(CLINICS) Surgery Notes +CPG

SURGERY
SURGERY CLINICS Page 1 of 53

HISTORY TAKING
 Should not delay resuscitation of the acutely
ill patient
 2 types:
1) OPD / ER
- With a specific complaint
- DX through History & PE with
diagnostic tests and imaging
- DRE is a must
2) Elective Surgery
- Assess if patient is suitable for
operation
- Assess if procedure planned is
correctly indicated
 Components:
o Source & Reliability
o General Information – Religion is important
o Chief complaint
o History of present illness
o Past Medical History
- Chronological
- All diseases ( previous to present)

- Previous operations / accidents
(adhesions)
- Food and drug allergy
o Family History
- Heredofamilial disease
- Cancer
o Personal & Social History
- Diet
- Mental status
- Vices: alcohol, smoking, drug use
- Bowel and urinary patterns
- Sleep
- OB and Menstrual History
o Physical Exam
o Formulation (paragraph form)
- Primary impression
- Differential diagnosis
- Diagnostic plan
- Treatment plan
 Definitive (Surgery)
 Supportive (Medical)

COMMON COMPLAINTS
TO SURGERY:
1) PAIN – most common (abdominal)
2) MASS / SWELLING
3) VOMITING – ex. Obstruction due to mass, GERD
4) BLEEDING – ex. PUD
5) DISCHARGE – ex. Soft tissue infection, Diabetic Foot
6) DEFORMITY – ex. Trauma cases
ABDOMINAL PAIN:
 SITE
 ONSET
 SEVERITY
 NATURE
 PROGRESSION
 DURATION
 AGGRAVATING & ALLEVIATING FACTORS
 RADIATION
 PAIN SCORE

EXAMINATION OF THE
ABDOMEN:
 EXPOSURE: Nipple to Knee
 Lower extremity flexed at the hip to relax
the abdominal muscles
 Steps:
1. Inspection
2. Auscultation
3. Percussion
4. Palpate
 Check MASS:
 Location
 Color and Texture of overlying skin
 Temperature
 Tenderness
 Shape
 Size
 Borders
 Consistency
 Reducibility (hernia)
 Pulsatility, Compressibility (Vascular)

DRUGS USED FOR PROPHYLAXIS IN SURGERY:
ACUTE & UNCOMPLICATED APPENDICITIS:

Dosage
Adults Children
2 g IV single 40 mg/kg IV
CEFOXITIN
dose single dose
Alternative agents
AMPICILLIN- 1.5-3 g IV 75 mg/kg IV
SULBACTAM single dose single dose
AMOXICILLIN- 1.2-2.4 g IV 45 mg/kg IV
CLAVULANATE single dose single dose
For patients with allergy to β-lactam antibiotics:
80-120 mg IV 2.5 mg/kg IV
GENTAMICIN
single dose single dose
+
600 mg IV 7.5-10 mg/kg IV
CLINDAMYCIN
single dose single dose
BREAST SURGERY:
(Mastectomy, Axillary lymph node dissection, Reduction
mammoplasty, Excisional biopsy and lumpectomy)
Dosage (Adults)
CEFAZOLIN 2 g IV single dose

Alternative agents
CEFUROXIME 1.5 g IV single dose

INGUINAL HERNIA SURGERY:
Antibiotic prophylaxis is NOT recommended in

elective groin hernia surgery.
BILIARY SURGERY:
(Cholecystectomy; Sphincterotomy; Cholecystectomy +
sphincterotomy; Choledochoenterostomy:
Choledochoduodenostomy, Choledochoduodenostomy +
sphincterotomy, Choledochojejunostomy;
Cytsojejunostomy; CBD exploration)
Dosage (Adults)

Alternative agents

GASTRIC & DOUDENAL SURGERY:

(Gastric ulcer, Chronic or Bleeding gastric Ulcers,
Bleeding or Obstructing duodenal ulcers)
Dosage (Adults)

Alternative agents
COLORECTAL SURGERY:
(Right hemicolectomy; Left hemicolectomy; Transverse
colectomy; Segmental colon resection; Anterior
resection; Low anterior resection; Hartmann’s
procedure; Abdominoperineal resection; Total
abdominal colectomy)
Dosage (Adults)
ERTAPENEM 1 g IV single dose

