Surgical Instruments
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Mohammad TaufiqContents
Section 1: General Surgery Duodenal Injury 45
Small Bowel Injury 45
Chapter 1: Basic Principles of Surgery 1 Colonic Injury 46
Basic Concepts in Homeostasis 1 Abdominal Compartment Syndrome 46
Metabolic Response to Injury 2 Seat-Belt Injuries 47
Metabolic Changes After Trauma 3 Medicolegal Aspects of Wound Healing 47
Enhanced Recovery After Surgery 5 Chapter 4: Infectious Diseases 49
Tissue Engineering and Regenerative Medicines 5 Surgical Infection 49
Doctor–Patient Relationship 8 Cellulitis 50
Communication and Counselling 8 Erysipelas 52
Clinical Research in Surgery 10 Lymphangitis 52
Biomedical Waste Management (Biohazard Disposal) 10 Abscess 53
Perioperative Care 11 Metastatic and Pyaemic Abscess 57
Safe General Surgery 12 Bacteraemia 58
Antibiotic Therapy in Surgical Patients 13 Septicaemia 58
Chapter 2: Wounds and Wound Healing 15 Pyaemia 58
Wounds 15 Boil (Furuncle) 59
Classification of Wounds 15 Hidradenitis Suppurativa 59
Different Wound Classifications Refer Online Modified Sartorius Scoring System for
Wound Healing 19 Hidradenitis Suppurativa (HS) Refer Online
Compartment Syndrome 24 Carbuncle (Word Meaning of Carbuncle is Charcoal) 60
Crush Injury 25 Pott’s Puffy Tumour 61
Crush Syndrome 25 Pyogenic Granuloma (Granuloma Pyogenicum) 61
Degloving Injuries 26 Impetigo 62
Degloving Injuries—Box Refer Online Tetanus 62
Scar 26 Gas Gangrene 66
Keloid: ‘Like a Claw’ 27 Tuberculosis 68
Hypertrophic Scar 28 Leprosy 69
Problems with Wound Healing 29 Syphilis (Great Pox) (French Disease) 69
Chapter 3: Trauma 30 Actinomycosis 70
Principles of First Aid 31 Madura Foot (Mycetoma Pedis) 70
Mass Casualties (Multi Casualty Incidents) 31 Rabies (Hydrophobia) 72
Triage 32 Rabies in Dogs Refer Online
Concepts in Trauma Management 34 Nosocomial and Opportunistic Infections 75
Spinal Injury 35 Necrotising Soft Tissue Infection Refer Online
Neck Injuries 36 Necrotising Fasciitis (Wilson, 1952) 75
Weapon Injuries and War Injuries Refer Online Acute (Tropical) Pyomyositis 77
Bullet Injuries 36 Surgical Site Infection 78
Blast Injuries 37 HIV Infection and AIDS (Acquired Immunodeficiency
Penetrating Injuries 37 Syndrome) 81
Soft Tissue Injuries 37 Chapter 5: Shock 85
Assessment in Trauma and Shock 85
Thromboelastography Refer Online Stages of Shock 86
Polytrauma 38 Effects of Shock 87
Abdominal Trauma 40 Anaphylactic Shock Refer Online
Blunt Trauma of Abdomen 42 Clinical Features of Shock (Hypovolaemic Shock) 89
xiv Contents
Assessment, Investigations and Monitoring 90 Diabetic Ulcer and Diabetic Foot 151
SRB's MANUAL OF SURGERY
Central Venous Pressure 91 Meleney’s Ulcer (1924, Postoperative Progressive
Pulmonary Capillary Wedge Pressure 92 Bacterial Synergistic Gangrene) 154
Systemic Inflammatory Response Syndrome 92 Lupus Vulgaris (‘Lupus’—Wolf) 154
Multiple Organ Dysfunction Syndrome 93 Tuberculous Ulcer 155
Oxygen Therapy 93 Tropical Ulcer 155
Cardiac Arrest 93 Venous Ulcer (Gravitational Ulcer) 155
Chapter 6: Haemorrhage and Blood Transfusion 96 Syphilitic Ulcer Refer Online
Haemorrhage 96 Chapter 10: Sinus and Fistula 157
Blood Transfusion 100 Sinus 157
Massive Blood Transfusion 103 Fistula 157
Artificial Blood 103 Median Mental Sinus 160
Tourniquets 104 Sequestrum 160
Disseminated Intravascular Coagulation 104 Preauricular Sinus 161
Mechanism of Blood Coagulation (Haemostasis) 105
Chapter 11: Swellings 163
Chapter 7: Electrolyte and Nutrition 107 Lipoma 163
Normal Physiology 107 Cysts 166
Water Loss (Volume Loss) 107 Dermoids 167
Water Excess (ECF Volume Excess) 108 Sebaceous Cyst (Wen) 171
Hyponatraemia 108 Neuroma 173
Hypernatraemia 109 Fibroma 174
Hypermagnesaemia 112 Neurofibroma 174
Hypomagnesaemia 112 Neurilemmoma (Schwannoma) 176
Acid-Base Balance 112 Ganglion (Ganglion Cyst) 176
Metabolic Alkalosis 113 Papilloma 177
Respiratory Alkalosis 113 Warts 177
Metabolic Acidosis 113 Glomus Tumour 178
Respiratory Acidosis 114 Bursae 178
Anion Gap 114 Semimembranosus Bursa 180
Fluid Therapy 114 Morrant Baker’s Cyst (Popliteal Cyst) 181
Nutrition 118 Lymphangioma 181
Gastrostomy 119 Lymph Cyst (Lymphatic Cyst) 182
Jejunostomy 120 Calcinosis Cutis 182
Total Parenteral Nutrition 121 Chordoma 183
Refeeding Syndrome 122 Epignathus 183
Obesity and Morbid Obesity 122
Chapter 12: Hand and Foot 184
Chapter 8: Burns 127 Hand 184
Burns 127 Hand Infections 185
Management of Burns 132 Acute Paronychia 187
Eschar 134 Apical Subungual Infection 188
Contracture in Burn Wound 135 Terminal Pulp Space Infection (Felon) 188
Electrical Burns 137 Infection of Web Spaces 189
Inhalation Injury 138 Deep Palmar Space Infection 190
Chemical Burns 138 Space of Parona Infection 191
Chapter 9: Ulcer 140 Acute Suppurative Tenosynovitis 191
Ulcer 140 Compound Palmar Ganglion 192
Granulation Tissue 144 Hand Injuries 193
Investigations for an Ulcer 145 Dupuytren’s Contracture 194
Management of an Ulcer 145 Volkmann’s Ischaemic Contracture 195
Traumatic Ulcer 148 Syndactyly 196
Trophic Ulcer (Pressure Sore/Decubitus Ulcer) 148 Foot 196
Martorell’s Ulcer (1945) 149 Callosity 196
Arterial/Ischaemic Ulcer 149 Corn 197
Carcinomatous Ulcer (Epithelioma, Squamous Cell Plantar Fasciitis (Policeman’s Heel) 197
Carcinoma) 150 Ingrowing Toe Nail (Onychocryptosis) 197
Rodent Ulcer 150 Athlete’s Foot 198
Melanotic Ulcer 150 Hallux Valgus 198
Contents xv
Chapter 13: Arterial Diseases 200 Varicose Veins 261
SRB's MANUAL OF SURGERY
Surgical Anatomy of Thoracic Outlet 200 Venous Ulcer (Gravitational Ulcer) 274
Arteries of Upper Limb 200 Compression Therapy for Varicose Veins 276
Arteries of Lower Limb 201 Thrombophlebitis 277
Arterial Diseases 201 Klippel-Trenaunay Syndrome 277
Intermittent Claudication 201 Anticoagulants 277
Rest Pain 202 Oral Anticoagulants 278
Limb Ischaemia 202 Pelvic Congestion Syndrome 279
Different Levels of Arterial Obstruction 204 Pulmonary Embolism 279
Other Features of Poor Circulation 205 Chapter 16: Lymphatics 281
Investigations for Arterial Diseases 206 Surgical Anatomy 281
Diseases of the Arteries 208 Lymphangiography 283
Atherosclerosis 209 Acute Lymphangitis and Lymphadenitis 283
Trans-Atlantic Inter-Society Consensus Lymphoedema 284
Classification Refer Online Lymphomas 291
Thromboangiitis Obliterans (Syn. Buerger’s Disease) 211 Mantle Cell Lymphoma 297
Raynaud’s Phenomenon 215 Malt Lymphoma (Maltoma) 298
Treatment of Arterial Diseases 217 Burkitt’s Lymphoma (Malignant Lymphoma of Africa) 298
Subclavian Steal Syndrome 222 Cutaneous T Cell Lymphoma 299
Acute Arterial Occlusion 223 Chylous Ascites Refer Online
Traumatic Acute Arterial Occlusion 223 Chyothorax Refer Online
Embolism 224 Chyluria Refer Online
Reperfusion Injury 226
Sarcoidosis (with Figure) Refer Online
Saddle Embolus 226
Embolectomy 226 Chapter 17: Peripheral Nerves 301
Fat Embolism (Ernst Von Bergmann in 1873) 227 Peripheral Nerve Injuries 301
Tinel’s Sign 303
Air/Gas Embolism 228
Brachial Plexus Injuries 303
Therapeutic Embolisation 228
Causalgia 303
Caisson’s Disease or Decompression Disease
Median Nerve Injury 304
(Bend’s Disease) 228
Carpal Tunnel Syndrome 304
Aneurysm 229
Ulnar Nerve Injury 306
Mycotic Aneurysm (Infective Aneurysm) (3%) 231
Claw Hand 306
Abdominal Aneurysm 232
Radial Nerve Injury 307
Abdominal Aortic Aneurysm 232
Common Peroneal Nerve Injury 308
Peripheral Aneurysm 236
Foot Drop 308
Carotid Artery Aneurysm (Extracranial) 237
Medial Popliteal Nerve Injury 308
Dissecting Aneurysm 237
Axillary Nerve Injury 309
Takayasu’s Pulseless Arteritis (Mikito Takayasu,
Long Thoracic Nerve Injury (Nerve of Bell) 309
1938—Ophthalmologist, Japan) 238
Meralgia Paraesthetica 309
Polyarteritis Nodosa 238
Scleroderma/Systemic Sclerosis 239 Chapter 18: Neoplasm 310
Gangrene 239 Definition 310
Diabetic Foot and Diabetic Gangrene 240 Dysplasia 311
Endovascular Surgeries 242 Carcinoma in Situ 311
Upper Limb Ischaemia 242 Cancer Initiation, Promotion Oncogenes and Oncogene
Arterial Substitutes 244 Activation 311
Aetiologic Factors 312
Chapter 14: Vascular Lesions 246 Spread of Malignant Tumours 312
Vascular Anomalies 246
Grading of Tumour 313
Haemangioma 247 Staging of the Tumour 314
Vascular Malformations 250 Paraneoplastic Syndromes 315
Cirsoid Aneurysm 250 Investigations for Neoplasm 315
Arteriovenous Fistula 251 Management Strategy for Cancers 320
Chapter 15: Venous Diseases 255 Oncological Emergencies 321
Anatomy of Veins of Lower Limb 255 Cancer Prevention, Screening, Vaccination and Cancer
Physiology of Venous Blood Flow in Lower Limb 257 Registry 323
Deep Vein Thrombosis 257 Early Detection of Cancer 324
xvi Contents
Chapter 19: Skin Tumours 326 Small Bowel Transplantation 392
SRB's MANUAL OF SURGERY
Anatomy 326 Dialysis 392
Classification of Skin Tumours 327 Cimino Fistula (Cimino-Brescia) 393
Skin Appendageal/Adnexal Tumours 328 Legal and Ethical Issues in Relation to Organ
Dermatofibroma (Sclerosing Angioma or Transplantation 393
Subepithelial Benign Nodular Fibrosis) 329 Chapter 24: Pain 394
Dermatofibrosarcoma Protuberans 329 Gate Control Theory 394
Keratoacanthoma (Molluscum Sebaceum) 330 Chapter 25: Faciomaxillary Diseases 398
Rhinophyma (Potato Nose) (Bottle Nose) 330 Diseases of the Palate 398
Seborrhoeic Keratosis (Seborrhoeic Wart, Orthopantomogram 398
Basal Cell Papilloma) 331 Cleft Lip and Cleft Palate 398
Squamous Cell Carcinoma (Epithelioma) 332 Maxillofacial Injuries 402
Basal Cell Carcinoma (Rodent Ulcer) 335 Primary Care (Early Care) in Maxillofacial Injuries 403
Turban Tumour 337 Fracture Middle Third Area 404
Naevi (Moles) 337 Zygomatic Complex Fracture 405
Melanoma 339 Fracture of the Mandible 406
Chapter 20: Soft Tissue Tumours and Sarcomas 349 Dislocation of the Mandible 408
Sarcoma 349 Jaw Tumours 409
Epulis (Greek—Means Upon Gum) 410
Classification of Soft Tissue Tumours Refer Online
Ameloblastoma (Adamantinoma, Eve’s Disease, Multilocular
Liposarcoma 358
Cystic Disease of the Jaw) 411
Fibrosarcoma (11%) 358
Dentigerous Cyst (Follicular Odontome) 412
Undifferentiated Pleomorphic Sarcoma
Dental Cyst (Radicular Cyst, Periapical Cyst) 412
(UPS/Older MFH) 358 Osteomyelitis of Jaw 412
Leiomyosarcoma 359
Alveolar Abscess (Dental Abscess) 413
Rhabdomyosarcoma 359
Fibrous Dysplasia of Bone/Jaw 414
Chondrosarcoma 359 Cherubism (Cherub—Angelic Being) 415
Malignant Vascular Tumours 359
Chapter 26: Oral Cavity 416
Synovial Sarcoma (7%) 360
Ranula 416
Malignant Peripheral Nerve Sheath Tumour (5–10%) 360
Sublingual Dermoids 417
Kaposi’s Sarcoma 360
Stomatitis 417
Chapter 21: Amputations 362 Cancrum Oris (Noma) 418
Amputation 362 Syphilitic Lesions of Oral Cavity 418
Complications of Amputations 369 Leukoplakia 419
Prosthesis 370 Erythroplakia 420
Surgical Offload 371 Oral Submucosal Fibrosis 420
Chapter 22: Reconstruction 372 Oral and Upper Aerodigestive Cancers 422
Reconstruction/Reconstructive Surgery 372 Cheek 423
Graft 372 Carcinoma Cheek/Buccal Mucosa 424
Skin Grafts 372 Newer Concepts 435
Flaps 376 Lip 436
Other Classification of Flaps Refer Online Neoplasm of Lip 437
Abdominoplasty 382 Carcinoma Lip 437
Tongue 440
Tendon 382
Tongue Ulcers 441
Tendon Repair 383
Benign Tumours of Tongue 442
Tendon Transfer 383
Tongue Fissure 443
Tendon Graft 383
