Surgery 2.0 Part 1 PDF

Surgery - Dr. Risheek Gupta Kindly report any errors @Gup2000109 or in BTR group chat Nerve Injuries ILN injured in Pyriformis fossa -Breast surgery axilla cl...

Surgery - Dr. Risheek Gupta Kindly report any errors @Gup2000109 or in BTR group chat Nerve Injuries ILN injured in Pyriformis fossa -Breast surgery axilla clearance- Inter-costo-brachial trunk # T2 Apex of axilla 2 axilla T4 Nipples T2 x 2 nipples= T4 -Thyroid surgery- ELN>SLN>RLN [ILN doesn’t injure in thyroid Sx] T6 Xiphoid process T-siX -Parotid surgery- a) Deviation of angle- Marginal mandibular nerve T10 Umbilicus Umbilicus is round like 0 b) Anaesthesia at angle- Great auricular nerve(C2-C3) Submandibular injury d/t T12 Inguinal ligament Sialolithiasis surgery/ c) Frey- Auriculotemporal nerve(gustatory sweating) Wharton duct involvement - Lingual nerve -Submandibular surgery- Marginal mandibular nerve -Hernia surgery- a) Loss of sensation over lateral thigh Lat. cut. n. of thigh(MC n. # in Lap. Hernia Sx) b) Loss of sensation over suprapubic region Iliohypogastric n. (Mesh entrapment assd. #) c) Loss of sensation over root of penis Ilio-inguinal n.(MC # in Open hernia (Vowels stick together) repair) d) Loss of Cremasteric reflex Genito-femoral n.(both afferent & efferent of reflex) -Thymectomy Phrenic nerve Retrograde ejaculation Lateral Cut. N. of Thigh # -Rectal Ca Surgeries (IMA ligation)Superior hypogastric plexus # (Sympathetic Meralgia paraesthetica Hernia surgery(MC in Lap. Hernia Sx) -Pelvic dissection Nervi-erigentes #(leads to Impotence) fibre) Extreme lithotomy/McRobert’s position during management of Shoulder dystocia SUTURES Monofilament : weaker but lesser r/o infection Polyfilament : stronger but higher r/o infection Absorbable Non - Absorbable Mechanism: Hydrolysis Synthetic Natural Synthetic Natural SILK Monocryl: CATGUT Nylon-Polyamide/ Ethilon Polygycaparone PDS: Polydiaxonone Microsurgical suture Prolene – Polypropylene Vicryl: Polygalactin Novafil - Polybutester Dexon: Polyglycolic acid Polyester- Ethibond  Everted edges desired in skin sutures SUTURES Inverted edges desired in bowel sutures Purse string sutures Simple continuous suture RECTAL PROLAPSE Perineal-TAD bit too easy Thiersche cerclage Altemier’s procedure Simple interrupted sutures Delorme procedure Abdominal- Cervical incompetence Ripstein rectopexy Herniotomy for Congenital hydrocele Wells Rectal prolapse JENKIN’S RULE: Subcuticular sutures Length Of Suture Should Be 4 Times The Length Of Wound Angle Of Entry Of Suture Needle, IM injection: 90 Verees Needle Angle, SC Injection: 45 Horizontal mattress suture ID injection:10-15 Verees needle(Bevelled margins to reduce trauma) : Pneumoperitoneum creation CO2 MC used for insuffalation because : for Lap. Sx Vertical mattress sutures CO2 : soluble in blood(no risk of air embolism) 15-20mmHg Non-combustible(cautery can be used safely) pressure, Only theoretical risk of hypercarbia therefore avoided in 500ML BLOOD LOSS? minutes before incision Post - Op Fever Timing Etiology Prevention Mnemonic Anytime Drug reactions, - Wonder Incentive spirometer malignant drugs hyperthermia POD 1-3 MCC ON D1- Incentive spirometry, Wind Atelectasis early mobilization antibiotics POD 3-4 MCC OVERALL- Shot-term foley use Water UTI POD 4-5 Deep venous Early mobilization, Walking thrombosis LMWH, sequential compression socks POD 7+ Surgical site infection Dressing changes, Wound preoperative antibiotics  SSI SSI definition- within 30 days of Surgery/1 yr of implant Southampton wound grading score BURST ABDOMEN Day- D6 Salmon colored Pathognomic sign: serosanguinous