*RESPONSE TO TRAUMA*

*Phases*

*1. Ebb Phase (Immediate Phase)*

Duration: First 12–24 hours after major trauma.

Goal: Maintain perfusion to vital organs (brain, heart).

*Key Features:*

[Link] output

[Link] rate

[Link] consumption

Hypovolemia due to blood loss

Peripheral vasoconstriction

Cold extremities, hypotension

*Hormonal Response:*

Inc. Catecholamines (epinephrine, norepinephrine)

[Link] and Glucagon

*Clinical Action:*

Resuscitation phase – fluids, blood products, airway, breathing, circulation (ABCs).

*2. Flow Phase (Catabolic Phase)*

Duration: 2–10 days after trauma (can be longer depending on severity).

Goal: Mobilize energy stores for repair and immune response. Hence weight loss

*Key Features:*
[Link] output

[Link] rate

[Link] temperature

Hyperglycemia(primarily due to gluconeogenesis b/c the body metabolizes the broken down
muscles and tissues into glucose for energy)

Protein catabolism → muscle wasting

Negative nitrogen balance

*Hormonal & Cytokine Response:*

Inc. Cortisol, catecholamines, IL-1, IL-6, TNF-alpha

SIRS (Systemic Inflammatory Response Syndrome) may occur

*Clinical Action:*

Supportive care, nutritional support, monitor for infections or MODS (multi-organ dysfunction
syndrome).

*3. Anabolic (Recovery) Phase*

Duration: Days to weeks after injury (depends on initial severity).

Goal: Restore body mass and function.

*Key Features:*

[Link] hormones back to baseline

[Link] (protein synthesis)

[Link] and energy stores

Tissue healing and repair

Normalization of metabolic parameters

*Clinical Action:*

Gradual return to normal diet

Physical rehabilitation
Psychological support

*Additional Concepts*

*SIRS (Systemic Inflammatory Response Syndrome)*

Can occur in the flow phase.

*Criteria (2 or more):*

Temp >38°C or <36°C

HR >90

RR >20 or PaCO₂ <32 mmHg

WBC >12,000 or <4,000 or >10% bands

*MODS (Multi-Organ Dysfunction Syndrome),

Failure of two or more organ systems.

Can result from prolonged uncontrolled inflammatory response.

*Immunological Phases*

Pro-inflammatory → risk of SIRS, sepsis

Anti-inflammatory → risk of immunosuppression, secondary infection

*SEPSIS SIX*
1- Oxygen
2- Blood culture
3- Antibiotics
4- Lactate
5- Fluids
6- Urine output

ANESTHESIA​
1- General Anesthesia:
major surgeries (abdo., thoracic,neuro), uncooperative pts or children
Avoid in resp or cardiac pts

2- Spinal anesthesia:
Lower abdo surgeries(hernia), lower limb surgery ( hip and Ortho procedures like knee
replacement), urologic procedures( turp)
Avoid in coagulopathy and raised icp

3- nerve block:
Limb surgeries typically longer duration ones( brachial plexus block for upper limb)
Rib fractures( intercostal block)

4- Bier's block:(IV)
For shorter surgeries of fingers, wrist typically but also for ankle sometimes
(Digital nerve block for short finger surgeries)

5- epidural:
Obstetric analgesia( labour, c section)
Post op pain management, rub fractures with [Link]

6- local:
For Minor surgical procedures like suturing wounds, dental , small skin excisions, I and D

Anesthesia Imp Point:

●​ White injection propofol
●​ Most common inhalation sevoflurane
●​ Malignant hyperthermia by suxamethonium
●​ Post Spinal headache cause is leaking of csf
●​ Lignocaine 3mg dose without adrenaline
●​ With adrenaline 7 mg
●​ Finger anesthesia ring / digital block
●​ Forearm fracture bier block
●​ Spinal root segment s1 s2 at which vertebrae region L1 L2
●​ Spinal goes to subarachnoid space
●​ Burning pain at inj site by propofol
●​ Cardiotoxic local anesthetic is bupivicaine
​
FLUIDS
Normal saline: vomiting, dka, shock, blood transfusions

