Alasdair Scott

160 Pages·2012·2.46 MB·English

Surgery

Alasdair Scott

BSc (Hons) MBBS PhD

2012

[email protected]
Table of Contents

1. Perioperative Management .................................................................................... 1
2. Fluids and Nutrition .............................................................................................. 11
3. Trauma ................................................................................................................. 17
4. Upper GI Surgery ................................................................................................. 25
5. Hepatobiliary Surgery ........................................................................................... 35
6. Lower GI Surgery ................................................................................................. 43
7. Perianal Surgery................................................................................................... 58
8. Hernias ................................................................................................................. 64
9. Superficial Lesions ............................................................................................... 69
10. Breast Surgery ................................................................................................... 80
11. Vascular Surgery ................................................................................................ 85
12. Urology ............................................................................................................... 94
13. Orthopaedics .................................................................................................... 109
14. Ear, Nose and Throat ....................................................................................... 131
15. Ophthalmology ................................................................................................. 144
Perioperative Management
Contents
Pre-Operative Assessment and Planning ..................................................................................................................................... 2 
Specific Pre-operative Complications ............................................................................................................................................ 3 
Anaesthesia ................................................................................................................................................................................... 4 
Analgesia ....................................................................................................................................................................................... 4 
Enhanced Recovery After Surgery ................................................................................................................................................ 5 
Surgical Complications .................................................................................................................................................................. 5 
Post-op Complications: General .................................................................................................................................................... 6 
Post-op Complications: Specific .................................................................................................................................................... 7 
Post-op Pyrexia ............................................................................................................................................................................. 8 
DVT ................................................................................................................................................................................................ 9 
Other Common Post-Operative Presentations ............................................................................................................................ 10 

© Alasdair Scott, 2012 1
Pre-Operative Assessment and Planning

Aims Preparation
 Informed consent
 Assess risk vs. benefits NBM
 Optimise fitness of patient  ≥2h for clear fluids, ≥6h for solids
 Check anaesthesia / analgesia type ¯c anaesthetist

Bowel Prep
Pre-op Checks: OP CHECS  May be needed in left-sided ops
 Picolax: picosulfate and Mg citrate
 Operative fitness: cardiorespiratory comorbidities
 Klean-Prep: macrogol
 Pills
 Not usually needed in right-sided procedures
 Consent
 Necessity is controversial as benefit of minimising post-
 History
op infection might not outweigh risks
 MI, asthma, HTN, jaundice
 Liquid bowel contents spilled during surgery
 Complications of anaesthesia: DVT, anaphylaxis
 Electrolyte disturbance
 Ease of intubation: neck arthritis, dentures, loose teeth
 Dehydration
 Clexane: DVT prophylaxis
 ↑ rate of post-op anastomotic leak
 Site: correct and marked

Prophylactic Abx
Drugs  Use
 GI surgery (20% post-op infection if elective)
Anti-coagulants  Joint replacement
 Balance risk of haemorrhage ¯c risk of thrombosis  Give 15-60min before surgery
 Avoid epidural, spinal and regional blocks  Regimens: (see local guidelines)
 Biliary: Cef 1.5g + Met 500mg IV
AED  CR or appendicetomy: Cef+Met TDS
 Give as usual  Vascular: co-amoxiclav 1.2g IV TDS
 Post-op give IV or via NGT if unable to tolerate orally  MRSA+ve: vancomycin

OCP / HRT
DVT Prophylaxis
 Stop 4wks before major / leg surgery
 Stratify pts according to patient factors and type of
 Restart 2wks post-op if mobile
surgery.

β-Blockers  Low risk: early mobilisation
 Continue as usual  Med: early mobilisation + TEDS + 20mg enoxaparin
 High: early mobilisation + TEDS + 40mg enoxaparin +
intermittent compression boots perioperatively.