Glossitis 444
Microvascular Surgery Refer Online Tongue Tie 444
Chapter 23: Transplantation 385 Carcinoma Tongue 444
Preoperative Evaluation 385 Carcinoma of Posterior One-third/Base of the Tongue 447
Organ Procurement 386 Nasopharyngeal Carcinoma 448
Graft Rejection (Transplant Rejection) 387 Maxillary Tumours 449
Immunosuppressive Agents 387 Malignant Tumours of Tonsil 451
Renal Transplantation 388 Carcinoma Hard Palate 451
Liver Transplantation 390 Laryngeal Tumours 452
Bone Marrow Transplantation 391 Malignant Tumours of Larynx 452
Pancreatic Transplantation 391 Trismus 454
Contents xvii
Chapter 27: Neck 456 Thyroid Function Tests 518
SRB's MANUAL OF SURGERY
Anatomy of Lymphatics of Head and Neck 456 Fnac of Thyroid 519
Thoracic Outlet Syndrome 457 Classification of Goitre 519
Cervical Rib 458 Diffuse Hyperplastic Goitre 520
Branchial Cyst 461 Multinodular Goitre 520
Branchial Fistula 462 Discrete Thyroid Nodule 523
Pharyngeal Pouch (Zenker’s) 463 Solitary Thyroid Nodule 523
Laryngocele 464 Retrosternal Goitre 527
Cystic Hygroma (Cavernous Lymphangioma) 466 Thyrotoxicosis and Hyperthyroidism 529
Ludwig’s Angina 467 Radioactive Iodine 537
Parapharyngeal Abscess 468 Thyroid Neoplasms 538
Retropharyngeal Abscess 468 Papillary Thyroid Carcinoma 539
Subhyoid Bursitis (Retrohyoid Bursa/Boyer’s Bursa) 469 Follicular Carcinoma of Thyroid 541
Carotid Body Tumour (Potato Tumour, Differentiated Thyroid Carcinoma 544
Chemodectoma, Nonchromaffin Paraganglioma) 470 Anaplastic Carcinoma of Thyroid 546
Torticollis (Wry Neck) 472 Medullary Carcinoma of Thyroid 548
Sternomastoid Tumour 472 Malignant Lymphoma 550
Tuberculous Lymphadenitis 474 Hashimoto’s Thyroiditis (Struma Lymphomatosa) 550
Cold Abscess 476 De-Quervain’s Subacute Granulomatous Thyroiditis 550
Secondaries in Neck Lymph Nodes 477 Riedel’s Thyroiditis (‘Woody Thyroiditis’, ‘Ligneous
Chemotherapy for Head and Neck Cancers 486 Thyroiditis’) 550
Chapter 28: Salivary Glands 488 Thyroid Incidentaloma 551
Anatomy 488 Thyroidectomy 551
Saliva 491 Emil Theodor Kocher 558
Sialography 491 Kocher’s Test 558
Salivary Calculus and Sialadenitis 492 Hypothyroidism 558
Parotid Abscess (Suppurative Parotitis) 494 Recurrent Laryngeal Nerve Palsy 559
Parotid Fistula 495 Chapter 30: Parathyroids and Adrenals 562
Recurrent Childhood Parotitis 496 Anatomy 562
Sjögren’s Syndrome 496 Calcium 563
Sialosis 496 Hyperparathyroidism 563
Sialectasis 496 Parathyroidectomy 566
Salivary Neoplasms 497 MEN Syndrome (MEA Syndrome) 569
Pleomorphic Adenoma (Mixed Salivary Tumour) 498 Apudomas 569
Adenolymphoma (Warthin’s Tumour, Papillary Cystadenoma Hypoparathyroidism 570
Lymphomatosum) 500 Tetany 571
Oncocytoma (Oxyphil Adenoma) 501 Adrenals 571
Basal Cell Adenoma 501 Adrenal Cortical Tumours 571
Mucoepidermoid Tumour 501 Adrenocortical Carcinoma 572
Adenoid Cystic Carcinoma (10% of Salivary Tumours) 502 Cushing’s Syndrome 573
Acinic Cell Tumour 502 Conn’s Syndrome (Jerome Conn, 1954) 573
Malignant Mixed Tumour 502 Virilising Syndrome or Adrenogenital Syndrome 574
Adenocarcinoma of Salivary Glands 502 Neuroblastoma 574
Squamous Cell Carcinoma of Salivary Glands 502 Phaeochromocytoma 575
Submandibular Salivary Gland Tumours 503 Chapter 31: Breast 579
Management of Malignant Salivary Tumours 504 Anatomy 579
Minor Salivary Gland Tumours 506 Mammography 582
Parotid Lymphoma 506 Aberration of Normal Development and Involution
Parotidectomy 507 of the Breast 583
Frey’s Syndrome (Auriculotemporal Syndrome, Gustatory Fibroadenoma 583
Sweating); (Lucie Frey—Polish Surgeon—1932) 509 Fibrocystadenosis (Fibrocystic Disease of the Breast/
Facial Nerve Injury (Lower Motor Nerve Lesion, Surgically Mammary Dysplasia/Cyclical Mastalgia with
Related) 509 Nodularity) 585
Chapter 29: Thyroid 512 Sclerosing Adenosis 587
Development 512 Phyllodes Tumour (Cystosarcoma Phyllodes/Serocystic
Surgical Anatomy (Thyroid Means—in Greek “Shield”) 512 Disease of Brodie) 587
Physiology 514 Mastalgia (“Pain in the Breast”) 589
Congenital Anomalies 515 Traumatic Fat Necrosis 590
xviii Contents
Galactocele 590 Liver Injury 670
SRB's MANUAL OF SURGERY
Mastitis 591 Infections of Liver 673
Antibioma 593 Liver Tumours Benign Tumours of the Liver 684
Periductal Mastitis and Duct Ectasia 593 Liver Cysts 692
Mondor’s Disease (Henri Mondor—Paris, 1939) 593 Portal Hypertension 693
Tuberculosis of the Breast 594 Oesophageal Varices 697
Breast Cysts 594 Emergency Management in Severe Haemorrhage 699
Galactorrhoea 595 Ascites 704
Gynaecomastia (Greek—Women Breast) 596 Ascites in Portal Hypertension 706
Duct Papilloma 597 Budd-Chiari’s Syndrome 706
Carcinoma Breast 598 Hepatic Failure 707
Tnm Staging of Carcinoma Breast 609 Hepatic Encephalopathy 707
Management of Early Carcinoma Breast 626 Hepatorenal Syndrome 708
Advanced Carcinoma Breast 627 Hepatic Resection 708
Prognostic Factors in Carcinoma Breast 629 Portal Biliopathy 710
Prophylactic Mastectomy 630 Chapter 35: Gallbladder 711
Carcinoma of Male Breast 630 Surgical Anatomy 711
Breast Reconstruction 631 Oral Cholecystogram (OCG; Graham-Cole Test) 713
Breast Implants 634 Intravenous Cholangiogram 713
Nipple Retraction 634 Endoscopic Retrograde Cholangiopancreatography 713
Percutaneous Transhepatic Cholangiography 714
Section 2: Gastrointestinal Surgery Magnetic Resonance Cholangiopancreatography 715
Radioisotope Scan Study 715
Chapter 32: Peritoneum 637 Peroperative Cholangiogram 715
Anatomy 637 Postoperative T-tube Cholangiogram 715
Physiology 638 Congenital Anomalies of Gallbladder 715
Acute Peritonitis 638 Choledochal Cysts 716
Treatment 639 Caroli’s Disease 718
Spontaneous Bacterial Peritonitis 645 Biliary Atresia 718
Sclerosing Peritonitis 645 Gallstones 720
Biliary Peritonitis 645 Acute Cholecystitis 724
Postoperative Peritonitis 646 Acute Acalculous Cholecystitis (20%) 726
Other Forms of Peritonitis 646 Mirizzi Syndrome (Pablo Luis Mirizzi, Surgeon,
Pelvic Abscess 647 Argentina, 1948) 727
Subphrenic Spaces and Subphrenic Abscess 647 Empyema Gallbladder 727
Mesenteric Cysts 650 Mucocele of the Gallbladder (Hydrops Gallbladder) 728
Mesenteric Panniculitis 651 Chronic Cholecystitis 728
Acute Mesenteric Lymphadenitis 651 Murphy’s Sign 729
Mesenteric Malignancy 651 Gallstone Ileus (0.4%) 730
Mesenteric Trauma 652 Cholecystoses 731
Peritoneal Malignancy 652 Dissolution Therapy for Gallstones 731
Omental Cyst 654 Choledocholithiasis 732
Omental Torsion 654
Sump Syndrome 735
Omental Tumour 654
Courvoisier’s Law (Sign) 736
Chapter 33: Abdominal Tuberculosis 656 Surgical Jaundice (Obstructive Jaundice) 736
Abdominal Tuberculosis 656 CBD Strictures (Biliary Strictures) 739
Ileocaecal Tuberculosis 657 Sclerosing Cholangitis 740
Ileal Tuberculosis 661 Gallbladder Polyp 740
Peritoneal Tuberculosis 662 Benign Biliary Papilloma 741
Tuberculous Mesenteric Lymphadenitis 665 Carcinoma Gallbladder 741
Ano-recto-sigmoidal Tuberculosis 666 Cholangiocarcinoma (Bile Duct Carcinoma) 743
Tuberculosis of the Omentum 666 Klatskin Tumour 744
Chapter 34: Liver 668 Biliary Fistulas 745
Surgical Anatomy of Liver 668 Hemobilia 745
Liver Function Tests 669 White Bile 745
Alpha Fetoprotein 670 Cholecystectomy 746
Liver Biopsy 670 Open Approach Cholecystectomy 746
Contents xix
Laparoscopic Cholecystectomy 747 Chapter 38: Retroperitoneal Space 808
SRB's MANUAL OF SURGERY
Single Incision Laparoscopic Surgery in Anatomy of Retroperitoneum 808
Cholecystectomy 748 Retroperitoneal Fibrosis 809
Bile Duct Injuries 749 Retroperitoneal Swellings 809
Post-cholecystectomy Syndrome (15%) 750 Retroperitoneal Tumours 810
Biliary Dyskinesia 750 Psoas Abscess (Retroperitoneal Abscess) 813
Chapter 36: Spleen 752 Retroperitoneal Haematoma 814
Surgical Anatomy 752 Chapter 39: Differential Diagnosis of Mass Abdomen 816
Functions of the Spleen 753 Mass in the Right Hypochondrium 818
Splenunculi (30%) 753 Mass in the Epigastrium 820
Splenic Injury (Rupture Spleen) 754 Mass in the Left Hypochondrium 821
Atraumatic Rupture of Spleen 757 Mass in the Lumbar Region 821
Splenomegaly 758 Mass in the Umbilical Region 823
Hereditary Spherocytosis 758 Mass in the Right Iliac Fossa 823
Immune Haemolytic Anaemia 759 Mass in the Left Iliac Fossa 823
Thalassaemia (Mediterranean Anaemia/Cooley’s Anaemia/ Mass in the Hypogastrium 823
Erythroblastic Target Cell Anaemia) 759 Digital Rectal Examination for Prostate and Other
Sickle Cell Disease 759 Conditions 825
Idiopathic (Immune) Thrombocytopaenic Purpura 760 Chapter 40: Abdominal Wall and Umbilicus 829
Thrombotic Thrombocytopaenic Purpura 761 Diseases of the Umbilicus 829
Splenectomy 762 Omphalitis 829
Overwhelming Post-splenectomy Infection 763 Umbilical Granuloma 830
Splenic Artery Aneurysm 764 Anomalies of Vitellointestinal Duct 830
Splenic Abscess 764 Umbilical Sinus 831
Hypersplenism 765 Umbilical Adenoma (Raspberry Tumour) 831
Splenic Cyst 765 Umbilical Fistula 832
Chapter 37: Pancreas 767 Patent Urachus 832
Surgical Anatomy 767 Burst Abdomen (Abdominal Wound Dehiscence)
Serum Amylase 769 (Acute Wound Failure) 832
Serum Lipase 770 Abdominal Wall Tumours 834
Magnetic Resonance Cholangiopancreatography 770 Desmoid Tumour 835
Pancreatitis 770 Exomphalos (Omphalocele) 836
Acute Pancreatitis 770 Gastroschisis (Belly Cleft) 837
Complications of Acute Pancreatitis 777 Rectus Sheath Haematoma 838
Pseudocyst of Pancreas 778 Abdominal Wall Abscess 838
Chronic Pancreatitis 781 Meleney’s Progressive Synergistic Bacterial Gangrene of
Pancreatic Tumours 789 Abdominal Wall 838
Exocrine Pancreatic Tumours 789 Divarication of Recti (Diastasis Recti) 839
Carcinoma Pancreas 792 Chapter 41. Hernia 840
Pancreatic Neuroendocrine Tumours Aetiology 841
(panNENs/PNENs/pNETs) 799 Parts of Hernia 842
Insulinomas 799 Classification of Hernia 843
Gastrinomas 800 Inguinal Hernia 844
Glucagonomas 801 Strangulated Hernia 861
Zollinger-Ellison Syndrome 801 Sliding Groin/Inguinal Hernia (Hernia-en-Glissade) 864
Cystic Fibrosis 802 Pantaloon Hernia (Double Hernia, Saddle Hernia,
Annular Pancreas 802 Romberg Hernia) 864
Ectopic (Accessory) Pancreatic Tissue 803 Femoral Hernia 865
Pancreatic Divisum 803 Ventral Hernia 867
Pancreatic Calculus 803 Incisional Hernia 868
Pancreatic Ascites 803 Umbilical Hernia 872
Pancreatic Fistulae 804 Paraumbilical Hernia
Pancreatic Necrosis 804 (Supra- and Infraumbilical Hernia) 873
Pancreatic Trauma 805 Epigastric Hernia (Fatty Hernia of Linea Alba) 874
Cystic Lesions of Pancreas 806 Spigelian Hernia 875
Pancreatic Exocrine Insufficiency (Exocrine Pancreatic Obturator Hernia 875
Disease) 806 Richter’s Hernia 876
xx Contents
Lumbar Hernia 876 Duodenal Diverticula 943
SRB's MANUAL OF SURGERY
Sciatic Hernia 877 Carcinoma Stomach 944
Complications of Hernia Surgery 877 Gastric Lymphoma 956
Perineal Hernia 878 Gastric Sarcomas 957
Parastomal Hernia 878 Gastrointestinal Stromal Tumours 958
Biomaterials Used in Hernia Surgery 878 Pyloroplasty 959
Chapter 42: Oesophagus 880 Gastrectomy 959
Anatomy 880 Gastrojejunostomy 960
Lower Oesophageal Sphincter 882 Retrograde Jejunogastric Intussusception 960
Dysphagia 882 Vagotomy 960
Contrast Study of Oesophagus 884 Chapter 44: Small Intestine 962
Oesophagoscopy 884 Anatomy 962
Oesophageal Endosonography 885 Meckel’s Diverticulum 963