Ringer lactate: diarrhea, acute blood loss, shock, burns, dehydration ( avoid in severe liver
compromise)

Hypertonic saline (3%) - symptomatic hyponatremia

Dextrose 5% - hyponatremia, cirrhosis, diabetes insipidus

(Avoid in resuscitation)

Ionotropes- cardiogenic shock

Vasopressors: distributive shock

Albumin: when draining a pt with ascites due to cld

Maintenance fluid post op: RL or 5% dextrose water + 0.9% NS

Refeeding syndrome: hypophosphatemia, hypomagnesemia, hypocalcemia

*BLOOD PRODUCTS TRANSFUSION*

*Whole blood*
In active bleeding

*Complications of massive transfusion*

Dilutional coagulopathy
Dic
Hypocalcemia
Hyperkalemia
Hypokalemia(rare)
Hypothermia
Infections
Allergic and transfusion reactions

*Packed rbc*
during surgery kio k volume overload ni krna
Ya severe anemia m
Sirf hb brhana h

*Ffps*
Coagulopathy m
Liver disease m
Emergency Warfarin reversal m if pcc unavailable
*Cryoprecipitate*
Hemophilia
Von willebrand

*Vit k*
In minor bleeding, and non emergency warfarin reversal, can't be used in liver disease

*Prothromin complex concentrate*

Massive bleeing and emergency warfarin reversal

*Platelets*
If platelets
<10,000
<20,000 - fever or sepsis
<50,000 - active bleeding, before major surgeries or invasive procedures
<100,000 - major bleeding or trauma, Neuro and opthamlo surgery

*TRAUMA CHEAT SHEET (Based on Bailey & Love's

Short Practice of Surgery)*
*1. HEAD TRAUMA*
*Investigations:*

* Glasgow Coma Scale (GCS)

* *Investigation of choice:* CT Brain (non-contrast)
* Cervical spine CT/X-ray

*Management:*

* Airway + cervical spine protection

* Observation or surgical intervention (EDH/SDH)
* ICP management: elevate head, mannitol/hypertonic saline
* Craniotomy or decompression if needed

---

*2. NECK & SPINE TRAUMA*

*Investigations:*

* *Investigation of choice:* CT Cervical spine

* MRI Spine (for cord/ligament injury)
* ASIA neurological assessment

*Management:*

* Cervical spine immobilization (collar)

* Surgical stabilization if needed
* Careful airway control

---

*3. CHEST TRAUMA*

*A. Blunt Chest Trauma*

*Investigations:*

* Chest X-ray (AP view)

* eFAST scan(if unstable)
* CT Thorax
* ABG, ECG, Troponins
* *Investigation of choice:* CT Thorax (if stable)

*Management:*

* Oxygenation and pain control (rib fractures/flail chest) or if surgery is required thoracotomy
* Chest tube for pneumothorax or hemothorax, needle decompression for tension pneumo
* Monitor for pulmonary contusion
* Supportive ventilation if needed
* *Pericardiocentesis*: may be useful for blunt cardiac tamponade (temporary measure before
surgery)
* *Diaphragmatic injury*: Suspect with elevated hemidiaphragm or bowel in chest; CT
chest/abdomen or laparoscopy confirms

*B. Penetrating Chest Trauma*

*Investigations:*
* Chest X-ray, eFAST, CT (if stable)
* Assess entry/exit wounds
* *Investigation of choice:* eFAST (for unstable); CT Chest (if stable)

*Management:*

* Immediate chest tube insertion (hemopneumothorax)

* Occlusive dressing (open pneumothorax)
* Emergency thoracotomy for cardiac tamponade or massive bleeding
* Surgical repair if major vascular injury

---

*4. ABDOMINAL TRAUMA*

*A. Blunt Abdominal Trauma*

*Investigations:*

* eFAST
* CT Abdomen (contrast)
* Serial abdominal exams
* *Investigation of choice:* CT Abdomen with contrast (if stable); eFAST (if unstable)

