    Atypical ductal
                     or lobular cells
                     x4-5 greater risk
                     of breast cancer
Breast pain / inflammatory lesions

         Pathology                             Features              Treatment

Mastalgi Cyclical Mastaliga                                                Weight loss
a                                                                          Supportive
             Young women (Any age up to                                    bra
                menopause)                                                 Evening
             3-7 days pre menstrual cycle                                  primrose oil
             Improves at menstruation                                     NSAIDs
             Usually lateral part of breast
                affected

         Non-Cyclical Mastalgia                                            Supporting
                                                                            bra
               Older women (45+)                                          Weight loss

Breast Lactating                                                           Rx:
abscess                                                                     Antibiotics /
           Mastitis neonatorum - first                                     I&D
              few weeks of life
           Infected enlarged breast bud
           Caused by s.aureus / e.coli


                                                     Nipple               Antibiotics
                                                      discharg             Aspiration
         Non-Lactating                               Breast pain          I&DS
                                                     Retraction /
            1. Peri-areolar                           inversion
                   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
              2. Duct fistula: -




Benign Neoplasms

                                              Usually small,
                                               symptomless
                                                                        Mammography,
Duct               Common                    Bloody
                                                                         ductography
papilloma          Single / multiple          discharge if
                                                                        Rx: Microdochectomy
                                               duct
                                               involvement

                   Soft lobulated
Lipoma              radiolucent
                    lesion




Nipple discharge

   1.    White = Milk: lactating breast (physiological / prolactinoma)
   2.    Yellow = Exudate: abscess
   3.    Green = Cellular debris: duct ectasia
   4.    Red = Blood: ductal papilloma or carcinoma

Determine whether single or multiduct (not usually pathological except in hormone
producing endocrine tumours)

Mangement

   1.    Haemo-stix
   2.    Cytology
   3.    Mammography / USS
   4.    Ductography / ductoscopy (washings can be taken for cytology)




Breast Cancer: Aetiology & Clinical features

Risk factors: OESTROGEN EXPOSURE

   1.    Age
   2.    Early menarche, late menopause, nulliparity
   3.    Diet / obesity (fat turned into oestrogens/phyto-oestrogens)
   4.    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          NCB
              Cytology     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.   Node positive = <20% survival
   2.   High Grade (1-well, 3-poor)
   3.   Size
   4.   Vascular invasion
   5.   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

                                                                                M-
           T - Tumour                                    N - Node
                                                                                Metastasis

       0 Subclinical                                     No nodes               No mets

                                                         Ipsilateral axillary
       1 <2cm                                                                   Distant mets
                                                         (mobile)

                                                         Ipsilateral axillary
       2 2-5
                                                         (fixed)

       3 >5                                              Ipsilateral mammary

           Any size with (a) chest wall or (b) skin
       4
           extension


      Manchester system / Columbia system

       TNM Manchester                                                               Columbia

                Stage 1
       - T1
       - N0-                                                                        Stage A
                     o    Confined to breast < 5cm
       N1            o    With or without skin involvement

                Stage 2

       T2N1b                                                                        Stage B
                     o    Confined to breast <5cm
                     o    Nodes involved but not fixed

                Stage 3
       T3-T4
                     o    Locally advanced disease >5cm                             Stage C
       N2-N3
                     o    Affects underlying muscle/overlying skin or fixed lymph
                          nodes
                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   WLE / Quadranetectomy / Segementectomy
            o   Remove tumour + adequate resection margins (>5mm margins)
            o   Adequate skin flaps for cover
            o   Breast reconstruction: pedicled flaps, free flaps (DIEP)
   2. Axilla
            oLevel 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.   Fix lump between finger and thumb
   2.   Incision made circumferentially if close to nipple, radially if placed distally
   3.   Grasp lump with forceps and retract out of wound
   4.   Expose interior of cavity and diathermy bleeding points
   5.   Obliterate cavity +/- suction drain
   6.   Close skin with subcuticular stitch

Complications

       Haematoma
       Distortion of breast architecture
       Recurrence of lump


Fine Needle Aspiration (FNA)