Third Space Endoscopy 885 Regional Enteritis (Crohn’s Disease) 965
Gastro-oesophageal Reflux Disease 885 Surgical Complications of Typhoid 969
Hiatus Hernia 890 Surgical Complications of
Rolling Hernia (Paraoesophageal Hernia) 890 Roundworm (Ascaris lumbricoides) 970
Reflux Oesophagitis 891 Pneumatosis Cystoides Intestinalis 971
Barrett’s Oesophagus (Norman Barrett, British, 1950) 892 Mesenteric Vessel Ischaemia 972
Barrett’s Ulcer 892 Necrotising Enterocolitis 974
Oesophageal Motility Disorders 892 Small Bowel Tumours 975
Achalasia Cardia (Cardiospasm) 893 Benign Tumours of Small Bowel 976
Plummer-Vinson Syndrome (Paterson-Kelly Syndrome) 896 Malignant Tumours of Small Bowel 977
Corrosive Stricture of Oesophagus 896
Neuroendocrine Neoplasms/Tumours; NENS/NETS
Schatzki’s Rings 898
(Carcinoid Tumour) 978
Boerhaave’s Syndrome 898
Short Bowel Syndrome (Short Gut Syndrome) 981
Mallory-Weiss Syndrome 899
Small Bowel Enema (Enteroclysis) 982
Tracheo-oesophageal Fistula (Oesophageal Atresia) 899
Capsule Endoscopy 982
Oesophageal Diverticulum 900
Small Bowel Enteroscopy 983
Oesophageal Carcinoma 900
Enteric/Gastrointestinal Fistula 983
Benign Tumours of the Oesophagus 908
Oesophageal Perforation 909 Chapter 45: Large Intestine 988
Anatomy 988
Chapter 43: Stomach 911
Hirschsprung’s Disease (Congenital Megacolon) 989
Anatomy 911
Diverticular Disease of the Colon 991
Gastric Physiology 913
Ulcerative Colitis 995
Gastric Function Tests 914
Ischaemic Colitis 1000
Gastrin 915
Pseudomembranous Colitis 1000
Barium Meal Study 915
Gastroscopy 916 Surgical Complications of Intestinal Amoebiasis 1001
Congenital (Infantile) Hypertrophic Pyloric Stenosis 918 Tumours of Colon 1001
Gastritis 919 Carcinoma Colon 1005
Acute Peptic Ulcer (Duodenal or Gastric Ulcer) 920 Angiodysplasia of Colon 1015
Gastric Ulcer 921 Ogilvie’s Syndrome 1015
Duodenal Ulcer 924 Colostomy 1016
Pyloric Stenosis Due to Chronic Duodenal Ulcer 926 Stoma Care 1017
Perforated Peptic Ulcer 928 Stoma Appliances 1019
Bleeding Peptic Ulcer 932 Faecal Fistula 1019
Haematemesis 935 Preparation of Large Bowel for Surgery 1020
Complications of Gastric Surgery 936 Surgical Pouches 1021
Trichobezoar (Rapunzel Syndrome) 940 Barium Enema 1021
Chronic Duodenal Ileus (Wilkie’s Syndrome) 940 Chapter 46: Intestinal Obstruction 1023
Dunbar’s (MALS) Syndrome Intestinal Obstruction: Types 1023
(Harjola-Marable Syndrome) 941 Dynamic Obstruction 1024
Acute Gastric Dilatation 941 Duodenal Atresia 1030
Gastric Volvulus 942 Small Intestine Atresia (Intestinal Atresia) 1031
Gastric Polyp 942 Malrotation 1032
Menetrier’s Disease 943 Meconium Ileus 1033
Contents xxi
Intussusception 1035 Micturating Cystourethrography 1111
SRB's MANUAL OF SURGERY
Volvulus 1037 Ascending Urethrogram 1111
Sigmoid Volvulus (Volvulus of Pelvic Colon) 1038 Isotope Renography 1111
Paralytic Ileus (Adynamic Intestinal Obstruction) 1039 Cystoscopy 1112
Adhesions and Bands 1040 Catheters 1113
Internal Hernias 1043 Nephrostomy 1115
Chapter 47: Appendix 1045 Suprapubic Cystostomy 1115
Surgical Anatomy 1045 Haematuria 1116
Acute Appendicitis 1046 Horseshoe Kidney 1116
Incidental Appendicectomy 1054 Cystic Diseases of the Kidney 1117
Appendicular Mass Duplication of Renal Pelvis and Ureter 1118
(Periappendicular Phlegmon) 1055 Retrocaval Ureter 1119
Appendicular Abscess 1056 Ureterocele 1119
Faecal Fistula After Appendicectomy 1056 Injuries to Kidney 1120
Mucocele of Appendix 1057 Renal Tuberculosis 1122
Neoplasms of the Appendix 1057 Hydronephrosis 1124
Laparoscopic Appendicectomy 1058 Pyonephrosis 1127
Chapter 48: Rectum and Anal Canal 1061 Carbuncle of Kidney (Renal Carbuncle) 1128
Surgical Anatomy of Rectum 1061 Perinephric Abscess 1128
Surgical Anatomy of Anal Canal 1062 Renal Calculus 1129
Per-rectal Examination 1064 Ureteric Calculi 1133
Proctoscopy (Kelly’s) 1064 Staghorn Calculus 1135
Sigmoidoscopy 1064 Benign Tumours of Kidney 1136
Colonoscopy 1065 Wilms’ Tumour (Nephroblastoma) 1136
Carcinoma Rectum 1065 Renal Cell Carcinoma 1137
Solitary Ulcer Syndrome 1071 B. Urinary Bladder 1143
Rectal Prolapse 1071 Anatomy 1143
Anorectal Malformations 1076 Ectopia Vesicae (Extrophy of the Bladder) 1144
Pilonidal Sinus/Disease Urachal Anomalies 1144
(Jeep Bottom; Driver’s Bottom) 1078 Vesical Calculus 1144
Piles/Haemorrhoids 1080 Cystitis 1146
Anal Fissure (Fissure-in-Ano) 1088 Recurrent Cystitis 1146
Anorectal Abscess 1090
Interstitial Cystitis (Hunner’s Ulcer, Elusive Ulcer) 1147
Fistula-in-Ano 1092
Schistosomiasis (Endemic Haematuria,
Anorectal Strictures 1096
Urinary Bilharziasis) (Swimmer’s Itch) 1147
Condyloma Acuminata 1097
Thimble or Systolic Bladder 1148
Anal Intraepithelial Neoplasia 1097
Bladder Tumours 1148
Malignant Tumours of Anal Area 1097
Transitional Cell Carcinoma 1148
Sacrococcygeal Teratoma 1099
Ureterosigmoidostomy 1151
Anal Incontinence 1099
Rupture Bladder (Bladder Injury) 1152
Descending Perineal Syndrome 1100
Residual Urine 1153
Proctitis 1100
Malakoplakia 1153
Proctalgia Fugax 1100
Neurogenic Bladder 1153
Hidradenitis Suppurativa of Anal Region 1100
Vesicoureteric Reflux 1154
Pruritus Ani 1101
Bladder Diverticula 1154
Gastrointestinal Haemorrhage (GI Bleed) 1101
Urinary Diversion 1155
Urinary Fistulas 1156
Section 3: Specialities and Other Surgeries C. Prostate 1158
Chapter 49: Urology 1107 Anatomy 1158
Acid Phosphatase 1158
A. Kidney 1107
Prostate Specific Antigen 1158
Anatomy of Kidney and Ureter 1107
Benign Prostatic Hyperplasia 1159
Plain X-ray—Kidney, Ureter and Bladder 1108
Prostatitis 1162
Intravenous Urogram 1109
Bladder Outlet Obstruction 1163
Retrograde Pyelography 1110
Carcinoma Prostate 1163
Renal Angiogram 1110
xxii Contents
D. Urethra 1167 Craniopharyngiomas 1224
SRB's MANUAL OF SURGERY
Anatomy 1167 Spinal Dysraphism Refer Online
Urethral Injury 1167 Myelocele; Syringomyelocele; Meningocele;
Stricture Urethra 1169
Spina Bifida Refer Online
Hypospadias 1171
Intervertebral Disc Prolapse Refer Online
Epispadias 1172
Posterior Urethral Valve 1172 Tuberculosis of Spine Refer Online
Urethral Calculi 1172 Spinal Tumours Refer Online
Urethritis 1173 Chapter 51: Thorax 1225
Extravasation of Urine 1173 Chest Injuries 1225
Retention of Urine 1174 Fracture Ribs 1228
E. Penis 1176 Flail Chest and Stove in Chest 1228
Phimosis 1177 Pneumothorax 1229
Paraphimosis 1177 Tension Pneumothorax 1229
Circumcision 1178 Haemothorax 1230
Balanoposthitis 1179 Pleural Tap 1230
Chordee (Cordee) 1179 Bronchoscopy 1231
Priapism 1179 Empyema Thoracis 1231
Peyronie’s Disease (Induratio Penis Plastica) 1180 Empyema Necessitans 1232
Ram’s Horn Penis 1180 Lung Abscess 1233
Carcinoma Penis 1180 Intercostal Tube Drainage 1234
Buschke-Löwenstein Tumour 1185 Shock Lung (Stiff Lung) 1236
F. Scrotum 1186 Pulmonary Embolism 1236
Anatomy 1186 Surgical Emphysema 1236
Fournier’s Gangrene 1186 Lung Cysts 1237
Hydrocele 1187 Mediastinal Tumours 1238
Haematocele 1191 Thymomas 1239
Pyocele 1192 Lung Cancers 1240
Cyst of Epididymis 1193 Pancoast Tumours (Superior Sulcus Tumour) 1240
Spermatocele 1193 Chest Wall Tumours 1241
Varicocele 1193 Pericarditis 1241
Pericardial Tap 1242
G. Testis 1196
Cardiac (Pericardial) Tamponade 1242
Anatomy 1196
Diaphragmatic Hernia 1242
Undescended Testis 1197
Pulmonary Complications During Postoperative Period 1245
Ectopic Testis 1199
Surgical Management of Pulmonary Tuberculosis 1245
Retractile Testis 1199
Video-Assisted Thoracoscopic Surgery 1246
Torsion of the Testis 1200
Testicular Tumours 1201 Cardiac Surgery Refer Online
Paratesticular Tumours 1207 Chapter 52: Adjuvant Therapy 1248
Orchitis 1207 Radiotherapy 1248
Epididymitis 1208 Chemotherapy 1250
Chapter 50: Neurosurgery 1209 Cell Cycle 1250
Head Injuries 1209 Antimalignancy Drugs 1252
Extradural Haematoma 1214 Hormone Therapy in Cancer 1252
Subdural Haematoma 1215 Immunosuppression 1252
Subarachnoid Haemorrhage 1216 Immunotherapy 1253
Fracture Skull 1217 Hybridoma 1253
Depressed Skull Fracture 1217 Gene Therapy 1253
CSF Rhinorrhoea 1218 Chapter 53: Anaesthesia 1254
Hydrocephalus 1218 Preoperative Assessment 1254
Intracranial Abscess 1219 General Anaesthesia 1255
Intracranial Aneurysms 1220 Regional Anaesthesia 1258
Intracranial Tumours 1220 Spinal Anaesthesia 1258
Pituitary Tumours 1223 Epidural Anaesthesia 1259
Contents xxiii
Chapter 54: Advanced Imaging Methods 1260 Kehr’s ‘T’ Tube 1276
SRB's MANUAL OF SURGERY
Ultrasound 1260 Proctoscope 1276
Doppler 1262 Flatus Tube 1276
CT Scan 1262 Suture Materials 1277
Magnetic Resonance Imaging 1264 Classification I 1277
Radionuclide Imaging 1265 Classification II 1277
Positron-Emission Tomography Scan 1266 Classification III 1277
Narrow Band Imaging 1266 Classification IV 1277
Chapter 55: Operative Surgery 1267 Classification V 1278
A. Sterilisation and Instruments 1267 Diathermy (Electrocautery) 1278
Sterilisation 1267 B. Operative Procedure 1280
Different Methods of Disinfection/Sterilisation 1268 Abdominal Incisions 1280
Instruments 1269 Vasectomy 1280
Cheatle’s Forceps 1269 Circumcision 1281
Sponge Holding Forceps (Rampley’s) 1269 Hydrocele 1281
Mayo’s Towel Clip 1270 Inguinal Hernia 1281
Artery Forceps (Haemostat) 1270 Appendicectomy 1281
Right Angle Forceps 1270 Thyroidectomy 1281
Kocher’s Forceps 1270 Tracheostomy 1281
Allis’ Tissue Holding Forceps 1270 Cryosurgery 1283
Babcock’s Forceps 1271 Lasers in Surgery 1283
Lane’s Tissue Holding Forceps 1271 Staplers in Surgery 1284
Morant-Baker’s Appendix Holding Forceps 1271 Nasojejunal Tube Feeding 1284
Volkmann’s Retractor 1271 Gossypiboma (Gossypiboma—Cotton Based in Latin) 1285
Langenbeck’s Retractor 1271 Laparoscopic Surgery 1285
Czerny’s Retractor (Hernia Retractor) 1271 Advantages of Laparoscopic Surgery 1285
Morris Retractor 1272 Laparoscopic Cholecystectomy 1286
Deaver’s Retractor 1272 Laparoscopic Appendicectomy 1286
Doyen’s Retractor 1272 Advanced Laparoscopic Surgeries 1286
Self-retaining Retractor 1272 Diagnostic Laparoscopy 1286
Single Hook Retractor 1272 Retroperitoneoscopy 1287
Plain Non-toothed Dissecting Forceps 1272 Natural Orifice Transluminal Endoscopic Surgery 1287
Toothed Dissecting Forceps 1272 C. Dressings and Bandages 1289
Surgical Needles 1272 Dressings 1289
Needle Holder 1273 Bandages 1289
Joll’s Thyroid Retractor 1273
D. Day-Care Surgery 1290
Moynihan’s Occlusion Clamp 1273
Day-Care Surgery 1290
Payr’s Crushing Clamp (Gastric) 1273
Surgical Audit 1291
Desjardin’s Choledocholithotomy Forceps 1274
Surgeon and Law 1292
Bake’s Dilator 1274
Sinus Forceps (Lister’s) 1274 Chapter 56: Miscellaneous 1293
Scissors 1274 A. Fascinating Signs in Surgery 1293
Volkmann’s Scoop 1274 B. Triads in Surgery 1303
Tracheostomy Tube 1274
C. Misnomers in Surgery 1304
Drains 1274
Foley’s Catheter 1275 D. Triangles in Surgery 1305
Malecot’s Catheter 1275 Further Reading 1307
Simple Red Rubber Catheter 1275 Appendix 1309
Lister’s Urethral Dilator 1275
Index 1311
Ryle’s Tube 1275
Infant Feeding Tube 1276
CHAPTER
55 Operative Surgery
S
ER
Bearing in mind that it is from the vitality of the atmospheric particles that all the mischief arises, it appears that all that is requisite is
to dress the wound with some material capable of killing these septic germs, provided that any substance can be found reliable for this
purpose, yet not too potent as a caustic.