*Management:*

* Non-operative for stable solid organ injuries (spleen/liver)

* Laparotomy if unstable or signs of peritonitis
* Damage control surgery if needed

* *Liver injuries:*
 * Grade I–III: Conservative management with monitoring, in grade III surgery if unstable
* Grade IV–V: May need angioembolization(if stable) or surgery (hepatorrhaphy, packing, or
resection) - dmg control surgery

* *Splenic injuries:*
 * Grade I–III: Conservative (bed rest, monitoring), in grade III, surgery if unstable
* Grade IV–V or ongoing bleeding: Angioembolization(if stable) or splenectomy (with post-op
vaccination), In grade V splenectomy is the only option

* *Bowel, Colon, and Rectal injuries:*

* Small bowel: primary repair or resection and anastomosis

* Colon: primary repair if minimal contamination; otherwise resection + diversion (colostomy)
 * Rectal: extra-peritoneal → diversion (loop colostomy); intra-peritoneal → primary repair ±
diversion

*B. Penetrating Abdominal Trauma*

*Investigations:*

* eFAST
* CT Abdomen if stable
* Local wound exploration if unclear trajectory
* *Investigation of choice:* Exploratory laparotomy (if unstable or peritonitis); CT Abdomen (if
stable)

*Management:*

* Exploratory laparotomy for peritonitis, evisceration, or instability

* Selective non-operative management if stable and no signs of organ injury
* Tetanus prophylaxis + antibiotics
* Same bowel/colon/rectal injury principles as above
*In penetrating injuries of diaphragm repair should always be abdominal not through thoracic
route
---

*5. PELVIC TRAUMA*

*Investigations:*

* Pelvic X-ray (AP view)

* CT Pelvis
* FAST scan
* Retrograde urethrogram
* *Investigation of choice:* Pelvic X-ray (initial); CT Pelvis (for detailed evaluation)

*Management:*

* Apply pelvic binder

* Angioembolization for bleeding
* External fixation if unstable
* Massive transfusion protocol if needed
* *Bladder & Urinary Tract Injury:*

* Suspect if hematuria, pelvic fracture, or inability to void

* *Urethral injury:* Retrograde urethrogram before catheterization; avoid Foley if suspected
* *Bladder injury:* Cystogram to differentiate intraperitoneal (requires surgery) vs
extraperitoneal (may be managed conservatively with catheter)
 * Surgical repair for intraperitoneal rupture; catheter drainage for uncomplicated
extraperitoneal injury

---

*6. FACIAL TRAUMA*

*Investigations:*

* CT Face/Orbit
* Ophthalmologic exam
* Assess occlusion, septal hematoma
* *Investigation of choice:* CT Face/Orbit
* OPT and PA radiograph are also done in mandible fractures

*Management:*

* Secure airway
* ORIF for facial fractures
* ENT/maxillofacial involvement
* Antibiotics + tetanus

*DAMAGE CONTROL SURGERY*

*.PRE - OP MANAGEMENT*
*1. GENERAL ASSESSMENT*

History: Medical, surgical, anesthesia history, medications, allergies.

Physical exam: Cardiorespiratory, nutritional status, airway (Mallampati), BMI.

Investigations (as indicated):

CBC, U&E, LFTs

ECG (age >65 or cardiac history)

CXR (if respiratory symptoms)

Coagulation profile (if on anticoagulants or liver disease)

HbA1c for diabetics

ASA classification: Grades I–V (I = healthy, V = moribund).

*2. COMORBIDITY-SPECIFIC PREOPERATIVE MANAGEMENT*

*A. DIABETES MELLITUS*

Target HbA1c <7.5% or 69 mmol/mol before elective surgery. And blood glucose should be 200
mg/dl or less

Stop metformin 24–48 hours pre-op (lactic acidosis risk).

Use VRII (Variable Rate Insulin Infusion) perioperatively.

Monitor glucose hourly (target: 6–10 mmol/L).