Procedure

   1.   Explain to patient
   2.   Sterile field
   3.   21G needle, syring + 2ml of air (for explusion of contents)
   4.   Prepare slides
   5.   Fix breast lump
   6.   Pass needle through lesion in several directions maintaining suction
   7.   Release suction, withdraw needle
   8.   Air used to blow out cells to slides
   9.   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 3-
               4mm 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.   Papillary 70% - younger population, good prognosis, TSH-dependent
   2.   Follicular 20%
   3.   Anaplastic 5% - older population
   4.   Medullary 5% - from parafollicular C-cells
   5.   Lymphoma - rare

Management of thyroid disease

   1. History
           o  Thyroid symptoms
           o  Medications
           o  Previous radiation exposure
           o  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.   Curvilinear incision (including previous biopsy sites)
   2.   Incise around segment and deepen incision (maintain >1cm tumour clearance)
   3.   Separate breast tissue from pectoralis fascia
   4.   Remove tumour (insert silk sutures to identify parts of tumour)
   5.   Haemostasis + suction drains
   6.   Obliterate cavity
   7.   Close skin

Axillary clearance

   1.   Incise skin + elevate flaps superiorly/inferiorly
   2.   Identify lateral border of pectoralis major and anterior border of latissimus dorsi
   3.   Identify and divide pectoralis minor.
   4.   Preserve thoracodorsal (lat dorsi) and long thoracic nerve of bell (to serratus
        anterior). Preserve intercostobrachial nerve (axillary sensation)
   5.   Upper limit of dissection is axillary vein
   6.   Dissect contents away from vital structures, remove en masse.
   7.   Drain axilla with suction drain
   8.   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.   Hypertension - leads to increased shearing forces across intima
   2.   Traumatic injury to aorta
   3.   Iatrogenic - cardiac catheterisation, aortic cannulation, AV replacement
   4.   Pregnancy
   5.   Inherited defects
            o    Marfan's - 15q fibrillin defect
            o    Ehlers-Danlos - procollagen formation
            o    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. Resuscitate: fluids, maintain cardiac index (CO/BSA) and renal function
   2. Bloods
   3. Central line: monitor filling pressures
   4. Pharmacological
          o Labetalol - control ejection fraction and arterial pressure
          o Sodium nitroprusside (can cause reflex tachycardia)
   5. Transfer to cardiothoracic unit
           o   Type A: Replacement of diseased segment of aorta with interpositional graft
               and re-implantation of coronary arteries if root involved +/- valve
               replacement
           o   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 Embolism
            o 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.   Vagal manoeuvres
   2.   Adenosine 6mg/12mg/12mg
   3.   B-blocker rate control
   4.   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.    Right/left posterio-lateral thoracotomy
   2.    Spread ribs
   3.    Get anaesthetist to collapse one side of lungs
   4.    Enter pleural cavity
   5.    Define anatomy (dissect through fissues) to hilum
   6.    Dissect vein (superior), artery (inferior) and bronchus (posterior)
   7.    Ligate all three
   8.    Divide lung
   9.    Check for air leak (fill cavity with water and ask anaesthetis to blow on lung)
   10.   Insert apical chest drain
   11.   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.   Early recognition (esp tension)
   2.   100% O2
   3.   Tension - needle decompression (2ICS)
   4.   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.   Curved incision 2cm below scapula
   2.   Dissect through skin, fat
   3.   Divide latissimus dorsi fibres
   4.   Spread off serratus anterior
   5.   Divide through intercostal muscles (at level of 5th rib - count from second rib)
   6.   Enter pleural cavity

Closure

   1.   Appose ribs
   2.   Sew deep fascia onto intercostal muscles
   3.   Close serratus anterior layer
   4.   Sew latissimus dorsi
   5.   Close skin

Emergency Thoracotomy

Indications

       Penetrating injury with cardiac arrest
       Massive thoracic bleeding

Procedure
    1.   Positioned obliquely with ipsilateral hip and shoulder supported on sandbags
    2.   Submammary incision made starting near midline and extending into axilla
    3.   Pass through all layers to enter chest in 5th ICS
    4.   Ribs separated with spreader
    5.   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




                Aortic                                    Mitral

Stenosis        Rheumatic heart disease                   Rheumatic heart disease
                Calcification                             Calcification of valve/chordae
                Congenital                                Congenital

Regurgitation Rheumatic heart disease                     Rheumatic heart disease
              Endocarditis                                Valve prolapse
              Congenital                                  LV dilation
              Inflammatory - SLE, Ank spond               Ischaemia / papillary muscle
              Dilation of aortic root - Marfan's,         disruption
              dissection                                  Bacterial endocarditis
              Systemic disease - UC, syphilis
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         Example                                           Complications