Mx- Bagota bag/Urobag fluid Laparotomy Intra-abdominal abscess MC site: Supine- Hepato Overall/ Ambulatory- Pelvis/ IOC CECT renal POD TOC Pigtail pouch drainage Criterion ASEPSIS score A Additional Treatment S Serous discharge E Erythema P Purulent exudates S Separation of deep tissues I Isolation of bacteria Induration is not a S Stay in hospital prolonged over 14 days part of the score Types of surgery -Gross purulence or existing infection? Class IV-Dirty /Infected -Perforated viscera˃ 4 hours old? Yes e.g. surgical management of -Traumatic wound open ˃4 hours? abscess, repair of perforated -Penetrating injury ˃4 hours old? bowel NO -Acute, non-purulent inflammation? Class III- Contaminated -Unplanned entrance into GI/GU/ respiratory Yes e.g. non –sterile debris in field, tracts? cholecystectomy with bile spillage -Major break in sterile technique? or acute inflammation, Open cardiac massage NO Elective Yes Controlled/international entry into the GI,GU, Class II- Clean-Contaminated or respiratory tracts? e.g. hysterectomy, lobectomy, laryngectomy, small bowel resection, TURP, LSCS NO Class I- Clean e.g. mastectomy, hernia repair, thyroidectomy, TKR, THR, CABG  qSOFA score ~ Revised Trauma score(RTS) White THR(SBP not a component) SIRS –2 or more +: Core Temperature ˂36oC or ˃ 38oC HR >90bpm RR ˃20/min or Pco2 ˂32 mmHg GCS RR BP White blood cell count ˃12,000 /μL, 70%: state Shock index- HR/SBP Septic shock Neurogenic Modified shock index- HR/MAP -Best clinical indicator of adequacy of resuscitation: Urine output ADULT: >0.5mL/kg/hr CHILDREN: >1mL/kg/hr INFANTS:>2mL/kg/hr -Best indicator to estimate fluid required for resuscitation: CVP(Rt. Atrial Pressr.) -Best lab parameter to monitor tissue perfusion: Lactate/Base deficit Trauma-Basics TRIAGE: PRIMARY SURVEY: Immediate: immediately life-threatening injuries A Airway w/ C-spine stabilisation Delayed: injuries requiring treatment within 6 hours B Breathing w/ Ventilation Minimal: walking wounded Dead C Circulation D Disability - neurological assessment Primary survey Identify what (W/in is killing the patient 6hrs) ADJUNCTS: E Exposure w/ environmental control CXR/Pelvic X-ray/eFAST Field: cABCDE where c = control of Resuscitation Treat what is killing the patient haemorrhage/exsanguinating bleed Secondary survey Identify other possible injuries CT scan Definitive : oral ET Definitive care Make a management plan intubation failure OR C/I to intubate eg. maxillofacial #) Immediate : Jaw thrust Head tilt- Cricothyroidotomy f Definitive : C-spine # Chin lift Tracheostomy CHEST TRAUMA Flail chest not included Triage level : RED TENSION MASSIVE CONSOLIDATION / CARDIAC PNEUMOTHORAX HEMOTHORAX CONTUSION TAMPONADE TYPE OF SHOCK Obstructive Hypovolemic - Obstructive JVD Increase Decrease Normal Increase TRACHEAL SHIFT C/L C/L No shift No shift BREATH SOUNDS / VOCAL FREMITUS Decrease Decrease Increase Normal PERCUSSION Hyper-resonant Dull Dull Dull(Ewart sign) HEART SOUNDS Normal Normal Normal Muffled Beck’s triad of CT : Muffled heart sounds + Raised JVP + Obstructive shock Management of Cardiac tamponade: Emergency Pericardiocentesis f/b Thoracotomy  Triangle of safety : P.major(ant.), Insert tube along Upper border of Lower rib as CHEST TRAUMA Latissimus dorsi (post.) & 5th ICS(floor) with axillary apex as apex neurovascular bundle is present around lower border of upper rib Inferior rib notching seen in Coarctation of aorta(Rosler’s sign) Air fluid levels in a spherical cavity : Lung abscess Seashore sign ~ Normal M-mode USG Air fluid levels in Xray : Diaphragm injury : Haemothorax Pneumothorax Hydropneumothorax