*Scenario wise*
- If BG is high (≥200 mg/dL) with ketosis/DKA: postpone surgery (if possible) to treat DKA first.,
if without ketosis start iv insulin to control glucose and then start surgery while monitoring
glucose especially if diabetes is poorly controlled in well controlled diabetes without any other
signs surgery can generally proceed while close monitoring
- For urgent/emergent cases: Proceed with surgery while managing hyperglycemia aggressively
(IV insulin + close monitoring).

*B. HYPERTENSION*

Postpone elective surgery if BP >160/110 mmHg.

Continue most antihypertensives except ACE inhibitors/ARBs (stop on day of surgery).

Avoid intra-op BP swings.

*Scenario wise*
If bp <160/100
- we can proceed with surgery if asymptomatic
- If symptomatic and surgery is elective then consider delaying and start anti HTN drugs then
reassess in 1-2 hrs
- if surgery is urgent and life saving then proceed but with really strict bp monitoring with IV
meds
- if bp is over 160/100 then delay anyways and start HTN drugs to control bp, but if emergency
then proceed with strict monitoring

*C. ANTICOAGULANTS / ANTIPLATELETS*

Warfarin:

Stop 5 days before surgery.

Bridge with LMWH if high thrombotic risk.

INR should be <1.5 pre-op.

Target PT shouldn't be more than 2

Aspirin:

Stop 7 days before surgery (clopidogrel 10 days)

If high thrombotic risk, hx of CAD, or recent stent placement last 12 months, then consult
cardiologist and ideally don't stop aspirin

DOACs (e.g., apixaban): Stop 24–72 hrs pre-op depending on renal function and bleeding risk.
.

*D. INFECTION*

Elective surgery should be postponed in active infection.

For urgent surgery, start broad-spectrum antibiotics and control infection source.

If septic, initiate Sepsis 6 (O2, cultures, fluids, antibiotics, lactate, urine output).

*E. RESPIRATORY DISEASE*

Stop smoking 4 weeks( [Link] IM) ≥6 weeks([Link] net) pre-op

Optimize asthma/COPD: bronchodilators, steroids, treat infections.

Pre-op physiotherapy and incentive spirometry.

PFTs(delay surgery if pef less than 30)/ABG if symptomatic or CO2 retention suspected.

Refer to pulmo if rt heart failure, major surgery planned in pt with severe resp comorbs or young
pt with severe resp problems, pt is deteriorating

*F. CARDIOVASCULAR DISEASE*

Defer surgery if recent MI (3-6 months), unstable angina, or decompensated heart failure.

ECG in all >65 or cardiac history.

Echocardiography if murmur, poor EF, or valve disease is suspected.

Continue beta-blockers (do not initiate newly).

Cardiology consult if recent PCI or stents are placed.

*G. RENAL DISEASE (CKD/ESRD)*

Check U&E, creatinine, eGFR.

Avoid nephrotoxic drugs (NSAIDs, contrast, aminoglycosides).

Adjust medication doses for renal function.

Correct anemia (EPO), hyperkalemia, acidosis.

Dialyze within 24 hours pre-op if ESRD.

Avoid damage to AV fistula.

Watch for bleeding tendency due to

uremia.

*[Link]*
- If *acute hepatitis*, postpone surgery
- If *chronic*, proceed
- If *obstructive jaundice*, pt is at risk of developing renal failure post op, also ar risk of clotting
disorders, proceed with caution, while maintaining hydration, monitoring urine, prophylactic
antibiotics and lfts,UCE daily.
- if *cirrhosis* - do child Pugh scoring, if class A or B, treat ascites, coagulopathy, enceph first
then proceed, if Class C postpone surgery

*3. OTHER ESSENTIAL AREAS*

*PREOPERATIVE FASTING*

Solids: Stop 6 hours pre-op.

Clear fluids: Up to 2 hours before surgery.

*POST OP CARE*
*1. Immediate Postoperative Care (PACU/Recovery Room)*

Airway, breathing, circulation (ABC) always reassessed.