DIFFERENTIAL DIAGNOSES OF ABDOMINAL PAIN
BY LOCAION
Harrison's Principles of Internal Medicine (19th edition)

SKILLS

SURGICAL HANDSCRUBING & GOWNING
Purpose of surgical hand scrubo:

 Remove debris and transient microorganisms from the nails,
hands, and forearms
 Reduce the resident microbial count to a minimum, and
 Inhibit rapid rebound growth of microorganisms.
All sterile team members should perform the hand and arm
scrub before entering the surgical suite. The basic principle of the
scrub is to wash the hands thoroughly, and then to wash from a
clean area (the hand) to a less clean area (the arm). A systematic
approach to the scrub is an efficient way to ensure proper
technique.
SURGICAL SCRUB TECHNIQUES

 Remove all jewelry (rings, watches, bracelets).
 Wash hands and arms with antimicrobial soap.
 Clean subungual areas with a nail file.
 Scrub each side of each finger, between the fingers, and the
back and front of the hand.
 Proceed to scrub the arms, keeping the hand higher than the
arm at all times. This prevents bacteria-laden soap and water
from contaminating the hand.
 Wash each side of the arm to three inches above the elbow.
 Repeat the process on the other hand and arm, keeping
hands above elbows at all times.
 Rinse hands and arms by passing them through the water in
one direction only, from fingertips to elbow. Do not move the
arm back and forth through the water.
 Proceed to the operating room suite holding hands above
elbows.

 Once in the operating room suite, hands and arms should be
dried using a sterile towel and aseptic technique. You are now
ready to don your gown and sterile gloves.
Source:
http://www.infectioncontroltoday.com/
How to Perform Surgical Hand Scrubs ARTICLE; May 1, 2001

GOWNING:
 When gowning oneself, grasp the gown firmly and bring it away from
the table. It has already been folded so that the outside faces away.
Holding the gown at the shoulders, allow it to unfold gently. Do not
shake the gown.
 Place hands inside the armholes and guide each arm through the
sleeves by raising and spreading the arms. Do not allow hands to slide
outside the gown cuff. The circulator will assist by pulling the gown up
over the shoulders and tying it.

CLOSED GLOVING:
 Lay the glove palm down over the cuff of the gown. The fingers of
the glove face toward you.
 Working through the gown sleeve, grasp the cuff of the glove and
bring it over the open cuff of the sleeve.
 Unroll the glove cuff so that it covers the sleeve cuff.
 Proceed with the opposite hand, using the same technique. Never
allow the bare hand to contact the gown cuff edge or outside of
glove.

OPEN GLOVING:
1. Pick up the cuff of the right glove with your

left hand. Slide your right hand into the
glove until you have a snug fit over the
thumb joints and knuckles. Your bare left
hand should only touch the folded cuff –
the rest of the glove remains sterile.
2. Slide your fingertips into the folded cuff of

the left glove.
3. Use gloved left hand pick up folded cuff of

right glove and pull glove up to gowned wrist.
4. Place the fingers of the gloved right hand under the cuff of the
partially gloved left hand. Unfold the cuff down over your gown
sleeves. Make sure your gloved finger tips do not touch your bare
forearms or wrists.
Source: https://stratog.rcog.org.uk/tutorial/general-principles/open-glove-
technique-6076

KNOT TYING (SQUARE KNOT)
TWO HAND TECHNIQUE

1. White strand placed over
extended index finger of left hand
acting as bridge, and held in palm
of left hand. Purple strand held in
right hand.
2. Purple strand held in right hand

brought between left thumb and
index finger.
3. Left hand turned inward by

pronation, and thumb swung
under white strand to form the
first loop.
4. Purple strand crossed over white

and held between thumb and
index finger of left hand.

5. Right hand releases purple strand.
Then left hand supinated, with
thumb and index finger still
grasping purple strand, to bring
purple strand through the white
loop. Regrasp purple strand with
right hand.
6. Purple strand released by left

hand and grasped by right.
Horizontal tension is applied with
left hand toward and right hand
away from operator. This
completes first half hitch.
7. Left index finger released from

white strand and left hand again
supinated to loop white strand
over left thumb. Purple strand
held in right hand is angled slightly
to the left.
8. Purple strand brought toward the

operator with the right hand and
placed between left thumb and
index finger. Purple strand crosses
over whit strand.