fundal air bubble in A. Stable/unstable A. Stable managed by ICD Managed by ICD(no role thorax managed by ICD in triangle of safety of needle ICD is C/I B. No role of Needle B. Unstable(Tension) decompression ) placement managed by Needle f/b ICD Barcode/Stratosphere sign ~ Ptx Indications of Thoracotomy MC in Penetrating trauma -IOC:Diagnostic laparoscopy > CECT -Mx: Surgical repair -Triad:Bergiust triad : Diaphragm # + rib # + spine/pelvis # Shock Parameter Class I Class II Class III Class IV (Mild) (Moderate) (Severe) Blood loss ˂15% 15-30% 31-40% ˃40% 2000mL Heart rate ↔ ↑ ↑ ↑↑ Blood pressure ↔ ↔ ↓ ↓ Pulse pressure ↔ ↓ ↓ ↓ Respiratory rate ↔ ↔ ↑ ↑ Urine output ↔ ↔ ↓ ↓↓ Tranexamic acid Glasgow coma ↔ ↔ ↓ ↓ scale score Base deficit* 0 to -2mEq/L -2 to -6mEq/L -6 to -10 m Eq/L -10mEq/L or less Need for blood Monitor Possible Yes Massive Any pt. with products Transfusion SBP < 110 OR HR > 110 Mx of hypovolemic patients in shock (ATLS): Min Cannula- 18G Fluid type- Isotonic Fluid volume- 1Ltr. prewarmed bolus(if (green) crystalloid 30mmHg = indication of fasciotomy Abdominal compartment IOC: Intravesical pressure Anuria: Decompression GU Trauma AAST -IOC for renal trauma in stable: CT Urography Grade I: Subcapsular hematoma or contusion -IOC for renal trauma in unstable: Single shot IVP Grade II -IOC for bladder injury: CT Cystography o Superficial laceration ≤1 cm depth not involving the collecting -IOC for urethral injury:Retrograde Urethrogram(RGU) system o Perirenal hematoma confined within the fascia Mgt. : Grade III o Laceration >1 cm not involving the collecting system Surgery o Vascular injury or active bleeding confined within the perirenal fascia Grade IV o Laceration involving the collecting system with urinary Mgt. : extravasation Leaking Foley’s contrast Urinoma +ve catheter o Vascular injury to segmental renal artery or vein o Segmental infractions without associated active bleeding o Active bleeding extending beyond the perirenal fascia Dome rupture o Grade V o Shattered kidney Intraperitoneal Extraperitoneal o Avulsion of renal hilum or laceration of the main renal artery or bladder rupture bladder rupture(MC) vein: Devascularised kidney with active bleeding  Distal urethral rupture : Straddle # - Penile/Bulbar Urethra # URETHRAL TRAUMA Proximal urethral rupture : Pelvic # - Membranous/Prostatic urethra # C/F: Inability to void + High riding prostate on DRE(not done + nowadays d/t r/o Bloods at meatus aggravating trauma) Wait & watch if bladder IOC: RGU not palpable for SPC Normal RGU Thigh(only up to Holden’s line if at all) Supra-pubic Cystostomy(SPC) Q. A 14 year old boy presents to the ED after a straddle injury and rupture of bulbar urethra. Delayed Extravasated urine can be seen Urethroplasty in: (after 4-6 wks) a) Scrotum Buccal mucosal graft b) Thigh c) Ischiorectal fossa d) Deep perineal space Bulbar Urethral rupture  HEAD TRAUMA NCCT is IOC for head trauma except DAI(IOC : MRI) Alcoholic-fall H/o RTA H/o RTA H/o RTA, GCS-9 Intraparenchymal Star of death Microbleeds : Blooming pattern bleed/Contusion d/t coup-countercoup # Acute SDH Acute EDH Acute SAH Gold std. - DSA Diffusely Axonal Thunderclap headache Injury (Worst headache of life) Bridging veins Artery Ant. div. of Trauma> Aneurysm NCCT Normal/ IOC : CTA Trivial trauma RTA MMA MC site: petechial Circle of Willis TOC : Endovasvular Sutures: Can cross Sutures: X hemorrhage Midline X Midline Can cross ACA - ACOM jn. Coiling IOC: MRI/SWI Adam’s classification: 1 - GM-WM 2 - Corpus callosum 3 - Brainstem HEAD TRAUMA Transtentorial herniation Base of mandible MC injured Most