—Joseph Lister, 1867
TH
COMPETENCY
SU14.1 : Describe aseptic techniques, sterilization and disinfection.
SU14.2 : Describe surgical approaches, incisions and the use of appropriate instruments in surgery in general.
SU14.3 : Describe the materials and methods used for surgical wound closure and anastomosis (sutures, knots and needles).
SU14.4 : Demonstrate the techniques of asepsis and suturing in a simulated environment.
SU16.1
SU10.3
SU10.4
AN44.7
:
:
:
:
O
Minimally invasive general surgery: Describe indications advantages and disadvantages of minimally invasive general surgery.
Observe common surgical procedures and assist in minor surgical procedures; observe emergency lifesaving surgical procedures.
Perform basic surgical skills such as first aid including suturing and minor surgical procedures in simulated environment.
Enumerate common abdominal incisions.
BR
SU11.4 : Enumerate the indications and principles of day-care general surgery.
SU7.1 : Describe the planning and conduct of surgical audit.
CHAPTER OUTLINE
A. Sterilisation and Instruments ) Thyroidectomy x Diagnostic Laparoscopy
EE
) Sterilisation ) Tracheostomy x Retroperitoneoscopy
) Instruments ) Cryosurgery x Natural Orifice Transluminal
) Suture Materials ) Lasers in Surgery Endoscopic Surgery
) Diathermy ) Staplers in Surgery C. Dressings and Bandages
B. Operative Procedure ) Nasojejunal Tube Feeding ) Dressings
) Abdominal Incisions ) Gossypiboma ) Bandages
) Vasectomy ) Laparoscopic Surgery D. Day-Care Surgery
YP
) Circumcision x Advantages of Laparoscopic Surgery ) Day-Care Surgery
) Hydrocele x Laparoscopic Cholecystectomy ) Surgical Audit
) Inguinal Hernia x Laparoscopic Appendicectomy ) Surgeon and Law
) Appendicectomy x Advanced Laparoscopic Surgeries
JA
A. Sterilisation and Instruments
STERILISATION Disinfection: It is killing of all bacteria, fungi and viruses
but not spores.
Antisepsis: It is inhibition of growth of microorganisms.
Sterilisation: It is freeing an article by removing or killing
Asepsis: Asepsis means—organisms are prevented to
all bacteria, spores, fungi and viruses.
access the patient or individual.
Treat the patient as a whole, “Half a sheep is mutton”.
1268 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
underpressure for 20 minutes. Green coloured strip turns
DIFFERENT METHODS OF DISINFECTION/ to black if autoclave is complete (signaloc). Surgical gloves,
STERILISATION linen, cotton, dressings, surgical instruments are sterilised
by this method. Sharp and plastic instruments cannot be
Physical Agents sterilised by this method. Bacillus thermophilus spores
Burning or incineration is used to disinfect contaminated are used to assess the completeness of the sterilisation in
articles like dressings. mass scale. Double autoclaving is done for instruments of
Hot-air oven: Here temperature used is 160 to 180 degree orthopaedic or ophthalmic surgeries (Figs. 55.1 and 55.2).
for one hour. The Bowie-Dick method is also used to check the
S
Boiling: It kills bacteria but not spores and viruses. completeness of sterilisation.
Temperature is between 90 to 99 degree. It is used to Radiation: Ionising type of radiation: Atomic gamma
disinfect syringes, utensils. It is not useful for gloves, rubber radiation is used as commercial method to sterilise suture
ER
materials. materials, disposable materials in packets. It is viable, safe
Autoclave: It is steam under pressure. Temperature attained and cheaper.
is between 120–135 degree. It is sterilised for 20 minutes with Non-ionizing radiation either infrared radiation or ultraviolet
15 pounds/sq. inch pressure. It kills all organisms including radiation is used to reduce the bacteria in air, water. Bacteria
spores. Completeness of sterilisation is confirmed by using and virus are vulnerable to ultraviolet rays below 3000Å.
specific gelatin protein which precipitates only in steam Exposure to eyes and skin can cause burn injury.
TH
Methods of sterilisation
Materials Method of sterilisation
All theatre appliances Autoclave
Sharp instruments (scissors, needles, blades), plastic materials
Endoscopes
OGlutaraldehyde 2%, lysol
Glutaraldehyde
BR
Rubber equipments Glutaraldehyde
Syringes Autoclave, hot air oven, gamma radiation
Heart-lung machine Ethylene oxide
Disposable articles Gamma radiation
Operation theatre and rooms Ideally by ultraviolet radiation or by formaldehyde
EE
Sera and biological materials Filtration
Laboratory glassware Hot-air oven
Ward, sick room, furniture Formaldehyde, iodophor spray, glutaraldehyde
Clothes, bed sheets especially for burns patients Autoclaving
Soiled dressings, materials, animal carcasses Incineration, lysol, iodophors
YP
Excreta Lysol, iodophors
Cleaning of skin before surgery Iodophors 2%, savlon, spirit
For cleaning infected wounds Iodophors, acriflavine, savlon, H2O2
To remove slough from the wounds EUSOL, H2O2
JA
Before injection Spirit is used to clean the skin
Cleaning the ward Phenol, cresol, lysol
Hand wash Chloroxylenol, savlon, spirit, iodophors
Bladder wash 0.1% potassium permanganate solution (Condy’s lotion), solution of acetic
acid and silver nitrate
Water Chlorination, potassium permanganate
Fruits, vegetables Potassium permanganate
Anger is a short madness which often creates life-long tragedy.
CHAPTER 55: Operative Surgery 1269
humidity of 80–90%. It is commonly used to fumigate the
SRB's MANUAL OF SURGERY
room. 500 mL of formalin with one litre of water is boiled
to get formaldehyde vapour. Formaldehyde vapour can be
created by adding potassium permanganate to the same
solution. Room is kept closed for 12 hours.
Glutaraldehyde (cidex 2%): It is used to sterilise sharp
instruments. Instrument should be dipped for 10 hours
to achieve complete sterilisation. It is potent bactericide,
sporicide, fungicide and viricide.
S
Hydrogen peroxide (H2O2): It is used as topical oxygen
therapy. Because of its effervescence and release of nascent
oxygen it removes the tissue debris. It is used to clean
ER
Fig. 55.1: Autoclave machine for sterilisation. wounds, cavities, ulcers, as mouth wash and as ear drops
to clear earwax.
Acriflavine and proflavine are orange-red coloured dyes
used as antiseptics. It is effective against Gram-positive and
few Gram-negative organisms. It retains its activity in pus
and body fluids.
TH
Fig. 55.2: Signaloc used for confirmation of completion
Chemical Agents
of proper sterilisation.
O
BR
Phenol: It is used as standard to compare the efficacy of
other agents.
Cresol is more powerful and nontoxic. 5% solution is used.
Lysol is emulsified cresol with soap. 2% solution is effective. A B
Chlorhexidine (hibitane) is useful antiseptic. Figs. 55.3A and B: Operation theatre mop rack to keep ‘used mops’
Hexachlorophane: It is not used in infants and children during surgery after use.
because it can get absorbed through intact skin in this age
EE
group causing severe neurotoxicity. INSTRUMENTS
Dettol (chloroxylenol) 5% solution is used.
Cetrimide is cationic surfactant (cetavlon) 2% solution is
CHEATLE’S FORCEPS
used.
Savlon is combination of cetrimide and hibitane. It is very It is used to pick sterilised articles like instruments and
YP
commonly used antiseptic in operation theatres, wards. drapes so that touching of the instruments is avoided while
transferring them. It is kept dipped in antiseptic solutions. It
Halogens does not have lock.
Bleaching powder.
Sodium hypochlorite.
EUSOL: Edinburg University Solution contains sodium
JA
hypochlorite, boric acid and calcium hydroxide.
EUSOL bath is dipping the ulcer bearing part in dilute
EUSOL solution for 30 minutes 2–3 times a day.
Iodine
Iodophors: These are antiseptics and also sporicidals. They Fig. 55.4: Cheatle’s forceps.
are non-irritant and do not stain skin. Povidone-iodine is
a good example which is commonly used.
Alcohols: Ethyl or isopropyl alcohols are used.
SPONGE HOLDING FORCEPS (RAMPLEY’S)
Formaldehyde: It is useful to disinfect the rooms like It has got fenestrated, serrated, flat distal end. It is used to
operation theatre. It is effective at a high temperature and clean the operative field, to swab the cavities, to mop the
Surgery is easy to watch, difficult to do.
1270 SECTION 3: Specialities and Other Surgeries
Features of Artery Forceps
SRB's MANUAL OF SURGERY
oozing area, to hold gallbladder and cervix during surgeries,
for blunt dissections, as ovum forceps.
Distal blades have transverse serrations which are well-
apposed. Lock in the proximal part.
Uses
x To catch bleeding points
Fig. 55.5: Sponge holding forceps. x To open the fascial planes in different surgeries
S
x To pass a ligature
To hold fascia, peritoneum, aponeurosis
MAYO’S TOWEL CLIP x
x To hold sutures
ER
It is used to fix drapes in operative field. x To drain an abscess like a sinus forceps
It is used to fix suction tubes, diathermy wires, laparoscopic x To hold gauze as peanut
cables in operative table.
It is used to fix ribs in flail chest.
RIGHT ANGLE FORCEPS
It is used to dissect pedicles and to pass ligatures.
TH
Fig. 55.6: Mayo‘s towel clip.
O Fig. 55.8: Right angle forceps.
BR
ARTERY FORCEPS (HAEMOSTAT)
Types KOCHER’S FORCEPS
Based on size: It has got serrations in the distal blades and apposing tooth
a. Small or mosquito artery forceps. in the tip.
b. Medium-sized artery forceps. It is used to hold pedicles, tough structures, cut ends of
c. Large artery forceps. the muscles.
EE
Based on shape: It is used to hold gauze for blunt dissection, to hold resected
a. Straight artery forceps. bowel, to hold ribs during rib resection.
b. Curved artery forceps.
YP
A
JA
B Fig. 55.9: Kocher’s forceps.
ALLIS’ TISSUE HOLDING FORCEPS
Here distal blades are not apposing each other.
Tip has got teeth in each blade which are apposing.
C
It has got a lock on the proximal part.
Figs. 55.7A to C: Artery forceps: (A) Straight; (B) Curved; It is used to hold skin flaps, fasciae, aponeurosis, bladder
(C) Mosquito. wall.
Surgery is always second best; if you can do something else, its’ better.—John Kirklin
CHAPTER 55: Operative Surgery 1271
SRB's MANUAL OF SURGERY
MORANT-BAKER’S APPENDIX HOLDING FORCEPS
It is like Lane’s forceps but with apposing serrations
proximal to the tooth. These serrations give a good grip in
mesoappendix while holding appendix in appendicectomy.
Its use is replaced by Babcock’s forceps.
S
Fig. 55.10: Allis’ tissue holding forceps.
ER
BABCOCK’S FORCEPS
Its distal part of distal blades are curved with a triangular
fenestra in it which allow soft tissues to bulge out. Tip is
non-traumatic with transverse serrations on it. It has got a Fig. 55.13: Morant-Baker’s appendix holding forceps.
lock in the proximal part.
TH
VOLKMANN’S RETRACTOR
It is used to retract fasciae in soles and palms.
O Fig. 55.14: Volkmann’s retractor.
BR
Fig. 55.11: Babcock’s forceps.
Retractors
It is used to hold any part of the bowel, fallopian tubes, x Superficial retractors
x Deep retractors
appendix, ureter, cord, etc.
x Self-retaining retractors
LANE’S TISSUE HOLDING FORCEPS
EE
It has got thick, stout distal blades with oval fenestra in LANGENBECK’S RETRACTOR
each blade. It has got a long handle and a small solid blade. It is used in
It has got apposing tooth in the tip. hernia surgery or any superficial surgeries to retract skin,
It has got a lock in the proximal part. fasciae and aponeurosis, etc.
YP
JA
Fig. 55.15: Langenbeck’s retractor.
CZERNY’S RETRACTOR (HERNIA RETRACTOR)
Fig. 55.12: Lane’s tissue holding forceps. This retractor has got thick, small blade on one side and
It is used to hold bulky and tough structures, to hold lymph biflanged hook on the other side in opposite directions. It is
nodes. used in surgeries like hernia, laparotomy especially during
It is also used as towel clip, as sponge holding forceps. closure.
The postoperative treatment is as essential as the operation and the surgeon is as much responsible for the postoperative
treatment as for the operation.— Roscoe C Giles
1272 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
Fig. 55.16: Czerny’s retractor.
S
MORRIS RETRACTOR
ER
It may be single blade type or double blade type.
It is used to retract abdominal wall. Fig. 55.20: Self-retaining retractor.
SINGLE HOOK RETRACTOR
It is used to retract skin.
TH
Fig. 55.17: Morris retractor. Fig. 55.21: Single hook retractor.
O PLAIN NON-TOOTHED DISSECTING FORCEPS
DEAVER’S RETRACTOR It is used to hold delicate structures like peritoneum, vessels,
bowel, nerves, tendons.
BR
TOOTHED DISSECTING FORCEPS
It is used to hold skin and tough structures.
A
Fig. 55.18: Deaver’s retractor.
EE
It is a retractor with a broad, gently curved blade.
It is used to retract liver, spleen and other abdominal
viscera.
It is atraumatic and gives adequate exposure of the surgical B
field.