Mechanical      1. Ball & Cage                                 Structural Valve failure
                        o Starr-Edwards
                        o Barium-impregnated silastic ball     Prosthetic valve
                            retained in cage                   endocarditis
                2. Tilting valve disc
                        o Bjork-Shiley                         Paravalvular leak
                        o Single disc opens and closes with
                            blood flow                                Related to
                3. Bileaflet                                           endocarditis episode
                        o St Jude Medical valve                       Leaflet degeneration
                        o Two disc occluders


Biological   Autografts
                                                               Thrombosis /
                   Harvest patient's own pulmonary valve      Thromboembolism
                    into aortic position (Ross procedure)
                   Excellent haemodynamic function (but              Mechanical 2.5 - 3.5
                    technically demanding)                            Tissue 1.5 - 2.5
                   Autologous pericardial valves

             Homografts/Allografts - Removed from
           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
             o5mm port RIF under direct vision
             o5mm port LIF
             oGrasp caecum and move towards spleen
             oAspirate 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   Intussuception
   2. Mural
           o Malignancy
           o Inflammatory bowel disease
   3. Extra-mural
          o Hernia
          o Adhesions

Frequency of causes

   1.   Adhesions - 60%
   2.   Herniae - 15%
   3.   Malignancy - 6%
   4.   IBD
   5.   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  Previous operations
           o  Abdominal diseases
           o  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.   Bile duct injury
   2.   Haemorrhage - slipping of clips
   3.   Retained stone
   4.   Biliary stricture
   5.   Duodenal injury


Colorectal cancer



Management

   1. History
            o Characteristics of PR bleeding
            o Change bowel habit
            o Weight loss
            o 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 Divide along white line (avascular plane)
              o Sweep sigmoid off mesentry
              o Identify and protect gonadal vessels and left ureter
   3.   Divide bowel
            o Transilluminate mesentry, identify and ligate vessels
            o Place non-crushing clamps across distal and proximal bowel
            o Excise diseased segment
   4.   Close distal colon with two layers of continous sutures
            o Hitch bowel to presacral fascia making it easier for reversa
   5.   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
   6.   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.   GA + Lloyd-Davies position + Catheter
   2.   Enter peritoneum
   3.   Mobilise bowel
   4.   Colorectal anastamosis
   5.   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.   Incision should be able to convert to a radical procedure should this be necessary
   2.   Deepen incision
   3.   Identify lymph node
   4.   Dissect node (+ vascular pedicle)
   5.   Diathermy / tie pedicle, excise node
   6.   Ensure haemostasis, close wound


Excision of sebaceous cyst

Indications

       Cosmetic
       Recurrent infections, sebaceous horn




Procedure

   1.   LA
   2.   Elliptical incision over cyst (include punctum)
   3.   Grasp cyst and free from base
   4.   Close with interrupted non-absorbable sutures


Excision of toenail

Indications

       Ingrowing toenail
       Onychogryphosis
       Nail infections

Procedure (Zadik's operation)

   1. LA ring block
   2. Apply rubber tourniquet
   3. Incise nail bed (transversely) + elevate flaps
   4. Remove nail plate with heavy scissors
   5. 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. Adequate bowel prep - fluid restriction 48 hours prior + picolax 24 hours prior
   2. DVT prophylaxis
   3. IV antibiotic prophylaxis - metronidazole / cefotaxime
   4. Catherise
   5. NGT
   6. 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.   Surgery
   2.   Stoma
   3.   "General"
   4.   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.   Prepared + consented + phosphate enema
   2.   Lithotomy position + GA
   3.   Skin or anus/perineum prepared + Parkes proctoscope passed PR
   4.   Gently draw haemorrhoid towards surgeon and then make V-shaped incision in anal
        skin at base of haemorrhoid
   5.   Raise haemorrhoid towards lumen away from sphincter fibres + transfixed and
        ligated with vicryl suture
   6.   Divide haemorrhoid 5mm distal to ligation and removed
   7.   Repeat for other haemorrhoids (3,7,11 position)
   8.   Pack anal canal with gauze or spone to keep mucocutaneous bridges flat against the
        internal sphincter (prevents an anal stricture forming)
   9.   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.   Bleeding
   2.   Constipation
   3.   Anal stenosis
   4.   Faecal incontinence due to damage of sphincter mechanism
   5.   Anal fissure
   6.   Recurrence
   7.   Perianal fistula




