Surgery Marrow Pg 447-456 (Trauma&Hernia)

Thermal Injuries

• 3rd and 4th degree burns:
  • Black, charred appearance.
  • No blanching.
  • Painless due to nerve damage.
  • Require early excision and skin grafting.

Overall Burns Management

• General measures:
  • Wash burns with room temperature water.
  • Insert a Ryle's tube for patients with >15-20% burns to prevent vomiting associated with ileus.
  • Avoid bursting blisters as they protect the burn.
  • Perform fluid resuscitation.
  • Administer intramuscular and subcutaneous injections.

Compartment Syndrome

• Features of compartment syndrome

  • Pressure within the compartment exceeds 30 mm Hg.
  • Often caused by circumferential eschar.

• Treatment:

  • Escharotomy, a type of fasciotomy.

• Clinical features of compartment syndrome:

  • Severe pain not relieved by medication.
  • Pain on passive flexion.

• Layers cut during escharotomy:

  • Skin
  • Subcutaneous tissue
  • Superficial fascia
  • Deep fascia until muscle is exposed.

Nutrition

• Basal/resting energy expenditure (BEE/REE):

  • Normal BEE/REE is 1.
  • Increased in sepsis and severe burns.
    • Mild/moderate sepsis: 1.4
    • Severe sepsis: 1.8
    • Severe burns: 2 (40 kcal/kg/day)

• Calorie requirement:

  • Curreri/Sutherland formula is used to calculate calorie requirements.

• Protein requirement:

  • Day 5 to Day 10: Negative nitrogen balance due to increased protein breakdown.
  • Davies formula is used to calculate protein requirements.
  • Protein should constitute 20% of total nutritional intake.

Dressing materials

• Aims of dressing materials:

  • Protect damaged epithelium.
  • Minimize infection.
  • Promote healing.

• Types of dressings:

  • 1st degree burns:
    • Expose the wound.
    • Use Vaseline/paraffin gauze, collagen dressing (if not infected) or hydrocolloid dressing.

Herniopathy

• Indications for herniopathy:

  • Surgery of choice for congenital inguinal hernia, congenital hydrocele, and inguinal hernia in children.

• Disadvantages:

  • Highest recurrence rate.

• Anatomy:

  • High muscle tone spontaneously blocks the defect, reducing the risk of recurrence.

Hernioplasty

• Indications for hernioplasty:

  • Surgery of choice.
  • Least recurrence rate.
  • Used for infected hernias.

• Types of mesh:

  • Synthetic:
    • Examples: Prolene, Vipro (Vicryl + Prolene), PTFE (Polytetrafluoroethylene - can be placed intraperitoneally).
    • Cannot be used for infected hernias.
  • Biological:
    • Examples: Acellular human dermis (AlloDerm), Acellular porcine dermis.
    • Can be used when infection is present.

Hernia: Part 1

• Taxis:

  • Process of hernia reduction.
  • Contraindicated in obstructed or strangulated hernias.
  • Can lead to reduction en masse, which can cause obstruction.

• Types of hernias based on content:

  • Omentocele:

    • Content: Omentum.
    • Peristalsis: Absent.
    • Consistency: Doughy.
    • Reducibility: Easy to reduce initially.
    • Percussion: Dull note.
    • Bowel sounds: Absent.

  • Enterocele:

    • Content: Bowel.
    • Peristalsis: Present.
    • Consistency: Variable.
    • Reducibility: Difficult to reduce initially but easy to reduce later.
    • Percussion: Tympanic note.
    • Bowel sounds: Present.

• Named hernias:

  • Enterocele.
  • Amyand's Hernia.
  • Littre's Hernia.

Basics of Hernia Surgery

• Types:

  • Herniorrhaphy.
  • Hernioplasty.
  • Herniotomy.

• Steps:

  1. Identify the sac (glistening white).
  2. Open the sac.
  3. Push contents down.
  4. Cut the excess sac and close the sac.
  5. Defect is left intact.

Inguinal Hernias

• Mesh materials:

  • Prolene: Hydrophobic, reducing bacterial contamination.
  • Polyester: Hydrophilic, encouraging faster cellular ingrowth.
  • PTFE: Does not adhere to the bowel inside the peritoneal cavity.

• Mesh overlap:

  • Weight of mesh: Low weight (80 g/m²) leads to more shrinkage.
  • Ideal hernia mesh: Covers 5 cm beyond the defect in all directions to prevent recurrence after shrinkage.
  • Plug mesh:
    • Low weight.
    • Thin fibers.
    • Large pores.

• Complication: Meshoma due to excessive collagen deposition can lead to pain due to nerve entrapment.

• Types of inguinal hernias:

  • Most common overall: Indirect inguinal hernia.
  • Most common in men and women: Indirect inguinal hernia.

• Anatomy:

  • Internal inguinal ring: Modification of the transversalis fascia.
  • External inguinal ring: Modification of the external oblique aponeurosis.