YP
DOYEN’S RETRACTOR C
Figs. 55.22A to C: Dissecting forceps: (A) Non-toothed;
It is used in pelvic surgeries.
(B and C) Toothed.
SURGICAL NEEDLES
JA
Types
Fig. 55.19: Doyen’s retractor. Based on the edge
x Round body needle
x Cutting needle
SELF-RETAINING RETRACTOR x Reverse cutting needle
x Taper cut needle
It has got different adjustable blades so as to retract abdominal
x Side-to-side flat—Hagedron needle
wall and tissues during surgery (Balfour’s retractor).
Surgery is an art of learning not only when to cut but also when not to cut.
CHAPTER 55: Operative Surgery 1273
2/3rd and distal 1/3rd. Needle holder should be held
SRB's MANUAL OF SURGERY
between thumb and ring finger.
Based on curvature
x Straight needle JOLL’S THYROID RETRACTOR
x Curved needle. Half circle; 5/8 circle, etc.
It is a self-retaining retractor specifically used for thyroid
surgeries.
Based on Existence of the Eye
Atraumatic needle is eyeless. Here suture material is
attached to the needle by swaging. Size of the suture
S
material and that of needle is same and so tissue trauma is
less. Needle once used is disposed of (not reusable).
Traumatic needle: It is eyed needle. Needle in the eye area
ER
is wider than the body of the needle and so tissue trauma
is more. These needles are reusable.
Fig. 55.25: Joll’s thyroid retractor.
TH
MOYNIHAN’S OCCLUSION CLAMP
It has got long distal blades with longitudinal serrations.
It may be straight or curved.
It is non-traumatic, non-crushing type.
O It occludes lumen of the bowel/stomach and so prevents
spillage of the content of the bowel.
It also occludes the vessels in the wall of the bowel and so
prevents bleeding during surgery.
BR
It is used during anastomosis of the stomach and other
parts of the bowel.
Fig. 55.23: Needles.
Round-body needles are used in soft structures like perito
neum, muscle, vessel, nerves, tendons, bowel, soft tissues.
EE
Cutting needles are used to suture skin, aponeurosis and
tough structures.
Reverse cutting needle is used to suture mucoperiosteum.
Fig. 55.26: Moynihan’s occlusion clamp.
NEEDLE HOLDER
PAYR’S CRUSHING CLAMP (GASTRIC)
YP
Smaller distal blades with criss-cross serrations often with
a groove in the middle are the features of a needle holder. It is stout and heavy instrument with double lever in the
handle.
JA
Fig. 55.27: Payr’s crushing clamp.
It crushes the bowel once applied. So before applying it,
Fig. 55.24: Needle holder.
line of resection of stomach/bowel should be assessed
It may be straight or curved. It may be available with properly. It is applied to the part which is removed. Viability
different sizes. While holding a needle in a needle holder of the bowel is lost once it is applied.
one should get a good control and good grip. This is It is used in gastrectomy and resection and anastomosis
achieved by placing the needle at the junction of proximal of the bowel.
Surgery is an irreversible repair but often it can be irreversible damage also !!!
1274 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
DESJARDIN’S CHOLEDOCHOLITHOTOMY FORCEPS VOLKMANN’S SCOOP
It has got long distal blades with smooth serrations and To scoop cavities, ulcer bed, granulation tissues.
fenestra in the tip. It does not have lock and so accidental On either side different sized scoops are present.
damage of CBD mucosa or crushing of the CBD stone are
avoided.
Fig. 55.32: Volkmann’s scoop.
S
TRACHEOSTOMY TUBE
ER
Refer Chapter 55B, page 1281.
Fig. 55.28: Desjardin’s choledocholithotomy forceps.
It is used for choledocholithotomy (removal of CBD stones). DRAINS
A drain is a created channel which allows any fluid collected,
BAKE’S DILATOR to come out after closure of the main wound.
TH
It is long malleable metallic instrument with club at the
terminal end. Types
It is used to assess the CBD, duodenal papilla for patency Corrugated rubber drain: It drains by capillary action and
or block. gravity. It is cheaper and technically easier. But it allows
soakage of dressings and causes discomfort to the patient.
Tube drains
Fig. 55.29: Bake’s dilator.
SINUS FORCEPS (LISTER’s)
O • Malecot catheter can be used as a tube drain.
• Penrose soft latex rubber tube.
• Multiple perforated tubes.
BR
It has got straight, long blades with serrations in the tip. It
does not have a lock.
It is used to drain pus from abscess cavity (Hilton’s
method). It is called as sinus forceps because it was initially
originated to pack the sinus cavities. It is less traumatic. A
Sinus forceps has no lock; no serrations; broad tip; blunt.
EE
C
Figs. 55.33A to C: Drains: (A) Corrugated rubber drains; (B) Multiple
perforated drains; (C) Tube drain.
YP
Fig. 55.30: Lister’s sinus forceps. Advantages of tube drains
x Quantity of fluid like bile, pus can be measured
SCISSORS x It can be kept for longer time
JA
x Skin excoriation will not occur
x Patient remains more comfortable
x Infection rate is less; removal is easier
x Dye can be injected and cavity or communication can be assessed
using ‘C-arm’
Closed suction tube drain system.
Glove drain.
Wick drain is a gauze drain to drain pus, discharge, etc.
Sump drain: This is a type of drain where parallel air vent
prevents the adjacent soft tissues from being sucked into
Fig. 55.31: Scissors. the drain when negative pressure is applied.
A surgeon should have a heart of lion, eyes of a hawk and hands of a woman.—John Halle
CHAPTER 55: Operative Surgery 1275
Sump suction drain: Here negative suction with a parallel
SRB's MANUAL OF SURGERY
air-vent is used to prevent the adjacent soft tissues being
Advantages of sump drain sucked into the lumen of the drain.
x No drain blockade Under water seal drain to drain pleural space.
x Resists collapse of the structure when suction is applied.
Indications for drains
Uses of sump drain x In drainage of an abscess
S
x Collection of irritant discharges (enterocutaneous fistula) x In bleeding surgical conditions like trauma, peroperative bleed
x Collection of secretions having activated enzymes (high small x haemo-, pyo- or pneumothorax
bowel, pancreatic fistula) x In acute abdominal conditions like peritonitis, haemoperitoneum
ER
x Draining proximal stump in TEF with oesophageal atresia to prevent x In major abdominal surgeries like of pancreas, biliary tree,
aspiration stomach, etc.
x In thyroid surgery
x In hydrocele surgery
Problems in Drains
TH
Infection can occur through the drain.
Displacement.
It may not drain adequately and can give a false information.
It may interfere with healing process inside.
Presently keeping a drain itself is a questioned debate and
Fig. 55.34: Suction drain used in thyroid surgery.
O controversy all over.
Older dictum was ‘when in doubt keep a drain and the
surgeon can sleep happily’—is questioned at present.
BR
Drains if not used properly may be counterproductive.
FOLEY’S CATHETER
Refer Chapter 49A, page 1113.
MALECOT’S CATHETER
EE
Refer Chapter 49A, page 1114.
SIMPLE RED RUBBER CATHETER
Refer Chapter 49A, page 1114.
YP
LISTER’S URETHRAL DILATOR
Fig. 55.35: Romovac suction drain. Here suction is created by pressing
the suction corrugation. There is a sharp metallic introducer to pass Refer Chapter 49D, page 1170.
the tube into the required area after puncturing the skin. It is used for
thyroidectomy, mastectomy, radical dissection, wide excisions, flap
RYLE’S TUBE
JA
surgeries, etc.
It is one meter long and is made of red rubber or plastic.
Classification of Drain Systems It has got three lead shots in the tip which makes it
Open (static) drain: For example, corrugated drain, radiopaque. It also facilitates easy passage of the tube through
penrose drain. Infection rate is higher. the oesophagus.
Closed siphon drain: Here drain is connected to a sterile It has got markings at different levels:
bag with or without one-way valve. It reduces the infection. At 40 cm distance, at the level of gastro-oesophageal
Closed suction drain: Here negative pressure of—100 to junction.
500 mm Hg is used to create vacuum to drain the secretions. At 50 cm distance, at the level of body of the stomach.
Surgery is not just cutting, but it is an art; it is not only an art but also a merciful art.
1276 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
At 60 cm distance, at the level of the pylorus.
At 65 cm distance, at the level of the duodenum.
KEHR’S ‘T’ TUBE
It is used after opening common bile duct (CBD)
(choledochotomy). CBD is closed once ‘T’ tube is placed
in the CBD.
It is made up of latex or red rubber.
‘T’ tube has got horizontal part which is placed in the CBD
and vertical part which is allowed to come out, to drain bile.
Amount of bile draining daily is measured.
S
Before removal of the “T” tube, patency of CBD should be
confirmed.
It is done by following methods:
ER
The vertical limb is clamped (done in 12–14 days) and the
patient is observed for development of pain, fever and
jaundice in 24 hours. If normal, then one can presume that
there is no obstruction in the CBD.
Water soluble iodine dye is injected through the tube
to visualize biliary tree and free flow of dye into the
TH
Fig. 55.36: Ryle’s tube. duodenum. (postoperative ‘T’ tube cholangiogram). It
is done in 14 days which is the time required to develop
fibrous track. Once there is free flow, tube is removed and
Indications track gets closed on its own.
Diagnostic
x Hollander’s test for completion of vagotomy
x To diagnose tracheo-oesophageal fistula
x Baid test for pseudocyst of the pancreas
O
x For gastric function tests—to assess free acid and total acid
BR
Therapeutic
x In acute abdominal conditions like peritonitis/obstruction
x In abdominal trauma
x After abdominal surgeries
x In pyloric stenosis
x In upper gastrointestinal bleeding
x In paralytic ileus Fig. 55.38: Kehr’s ‘T’ tube.
x For feeding purpose in conditions like comatose patients,
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faciomaxillary injuries, major head and neck surgeries
PROCTOSCOPE
INFANT FEEDING TUBE Refer Chapter 48, page 1064.
There are no lead shots and markings on the tube.
It is used for feeding purpose in infants who is under coma, FLATUS TUBE
YP
with faciomaxillary injuries and anorexia.
JA
Fig. 55.39: Flatus tube.
It is made up of India rubber, 45 cm in length. There is one
Fig. 55.37: Infant feeding tube. opening in the tip and another on the side proximal to the
Remember, the most important person in an operation theatre is the patient. —Berkehy George Andrew Moynihan
CHAPTER 55: Operative Surgery 1277
tip. (Urinary catheter like red rubber catheter has no opening
SRB's MANUAL OF SURGERY
x In cholecystojejunostomy (CCJ), choledochojejunostomy (CDJ),
in the tip, only side opening is present). It is used in sigmoid pancreaticojejunostomy. Vicryl is used
volvulus to decompress and derotate; in paralytic ileus; in x In suturing muscle, fascia, peritoneum, subcutaneous tissue,
subacute intestinal obstruction. It is passed per anal into mucosa
the recto-sigmoid area. Proximal end is connected to water x In ligating pedicles. 1-zero chromic catgut or vicryl are used, e.g.
ligation of pedicles during hysterectomy
container to observe the quantity of air bubble which signifies
x In circumcision, usually 3-zero plain or chromic catgut are used
the amount of gas getting deflated.
Absorbable suture materials should not be used for
SUTURE MATERIALS suturing tendon, nerves, vessels (vascular anastomosis).
S
Non-absorbable Suture Materials
ER
Features of ideal suture material Silk is natural, multifilament, braided, non-absorbable
suture material derived from cocoon of silkworm larva.
x Adequate tensile strength x Easy handling property
It is black in colour. It is coated suture material to reduce
x Good knot holding property x Should have less memory
capillary action.
x Should be least reactive x Should be easily available and
cost effective Polypropylene (prolene) is synthetic, monofilam ent
suture material. It is blue in colour. It has got high memory.
TH
(memory of suture material is recoiling tendency after
removal from the packet. Ideally suture material should
CLASSIFICATION I have low memory.) (Prolene mesh used for hernioplasty
Absorbable Suture Materials is white in colour).
Plain catgut is derived from submucosa of jejunum of sheep. Polyethylene (ethylene) is synthetic monofilament
• It is yellowish white in colour. nonabsorbable suture material. It is black in colour.
• It is absorbed by inflammator y reaction and
phagocytosis—absorption time is 7 days.
• It is used for subcutaneous tissue, muscle, circumcision
O
Cotton is twisted multifilament natural nonabsorbable
suture material. It is white in colour.
Linen is derived from bark of cotton tree.
BR
in children. Steel, polyester, polyamide, nylon are other non
absorbable suture materials.
Chromic catgut is catgut with chromic acid salt.
• It is brown in colour.
• Its absorption time is 21 days.
• It is used for suturing muscle, fascia, external oblique Uses of non-absorbable suture materials
aponeurosis, ligating pedicles, etc. x In herniorrhaphy for repair
Vicryl (polyglactic acid): x For closure of abdomen after laparotomy
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x For vascular anastomosis (6-zero), nerve suturing, tendon suturing
• It is synthetic absorbable suture material. x For tension suturing in the abdomen
• It gets absorbed in 90 days. x For suturing the skincc
• Absorption is by hydrolysis.
• It is violet in colour (braided).
• It is multifilament and braided. CLASSIFICATION II
YP
• It is very good suture material for bowel anastomosis, Natural: Catgut silk, cotton, linen.
suturing muscles, closure of peritoneum. Synthetic: Vicryl, dexon, polydioxanone suture (PDS),
Dexon (polyglycolic acid) is synthetic absorbable suture maxon; polypropylene, polyethylene, polyester, polyamide.
material like vicryl. It is creamy yellow in colour (braided).
Maxon (polyglyconate) monofilament.
PDS (Poly Dioxanone Suture material) is absorbable suture CLASSIFICATION III
JA
material. It is creamy in colour with properties like vicryl. Braided: Polyester, polyamide, vicryl, dexon, silk.
It is costly but better suture material than vicryl. Twisted: Cotton, linen.
Monocryl (polyglecaprone) monofilament.
Biosyn (glycomer) monofilament.
CLASSIFICATION IV
Monofilament: Polypropylene, polyethylene, PDS, catgut,
steel.
Uses of absorbable suture materials
Multifilament: Polyester, polyamide, vicryl, dexon, silk,
x In bowel anastomosis like gastrojejunostomy, resection and
cotton.
anastomosis. Vicryl is used
Genius is one percent inspiration 99% perspiration.
1278 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
CLASSIFICATION V
Coated. Types of knots
Uncoated.
x Reef knot x Granny knot x Surgeon’s knot
Numbering of Suture Material
2-Thick. For 5-zero. For vascular anastomosis.
pedicle ligation.
