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Surgery

Surgery

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Published by whoosh2008
Easy to understand surgery notes for undergraduates
Easy to understand surgery notes for undergraduates

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Published by: whoosh2008 on Feb 25, 2009
Copyright:Attribution Non-commercial

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11/05/2013

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Paediatric Surgery
Oesophageal atresia
Hypertrophic pyloric stenosis - OHCM 494
Obstructive jaundice
Intestinal obstruction - Intussusceptions; Hirschsprung's disease
Omphaloceles
ARMs
Ambiguous genitalia
UTO - PUV & VUR 
Cardiovascular Surgery
Chest injury
Lung tumours - OHCM 182
Venous hypertension
-
Pulmonary Embolism - OHCM 194
-
Portal Hypertension
-
Varicose veins - OHCM 528
Rheumatic fever 
Cardiology
Valvular heart disease - OHCM 146-151
TOF
VSD - OHCM 160
Pericardial diseases - OHCM 158
 Neurosurgery
Head Injury
Hydrocephalus
The Spine
SOLs - OHCM 386
Tracheostomy
Reconstructive Surgery
Burns
Wound management + Flaps & Grafts
Skin malignancies - OHCM 430
KS - HIV
General Surgery
Pre- & Post op
Liver tumours - OHCM 242
Carcinoma of the pancreas - OHCM 248
Hydatid disease - OHCM 616
Oncology - OHCM + Pg 704
Practical procedures - OHCM
Emergencies - OHCM
General
Surgery Page 1
 
Anatomy
Extent
- From the
root of the nose
to the
base of the skull posteriorly; 3-5Kg
Scalp
S
kin
C
onnective tissue
A
 poneurosis or galeal aponeurotica
L
oose areolar tissue - Site for 
subgaleal haematomas
&
scalping injuries -
Bleed a lot cause the vessel
intima
has more elastic tissue thus they
retract 
on trauma keeping the edges of the vessel apart.
P
ericranium
Skull
a)The
Calvarium -
Layers;
Outer table
Diploe
Inner tableIt is especially
thin
in the
temporal
regions, but is cushioned here by the
temporalis muscle.
 b)The
base of the skull
is
irregular
, & this may contribute to injury of the
frontal & temporal lobes
as the brain moves within the skull during acceleration & deceleration.
Meninges
Lacerations of 
meningeal arteries
located between the dura & the internal surface of the skull (
epiduralspace
) may result in an
arterial epidural haematoma
; the most commonly injured meningeal vessel is the
middle meningeal artery
, which is located
over the temporal fossa.
Dural venous sinuses
can bleed massively if injured -
DO NOT
ligate the
superior sagittal sinus
except 
if collaterals have formed when the
anterior
may be ligated when absolutely necessary with relatively little risk.
In head injury, the veins that travel from the
surface of the brain
to the
superior sagittal sinus
in the midline(
bridging veins
) may tear, leading to the formation of a
subdural haematoma.
Haemorrhage may also occur in the
subarachnoid space
though is
more commonly associated
with a
ruptured aneurysm
but
head injury
is the
more frequent cause
.
Brain
Head Injury
Surgery Page 2
 
a)Cerebrum;
Left hemisphere -
Language centres (
dominant hemisphere in approximately
all right handed 
 people &
85% left-handed 
people
)
Frontal lobe -
Behaviour & Emotions,
motor 
function & on the dominant side,
expression
of speech(
motor speech areas
)
Parietal lobe -
Sensory
function & spatial orientation
Temporal lobe -
regulates certain
memory
functions
Occipital lobe -
Vision
 b)Brainstem;
Midbrain & upper pons -
 Reticular activating system
- responsible for the state of alertness
Medulla -
Cardio-respiratory centres
c)Cerebellum
-
Coordination & balance
Tentorium -
The tentorium cerebelii divides the head into the
 supra
tentorial compartment (
anterior & middle fossae
)
& the
infra
tentorial compartment
(posterior fossa)
with the
midbrain
through the
tentorial incisura
connecting the
cerebral hemispheres
to the rest of the
brainstem.
The
medial
part of the
temporal lobe
- the
uncus
- usually herniates through the tentorial notch -
Uncal herniation -
causing compression of the;i)
midbrain reticular activating system
causing
depressed level of consciousness
ii)
occulomotor nerve
(
Parasympathetic fibres
that are
pupillary constrictors
lie on the
surface of CN III
)that runs along the edge of the tentorium causing
 Ipsilateral 
pupillary dilatation
(due to unopposedsympathetic activity) and
loss of the pupillary light reflex
iii)
corticospinal (pyramidal) tract
in the midbrain causing
Contralateral 
hemiplegia
Thus, an
intracranial haematoma
is more likely to be
on the side of the dilated pupil
, but infrequently
(25%),
masslesions may push the
opposite side
of the midbrain against the tentorial edge, resulting in
ipsilateral hemiplegia
-
Kernohan's notch syndrome
With further compression of 
CN III
, a full
occulomotor paralysis
develops, causing the eye to deviate
inferiorly &laterally (
"down & out"
)
CSF
Intracranial Pressure -
 Normal ~
0-10mmHg (5-18cmH
2
O)
Monro-Kellie Doctrine - "
The total volume of intracranial contents must remain constant 
"
The cranial cavity normally contains a
brain
weighing approximately
1400gm
,
75mL of blood
, and
75mL of CSF.
Addition of a mass e.g. a haematoma results in the squeezing out of an equal volume of CSF & venous blood to maintain the ICP. However, when this compensatory mechanism is exhausted, there is an exponentialincrease in ICP for even a small additional increase in the volume of the haematoma
Cerebral Perfusion Pressure =
MAP- IC
= ~ 
70mmHg
**
M
ean
A
rterial
P
ressure (MAP) =
 D
 BP +
Pulse pressure
** Pulse pressure
=
SBP - DBP 
= ~
50mmHg (<~½ SBP)
Cerebral Blood Flow -
~ 50mL/100gm of brain/minute
;
<5mL/100gm of brain/minute - there is
cell deathor irreversible damage.
Autoregulation maintains CPP between
50-160mmHg
.
<50mmHg
, the CBF declines steeply, & >160mmHg,there is passive dilatation of the cerebral vessels & an increase in CBF
Pathophysiology of Head Injury
The initial trauma causes
Hypoxia
of the brain tissues by
 Ischemia or Anoxia
→ ↑
PCO
2
Vasodilatation
Cerebral blood flow
→ ↑
ICP
Pressure & narrowing of the blood vessels
Hypoxia
Surgery Page 3

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