 Prophylaxis started @ 1800 post-op
Pre-op Investigations
 May continue medical prophylaxis at home (up to 1mo)

Bloods
 Routine: FBC, U+E, G+S, clotting, glucose ASA Grades
 Specific 1. Normally healthy
 LFTs: liver disease, EtOH, jaundice 2. Mild systemic disease
 TFT: thyroid disease 3. Severe systemic disease that limits activity
 Se electrophoresis: Africa, West Indies, Med 4. Systemic disease which is a constant threat to life
 Cross-match 5. Moribund: not expected to survive 24h even ¯c op
 Gastrectomy: 4u
 AAA: 6u

Cardiopulmonary Function
 CXR: cardiorespiratory disease/symptoms, >65yrs
 Echo: poor LV function, Ix murmurs
 ECG: HTN, Hx of cardiac disease, >55yrs
 Cardiopulmonary Exercise Testing
 PFT: known pulmonary disease or obesity

Other
 Lat C-spine flexion and extension views: RA, AS
 MRSA swabs
© Alasdair Scott, 2012 2
Specific Pre-operative Complications

Diabetes Jaundice
 Best to avoid operating in jaundiced pts.
↑ Risk of post-operative complications  Use ERCP instead
 Surgery → stress hormones → antagonise insulin
 Pts. are NBM Risks
 ↑ risk of infection  Pts. ¯c obstructive jaundice have ↑ risk of post-op renal
 IHD and PVD failure  need to maintain good UO.
 Coagulopathy
Pre-op  ↑ infection risk: may → cholangitis
 Dipstick: proteinuria
 Venous glucose Pre-op
 U+E: K+  Avoid morphine in pre-med
 Check clotting and consider pre-op vitamin K
IDDM  Give 1L NS pre-op (unless CCF) → moderate diuresis
 Urinary catheter to monitor UPO
Practical Points  Abx prophylaxis: e.g. cef+met
 Put pt. first on list and inform surgeon and anaesthetist
 Some centres prefer to use GKI infusions Intra-op
 Sliding scale may not be necessary for minor ops  Hrly UO monitoring
 If in doubt, liaise ¯c diabetes specialist nurse  NS titrated to output

Insulin Post-op
 ± stop long-acting insulin the night before  Intensive monitoring of fluid status
 Omit AM insulin if surgery is in the morning  Consider CVP + frusemide if poor output despite NS

 Start sliding scale

 5% Dex ¯c 20mmol KCl 125ml/hr
Anticoagulated Patients
 Infusion pump ¯c 50u actrapid
 Check CPG hrly and adjust insulin rate  Balance risk of haemorrhage ¯c risk of thrombosis
 Check glucose hrly: aim for 7-11mM  Consult surgeon, anaesthetist and haematologist
 Post-op  Very minor surgery may be undertaken w/o stopping
 Continue sliding-scale until tolerating food warfarin if INR <3.5.
 Switch to SC regimen around a meal  Avoid epidural, spinal and regional blocks if
anticoagulated,
NIDDM  In general, continue aspirin/clopidogrel unless risk of
 If glucose control poor (fasting >10mM): treat as IDDM bleeding is high – then stop 7d before surgery

 Omit oral hypoglycaemics on the AM of surgery
Low thromboembolic risk: e.g. AF
 Eating post-op: resume oral hypoglycaemics ¯c meal
 Stop warfarin 5d pre-op: need INR <1.5
 No eating post-op
 Restart next day
 Check fasting glucose on AM of surgery

 Start insulin sliding scale
High thromboembolic risk: valves, recurrent VTE
 Consult specialist team ore. restarting PO Rx
 Need bridging ¯c LMWH
Diet Controlled  Stop warfarin 5d pre-op and start LMWH
 Stop LMWH 12-18h pre-op
 Usually no problem
 Restart LMWH 6h post-op
 Pt. may be briefly insulin-dependent post-op
 Restart warfarin next day
 Monitor CPG
 Stop LMWH when INR >2

Emergency Surgery
Steroids
 Discontinue warfarin

 Vit K .5mg slow IV
Risks
 Request FFP or PCC to cover surgery
 Poor wound healing

 Infection
COPD and Smoking
 Adrenal crisis

Risks
Mx
 Basal atelectasis
 Need to ↑ steroid to cope ¯c stress
 Aspiration
 Consider cover if high-dose steroids w/i last yr
 Chest infection
 Major surgery: hydrocortisone 50-100mg IV ¯c pre-med
then 6-8hrly for 3d.
Pre-op
 Minor: as for major but hydrocortisone only for 24h  CXR
 PFTs
 Physio for breathing exercises
 Quit smoking (at least 4wks prior to surgery)
© Alasdair Scott, 2012 3
Anaesthesia Analgesia