1- 6-zero.
S
0-zero. 7-zero.
1-zero. 8-zero.
2-zero. For 9-zero. For ophthalmic surgery.
ER
bowel suturing. Requires operating microscope.
3-zero.
4-zero.
Fig. 55.42: Types of knots: (1) Reef knot; (2) Granny knot;
TH
(3) Surgeon’s knot.
DIATHERMY (ELECTROCAUTERY)
It is the method to control bleeding or to cut the tissues during
Fig. 55.40: Photograph showing different types of surgery.
suture materials (with pack). O Types
Based on type of current used:
BR
Unipolar cautery.
Types of suturing
Bipolar cautery. It is safer because its effect is seen only in
x Continuous x Subcuticular between electrode points. Adjacent tissues will never get
x Interrupted simple x Horizontal tension
damaged.
x Interrupted mattress x Vertical tension
Based on type of action:
Coagulation cautery which causes haemostasis by
tissue coagulation. Here temperature is 100 degree (blue
EE
switch).
Cutting cautery: Here temperature is 1,000 degree which
disintegrate the tissues. It is not haemostatic (yellow
switch).
Blended current is combination of both coagulation and
cutting.
YP
Differences Between Unipolar and Bipolar Cautery
Unipolar cautery Bipolar cautery
Can be used for both coagulation and Only for coagulation
cutting
JA
Conducting plate should be kept No need
Cannot be used in patient with Can be used
artificial valves
Should be careful about adjacent Adjacent tissues will never get
tissues damaged
Uses
For coagulation of bleeders during surgery to achieve
haemostasis.
To cut muscles, fascia, etc.
Fig. 55.41: Types of suturing.
So long as enthusiasm lasts, so long is life still with us.
CHAPTER 55: Operative Surgery 1279
It is essential for laparoscopic surgical procedures. Bipolar
SRB's MANUAL OF SURGERY
is commonly used.
It is used to remove small cutaneous lesions, to control
bleeding duodenal ulcer.
Disadvantages
Infection.
Cauterisation of normal tissues.
Problem of explosion.
S
Diathermy burn to the patient at the site where diathermy
plate is kept.
Burn injury or electrical shock to surgeon and assisting
ER
personnel.
Precautions
Proper earthing.
Avoid loose contact of electrodes. Fig. 55.43: Diathermy machine with plate, foot switch for use.
It should be kept off when not in use during procedure.
TH
O
BR
EE
YP
JA
Adjustment with right people is always better than argument with wrong people.
1280 SECTION 3: Specialities and Other Surgeries
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B. Operative Procedure
• Upper incisions are always better.
ABDOMINAL INCISIONS • Horizontal incisions are better.
Principles • Paramedian is better than midline.
Incision should be long enough for a good exposure.
Splitting the muscle is better than cutting, except rectus
muscle.
S
Avoid cutting nerves and vessels in the abdominal wall.
Retract muscle, abdominal organs towards the neuro-
vascular supply.
ER
Insert a drainage tube through a separate incision.
Transverse incisions are better than vertical incisions.
Close the wound layer by layer.
TH
Requirements
x Accessibility x Extensibility x Security
Factors affecting the strength of the scar
x Type of surgery (acute
abdomen, surgery for
malignancy, major surgery)
x
x
Cough
Ascites
Nutrition
O
BR
x
x Obesity x Diabetes
x Pregnancy x Immunosuppression
x Straining x Type of incision
Complications of Abdominal Incision Fig. 55.44: Different incisions in the abdomen.
Wound infection.
EE
Wound pain. VASECTOMY
Burst abdomen.
Incisional hernia. Indications
Fistula formation. Family planning (parents should have two healthy children,
Adhesion and its complication. consent should be obtained).
Different abdominal incisions are: After prostatectomy, vasectomy is done to prevent
YP
Upper midline. retrograde infection of testes.
Upper right paramedian.
Upper left paramedian. Procedure
Kocher’s incision (right subcostal). Types
Left subcostal.
Classical method—scalpel technique.
JA
Bucket handle.
No scalpel technique (Shunqiang Li, China).
Upper horizontal.
Thoracoabdominal.
Subumbilical.
Classical Method
Incision for lumbar sympathectomy. After cleaning and draping the scrotum, 2–5 mL of xylocaine
Lower midline. plain 1 % is injected into root of the scrotum on lateral aspect.
Lower right or left paramedian. Skin, dartos are incised (1–2 cm vertical incision). Once
Incisions for appendicectomy—McBurney’s, Rutherfold spermatic fascia is incised cord structures are identified.
Morrison’s, Lanz, laparoscopic. Vas deferens is seen and felt as thickened whitish cord like
Pfannenstiel incision. structure. It is dissected using mosquito artery forceps.
Lower horizontal. It is held using Babcock’s forceps as loop outside the
I’m still learning.—Michelangelo
CHAPTER 55: Operative Surgery 1281
wound. Vas is clamped in two different places with a gap Advice
SRB's MANUAL OF SURGERY
in between using two artery forceps. A piece of the vas
To avoid sexual contact or to use contraception for 3 months.
(5–10 mm) is excised. Cut ends are ligated using non-
absorbable sutures like silk. Skin is closed with sutures.
Procedure is repeated on the other side. Dressing is placed.
Sutures removed after 7 days. Complications
x Haematoma x Sperm granuloma
No Scalpel Technique x Haematocele x Recanalisation occurs rarely
Two special instruments are used here. An extracutaneous x Infection but dangerous
Pyocele
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ring clamp and Chongquing’s sharpened curved mosquito x
clamp. After cleaning and draping, xylocaine 2% of 2–3 mL
When there is hernia or hydrocele, vasectomy is done along
is injected under the skin of midline raphe proximal aspect.
with specific procedures for hernia or hydrocele.
ER
Vas deferens of one side is felt and pushed under the raphe.
No scalpel vasectomy, using specialised instrum ents
It is carefully held with extracutaneous ring clamp. Skin
is incised using sharp tip of the curved mosquito clamp. is becoming popular. Procedure does not require any
Whitish cord like vas which is held with ring clamp is suturing.
dissected → clamped → a small piece of 5 mm is cut. Cut
ends are ligated using silk. Opposite vas is also similarly CIRCUMCISION
TH
brought into the same wound by manipulation and clamped Refer Chapter 49E, page 1178.
and ligated after cutting. Skin is not closed. It gets apposed
automatically and heals on its own. Post-operatively HYDROCELE
antibiotics and analgesics are given. It is a single incision Refer Chapter 49F, page 1187.
procedure also.
O INGUINAL HERNIA
Refer Chapter 41, page 844.
APPENDICECTOMY
BR
Refer Chapter 47, page 1051, 1054.
THYROIDECTOMY
Refer Chapter 29, page 551.
TRACHEOSTOMY
EE
Types
Emergency tracheostomy.
Elective tracheostomy.
A
Tracheostomy Tube
YP
Fuller’s bivalved tracheostomy tube: It has got outer tube
and inner tube. Outer tube is biflanged and so insertion is
easier. Inner tube is longer with an opening on its posterior
aspect. Inner tube can be removed and re-inserted easily
whenever required.
Jackson’s tracheostomy tube: It has got outer tube, inner
JA
tube and an obturator.
Red rubber tracheostomy tube.
Polyvinylchloride tracheostomy tube.
Modern tracheostomy tubes are made of plastic. They
are soft, least irritant and disposable. They have inflatable
cuff which makes it easier to give assisted ventilation. Cuff
should be deflated at regular intervals to prevent tracheal
pressure necrosis. (For assisted ventilation endotracheal
B tube can be kept for 7 days. Beyond that period patient needs
Figs. 55.45A and B: No scalpel vasectomy instruments and technique. tracheostomy for further ventilation.)
To learn a language is to have one more window from which to look at the world.—Chinese Proverb
1282 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
S
ER
B
Figs. 55.46A and B: Tracheostomy tube: (A) Fuller’s; Fig. 55.49: Vertical midline or transverse incisions are used for tracheostomy.
(B) Jackson’s tracheostomy tube. Vertical midline extends from cricoid cartilage to sternal notch. It is used
both in emergency and elective tracheostomy and commonly used incision.
TH
It gives rapid access with less dissection but leads into poor scar. Transverse
incision can be used in elective tracheostomy. It is placed two finger
breadths above the sternal notch with a length of about 5 cm transversely.
It has got a better cosmetic scar.
OIndications for tracheostomy
x
x
In head, neck and facial injuries
Tetanus
BR
x Tracheomalacia after thyroidectomy
x Laryngeal oedema/spasm/surgeries
x Major head and neck surgeries like commando’s operation, block
dissection, etc.
x ICU ventilation after 7 days
Fig. 55.47: Tracheostomy tube with inflation part and syringe
(inflated with air). Technique of Tracheostomy
Neck of the patient is hyperextended by placing sand bags
EE
under the shoulder. Vertical (midline) or horizontal incision
is made. Deep fascia is opened. Strap muscles are retracted
laterally. Isthmus is divided or retracted below. 2nd and 3rd
tracheal rings are opened and circular opening is made.
Tracheostomy tube is placed. It is tied around the neck.
YP
Note:
Endotracheal tube can be kept in situ only for 7 days.
JA
Fig. 55.48: Figure showing the position of tracheostomy tube. Fig. 55.50: Advanced secondaries in neck with tracheostomy tube to
control respiratory stridor.
The man who does not read has no advantage over the man who cannot read.—Mark Twain
CHAPTER 55: Operative Surgery 1283
Tracheostomy Care used laser is being named like Nd YAG (Neo dymium Ytrium
SRB's MANUAL OF SURGERY
Aluminum Garnet Laser), CO2, Neon, Holmium, Erbium,
Regular suctioning of the tube.
etc.
Cleaning of tracheostomy tube.
Humidification of the inspired air.
Types Based on Generation of Power
1. Continuous wave laser: Generates continuous power for
Complications of tracheostomy longer duration; it is commonly used in medical field.
x Tracheal stenosis 2. Pulsed laser: Generates high power for short intervals in
x Bleeding pulses. Nd-YAG pulsed laser is used in ophthalmology;
S
x Aspiration
diode pulsed laser is used in varicose veins.
x Pneumothorax
x Surgical emphysema in the neck
ER
x Mediastinal emphysema Types, Based on Material Used
x Tracheostomy dependency
Solid state laser: Nd-YAG laser (infrared light of 1064
wavelength). Nd-YAG laser is invisible which is absorbed
CRYOSURGERY easily by tissues; requires a visible guiding beam like red
It is the destruction of tissues by controlled cooling. helium or neon beam; it penetrates tissues deeply for 5
System contains an automatic defrosting device with a mm; easily and effectively vaporizes tissues; it is used
TH
cryoprobe. in endoscopic procedures, LITT (light induced thermal
therapy).
Gas lasers: helium, neon, CO2 lasers are gas lasers. CO2
Gases used are: laser has got wavelength of 10.6 mm; it penetrates tissues
x Nitrous oxide—minus 98°C temperature. very poorly; it is absorbed rapidly by water in the tissues;
x
x
x
CO2—minus 60°C.
Liquid N2—minus 180°C.
Freon—minus 190°C.
O
Commonly nitrous oxide is used as it is easily available, cheaper and
it is invisible and needs helium or neon beam; it is used I
surface lesions of skin and for haemorrhoids.
Dye lasers: Rhodamine organic dye laser.
Semiconductor lasers: They are diode lasers use low power.
BR
achieves optimum temperature required for different procedures.
Excited dimer (excimer) lasers: Argon, krypton, xenon
Mode of action: It produces intracellular crystallisation, which are mixed with chlorine or fluorine creating dimer.
dehydration and denaturation of proteins and cell death; Argon laser has got two wavelengths 514 (green) and
and it causes the obliteration of microcirculation and so 488 (blue); it is absorbed by haemoglobin red pigment;
cell death. tissue vaporization is poor; has got limited penetration
Indications: To remove warts and lesions in the skin; and so useful for surface lasers in skin, eye; it is useful in
cryotherapy for piles; for chronic cervicitis. photodynamic therapy also.
EE
Advantages: Relatively bloodless and painless; adequate
control of extent and depth in freezing; equally effective.
Disadvantages: Infection; discharge from the site. Applications
x Focused heat beam of laser light is used to coagulate, excise,
LASERS IN SURGERY vaporize the tissues.
YP
x It is used to cut tissues, cauterize blood vessels, photocoagulation.
It is Light Amplification Stimulated Emission of Radiation. x Photodynamic or photoradiation therapy using dye or diode laser
Electrons in high energy status leave towards excited level after injecting photosensitizer photofrin intravenously.
from ground state and eventually return to ground state Uses in surgery
releasing its energy as photon particle of light. This laser light x In gastroenterology—piles; debulking luminal malignancies like
has got one specific wavelength and is monochromatic. Laser oesophagus, rectum; arrest gastrointestinal bleeding; to remove
small tumour or angiodysplasias.
JA
light is unidirectional with one specific colour and is coherent
x In urology—to remove superficial low grade bladder tumours.
with a tight, strong and concentrated beam.
x In eye—in retinopathy, laser photocoagulation, retinal
Power density and laser energy are two important detachment, in glaucoma. Lasik surgery is done for myopia
parameters. Power density is the measure in unit beam area; using microkeratome to reshape the cornea. It is laser- induced
it is Watts/cm2. Laser energy is power delivered/second. keratoplasty.
Molecules are placed in a compact area and power x In ENT—removal of small mucosal lesions
x In skin—argon or CO2 lasers are used. Used in removal of tattoos
is passed through this so as to activate the molecules.
(ruby laser, pulsed); excision of small lesions, haemangiomas.
Molecules get activated at different periods and move in x Vascular—laser angioplasty can be done.
different directions, which they hit each other releasing x In gynaecology—in endometrial ablation, in removing
energy; this energy is allowed to act through optical system precancerous lesion of cervix, adhesiolysis, fimbrioplasty.
to area wherever required. Depending on the molecules
The capacity to learn is a gift; the ability to learn is a skill; the willingness to learn is a choice.—Brian Herbert
1284 SECTION 3: Specialities and Other Surgeries
Advantages: It is bloodless, small incision, fast recovery. Parts: Stapler gun, and cartridge with two rows of stapler
SRB's MANUAL OF SURGERY
Complications: Damage to normal tissues, adjacent bowel, pins for apposition. Loaded cartridge is detachable. Cut
vessels; Problem to operating beam—injury to skin, eyes ends of bowel are placed over gun and cartridge. Once gun
causing corneal or retinal damage, cataract formation. is shot, cartridge moves to the gun and creates anastomosis.