*Monitor for:*

Airway obstruction (tongue, secretions)

Hypoxia (atelectasis, aspiration, PE)

Hemodynamic instability (bleeding, hypovolemia)

Pain control (IV opioids, regional blocks)

*2. Vital Monitoring*

Continuous monitoring: ECG, BP, pulse, SpO₂, respiratory rate, temperature.

Urine output: should be >0.5 mL/kg/hr.

Early warning scores (EWS) may be used to detect deterioration.

*3. Fluid & Electrolyte Management*

Daily requirement: ~30–35 mL/kg water, 1 mmol/kg Na⁺, K⁺, Cl⁻.

Replace losses from drains, vomiting, diarrhea, fever, etc.

Monitor for hyponatremia (common) or hypokalemia.

*4. Pain Management*

Multimodal analgesia preferred:

Paracetamol, NSAIDs (if not contraindicated), opioids

Regional techniques (epidural, nerve blocks)

PCA (Patient-Controlled Analgesia) can be used post major surgery.

*5. Early Mobilization*

Reduces risk of DVT, PE, atelectasis, pressure sores.

Encouraged within 24 hours if possible.

Consider physiotherapy input post-op, especially in elderly.

*6. Postoperative Complications*

*Immediate (0–24 hrs):*

Hemorrhage, Shock, Airway compromise

*Early (1–7 days):*

Atelectasis(earliest out of these), pneumonia, DVT/PE, Wound infection, Urinary retention

*Late (>7 days):*

Wound dehiscence, Incisional hernia, Adhesive bowel obstruction

*7. Specific Postop Problems*

*Fever (5 W’s):*
Wind (atelectasis is the earliest cause/pneumonia)

Water (UTI)

Wound (SSI)

Walk (DVT/PE)

Wonder drugs (drug fever)

*Postoperative ileus:*

Absent bowel sounds, distension

Supportive care: NPO, NG tube, fluids

*Anastomotic leak:*

Suspect with fever, tachycardia, abdominal pain

Confirm with imaging (CT with contrast)

*[Link]*

LMWH + mechanical methods (compression stockings, IPC)

*9. Wound Care*

Daily inspection

Look for signs of SSI: pain, redness, discharge

Remove dressing after 48 hrs if dry and clean

*If drain is placed, it can be removed when output is less than 25 ml

​
*Burns*
*Classification By Depth*

Superficial (1st degree): Only epidermis involved (e.g. sunburn); red, painful, no blisters.

Partial thickness (2nd degree): Involves dermis

Superficial partial: blistering, red, painful

Deep partial: pale, reduced sensation

Full thickness (3rd degree): Entire dermis and epidermis destroyed; painless, leathery,
white/charred

Fourth degree: Extends to muscle, bone (rare)

*Assessment of Burn Surface Area*

Rule of Nines (Adults):

Lund and Browder Chart:

More accurate, especially in children (age-adjusted).

Palm Rule:
Patient’s palm ≈ 1% of body surface area (BSA)

*Burn Severity*

Major Burns:

> 20% TBSA in adults (total body surface area)

> 10% in children/elderly

Any full-thickness >10%

Burns of face, hands, feet, genitalia

Inhalational, electrical, chemical

*Primary Survey (ABCDE) in Burns*

A – Airway: Check for soot, hoarseness, singed nasal hair

B – Breathing: Look for inhalational injury (carbon monoxide, airway edema)

C – Circulation: Check for shock; fluid loss; monitor BP, cap refill

D – Disability: Conscious level (hypoxia, CO poisoning)

E – Exposure: Assess TBSA burned, prevent hypothermia

*Fluid Resuscitation (Parkland Formula)*

- crucial in all major burns

> 4 mL × Body weight (kg) × % TBSA burned

Half in first 8 hours, remainder over next 16 hrs

Use Ringer’s lactate

Adjust based on urine output (target: 0.5–1 mL/kg/hr)

Start time is from time of burn, not admission.

