General Surgery Introduction PDF

Introduction to general surgery General surgery involves many organ systems but most commonly involves the abdominal cavity and the organs contained within the cavity. However, there are surgical procedures that may be considered in the realm of another surgical specialty, but the general surgeon o...

Introduction to general surgery General surgery involves many organ systems but most commonly involves the abdominal cavity and the organs contained within the cavity. However, there are surgical procedures that may be considered in the realm of another surgical specialty, but the general surgeon often performs the procedures; for example, vein ligation and stripping is a vascular procedure for treating varicose veins or a muscle and nerve biopsy. Additionally, the general surgeon performs procedures on tissues and organs outside of the abdominal cavity, including breast and thyroid procedures. Instrumentation, equipment, and supplies vary widely with geographic region, hospital availability, and the surgeon\'s preference. The foundation set for many surgical procedures is the laparotomy set. INCISIONS In surgery, various incisions are used to gain access to the abdominal contents. The type chosen depends on the access desired, the procedure to be performed, the surgeon\'s preference, the ability to lengthen the incision, and wound security and healing. Other considerations include the patient\'s physical condition, speed of entry required, and sites of previous surgery. The types of incisions are vertical (median or midline, paramedian, supraumbilical, and infraumbilical), transverse, oblique (oblique lateral, McBurney \"muscle-splitting,\" and Kocher subcostal), and thoracoabdominal. Complications of wounds and their closure include infection, herniation, disruption, pain, and nerve damage. Appendectomy Appendicitis is one of the most common surgical emergencies in contemporary medicine, with a yearly incidence rate of about 100 per 100,000 inhabitants. Lifetime risk for appendicitis is 8.6% for males and 6.7% for females, with the highest incidence in the second decade of life. Perforated or complicated appendicitis is more common in the very young (age \65 years). The first known appendectomy was performed in 1736 by Claudius Amyand in London. He operated on an 1-year-old boy with a scrotal hermia and a fecal fistula. Within the hernia sac, Amyand found a perforated appendix surrounded by omentum. The appendix and omentum were amputated. The patient was discharged a month later in good condition. Appendectomy is performed for acute appendicitis or incidentally during other surgery as a prophylactic measure. Acute appendicitis is usually caused by obstruction of the appendiceal lumen, which manifests as inflammation that can affect other nearby organs. Perforation of the appendix or gangrene can result. Pylephlebitis, septic thrombosis of the portal venous system, can also occur. Symptoms of acute appendicitis include pain, which can be diffuse, central, or localized in the right lower quadrant; nausea and vomiting; and constipation or diarrhea. An elevated white blood cell count and fever are also common. Physical examination reveals tenderness especially on rebound or a palpable abdominal mass in the area of the appendix. The laparoscopic and open procedure is described. The anatomy, pathology, and preoperative diagnostic tests and procedures are the same for both procedures and are provided in the open procedure. Appendix is attached to cecum by the mesoappendix, which contains the appendiceal artery. Inflamed, infected appendix is called appendicitis; often due to impacted feces. Preoperative preparation includes: Supine position, General anesthesia, Skin prep: umbilicus to symphysis pubis and bilaterally as far as possible and Draping: square off RLQ with four towels; laparotomy drape. Surgical procedure: 1\. The McBurney\'s incision is typically used Procedural Consideration: Small retractors (e.g., U.S. Army) are placed and may be redirected several times as the incision proceeds through the muscle layers. 2\. The appendix is identified by following the cecaltaenia to the appendiceal base. This may require the gentle mobilization of the cecum into the wound. The appendix is identified, brought out of the wound, and grasped with a Babcock. Procedural Consideration: Be prepared to culture fluid, if present, as soon as the peritoneum is entered and have suction ready. 3\. The mesoappendix is transected from the free end tip of the appendix toward the base, by a series of double clamping, cutting, and ligation with 3-0 absorbable ties. Procedural Consideration: This step of the procedure may be reversed if the appendix is severely adhered or retrocecal. 4\. A clamp is placed across the appendix near the base, crushing the appendix, and is then removed and reapplied slightly distally. Procedural Consideration: Prepare purse string suture if surgeon uses that technique. Replace Babcock with Crile hemostat to grasp the tip of the appendix. 5\. A 3-0 absorbable suture on a small taper needle may be passed through the cecum, around the base of the appendix, in a purse string manner. Procedural Consideration: Suture and needle are contaminated and must be isolated after use; try to avoid touching them or change gloves) if necessary. 6\. The crushed base is then ligated with a 0 absorbable tie and the appendix is amputated electro surgically or with scissors or a scalpel. The appendiceal stump is inverted within the lumen of the cecum and the purse string suture is tightened and tied. The STSR gently pushes the stump into the lumen with the Crile hemostat and as the purse string suture is tightened, he or she unclamps the hemostat and gently removes it. Procedural Consideration: Have a kidney basin on the sterile field for placement of the appendix and contaminated instruments and pass off to the circulator. A Penrose drain may be placed in particular if the appendix was perforated; size according to surgeon\'s choice. Antibiotic irrigation solution may be used, especially in presence of wound contamination; have a small basin ready on the back table for the circulator to pour the saline and antibiotic in order to mix 7\. The incision is closed in layers. Procedural Consideration: The incision is small; be prepared to perform the counts quickly.