accessible Cricoid Suprasternal notch 3rd CN # Mount Fuji sign Max. mortality Chronic SDH EDH Tension Swirl sign pneumocephalus Active bleed is an indication of I/L dilated pupil Penetrating neck trauma = Breach of platysma Decompression using (Hutchinson pupil) Expanding or pulsatile hematoma Craniectomy/Burr Active bleeding I/L hemiplegia(d/t Shock hole compression of C/L Airway compromise crus cerebri(false Massive subcutaneous emphysema localising sign) Neurologic deficit ZONE 2  TRAUMA SCORES E4V5M6 Mangled Extremity Severity Score (MESS) ELISA Type Characteristic Injury Point Energy of injury s 1 Low energy Stab wound, simple closed fx, small-caliber 1 GSW 2 Medium 3 energy Open/multilevel fx, dislocation, moderate 2 4 High energy crush shotgun, high-velocity GSW 3 Massive crush 4 Logging, railroad, oil rig accidents Shock Group Shock Decerebrate 1 Normotensive BP stable 0 Transiently Decorticate 2 Hypotensive BP unstable in field but responsive to fluid 1 Prolonged SBP ˂90mmHg in field and responsive to IV 3 hypotension fluids 2 In OR Ischemia Group Limb Ischaemia 1 None Pulsatile, no signs of ischemia 1 Always score the better response 2 Mild Diminished pulses without signs of ischemia 2 No Doppler able pulse, sluggish cap refill, 3 Moderate Paresthesia, diminished motor activity 3 Max score : 15 GCS - P : Max score - 15 4 Advanced Pulseless, cool, paralyzed, numb without cap 4 refill Min score : 3 Min score - 1 Age Group Age Intubated patient : VNT(non-testable) 1 ˂30y/0 0 2 ˃30 ˂ 50 1  BURNS Depth Histology Appearance Sensation Healing Fist-degree Epidermis only Erythema; blanches with Intact; 3-6 days without scarring pressure mild to KEEP OPEN moderate pain Second degree Superficial Epidermis and superficial Erythema, Blisters, moist, Intact; 1-3 weeks without scarring dermis; skin appendages intact blanches with pressure severe pain DRESSING: Paraffin dressing Deep Epidermis and most dermis; White, dry, waxy, reduced Decreased; ＞3 weeks, Scarring and most skin appendages blanching to pressure less painful contractures destroyed Hydrocolloid/ Collagen dressing retains moisture EXCISION AND GRAFTING Third – Epidermis and all of dermis; White, charred, dry and Anesthetic; Does not heal; degree destruction of all skin leathery; does not blanch not painful severe scarring and appendages contractures ESCHAROTOMY EXCISION AND GRAFTING MCC of death in burns: IV Fluids Latest ATLS: -Immediate: Asphyxia > Neurgenic Fluid of choice in adults- R/L Adults: 2mL x wt. x %TBSA -Early: Hypovolemic shock shock Fluid of choice in children- R/L + 5% Tc99 Inability to extubate- B/L RLN # Sestamibi MCC of intra-op thyroid storm: MIAMI CRITERIA: >50% decline in 10minutes Inadequate patient preparation MCC of hypercalcemia in hospitalized patient: Malignancy MEN Inheritance Gene Manifestations Prophylactic thyroidectomy: MEN 1 = 1. Pituitary adenoma(MC Prolactinoma) AD Menin MEN2A : 5 years Wermer 2. Parathyroid hyperplasia > adenoma Chr 11 MEN2B/3 : 1 year 3. Pancreatic neoplasm(Gastrinoma MC) MEN2a= 1. Parathyroid adenoma Sipple RET AD 2. Medullary thyroid cancer Chr 10 3. Pheochromocytoma MEN2b=3 1. MTC 4. Mucosal neuroma RET 2. Pheo 5. Megacolon AD Chr 10 3. Marfanoid 6. Medullated habitus corneal n. fibre Non - > Insulinoma Passaro’s triangle : MC Pancreatic NET: functional jn. of D2-D3, Jn. of CHD & Cystic MC NET in MEN1: Gastrinoma Refractory ulcers, Diarrhea, ZES duct & Jn. Of Head & neck of pancreas IOC :DOTANOC PET scan(Somatostatin Rc) Most Panc.NETs lie in this triangle. NETs of MEN syndrome however mostly present outside this triangle & have poorer prognosis