Precautions GIA stapler (gastrointestinal anastomosis stapler) for
• All operating team staff should wear safety goggles. side to side anastomosis, like small bowel or ileocolic
• Drapes should be wet; dry materials should be used. anastomosis.
• Instruments ideally should be non-reflective (coated to Stapler for lung apposition.
avoid reflection). Endostaplers: These are used during laparoscopic
S
• Audible signals should be used. surgeries. It is commonly used for bowel anastomosis.
• Emergency shutter devices should be present. Endovascular staplers are used to ligate vascular
pedicles like renal pedicles during laparoscopic nephrec
ER
STAPLERS IN SURGERY tomy.
Stapled haemorrhoidopexy—costly.
Staplers are used for apposition of tissues. Used in skin, bowel, Disposable staplers are available but are costly.
lungs, etc. Advantages: Technically easier and faster.
Disadvantages: Cost factor, availability.
Types Problems with staplers:
TH
Cutaneous staplers give clean apposition. It is faster and It is not completely haemostatic and so bleeding can occur.
technically easier. Problem is removal requires specific Leak from anastomosis, improper apposition.
instrument and costlier than sutures. Intestinal obstruction.
NASOJEJUNAL TUBE FEEDING
O It is one of the methods of enteral nutrition. It is commonly
used in acute pancreatitis. It is also useful in other enteral
nutrition needs.
BR
A B
Figs. 55.51A and B: (A) Skin staplers; (B) Staplers removed instrument.
Linear staplers are used to close the bowel either
EE
completely or partially.
Circular staplers also called as EEA stapler—End to
End Anastomosis. It is commonly used for colorectal
anastomosis in anterior resection for carcinoma rectum,
oesophagogastric anastomosis after oesophagogastric
YP
resection in case of carcinoma at O-G junction.
Fig. 55.53: X-ray showing nasojejunal tube for enteral nutrition purpose.
It is useful and effective method of enteral nutrition. Its passage needs
expertise, C-arm guidance. It can be kept for long time for 3 months. Its
JA
position often to be confirmed by X-ray.
It is passed under C-arm guidance per nasally. It is passed
up to the first loop of the jejunum across the duodenal C
loop. It should be fixed properly to the nostril. Its position
should be confirmed by X-ray. One should take care not to
displace the tube.
Advantages are—it is safer, easier and can be kept for
3 months. Complications of long-term TPN are not there.
Disadvantages—irritation by tube, displacement,
Fig. 55.52: Circular stapler for colorectal anastomosis. aspiration.
If you’re the smartest person in the room, you’re in the wrong room.—Unknown
CHAPTER 55: Operative Surgery 1285
SRB's MANUAL OF SURGERY
GOSSYPIBOMA (Gossypiboma—Cotton Based in ADVANTAGES OF LAPAROSCOPIC SURGERY
Latin) Relatively less painful compared to open surgery. Trauma
By definition, it is the presence of cotton based foreign body
of access is very less.
Shorter hospital stay and early return to work.
that is in place of concealment following surgery.
Faster postoperative recovery.
Forgotten foreign bodies (mop, gauze, etc.) intraoperatively
Better visualisation of the anatomy, i.e., better approach
especially in abdominal cavity (can occur in any cavities
(thorax, pelvis) cause adhesions, provoke sepsis, often get for dissection and visualisation of other parts of abdomen
encapsulated. for any other pathology.
S
Instrumental access to different abdominal locations is
It may cause an inflammatory mass, bowel erosion/
perforation/peritonitis, intra-abdominal abscess, many times better compared to open method.
Minimal scar on the abdomen.
septicaemia, fistula formation.
ER
Presentations may be as—asymptomatic, pseudotumour,
abscess, septicaemia, fistula. Instruments Used
Often foreign body erodes and enters the bowel lumen and Zero degree laparoscope is commonly used. Side viewing
with peristalsis reaches ileocaecal valve causing intestinal scopes are also used to have better visualisation 30°.
obstruction. There are incidences patient has passed the Cold light source either halogen lamp or xenon lamp is
foreign body like mop per anally few months after surgery used. Halogen lamp is used commonly and is cheaper.
TH
(in 6% gossypiboma). Xenon lamp gives high visualisation.
Ultrasound, CT scan and MRI identifies the foreign body Camera: 3 chip camera is commonly used with high
(gossypiboma). Plain x-ray is of less value. resolution.
Incidende of gossypiboma is 1 in 3,000 surgeries. Migration Video-monitor to display images.
commonly occurs into intestine either small or large but CO2 insufflator.
can occur into urinary bladder or stomach.
instruments.
Commonest site is abdominal cavity 55%, vagina (20%),
O
70% of retained foreign bodies are sponges/mops; 30% are
Long fine dissectors like in open surgical techniques.
Hooks and spatulas are used along with cautery for
dissection.
Clip applicators.
BR
thorax (10%) and rest on other cavities. Needle holders.
Commonly gossypiboma present 3–12 weeks; rarely it can Endostaplers.
present as later as 5–7 years. Veress needle.
It is more commonly observed in emergency surgery, Suction-irrigation apparatus.
trauma, and surgery for malignancies. Trocars of different sizes—10 mm, 5 mm.
Treatment: Surgical exploration and extirpation of the Reducers to negotiate smaller instruments through larger
foreign body, antibiotics. ports.
EE
Legal problem: Gossypiboma amounts for criminal
negligence. Surgeon or team or hospital can be sewed for
negligence either in consumer court or criminal court.
LAPAROSCOPIC SURGERY
YP
History
First laparoscopic cholecystectomy was done by Muhe of
Germany in 1985 and by Mouret in Lyon in 1987.
McKeran and Saye performed the first laparoscopic
cholecystectomy in USA in 1988.
JA
First laparoscopic appendicectomy was done by Semm as
prophylaxis.
First laparoscopic appendicectomy for acute appendicitis
was done by Schreiber in 1987.
Semm changed 75% open gynaecological surgeries into A B
laparoscopic surgeries. Figs. 55.54A and B: Laparoscopic set showing trolley,
telescope and monitor instruments.
Professor TE Udwadia, Mumbai did first laparoscopic
cholecystectomy in India.
Never stop learning because life never stops teaching.—Unknown
1286 SECTION 3: Specialities and Other Surgeries
Preparation
SRB's MANUAL OF SURGERY
Gas emboli, though is rare but fatal.
Postoperative shoulder pain due to irritation of
Always general anaesthesia. Other preparations are same as
diaphragm.
for open method.
Cardiac dysfunction due to decreased venous return.
Injury to the abdominal wall vessels and nerves.
Technique
Cautery burn to abdominal structures.
Pressure bandages are applied to both legs to improve the Abdominal wall hernias.
venous return and to decrease the stasis. Wound infection.
Head end of the table is lowered to have easier insertion of Mortality—0.5%.
veress needle and scope.
S
Ryle’s tube and Foley’s catheter are essential before
Relative Contraindications
insertion of the trocars.
Patients with compromised cardiac status.
ER
Pneumoperitoneum is created using veress needle through
umbilical incision. Access can be achieved by open method Peritonitis.
through an umbilical incision. Previous abdominal surgeries.
Bleeding disorders.
Morbid obesity.
Third trimester pregnancy.
CO2 is commonly used to create pneumoperitoneum as:
Portal hypertension.
TH
x It is readily available x It has a high diffusion
It is cheaper coefficient
x
x It suppresses the combustion x It is quickly released via
Basic Laparoscopic Surgeries
x It is easily absorbed by tissues respiration Laparoscopic cholecystectomy.
Laparoscopic appendicectomy.
Other gases used are: Air, nitrous oxide, helium, argon.
Pneumoperitoneum is created up to a pressure of 15 mm
Hg which distends the abdominal cavity adequately to
have proper visualisation of the abdominal contents.
O
LAPAROSCOPIC CHOLECYSTECTOMY
Refer Chapter 35, page 747.
BR
Laparoscope is inserted through the umbilical port
(10 mm). Abdomen is evaluated for any pathology. Liver, LAPAROSCOPIC APPENDICECTOMY
gallbladder, pelvic organs are visualised.
Refer Chapter 47, page 1058.
Additional ports (3–4) through trocars are placed
depending on the procedure to be done. It may be either
5 mm port or 10 mm port. These ports are placed in such ADVANCED LAPAROSCOPIC SURGERIES
a way to have a proper triangulation of instruments for Presently most of the abdominal surgeries can be done
EE
dissection. through laparoscopy.
To use clip applicator 10 mm port is required. It requires advanced technology and skill. Surgeon should
be expert in doing intracorporeal and extrac orporeal
Physiologic Changes due to Pneumoperitoneum knotting.
CO2 causes hypercarbia, acidosis and hypoxia.
Pneumoperitoneum exerts pressure on the IVC, decreases Procedures
YP
the venous return and so the cardiac output. Laparoscopic hernia repair.
It increases the arterial pressure also. Laparoscopic splenectomy.
It compromises the respiratory function by compres Laparoscopic fundoplication.
sing over the diaphragm impairing the pulmonary Laparoscopic vagotomy and gastrojejunostomy.
compliance. Laparoscopic Nissen’s fundoplication.
JA
Laparoscopic colectomy.
Complications Laparoscopic hysterectomy. It is becoming very popular.
CO2 narcosis and hypoxia. Laparoscopic urologic surgeries.
Sepsis—subphrenic abscess, pelvic abscess, septicaemia. Laparoscopic paediatric surgeries.
IVC compression.
Bleeding. DIAGNOSTIC LAPAROSCOPY
Leak from the site, e.g., bile leak.
Organ injury during insertion of ports, e.g., major vessels, Indications
bowel, mesentery, liver. � Acute pelvic conditions; ovarian diseases.
Subcutaneous emphysema and pneumomediastinum. � Tubal pregnancy; infertility.
A reader lives a thousand lives before he dies. The man who never reads lives only one.—George RR Martin
CHAPTER 55: Operative Surgery 1287
Staging of the malignancy.
SRB's MANUAL OF SURGERY
Biopsy from the tumours.
In chronic pain abdomen where ultrasound, endoscopies,
barium studies are negative, then diagnostic laparoscopy
is useful.
Needle laparoscopy of 2 mm sized becoming popular
(especially for diagnostic purpose).
S
ER
Fig. 55.56: Port positions for retroperitoneoscopy.
Complications: Injury to vessels; Paralytic ileus; Bowel
(colon) injury.
Advantage: Complications of pneumoperitoneum is not
TH
present and so respiratory reserve is well-maintained.
A
NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC
SURGERY (NOTES)
O It is an experimental surgical technique whereby “scar less”
abdominal operations can be performed with an endoscope
passed through a natural orifice (mouth, urethra, anus, etc.)
BR
then through an internal incision in the stomach, vagina,
bladder or colorectum, thus avoiding any external incisions
or scars.
This technique has been used for diagnostic and therapeutic
procedures in animal models, including transgastric
B (through the stomach) organ removal. The transvesical and
Figs. 55.55A and B: Diagnostic laparoscopy showing ectopic pregnancy the transcolonic approaches are also used. Transgastric
EE
in right fallopian tube. It is removed by salpingectomy through laparoscopy. and transvesical combined approach is also used to
increase the feasibility of moderately complex procedures
Advantages: Laparotomy is avoided and once diagnosis is such as cholecystectomy.
made, therapeutic procedure also can be carried out in the NOTES was originally described in animals by researchers
same sitting. at Johns Hopkins University (Dr Anthony Kalloo et al.),
and was recently used for transgastric appendectomy in
YP
humans in India (by Dr GV Rao and Dr N Reddy).
RETROPERITONEOSCOPY
On June 25, 2007, Swanstrom and colleagues reported the
It is becoming popular in urology to assess kidney, ureter, first human transgastric cholecystectomy. In late 2008,
adrenals for various urologic procedures. surgeons from Johns Hopkins School of Medicine removed
Through a small loin approach, retroperitoneum is a healthy kidney from a woman donor using NOTES. The
expanded by inflating balloon in the space. Once space is
JA
surgery was called transvaginal donor kidney extraction.
created, different ports are placed to do dissections. The transvaginal access to NOTES seems to be the safest
and feasible. In 2007, the NOTES Research Group in Rio de
Janeiro, Brazil, lead by Dr Ricardo Zorron, performed the
Procedures done through retroperitoneoscopy are: first series of transvaginal NOTES cholecystectomy in four
x Nephrectomy x Ureterolithotomy patients. With fewer potential complications, the procedure
x Pyeloplasty x Retroperitoneal lymph has a disadvantage of being possible only in women.
x Adrenalectomy node dissection (RPLND)
Proponents and researchers in this field recognize the
x Pyelolithotomy
potential of this technique to revolutionize the field of
Life’s like a movie, write your own ending. Keep believing, keep pretending.—Jim Henson
1288 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
minimally invasive surgery by eliminating abdominal which is essential for proper surgical dissection. Poor
incisions. NOTES could be the next major paradigm shift in manoeuverability is the problem. Sepsis through this
surgery, just as laparoscopy was the major paradigm shift potentially infected area into sterile peritoneal cavity
during the 1980s and 1990s. is a real risk. After procedure non closure of the port
Advantages are—lower anaesthesia requirements; site opening in these approach sites or if closing their
faster recovery and shorter hospital stays; avoidance of inadequacy are the real risk in NOTES.
the potential complications of transabdominal wound The general impression is that NOTES will be accepted as
infections (e.g., hernias); less immunosuppression; better the newest frontier in minimally invasive surgery. As of
postoperative pulmonary and diaphragmatic function; and today non-Bariatric minimally invasive surgery fellowships
S
the potential for “scar less” abdominal surgery. offer the best opportunity to train in this new approach.
Disadvantages are—it is single port surgery and difficulty
in visualisation of the area in need from all directions
ER
TH
O
BR
EE
YP
JA
A meaningful silence is always better than meaningful words.
CHAPTER 55: Operative Surgery 1289
C. Dressings and Bandages
SRB's MANUAL OF SURGERY
– Reverse spiral turn: Here each spiral turn is reversed
DRESSINGS in opposite direction so as to attain uniform pressure.
They are the materials used to cover wounds, ulcers to provide It is used in limbs and areas which end as cones.
support and to encourage healing. – Figure eight turn: It is used in knee, elbow, wrist,
Depending on the condition and amount of discharge from ankle and for clavicle.
the wound/ulcer it is changed as required—twice a day/once – Recurrent turn: It is used in head, amputation stump.
S
a day/once in two days. Small dressings are done without Here initially circular rolls are made and over that
anaesthesia. Large areas like burn wounds or dressing in half turns are made to cover other parts of the area
children require general anaesthesia. required.