Principals and Practical Conduct Necessity
 Aims: hypnosis, analgesia, muscle relaxation  Pain → autonomic activation → arteriolar constriction →
 Induction: e.g. IV propofol ↓ wound perfusion → impaired wound healing
 Muscle Relaxation  Pain → ↓ mobilisation → ↑ VTE and ↓ function
 Depolarising: suxamethonium  Pain → ↓ respiratory excursion and ↓ cough →
 Non-depolarising: vecuronium, atracurium atelectasis and pneumonia
 Airway Control: ET tube, LMA  Humanitarian considerations
 Maintenance
 Usually volatile agent added to N O/O mix General Guidance
2 2
 E.g. halothane, enflurane  Give regular doses at fixed intervals
 End of Anaesthesia  Consider best route: oral when possible
 Change inspired gas to 100% O2  PCA should be considered: morphine, fentanyl
 Reverse paralysis: neostigmine + atropine (prevent
 Follow stepwise approach
muscarinic side effects)
 Liaise ¯c Acute Pain Service

Pre-Op
Pre-medication: 7As
 Epidural anaesthesia: e.g. ¯c bupivacaine
 Anxiolytics and Amnesia: e.g. temazepam

 Analgesics: e.g. opioids, paracetamol, NSAIDs
End-Op
 Anti-emetics: e.g. ondansetron 4mg / metoclop 10mg
 Infiltrate wound edge ¯c LA
 Antacids: e.g. lansoprazole
 Anti-sialogue e.g. glycopyrolate (↓ secretions)  Infiltrate major regional nerves ¯c LA
 Antibiotics
Post-Op: stepwise approach

Regional Anaesthesia 1. Non-opioid ± adjuvants
 Paracetamol
 May be used for minor procedures or if unsuitable for GA
 NSAIDs
 Nerve or spinal blocks
 Ibuprofen: 400mg/6h PO max
 CI: local infection, clotting abnormality
 Diclofenac: 50mg PO / 75mg IM
 Use long-acting agents: e.g. bupivacaine

2. Weak opioid + non-opioid ± adjuvants

 Codeine
Complications of Anaesthesia
 Dihydrocodeine

 Tramadol
Propofol Induction

 Cardiorespiratory depression
3. Strong opioid + non-opioid ± adjuvants

 Morphine: 5-10mg/2h max
Intubation
 Oxycodone
 Oro-pharyngeal injury ¯c laryngoscope
 Fentanyl
 Oesophageal intubation
Spinal or Epidural Anaesthesia
Loss of pain sensation
 ↓ SE as drugs more localised
 Urinary retention
 1st line for major bowel resection
 Pressure necrosis
 Caution
 Nerve palsies
 Respiratory depression

 Neurogenic shock → ↓BP
Loss of muscle power
 Corneal abrasion
 No cough → atelectasis + pneumonia

Malignant Hyperpyrexia
 Rare complication ppted by halothane or suxamethonium
 AD inheritance
 Rapid rise in temperature + masseter spasm
 Rx: dantrolene + cooling

Anaphylaxis
 Rare
 Possible triggers
 Antibiotics
 Colloid
 NM blockers: e.g. vecuronium

© Alasdair Scott, 2012 4
Enhanced Recovery After Surgery Surgical Complications

ERAS Immediate (<24h)
 Commonly employed in colorectal and orthopaedic surgery  Intubation → oropharyngeal trauma
 Surgical trauma to local structures
Aims  Primary or reactive haemorrhage
 Optimise pre-op preparation for surgery
 Avoid iatrogenic problems (e.g. ileus) Early (1d-1mo)
 Minimise adverse physiological / immunological responses  Secondary haemorrhage
to surgery  VTE
 ↑ cortisol and ↓ insulin (absolute or relative)  Urinary retention
 Hypercoagulability  Atelectasis and pneumonia
 Immunosuppression  Wound infection and dehiscence
 ↑ speeded of recovery and return to function  Antibiotic association colitis (AAC)
 Recognise abnormal recovery and allow early intervention
Late (>1mo)