*Escharotomy Indications*

Circumferential full-thickness burns causing vascular compromise or respiratory restriction

*Wound Care*

Clean with saline, Blisters may be deroofed if large

Topical antibiotics: Silver sulfadiazine, mupirocin

Dressing: Non-adherent, sterile

Early excision & skin grafting in full-thickness burns

*Tetanus Prophylaxis*

Give tetanus toxoid ± TIG depending on vaccination status

*Pain Management*

IV opioids (morphine), Avoid IM due to poor absorption

*Nutrition*

Hypermetabolic state – high calorie, high protein diet

Early enteral feeding via NG tube

*Infection Control*

Leading cause of death in burns

Monitor for sepsis:

Avoid prophylactic systemic antibiotics unless infection present

*Complications*

Hypovolemic shock, Sepsis, Compartment syndrome, Curling’s ulcer (stress ulcer – prophylactic
PPIs), Contractures, Psychological trauma/PTSD

*Inhalation Injury*

Suspect in closed space fire

Carbon monoxide poisoning → pulse oximetry may be misleading

Treat with 100% oxygen; consider hyperbaric O₂

*SKIN GRAFTING
*Functions of Skin*

Barrier to infection,Temperature regulation

Sensory perception,Vitamin D synthesis

Aesthetic & psychological role

*Wound Healing Types*

1. Primary Intention

Clean incised wounds closed with sutures

Minimal scarring

2. Secondary Intention

Wounds left open to heal by granulation

Slower healing, more scarring

3. Tertiary Intention (Delayed Primary Closure)

Initially open wound, later closed surgically

Keloid vs hypertrophic scar

Keloid: grows beyond margins, contain an excess of type b collagen, non regressing, high
recurrence rate, tx by excision and radiotherapy

Hypertrophic scar: stays within margins, regresses by itself in 6 months- 1 yr, low recurrence
rate, tx is for symptoms with ( silicone + steroids + pressure), surgery should be combined with
adjuncts otherwise high recurrence rates

*Types of Skin Grafts*

*1. Split-Thickness Skin Graft (STSG)*

Includes epidermis + part of dermis

Thin grafts: take easily, higher succes, poor cosmetic match, more contraction

*2. Full-Thickness Skin Graft (FTSG)*

Includes epidermis + entire dermis

Better function and appearance than split thickness

Requires a well-vascularized bed

More chance of graft failure

*Donor Sites for Grafts*

STSG: Thigh, buttock, upper arm

FTSG: Postauricular, supraclavicular, groin (areas with lax skin)

*Graft "Take" – 3 Phases*

1. Plasmatic Imbibition (Day 1–2): Nutrients by diffusion

2. Inosculation (Day 3–5): Capillaries connect to wound bed

3. Revascularization: New vessels form

*Good graft take requires:*

Clean, well-vascularized bed

Immobilization

No infection, hematoma, shearing

*Indications for Skin Grafts*

Post-burn wound cover

Trauma with skin loss

Chronic ulcers

After wide excision (e.g. skin cancer)

*Graft Failure – Causes*

Infection
Hematoma/seroma
Poor vascular bed (e.g. bone, tendon)
Shearing movement
Rejection (rare)

*Skin Substitutes & Alternatives*

Allografts: From another human

Xenografts: From another species (e.g. pig)

Bioengineered skin: e.g. Integra, Apligraf

Cultured epithelial autografts (CEA): For large burns

*Flaps vs Grafts*

Grafts: no blood supply(relies on recipient bed), thickness variable, used when bed is already
well vascularized, in burns and ulcers

Flaps: has own blood supply, full thickness, used when bed is poorly vascularized in complex
reconstructions like post cancer resection, trauma exposed bone,tendon or infected beds

Special graft techniques

Meshed grafts: Expanded for large wounds, allow drainage

Sheet grafts: Better cosmetic outcome, used on face/hands

Pinch grafts: Small islands of skin

Stamp grafts: Small square pieces (used in past)

*Complications of Skin Grafting*

Early: Hematoma, infection, graft failure

Late: Scar contracture, pigment changes, poor cosmesis

Donor site: Pain, delayed healing, infection

*Scar Management*

Pressure garments, Silicone sheets

Steroid injections, Surgical revision (Z-plasty)