9. By further supinating left hand,
white strand slides onto left index
finger to form a loop as purple
strand is grasped between left
index finger and thumb
10. Left hand rotated inward by

pronation with thumb carrying
purple strand through loop of
white strand. Purple strand is
grasped between right thumb and
index finger.
11. Horizontal tension applied with

left hand away from and right
hand toward the operator. This
completes the second half hitch.
12. The final tension on the final

throw should be as nearly
horizontal as possible

ONE-HAND TECHNIQUE
1. White strand held between
thumb and index finger of left
hand with loop over extended
index finger. Purple strand held
between thumb and index finger
of right hand.
2. Purple strand brought over white

strand on left index finger by
moving right hand away from
operator.
3. With purple strand supported in

right hand, the distal phalanx of
left index finger passes under the
white strand to place it over tip of
left index finger. Then the white
strand is pulled through loop in
preparation for applying tension.
4. The first half hitch is completed

by advancing tension in the
horizontal plane with ht left hand
drawn toward and right hand
away from the operator.

5. White strand looped around three
fingers of left hand with distal end
held between thumb and index
finger.
6. Purple strand held in right hand

brought toward the operator to
cross over the white strand.
Continue hand motion by flexing
distal phalanx of left middle finger
to bring it beneath white strand.
7. As the middle finger is extended

and the left hand pronated, the
white strand is brought beneath
the purple strand.
8. Horizontal tension applied with

the left hand away and right hand
toward the operator. This
completes the second half hitch
of the square knot. Final tension
should be as nearly horizontal as
possible.
Source:
http://www.uphs.upenn.edu/surgery/Education/medical_students/square_knot.html

WOUND SUTURING
Various types of sutures. From Dorland's, 2000.

SUTURING TECHNIQUES
General Principles
Many varieties of suture material and needles are available. The choice of
sutures and needles is determined by the location of the lesion, the
thickness of the skin in that location, and the amount of tension exerted on
the wound. Regardless of the specific suture and needle chosen, the basic
techniques of needle holding, needle driving, and knot placement remain
the same.
Suture placement
A needle holder is used to grasp the needle at the distal portion of the
body, one half to three quarters of the distance from the tip of the needle,
depending on the surgeon’s preference. The needle holder is tightened by
squeezing it until the first ratchet catches. The needle holder should not be
tightened excessively, because damage to both the needle and the needle
holder may result. The needle is held vertically and longitudinally
perpendicular to the needle holder.
Incorrect placement of the needle in the needle holder may result in a bent
needle, difficult penetration of the skin, or an undesirable angle of entry
into the tissue. The needle holder is held by placing the thumb and the
fourth finger into the loops and placing the index finger on the fulcrum of
the needle holder to provide stability. Alternatively, the needle holder may
be held in the palm to increase dexterity.
The tissue must be stabilized to allow suture placement. Depending on the
surgeon’s preference, toothed or untoothed forceps or skin hooks may be
used to grasp the tissue gently. Excessive trauma to the tissue being sutured
should be avoided to reduce the possibility of tissue strangulation and
necrosis.
Forceps are necessary for grasping the needle as it exits the tissue after a
pass. Before removal of the needle holder, grasping and stabilizing the
needle is important. This maneuver decreases the risk of losing the needle
in the dermis or subcutaneous fat, and it is especially important if small
needles are used in areas such as the back, where large needle bites are
necessary for proper tissue approximation.