 Scarring
Pre-op: optimisation
 Neuropathy
 Aggressive physiological optimisation
 Failure or recurrence
 Hydration
 BP (↑ / ↓)
 Anaemia
 DM
 Co-morbidities
 Smoking cessation: ≥4wks before surgery
 Admission on day of surgery, avoidance of prolonged fast
 Carb loading prior to surgery: e.g. carb drinks
 Fully informed pt., encouraged to participate in recovery

Intra-op: ↓ physical stress
 Short-acting anaesthetic agents
 Epidural use
 Minimally invasive techniques
 Avoid drains and NGTs where possible

Post-op: early return to function and mobilisation
 Aggressive Rx of pain and nausea
 Early mobilisation and physiotherapy
 Early resumption of oral intake (inc. carb drinks)
 Early discontinuation of IV fluids
 Remove drains and urinary catheters ASAP

© Alasdair Scott, 2012 5
Post-op Complications: General

Haemorrhage Classification Wound Infection
 5-7d post-op
 Primary: continuous bleeding starting during surgery
 Organisms: S. aureus and Coliforms
 Reactive

 Bleeding at the end of surgery or early post-op
 2O to ↑ CO and BP Operative Classification
 Clean: incise uninfected skin w/o opening viscus
 Secondary
 Bleeding >24h post-op  Clean/Cont: intra-op breach of viscus (not colon)
 Usually due to infection  Contaminated: breach of viscus + spillage or opening of
colon
 Dirty: site already contaminated – faeces, pus, trauma

Post-op Urinary Retention
Risk Factors

 Pre-operative
Causes
 ↑ Age
 Drugs: opioids, epidural/spinal, anti-AChM
 Comorbidities: e.g. DM
 Pain: sympathetic activation → sphincter contraction
 Pre-existing infection: e.g. appendix perforation
 Psychogenic: hospital environment
 Pt. colonisation: e.g. nasal MRSA

 Operative
Risk Factors
 Op classification and wound infection risk
 Male
 Duration
 ↑ age
 Technical: pre-op Abx, asepsis
 Neuropathy: e.g. DM, EtOH
 Post-operative
 BPH  Contamination of wound from staff
 Surgery type: hernia and anorectal
Mx
Mx  Regular wound dressing
 Conservative  Abx
 Privacy
 Abscess drainage
 Ambulation

 Void to running taps or in hot bath

 Analgesia
Wound Dehiscence
 Catheterise ± gent 2.5mg/kg IV stat
 TWOC = Trial w/o Catheter
 If failed, may be sent home ¯c silicone catheter Presentation
and urology outpt. f/up.  Occurs ~10d post-op
 Preceded by serosanguinous discharge from wound

Pulmonary Atelectasis Risk Factors
 Pre-Operative Factors
 Occurs after every nearly every GA
 ↑ age
 Mucus plugging + absorption of distal air → collapse
 Smoking

 Obesity, malnutrition, cachexia
Causes
 Comorbs: e.g. BM, uraemia, chronic cough, Ca
 Pre-op smoking
 Drugs: steroids, chemo, radio
 Anaesthetics ↑ mucus production ↓ mucociliary
 Operative Factors
clearance
 Length and orientation of incision
 Pain inhibits respiratory excursion and cough
 Closure technique: follow Jenkin’s Rule

 Suture material
Presentation
 Post-operative Factors
 w/i first 48hrs
 ↑ IAP: e.g. prolonged ileus → distension
 Mild pyrexia
 Infection
 Dyspnoea
 Haematoma / seroma formation
 Dull bases ¯c ↓AE
Mx
Mx  Replace abdo contents and cover ¯c sterile soaked gauze
 Good analgesia to aid coughing
 IV Abx: cef+met
 Chest physiotherapy
 Opioid analgesia

 Call senior and arrange theatre
 Repair in theatre
 Wash bowel
 Debride wound edges
 Close ¯c deep non-absorbable sutures (e.g. nylon)
 May require VAC dressing or grafting

© Alasdair Scott, 2012 6
Post-op Complications: Specific

General Surgery Vascular

Cholecystectomy Arterial Surgery
 Conversion to open: 5%  Thrombosis and embolization
 CBD injury: 0.3%  Anastomotic leak
 Bile leak  Graft infection
 Retained stones (needing ERCP)
Aortic Surgery
 Fat intolerance / loose stools
 Gut ischaemia

