Survival Guides Surgery

Contents: What is surgery? Conditions you will be asked about in your first week Case example: Inguinal hernia Dos and donts

WHAT IS SURGERY?
Surgery is defined as the art of healing by the scientific manipulation of anatomical structures. Consequently, it relies on the application of basic science subjects, such as anatomy and physiology, to clinical practice. A good knowledge of both is essential for safe surgical practice at all levels. In modern hospital medicine doctors are becoming increasingly more specialised, and the general surgeon is rarely encountered. Rather, surgeons subspecialise in one of the following areas: General surgery (upper gastrointestinal, lower gastrointestinal, hepatobiliary, etc) Vascular surgery Breast surgery Orthopaedic and trauma surgery Ear, nose and throat (ENT) surgery Maxillofacial surgery Plastic surgery Transplant surgery Neurosurgery Urology Military surgery (some countries) It is important to remember that crossover does occur among specialties and all surgeons undergo the same basic general surgical training.

CONDITIONS YOU WILL BE ASKED ABOUT IN YOUR FIRST WEEK

Surgeons love demonstrating the art of surgery. Part of the art includes quizzing medical students. Expect therefore a lot of questions (read Dos and Donts). These are mainly geared around anatomy and common surgical conditions know both! The most frequently encountered cases include: Groin lumps (hernias) Varicose veins Neck masses Breast lumps Jaundice Bowel obstruction You may also be quizzed about: o Anesthesia o Analgesia o Antibiotics o Intravenous fluids

CASE EXAMPLE: INGUINAL HERNIA Definitions Hernia

An abnormal protrusion of an organ or tissue through the wall or structure covering it

Inguinal hernia
An abnormal protrusion of omentum +/ bowel through the inguinal canal

Classification Location

Indirect: The hernial sac protrudes through the deep (internal) inguinal ring (lateral to Hesselbachs triangle), passes through the inguinal canal and may reach the scrotum Direct: The hernial sac protrudes through a defect in the posterior wall of the inguinal canal, in Hesselbachs triangle

Mobility
Incarcerated hernia: The hernial sac cannot be returned to the abdomen spontaneously or by palpation (irreducible). This may result in bowel obstruction Strangulated hernia: An incarcerated hernia where the blood supply is compromised, leading to ischemia and perforation

Epidemiology
75% of abdominal wall hernias occur in the groin Indirect hernias are twice a common a direct ones Right sided hernias are more common than left sided ones Men are more commonly affected than women (7:1)

Aetiology Congenital
Patent processus vaginalis

Acquired
Raised intra-abdominal pressure: o Obesity o Ascites o Pregnancy o Straining (coughing, constipation, prostatism) Connective tissue disorders or defective collagen synthesis, e.g.: o Marfans syndrome o EhlersDanlos syndrome

Clinical presentation Symptoms

Groin lump +/ dragging pain that increase as the day progresses or with coughing Bowel movements may be affected if the hernia becomes obstructed

Signs Inspection
Lump in the groin +/ scrotum Look for signs of increased intra-abdominal pressure, e.g.: o Cough o Abdominal distension Lump moves when the patient coughs (positive cough reflex) Identify anatomical structures: o Line drawn from the pubic tubercle to the anterior superior iliac spine: Inguinal hernias are situated above this line o Pubic tubercle: Mass protrudes medial to this o Mid-inguinal point (mid point of line described above): Indirect inguinal hernias are controlled by pressure over this point Direct inguinal hernias are not controlled by pressure over this point (this sign has been shown to be unreliable) Feel the scrotum for the presence of bowel

Palpation

Auscultation
Listen over the scrotum with a stethoscope for bowel sounds

Differential diagnosis
Femoral hernia Femoral artery aneurysm Saphenous vein varix Lymph node Ectopic testis Psoas abscess Sebaceous cyst Lipoma

Investigations
Ultrasound scan (not usually necessary)

Management Reduce modifiable risk factors

Reduce weight Stop smoking Correct raised intra-abdominal pressure

Conservative Surgical Laparoscopic or open approach

Watch and wait: o Most hernias need to be repaired though because of the risk of strangulation

An incision is made in the skin and subcutaneous tissues to expose the inguinal canal The bowel is returned to the abdominal cavity The abdominal wall defect is repaired: o Different techniques are used to repair and reinforce the abdominal wall defect and include the: Bassini approach McVay approach Lichtenstein approach Shouldice approach Plug and patch approach Note: you do not need to know the details of these different approaches as medical students!

DOS AND DONTS Be safe, be sensible, be sharp, be seen! Be safe

There is a great potential for many things to go very wrong very quickly in surgery Assume a mature and professional role in the team Know your patient: o History o Vital signs o Investigations results Remember that the most important person in the operating room is the patient not the surgeon Dont take risks or perform procedures you feel unsure about Do ask questions if in doubt it is better to be annoying rather than dangerous

Be sensible
Dont bluff if you know an answer say it! if you dont, admit it

Be logical and use common sense Dont rush Don't argue Be rational with answers and prioritise the order in which you list a differential diagnosis (list of causes): remember common conditions are common!

Be sharp
Be accurate, brief and clear (ABC) in the way you deliver answers or ask questions (Speak up, then shut up) Do dress smartly: o This implies respect for your patients, your teachers, your colleagues, and ultimately yourself o Wear ironed shirts, clean shoes (no sports shoes), smart trousers and skirt (of appropriate length), etc Be positive and proactive

Be seen
The more junior you are, the more experience you need Do come in early and leave late (but do get some sleep) Go to the operating room, theatre, and ward round and offer to help Dont ask When can I go home? Do see as many patients as possible and find out about their disease, treatment and concerns

History and examination

A full history, clinical examination and a set of relevant investigations must be performed on all surgical patients preoperatively Include all relevant nonsurgical issues

Questions to ask
What is the problem? What caused it (run through the risk factors)? What are the consequences and are there any complications? How long has it been occurring for? How has it changed? What makes it better or worse? Is the patient fit for surgery? o Are there other concomitant medical conditions? o Age? Is the disease amenable to surgical management? What does the patient want?

Questions to ask before surgery

Any previous surgery? Any previous reactions to anesthesia? When was the last time the patient ate or drank water? Any fever or rigors (signs of infection)? Any recent bleeding (hemoptysis, hematemesis, malena, vaginal bleed, hematuria) or bruising? Any risk of being pregnant (women)? Any allergies and medications?