Incisional Hernia repair

Risk factors for developing incisional herniae

   1. Surgical
           o     Careless suturing
           o     Inappropriate material
   2. Local
           o     Haematoma
           o     Infection
   3. Patient
           o     Malnutrition
           o     Obesity
           o     Jaundice
           o     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.  Incise skin 2cm above inguinal ligament from deep ring to superficial ring
   2.  Pass through superficial fascia/fat (Camper's)
   3.  Pass through deep fascia (Scarpa's)
   4.  Expose extern oblique apneurosis
   5.  Enter inguinal canal, identify and protect ilioinguinal nerve
   6.  Identify and protect the spermatic cord
   7.  Dissect hernia sac (anterior + superior to cord)
   8.  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                                   Disadvantages

       Smaller incisions, reduced tissue           Absent tactile feedback
        trauma                                      Difficult haemorrhage control
       Reduced post-op pain                         Learning curve
       Decreased incidence of wound                 May need consersion to open
        complications
       Decreased physiological insult to
        patient
       Reduced inpatient stay
       Improved cosmesis




Contraindications (things that really need open procedures being done)

   1. General
            o    Coagulopathy
            o    Shock
   2. Specific
            o    Peritonitis
            o    Obstruction




Essential components

   1.   Establish pneumoperitoneum
   2.   Insertion of trocar
   3.   Inpection of cavity
   4.   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.   Remove under direct vision
   2.   Check port site for haemostasis
   3.   Umbilical/epigastric ports should be closed formally
   4.   Skin closure by tapes/sutures
   5.   + 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             lenght of the incision and bites should
      full lenght of incision                         be taken 1cm from the wound edge
   5. Ensure no adherent viscera, avoid               at 1cm intervals
      bladder in lower midline




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                             Closure of Paramedian incision

   1. Incise skin 4cm from midline (over             Close peritoneum using over and over
      rectus)                                         technique
   2. Incise anterior rectus sheath                  Anterior rectus sheath closed as for
   3. Divide sheath from muscle at points             midline incision (applying Jenkins'
      of intersections                                rule)
   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
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. GA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + supine position
   2. Upper midline laparotomy
   3. Identify stomach + work distally to duodenum
   4. 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.   GA + NGT + Antibiotics + DVT prophylaxis + Urinary catheter + Supine position
   2.   Upper midline laparotomy
   3.   Identify stomach (distended with blood) with grey small bowel (cause of blood)
   4.   Insert two stay sutures on duodenum and open duodenum longitudinally (will be
        closed transversely - prevents stenosis)
   5.   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
   6.   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
   7.   Remove swabs, evacuate blood from stomach
   8.   Depending on degree of ulcer-related duodenal scarring proceed to
            o pyloroplasty (close duodenum transversely with interrupted sutures)
            o gastroenterostomy
   9.   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   Intersphincteric (between internal/external sphincters) 70%
            o   Transphincteric (across external sphincters) 25%
            o   Suprasphincteric (over sphincters)
            o   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.   Guarding / rebound suggests strangulation or perforation
   2.   Continous pain (rather than colic)
   3.   Tachycardia
   4.   Dehydration
   5.   WCC
   6.   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                   Treatment

Complete           Full thickness prolapse        1. Perineal approach
                   of rectum through anus                o Delorme's operation - rectal
                                                             mucosa removed
                          Weakness of                       circumferentially from
                           levator ani                       prolapsed rectum; sutured in
                          Starts at weak                    "concertina" fashion to reduce
                           anterior wall                     prolapse and create ring of
                          Protrudes 10-                     muscle within anal canal -
                           15cm in lenght                    narrows orifice and prevents
                          Contains pouch                    recurrence
                           of peritoneum          2. Abdominal approach
                           anteriorly (which             o Wells operation - rectum fixed
                           can sometimes                     firmly to sacrum by inserting
                           contain small                     sheet of polypropelene mesh
                           intestine)                        between them
                                                         o Suture rectopexy - 4-6
                                                             interrupted sutures used to fix
                                                             rectum to sacrum

Incomplete/partial Mucous membrane +              1. Digital repositioning
(mucosal)            submucosa of rectum           2. Phenol submucous injections
                     protrude outside of anus      3. Excision of prolapsed mucosa