 Renal failure
Inguinal Hernia Repair
 Aorto-enteric fistula
 Early
 Anterior spinal syndrome (paraplegia)
 Haematoma / seroma formation: 10%
 Emboli → distal ischaemia (trash foot)
 Intra-abdominal injury (lap)

 Infection: 1%
 Urinary retention Breast
 Late  Arm lymphoedema
 Recurrence (<2%)  Skin necrosis
 Ischaemic orchitis: 0l5%  Seroma
 Chronic groin pain / paraesthesia: 5%
Urological
Appendicectomy
 Sepsis (instrumentation ¯c infected urine)
 Abscess formation
 Uroma: extravasation of urine
 Fallopian tube trauma

 Right hemicolectomy (e.g. for carcinoid, caecal Prostatectomy
necrosis)
 Urinary incontinence

 Erectile dysfunction
Colonic Surgery
 Retrograde ejaculation
 Early
 Prostatitis
 Ileus

 AAC
ENT
 Anastomotic leak

 Enterocutaneous fistulae
Thyroidectomy
 Abdominal or pelvic abscess
 Wound haematoma → tracheal obstruction
 Late
 Recurrent laryngeal N. trauma → hoarse voice
 Adhesions → obstruction
 Transient in 1.5%
 Incisional hernia
 Permanent in 0.5%

 R commonest (more medial)
Post-op Ileus
 Hypoparathyroidism → hypocalcaemia
 Causes
 Bowel handling  Thyroid storm
 Anaesthesia  Hypothyroidism
 Electrolyte imbalance
 Presentation Tracheostomy
 Distension  Stenosis
 Constipation ± vomiting  Mediastinitis
 Absent bowel sounds  Surgical emphysema
 Rx
 IV fluids + NGT Orthopaedic Surgery
 TPN if prolonged
Fracture Repair
Anorectal Surgery  Mal-/non-union
 Anal incontinence  Osteomyelitis
 Stenosis  AVN
 Anal fissure  Compartment syndrome

Small Bowel Surgery Hip Replacement
 Short gut syndrome (≤250cm)  Deep infection
 VTE
Splenectomy  Dislocation
 Gastric dilatation (2O gastric ileus)  Nerve injury: sciatic, SGN
 Prevent ¯c NGT  Leg length discrepancy
 Thrombocytosis → VTE
 Infection: encapsulated organisms Cardiothoracic Surgery

 Pneumo-/haemo-thorax

 Infection: mediastinitis, empyema
© Alasdair Scott, 2012 7
Post-op Pyrexia

Causes Pneumonia

Early: 0-5d post-op Cause
 Blood transfusion  Anaesthesia → atelectasis
 Physiological: SIRS from trauma: 0-1d  Pain → ↓ cough
 Pulmonary atelectasis:24-48hr  Surgery → immunosuppression
 Infection: UTI, superficial thrombophlebitis, cellulitis
Rx
 Drug reaction
 Chest physio: encouraging coughing
Delayed: >5d post-op  Good analgesia
 Pneumonia  Abx
 VTE: 5-10d

 Wound infection: 5-7d
Collection
 Anastomotic leak: 7d
 Collection: 5-20d
Presentation
 Malaise
 Swinging fever, rigors
Examination of Post-Op Febrile Pt.
 Localised peritonitis
 Observation chart, notes and drug chart
 Shoulder tip pain (if subphrenic)
 Wound

 Abdo + DRE
Locations
 Legs
 Pelvic: present @ 4-10d post-op
 Chest
 Subphrenic: present @ 7-21d post-op
 Lines
 Paracolic gutters
 Urine
 Lesser sac
 Stool
 Hepatorenal recess (Morrison’s space)

 Small bowel (interloop spaces)

Ix
Ix
 Urine: dip + MCS
 FBC, CRP, cultures
 Blood: FBC, CRP, cultures ± LFTs
 US, CT
 Cultures: wound swabs, CVP tip for culture
 Diagnostic lap
 CXR
Rx
 Abx
 Drainage / washout

Cellulitis
 Acute infection of the subcutaneous connective tissue

Cause: β-haemolytic Streps + staph. aureus

Presentation
 Pain, swelling, erythema and warmth
 Systemic upset
 ± lymphadenopathy

Rx
 Benpen IV
 Pen V and fluclox PO

© Alasdair Scott, 2012 8