*Skin Lesions*
*1. Benign Lesions*

Seborrhoeic keratosis: "Stuck-on" appearance, common in elderly

Epidermoid cysts: Cheesy content, central punctum

Lipoma: Soft, mobile, subcutaneous fatty tumor

Nevi (moles): Symmetrical, uniform color, <6 mm

*2. Premalignant Lesions*

Actinic keratosis: Rough, scaly patch; sun-exposed areas; risk of SCC

Bowen’s disease: SCC in situ; red, scaly, well-defined

Keratoacanthoma: Rapidly growing nodule, resembles SCC

*Skin Cancers*

*1. Basal Cell Carcinoma (BCC) – “Rodent Ulcer”*

Most common skin cancer

Slow-growing, local invasion, rarely metastasizes

Features: pearly edge, telangiectasia, central ulceration

Treatment: Excision with 3–4 mm margin; Mohs surgery for face

*2. Squamous Cell Carcinoma (SCC)*

Arises from keratinocytes

May metastasize to lymph nodes

Risk factors: sun exposure, burns, immunosuppression

Features: ulcer with indurated, everted edges

Treatment: surgical excision with 4 mm margin if size <2cm across, 1 cm clearance if > 2cm
LN assessment

*3. Malignant Melanoma*

Arises from melanocytes

High metastatic potential (lymphatic + hematogenous)

ABCDE Criteria:

A – Asymmetry

B – Border irregularity

C – Color variation

D – Diameter >6 mm

E – Evolving lesion

*Types:*

Superficial spreading (most common)

Nodular (most aggressive)

Lentigo maligna (elderly, face)

Acral lentiginous (palms, soles; common in dark-skinned)

Breslow Thickness – most important prognostic factor

Clark Level – depth of invasion (less commonly used now)

*Treatment:*

Wide local excision depending on thickness

Sentinel lymph node biopsy if >1 mm thick

Lymphadenectomy if SBP is positive

Immunotherapy in advanced cases (e.g. anti-PD1, BRAF inhibitors)

*Other Notable Lesions*

Pyogenic granuloma: Red, friable lesion post-trauma; bleeds easily

Dermatofibroma: Firm, dimple sign on pinching

Cutaneous horn: May overlie actinic keratosis/SCC

Kaposi sarcoma: Purplish nodules in HIV/AIDS

(Tx: dressings initially, if it doesn't resolve it then biopsy)

*Investigations for skin lesions*

Dermoscopy, biopsy, fnac if LN involvement

Imaging if deep or metastatic lesion

*WOUND HEALING AND TISSUE REPAIR*

*Types of Wound Healing:*

*1. Primary Intention*

Clean wound edges are apposed directly (e.g. surgical incisions).

Minimal tissue loss and minimal scarring.
Fastest healing.

*2. Secondary Intention*

Wound is left open and heals by granulation tissue formation, contraction, and epithelialization.
Seen in ulcers, infected wounds.
Slower healing with more scarring.

*3. Tertiary Intention (Delayed Primary Closure)*

Wound is initially left open due to contamination/infection risk and closed after a few days.
Used in trauma or dirty wounds.

*Phases of Wound Healing:*

*1. Hemostasis (Immediate)*

Vasoconstriction → platelet aggregation → fibrin clot formation.

Releases cytokines and growth factors (e.g., PDGF, TGF-β).

*2. Inflammatory Phase (0–5 days)*

Neutrophils → monocytes/macrophages.
Function: Clean debris, kill bacteria, release more cytokines.

*3. Proliferative Phase (3–21 days)*

Fibroblasts: produce collagen (mainly type III).

Angiogenesis: capillary growth.

Granulation tissue forms.

Re-epithelialization: basal keratinocytes migrate.

*4. Maturation/Remodeling Phase (21 days to 1* year)

Type III collagen replaced by Type I collagen.

Wound contraction (myofibroblasts).

Increase in tensile strength (max ~80% of original).

*Factors Affecting Wound Healing:*

*Local Factors:*

Infection – most common cause of impaired healing.