ER
Advantages: It covers the wound and so prevents further – Spica bandage: It has got ascending and descending
contamination and gives comfort to the patient. turns, with each turn overlap and cross each other.
Disadvantages: It may get soaked and may delay the It is used in hip, groin, shoulder, breast or thumb.
epithelial layer formation. Spica means eye of a bean.
Types: b. ‘T’ bandages: It is used in perineum and groin.
• Dry dressings: It is used in clean, sutured operated c. Tailed bandages: It may be four tailed bandages or many
TH
wound. It is not changed at regular intervals tailed bandages. It is used to support dressings on a wide
• Wet dressings: It is used in ulcers and wounds. Dressings area like in burns dressing, over abdomen or chest wall.
are made wet by using jelly or sofra tulle sheets. d. Tubular bandages: These are stockings which are
Components of dressing unrolled over the limb to give pressure effects. It is used
• Inner contact layer. It is non-absorbent and only allows in lymphoedema, varicose veins and in the postoperative
secretion to pass into the absorbent layer. It does not period following surgeries of the limb (Tubifix, Tubipress).
wet. Either mesh gauze or sofra tulle is used.
• Intermediate absorbent layer made up of cotton which
O
allow penetration of granulation tissue. It is usually kept e. Triangular bandage: These are used for supporting the
elbow or forearm. Here a wide gauze is used to cover the
arm, forearm and elbow, which again winds around the
BR
absorbs the secretions. neck.
• Outer layer as supportive is made up of gauze. f. Cravat bandages: It is a folded type of triangular bandage,
Dressings are fixed to the place by: Bandages; plasters; which is used as sling around the neck, when elbow
Dynoplast; crepe bandages. requires to be rested.
BANDAGES Principles of Bandaging
Technique of bandaging is called as dysmergia. Bandage is applied to the part from distal to proximal end.
EE
Proper positioning of the limb is a must before bandaging.
After initial few circular turns, the required type of
Indications bandaging is then done.
Bandage is unrolled outwards.
x To reduce the swelling like in x To support splints
During bandaging, latter turn should overlap 2/3rd of
lymphoedema x To stop bleeding/oozing
YP
x To keep dressings in position earlier turn.
Firm, adequate pressure should be used during
bandaging.
Types of Bandages After completing the procedure, the knot should not lie over
a. Roller bandages the area or over the bony points or over the back.
• It is a continuous roll of material, which is rolled over It should not cause venous or arterial compression.
JA
the part to cover the area. Digits should be left open and circulation in the digits
• It is used in limbs. should be observed for:
• It is available in different lengths and widths—1 inch,
2 inches, 4 inches or 6 inches. Anatomical place Types of bandage
• It is used in different ways. Finger/toe 1 inch
– Circular turns: Continuous rolls placed over the Arm 2 and 1/2 inches
same place. Leg 4 inches
– Spiral turns: After the initial turn of the bandage, it Thigh 6 inches
ascends proximally overlapping the distal 2/3 of the Trunk 6 inches
previous turn. Head 4 inches
Life is either a daring adventure or nothing at all.—Helen Keller
1290 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
D. Day-Care Surgery
DAY-CARE SURGERY
Day-care surgery is discharge within 23 hours (USA); ASA (American Association of Anesthesiologists) grading of
surgery done without night stay (UK). the patient for surgery
Day-care surgery means patient is fit to return home in x Normal individual
23 hours usually with overnight stay. Ambulatory surgery x Mild-moderate systemic disease—diabetes and hypertension
S
means patient recovers after surgery and returns home on under control
x Severe systemic disease—uncontrolled diabetes and hypertension
the same evening. Office surgery means patient recovers
x Incapacitating systemic disease
from surgery and returns home in few hours. Outpatient x Moribund status
ER
surgery is different from day-care surgery in that, patient Class E—emergency surgery
is not previously fully assessed in outpatient surgery. Only
minor procedures are done in this. Patient is not admitted
in outpatient surgery. In day-care and ambulatory surgery
patient is admitted in the hospital. Exclusion criteria for day-care surgery are:
Day-care surgery has been defined by the Royal College of x ASA grade beyond III or more
TH
Surgeons as when the surgical day case patient is admitted x Obesity (BMT >35). Hypertension—not controlled
for investigation or operation on a planned non-resident x Surgery requiring more than one hour
basis and who nonetheless requires facilities for recovery. x Surgery with anticipation of major fluid/blood loss or needs
postoperative critical care
This definition excludes upper and lower GI endoscopies, x Preterm babies and infants less than 3 month’s age
outpatient procedures such as flexible cystoscopy, and x Patient living in far and not easily reachable or able transport
minor superficial surgery under local anaesthetic, none of easily
which require full day case facilities for recovery.
Day-care surgery is an upcoming field in surgical practice.
It is an unique method wherein general practitioner, nurse
O x
x
x
Unstable psychiatric illness
If proper caregiver is not available
Uncontrolled diabetes, alcohol abuse, chronic obstructive
pulmonary disease (COPD), severe asthma, epilepsy
BR
at day-care ward and theatre, surgeon, anaesthetist work x Pregnancy
in hand so that hospital stay and so the cost is reduced.
Patient comes to hospital at morning for surgery and leaves
the hospital on same day evening.
Levels of day-care surgery
Three levels are used but minor procedures in outpatient clinic,
accident cases are not included.
EE
Advantages x Minor ambulatory surgery.
x Minimal hospital stay x Patient acceptance x Major ambulatory surgery.
x Becomes cheaper x Inpatient surgery—patient stays overnight and get discharged
within a day.
Contraindications for day-care surgery are—age >70 years; Day-care surgery unit (DSU) is present in many centres. It
high-risk cardiac and respiratory patients; patients with
YP
may be hospital integrated or hospital based or free standing
bleeding disorders. or officer based. It should have a separate dedicated unit with
Basic requirements are: In house anaesthesiologist ; reception, surgery team, theatre, recovery unit, anaesthetist.
recovery room; theatre and recovery room/ward nurse; Patient selection is done prior to surgery including all
all essential surgical set up including monitor, ventilator. evaluations.
Alertness; ambulation; analgesia and alimentation—basis
Many surgeries are done as day-care surgery—hernia,
JA
for day-care of surgery.
haemorrhoidal procedures, laparoscopic surgeries,
Assessment done prior to surgery by: Pre-anaesthetic clinics
excisions, biopsies, laparoscopic cholecystectomy,
with system evaluations; health questionnaire by surgeon
appendicectomy, ovarian cystectomy, varicose vein surgery,
and physician; telephonic interviews.
all endoscopies, circumcision, orchidectomy, hydrocele
Patient selection, patient information, patient acceptance
surgery, vasectomy, renal stone procedures like ESWL, skin
are important parts in day-care surgery.
grafting, liposuction, fracture manipulation, arthroscopy,
surgical decompression of carpal tunnel syndrome, most
Selection Criteria of the eye surgeries, tympanoplasties, myringoplasty,
American Society for Anesthesiologist (ASA) category I and adenoidectomy, laryngoscopy, orthodontic surgeries,
II patients can be taken up for day-care surgery. ASA III/or laparoscopic sterilization, etc.
beyond are contraindicated for day-care surgery.
Very little is needed to make a happy life; it is all within yourself, in your way of thinking.—Marcus Aurelius
CHAPTER 55: Operative Surgery 1291
Any surgery which has got low-risk with less bleeding and early various aspects of patient care that includes structure, process
SRB's MANUAL OF SURGERY
ambulation can be done as day-care surgery with fulfilling the and outcome against explicit criteria.
selection criteria.
Aspects of Patient Care
Advantages are—less infection, home food, less chance of
Structure—includes what is there in that place—the people
DVT, early ambulation, reduced cost, reduced waiting list,
in place, their training and knowledge, the equipments
early return to work, psychological benefit.
and facilities provided, the organization, management and
Guidelines for safe discharge—stable vitals; proper their payment, etc.
orientation and recovery of the patient; tolerant for oral food Process—includes what procedure is followed in that
adequately; ability to pass urine; able to move with or without
S
place in managing referred patients, what antibiotics
support; no features of vomiting, nausea, severe pain, swelling used, what diagnostic tests done, use of ICU facilities, use
or bleeding. Responsible relative to take care of the patient at of postoperative rehabilitation care, what procedure used
ER
home should be present. for discharge of patients, etc.
Note: Outcome—includes the overall results that include
Modified Aldrete scoring system is used for deciding the discharge the morbidity, mortality, readmission, improvement/
from post-anaesthesia care unit (PACU). It includes activity; respiration; deterioration of the patient’s condition.
circulation and blood pressure; consciousness; O2 saturation.
Problems: Postoperative nausea and vomiting (50%); Explicit Criteria
TH
postoperative pain and postoperative drowsiness/dizziness Proposal for changes can be made in the care of the patient if
(50%) are the common complications in day-care anaesthesia. it falls short of the criteria chosen which can be undertaken
at one or more levels:
Precautions Individual level—more training can be given to the doctors.
Patient should be assessed properly before sending to Infrastructure—upgrading of the newer diagnostic tools.
day-care surgery. Team level—nurses getting more trained in handling the
The nurse should give proper instruction to the patient as
patient stays in the hospital for a short period.
Patient should be warned about possible problems like
O procedures along with the doctors.
Institution—change in the treatment strategy, or antibiotic
policy.
BR
bleeding, vomiting, pain, discomfort, and sedation. Regional level—providing a good referral centre with all
Before discharging, patient should be seen by the doctor facilities and trained personnel.
for the fitness. National level—introduction of screening programmes and
All records should be carefully documented. health campaigns.
Patient should be advised to rush to hospital if any Surgical audit is a systematic, critical analysis of the quality
problems arise or to communicate immediately. of surgical care that is reviewed by peers against explicit
Now hernia; small gynaecology procedures; ENT, cataract criteria or recognised standards, and then used to further
EE
surgeries are done as day-care procedures. inform and improve surgical practice with the ultimate goal
Nurses hold an important role in day-care surgery. of improving the quality of care for patients.
In surgical practice, there will be definitely variations in
Note:
Day-care surgery is different in that patient is sent home same day
the results of the surgery done by a trainee or an experienced
evening after surgery; it practiced in UK more often with slight altered surgeon, variations in outcome of the operation done in
criteria and policies. peripheral setup and in referral institutions, usage of modern
YP
equipments and technique used.
SURGICAL AUDIT Step 1
Determine scope
‘Clinical audit’ is a process used by clinicians who intend
It should be clearly defined, otherwise results in ineffective/
to improve the patient care. The process involves comparing
inappropriate data collection.
JA
Fig. 55.57: Surgical audit cycle.
Even if you’re on the right track, you’ll get run over if you just sit there.—Will Rogers
1292 SECTION 3: Specialities and Other Surgeries
SRB's MANUAL OF SURGERY
It should also be relevant, easily measurable. negligence are the two things surgeons are regularly
Common areas in scope of an audit include—duration of worried about and face often problems.
hospital stay/unplanned admissions/readmissions/operative It is better to have a fair idea about Consumer Protection
specific complications/30 days mortality/morbidity/investi- Act in relation to patient treatment.
gations done/management strategy/patient satisfaction. Surgeon should keep all documents regarding the patient
with him or in the hospital.
Step 2 Case sheet should be written in detail. Daily follow-up
Select standards should be written with date and time of visit with progress
Standards for the selected topic/practice area is decided based about the patient.
on relevant information obtained from:
S
It is better to take detailed consent after proper explanation
Evidence-based research and guidelines. about the disease and treatment protocol to patient and his
Local guidelines for local relevance. close attender/relative. It is better to get signature about
ER
New guidelines developed based on references from a discussion given from them with date and time. In many
library. centres, it is practiced to record the explanation part to
The standard which was already existing or developed keep it as document.
must be clearly described, measurable, specific, and realistic. Surgical method, its problems, risks due to anaesthesia,
Step 3 high-risk if any, risk of bleeding, complications, duration
Collect data of hospital stay should be discussed.
TH
It is important aspect of the audit which has to be informative One should make sure that anaesthetist will do pre
for the audit to be successful. The best quality data collected anaesthetic check up prior to surgery; he should also write
depends on by whom it is being collected; when—retrospective/ his preoperative/operative/postoperative anaesthetic
prospective collected; how—on form/PDA/computer; at/fter notes.
the time of surgery; follow-up data when collected; patient Daily information sheet should be used wherein patient
or party should be informed about the condition of the
identification in a prospective/retrospective study.
audit. Sometimes, the standards may need to be expanded
or reduced/or the data collection methods may need to be
O
Collected data must be relevant to the objectives of the surgical
patient. Timing of this and signature of surgeon and party
should be taken.
After surgery detailed surgical procedure technique should
BR
modified. be written in case sheet and should be informed to patient.
Specimens should be shown to patient party and should
Step 4 be sent for histology.
Present and interpret result with peer review Approximate cost of the procedure and entire bill in the
Audit aims in continuous improvement by experience and by hospital should be informed. One should also inform that
making changes which is ultimately rewarding. it may change depends on complications, number of days
The outcome of the audit should be presented and discussed in ICU, critical care, need for higher antibiotics, etc.
EE
in a clinical meeting. It should undergo peer review. It involves Negligence about retaining mops/instruments are
viewing and analyzing one’s outcome by one’s own peers who legally not acceptable; it is better to take care of enough
are none other than other experienced trained surgeons. It precautions about that.
should be conducted in an atmosphere of confidentiality, Surgeon has got vicarious liability about the mistakes done
trust and teamwork, should not be an opportunity to blame or by ward boys, nurses, theatre nurses, etc. So it is better to
brag but exchange of frank, non-confrontational discussions train them for proper care in OT, postoperative wards and
YP
between the colleagues. Mortality/morbidity meetings, grand ICU.
rounds are one form of peer review. It is ideal to show all reports to patient party and discuss/
brief with them about the condition especially when patient
Step 5
is in ICU.
Introduce changes and monitor progress
If patient or party become arrogant or aggressive it is better
Based on the conclusion of the audit and meetings certain
JA
to make a note of it in case sheet and inform police people
changes to be made in respect to the patient care are decided about the same.
and all the personnel involved in the process are informed or It is better to make a professional indemnity insurance
educated. The outcome due to changes made are monitored policy always to cover these problems in case if needed.
by follow-ups either by reauditing the whole process/ or only It is again ideal to have an advocate to discuss these matters
the part that has been changed. whenever needed.
It is care which surgeon gives not cure always.
SURGEON AND LAW
It is important to a surgeon to know legal aspects in relation
to his profession. Consumer Protection Act and criminal
When the pain of an obstacle is too great, challenge yourself to be stronger.
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