Concealed            Intersusseption of upper      1. Laxatives / stool bulking agents
                     anus into rectum              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   Haematological disorders
              o   Part of radical upper abdominal surgery
              o   Splenic tumours
              o   (Previously - staging of lymphoma)
   2. Emergency
         o Trauma

Preparation

   1. GA
   2. NGT
   3. Antibiotics
   4. DVT prophylaxis
   5. Supine position
   6. 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     Left paramedian
           o     Midline: for trauma
           o     Transverse
           o     Left subcostal
   2.   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)
   3.   Detach omentum from lower pole of spleen
            o Divide left gastroepiploic vessles between artey forceps + ligation with ties
   4.   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
   5.   Detach gastrosplenic ligament
   6.   Remove spleen + place suction drain in subphrenic space
   7.   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
             oMinor 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   Bleeding
             o   Atelectasis of lower lobe
             o   Ischaemic perforation of greater curvature of stomach
             o   Wound infection / subphrenic abscess
             o   Damage to organs causing gastric fistula, pancreatitis, pancreatic fistula
   2. Specific
             o   Thromobcythaemia (strokes, clots) + leucocytosis - commence aspirin
                 300mg daily if platelets >750
             o   Infection from encapsulated organisms




Umbilical hernia repair

Indication

       Symptomatic hernia (rare)

Procedure

   1.   Stab incision below umbilicus
   2.   Develop plane
   3.   Identify hernia sac
   4.   Divide sac from skin, open sac, reduce hernia
   5.   Close defect transversely
   6.   Close defect with interrupted absorbable sutures


        Orthopaedic Surgery
Anatomy of Walking

   1.   Heel strike
   2.   Stance phase
   3.   Push off
   4.   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.    tubercle of Scaphoid
   2.    ridge of Trapezium
   3.    Hook of hamate
   4.    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.    Idiopathic
   2.    Pregnancy
   3.    Obesity
   4.    Trauma
   5.    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. Informed consent, mark correct side
   2. LA / Regional / GA
   3. Limb exsanguinated + tourniquet, note inflation time
   4. 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  Psoas, iliacus (femoral nerve)
           o  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   Extracapsular - intertrochanteric, pertrochanteric, subtrochanteric
   2.   Angulation / alignment
            o Oblique / spiral / transverse
   3.   Displacement
   4.   Parts
            o Comminuted
   5.   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   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
           o   Measure lenght of insertion
           o   Ream with reamer -5mm of measured
           o   Insert screw + 4-hole plate to femoral shaft
           o   Confirm position with image intensifier
   5. Finish
           o   Close fascia lata with absorbable sutures
           o   Clips to skin
           o   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
                 Base of 5th MT (insertion of
Jones'
                 peroneus tertius)



Open fractures

Open Fracture
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     Mechanical stability
          o     Low coefficient of friction
          o     Low wear
          o     Biocompatible
   3. Surgery
          o     Secure fixation to skeleton
          o     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.   Secondary intention
   2.   Direct closure
   3.   Skin graft
   4.   Flap: local / distant / composite / island flaps
   5.   Tissue transfer




Factors affecting reconstruction

   1. Patient
             o
            Motivation
             o
            Health
             o
            Healing factors - nutrition, vitamins
             o
            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)                   Full thickness (FTSG)

Anatomy                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



Advantages             Large areas can be covered              Less contraction at graft site
                        (skin can be put through                 (important for hands and
                        mesh)                                    joints - that need movement)
                       Less likely to fail                     Better cosmesis

Disadvantages          Increased graft contraction at          Donor site must be primarily
                        donor site                               closed
                        Poor cosmesis                        More likely to fail because of
                        Creates second wound at               greater amount of tissue
                         donor site which needs caring         requiring vascularisation
                         for

Recipient sites         Any large wound
                        Line cavities
                        Resurface mucosal defects
                        Close flap donor sites
                        Resurface muscle flaps

Donor site        Any part of body but in particular
                  areas

                        Easily concealed by clothing
                        Position of easy post-
                         operative 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
              Local
              o
              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.   Informed consent, prepared
   2.   Supine position, GA / LA dorsal penile block
   3.   Free foreskin from glans with forceps
   4.   Pull foreskin down over glans; apply straight forceps, divide between forceps to
        ~5mm of corona
   5.   Incise laterally, circumferentially towards frenulum
   6.   Excise
   7.   Transfix frenulum
   8.   Two layers of skin brought together with interrupted absorbable sutures
   9.   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  Anterior/Transperitoneal
          o  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   Wound infection
           o   Bleeding
           o   Haemorrhage
           o   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) pre-
operative hyponatraemia