Poor blood supply
Foreign body
Wound tension or movement
Radiation

*Systemic Factors:*

Diabetes mellitus –
Malnutrition – especially low protein, zinc, vitamin C.
Immunosuppression – steroids, chemotherapy.
Smoking
Anemia or hypoxia

*Pathological Wound Healing:*

*1- hypertrophic scar* - already covered in skin

*2- keloid*(more common in black skinned) - already covered in skin

*3. Chronic Non-healing Wounds*

Often due to ischemia, infection, or diabetes.

Seen in pressure ulcers, venous ulcers.

*4. Wound Dehiscence*

Partial or total separation of wound layers, often due to infection or poor healing.

May lead to evisceration in abdominal wounds.

*5. Sinus and Fistula Formation*

Chronic inflammation with persistent drainage tract.

*Wound Strength:*

10% of original strength by 1 week.

50% by 4 weeks.

~80% by 3 months to 1 year (never reaches 100%).

*Role of Collagen in Healing:*

Type III: early wound healing.

Type I: replaces type III during remodeling.

Provides tensile strength to scar.

🔹 Clinical Examples:
Condition​ - Healing Pattern

Clean surgical wound​ - Primary intention

Abscess cavity - ​ Secondary intention
Contaminated trauma wound -​ Tertiary intention
Pressure ulcer​- Secondary intention
*Adjuncts to Promote Healing:*

Negative Pressure Wound Therapy (VAC)

Hyperbaric Oxygen Therapy

Growth Factors (e.g., PDGF)

Skin substitutes / grafts

Debridement of necrotic tissue

*Sutures and Healing:*

Skin: 7–10 days

Abdomen: 10–14 days

Subcutaneous tissue: absorbable sutures

*MINIMALLY INVASIVE SURGERY*

*Common Types*

*1. Laparoscopic Surgery* – Keyhole abdominal/pelvic surgery using trocars and a

laparoscope.

*2. Thoracoscopic Surgery (VATS)* – Minimally invasive chest procedures.

*3. Endoscopic Surgery* – Using natural orifices (e.g., GI endoscopy).

*4. Robotic Surgery* – Surgeon controls robotic arms (e.g., da Vinci system).

*5. NOTES (Natural Orifice Transluminal Endoscopic Surgery)* – Still experimental.

*Advantages of MIS:*

Smaller incisions → reduced postoperative pain

Faster recovery and mobilization
Shorter hospital stay
Lower risk of wound infection
Better cosmeticis
Reduced risk of incisional hernia

*Disadvantages / Limitations:*

Steep learning curve

Longer operative time (early in learning)
Higher equipment cost
Limited tactile feedback
Risk of injury to adjacent structures (due to limited visualization in unskilled hands)
Pneumoperitoneum effects: ↓ venous return, hypercarbia

*Common Laparoscopic Procedures:*

Cholecystectomy
Appendectomy
Inguinal hernia repair (TAPP/TEP)
Fundoplication
Colectomy
Adrenalectomy
Splenectomy
Diagnostic laparoscopy

*Contraindications (Relative/Absolute):*

Hemodynamic instability
Generalized peritonitis
Severe cardiopulmonary disease (pneumoperitoneum poorly tolerated)
Extensive abdominal adhesions
Massive obesity (technical difficulty)

*Complications:*

Injury to bowel, vessels, bladder, ureter

Gas embolism
CO₂ retention, hypercarbia
Subcutaneous emphysema
Port site hernia(if incisions not closed properly)
Port site infection
Conversion to open surgery (if complications or poor access)

*Robotic Surgery Highlights:*

Better precision and ergonomics

3D vision
Tremor filtration
Non existent tactile feedback
Used in urology, colorectal, and gynecologic surgeries

*Principles of Laparoscopic Surgery:*

Creation of pneumoperitoneum (usually with CO₂ gas) to create working space.

Use of trocars/ports to insert camera and instruments.

Visualization via laparoscope connected to a video monitor.

Procedures performed with long instruments under video guidance.

*Critical view of safety in lap chole*

Clear visualization of cystic artery and duct before clipping