• Other Structures:

  • Interior epigastric artery and vein.
  • Internal/deep inguinal ring.
  • Inferior epigastric vessels.

• Hesselbach Triangle:

  • Direct hernia: Through Hesselbach's triangle.
  • Indirect hernia: Lateral to Hesselbach's triangle, through the deep inguinal ring.

Myopectineal Orifice of Fruchaud

• Boundaries:

  • Superior: Arching fibers of internal oblique.
  • Medial: Outer border of rectus.
  • Lateral: Tendon of iliopsoas.
  • Inferior: Pectineal/Cooper's ligament.

• Significance: Covers the defects of:

  1. Inguinal hernia.
  2. Femoral hernia.
  3. Obturator hernia.

Clinical Examination

• Position for examination: Standing and lying down.

• Tests:

  • Helps differentiate between inguinal and femoral hernia.
  • Inguinal hernia: Above and medial to the pubic tubercle.
  • Femoral hernia: Below and lateral to the pubic tubercle.
  • Appreciate cough impulse.
  • Assess abdominal muscle tone.
  • Complete vs. incomplete hernia.

• Clinical tests:

  • Deep ring occlusion test: Single best test for hernia.
  • Ring invagination test:
    • Little finger placed in the superficial ring through the scrotum.
    • Low sensitivity.

Electrical Burns

• 3rd/4th degree burns

  • Types:

    • DC current.
    • AC current.

  • Management:

    • Examine both entry and exit wounds.
    • Administer IV fluids due to potential heart blocks, tetanus, muscle damage, and myoglobinuria.
    • Increased IV fluids are required to prevent acute tubular necrosis (ATN).
    • Arrhythmia is a common cause of death.

Lightning Injury

• Types:

  • Direct lightning strike:

    • High-grade electrical injury.
    • Arrhythmias.

  • Indirect lightning strike:

    • Filigree burns pattern.
    • Superficial burns due to sparks from an adjacent object.

Hypothermia

• Usually caused by: 30 minutes of cold exposure.

• Stages of hypothermia:

  • Stage I:

    • Conscious, shivering.
    • Core temperature 35°C to 32°C (95 to 89°F).
    • Treatment: Warm environment and clothing, warm sweet drinks, and active movement.

  • Stage II:

    • Impaired consciousness, not shivering.
    • ECG: J/Osborne waves.
    • Treatment: Passive rewarming (prevent heat loss) and active rewarming (provide heat).

Rewarming Techniques

• Active space: Likely refers to the area surrounding a patient in a trauma situation.

• Rewarming Techniques:

  • Passive rewarming (prevent heat loss):

    • Mild hypothermia (35°C to 32°C).

  • Active rewarming (provide heat):

    • External:

      • Heating pad.
      • Warm water, blankets.
      • Warm water bottles.
      • Warm water immersion.
      • External convection heaters (lamps and radiant warmers).
      • Cover the head.

    • Internal:

      • Heated intravenous fluids.
      • Gastric or colonic lavage.
      • Cardiopulmonary bypass (most effective).

Special Agents in 2º Burns

• Agent | Advantages | Disadvantages
• ------ | -------- | -------- 1% Silver sulphadiazine (m/c) | Effective against Pseudomonas, Gram negative bacteria | Requires frequent dressing changes.Doesn't penetrate eschar (useful only in superficial wounds).Silver nitrate | Effective against Pseudomonas, Gram negative bacteria | Black stain.Painful application.Metabolic acidosis.Expensive. 5% Mafenide acetate | Penetrates eschar |
  Cesium nitrate (best agent) | Immunomodulator |

Management of Complications

• Hypertrophic scar:

  • Spontaneous resolution with time.

• Keloids:

  • Intralesional triamcinolone injection.

• Contracture:

  • V-Y plasty or Z plasty.

• Marjolin's ulcer:

  • Wide local excision.

Causes of Death in Burns

• Time Period | Cause of Death
• ------ | -------- Immediate | Asphyxia, followed by neurogenic shock Early (1-3 days) | Hypovolemic shock Late (>3 days) | Septic shock (most common) - most common causative organism: Pseudomonas

Special Situations: Chemical Burns

• Alkali burns are deeper penetrating than acid burns.
• Management:
  • Wash with water (do not attempt neutralization).
  • Chemical powder: Brush off.
  • Hydrofluoric acid burns:
    • Features: ↓ Ca2+, ↑ K+, acidosis, tissue damage.
    • Management: Calcium gluconate (topical gel, oral, IV, IA).

m/c - most common

This quiz covers critical aspects of managing severe burns, especially 3rd and 4th-degree burns, and addresses the features and treatment of compartment syndrome. Understand essential protocols, including general measures for burn care and the surgical interventions required for complications. Test your knowledge and readiness for handling such medical emergencies.