Features:

      (hyponatraemia - swollen brain cells) - confusion, nausea, vomiting
      Fluid overload - pulmonary oedema
      Convulsions, coma

Symptoms occur generally when Na < 125 mmol/l
Up to 50% mortality rate

Treatment: support - O2, IV access, oral diuretics, fluid restrict


Suprapubic catheter / cystotomy

Indications
Procedure

Testicular Torsion

Differential Diagnosis

   1.   Testicular torsion
   2.   Torsion of testicular/epididymal appendage
   3.   Orchitis - mumps / epididymo-
   4.   Incarcerated hernia
   5.   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.   LA, supine position
   2.   Locate and fix vas (grab scrotum and roll between fingers)
   3.   Infiltrate local anaesthetic
   4.   1cm incision into scrotum (Skin, Dartos, ExtSpFasc, Cremaster, IntSpFasc, Tunica,
        Testis) in direction of vas
   5.   Dissect out vas with tissue forceps, pass forceps under vas to separate from
        coverings
   6.   Divide vas, turn ends backwards and tie ends
   7.   Bury lower end deep in scrotum to minimise risk of re-joining
   8.   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    Condition and mobility of patient (AKA more easy to transfer bed-bound
                patient)
           o    Ability for patient to be rehabilitated
           o    Psychological counselling
   2. Disease
           o  Pathology / severity of disease
           o  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    Haematoma
            o    Wound infection
            o    Dehiscence, flap necrosis
            o    DVT / PE
            o    Phantom limb pain
   2. Late
            o    Neuroma
            o    Bone spurs
            o    Stump ulceration
            o    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.   Thrombosis
   2.   Embolus
   3.   Haemorhage
   4.   Pressure effects - nerve, vertebral column
   5.   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 Ensure haemostasis
            o Close aneurysm sac around repair
            o Close posterior peritoneum (avoids fistulation)
            o Mass closure of wound using looped 0-nylon/PDS
            o 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.   GA / regional
   2.   Access femoral artery
   3.   Pass graft over guidewire
   4.   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 Reverese autologous long saphenous vein graft
            o Insitu long saphenous vein graft (disrupted with valvulotome)
   2. Synthetic
          o PTFE
          o Dacron

Complications

   1.   Bleeding
   2.   Infection: wound, graft
   3.   Suture line aneurysm
   4.   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.   Incision over sternocleidomastoid (oblique)
   4.   Dissect down to common carotid, external, internal carotid
   5.   Tape looped around external carotid for control
   6.   Heparin infused, longitudinal arteriotomy into carotid distal to site of stenosis
   7.   Plaque removed distal to proximal in one piece
   8.   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. Palpate femoral artery (mid inguinal point)
   2. Longitudinal incision over skin
   3. Deepen down to femoral artery
   4. Sling around CFA, SFA, Profunda
   5. Angled vascular clamp on each of three main vessels
   6. 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.   Repair arteriotomy (5/O non-absorbable)
   11.   Remove clamps, tapes, check haemostasis
   12.   Insert suction drain
   13.   Close wound
   14.   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.    Pass stripper down LSV to knee
   7.    Stab incision over stripper and deliver
   8.    Strip vein back to groin
   9.    Close incision
   10.   Avulse local varicosities in lower calf
   11.   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.   Bleeding / haematoma
   2.   Infection
   3.   Damage to facial nerve
   4.   Salivary fistula
   5.   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. Sandbag beneath shoulders to maintain neck extension
   3. Transverse skin incision midway between cricoid cartilate and suprasternal notch
   4. Separate pretracheal muscles
   5. Divide thyroid isthmus between clamps + oversew
   6. 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.   LA + fibre-optic bronchscopy to aid insertion
   2.   Small skin incision between cricoid / sternal notch
   3.   14G cannula
   4.   Guide wire through
   5.   Remove cannula
   6.   Ram Rhino dilator over guidewire to make a big hole
   7.   Pass tracheostomy over guidewire
   8.   Secure in place, get a CXR

Complications:

       Nerve, vessel damage, pleural injury
       Stenosis if incision too high
       Tracheo-inominate fistula if too low
       Bleeding
       Displacement
       Blockage
       Infection
       Mucosal ulceration

				
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