The needle should always penetrate the skin at a 90° angle, which
minimizes the size of the entry wound and promotes eversion of the skin
edges. The needle should be inserted 1-3 mm from the wound edge,
depending on skin thickness. The depth and angle of the suture depends on
the particular suturing technique. In general, the two sides of the suture
should become mirror images, and the needle should also exit the skin
perpendicular to the skin surface.
Knot tying
Once the suture is satisfactorily placed, it must be secured with a knot. The
instrument tie is used most commonly in cutaneous surgery. The square
knot is traditionally used.
First, the tip of the needle holder is rotated clockwise around the long end
of the suture for two complete turns. The tip of the needle holder is used to
grasp the short end of the suture. The short end of the suture is pulled
through the loops of the long end by crossing the hands, so that the two
ends of the suture are on opposite sides of the suture line. The needle
holder is rotated counterclockwise once around the long end of the suture.
The short end is then grasped with the needle holder tip and pulled through
the loop again.
The suture should be tightened sufficiently to approximate the wound

edges without constricting the tissue. Sometimes, leaving a small loop of
suture after the second throw is helpful. This reserve loop allows the stitch
to expand slightly and is helpful in preventing the strangulation of tissue
because the tension exerted on the suture increases with increased wound

edema. Depending on the surgeon’s preference, one or two additional
throws may be added.
Properly squaring successive ties is important. In other words, each tie must
be laid down perfectly parallel to the previous tie. This procedure is important
in preventing the creation of a granny knot, which tends to slip and is
inherently weaker than a properly squared knot. When the desired number of
throws is completed, the suture material may be cut (if interrupted stitches
are used), or the next suture may be placed.
PLACEMENT OF SPECIFIC SUTURE TYPES
A. Simple interrupted suture
The most commonly used and most versatile suture in cutaneous surgery
is the simple interrupted suture. This suture is placed by inserting the
needle perpendicular to the epidermis, traversing the epidermis and the
full thickness of the dermis, and exiting perpendicular to the epidermis on
the opposite side of the wound. The two sides of the stitch should be
symmetrically placed in terms of depth and width.
In general, the suture should have a flask-shaped configuration, that is,
the stitch should be wider at its base (dermal side) than at its superficial
portion (epidermal side). If the stitch encompasses a greater volume of
tissue at the base than at its apex, the resulting compression at the base
forces the tissue upward and promotes eversion of the wound edges (see
the image below). This maneuver decreases the likelihood of creating a
depressed scar as the wound retracts during healing.

Simple interrupted suture placement. Bottom right image shows a flask-
shaped stitch, which maximizes eversion.
As a rule, tissue bites should be evenly placed so that the wound edges
meet at the same level; this minimizes the possibility of mismatched
wound-edge heights (ie, stepping). However, the size of the bite taken
from the two sides of the wound can be deliberately varied by modifying
the distance of the needle insertion site from the wound edge, the
distance of the needle exit site from the wound edge, and the depth of
the bite taken.
The use of differently sized needle bites on each side of the wound can
correct preexisting asymmetry in edge thickness or height. Small bites can
be used to precisely coat wound edges. Large bites can be used to reduce
wound tension. Proper tension is important to ensure precise wound
approximation while preventing tissue strangulation.

B. Simple running suture
A simple running (continuous) suture is essentially an uninterrupted
series of simple interrupted sutures. The suture is started by placing a
simple interrupted stitch, which is tied but not cut. A series of simple
sutures are placed in succession, without the suture material being tied or
cut after each pass. The sutures should be evenly spaced, and tension
should be evenly distributed along the suture line.
The line of stitches is completed by tying a knot after the last pass at the
end of the suture line. The knot is tied between the tail end of the suture
material where it exits the wound and the loop of the last suture placed.
C. Running locked suture

A simple running suture may be either locked or left unlocked. The first
knot of a running locked suture is tied as in a traditional running suture
and may be locked by passing the needle through the loop preceding it as
each stitch is placed (see the image below). This suture is also known as
the baseball stitch because of the final appearance of the running locked
suture line.

D. Vertical mattress suture.
A vertical mattress suture is a variation of a simple interrupted suture. It
consists of a simple interrupted stitch placed wide and deep into the
wound edge and a second more superficial interrupted stitch placed
closer to the wound edge and in the opposite direction. The width of the
stitch should be increased in proportion to the amount of tension on the
wound—that is, the higher the tension, the wider the stitch.
E. Half-buried vertical mattress suture

A half-buried vertical mattress suture is a modification of a vertical
mattress suture that eliminates two of the four entry points, thereby
reducing scarring. It is placed in the same manner as the vertical mattress
suture, except that the needle penetrates the skin to the level of the deep
part of the dermis on one side of the wound, takes a bite in the deep part
of the dermis on the opposite side without exiting the skin, crosses back
to the original side, and finally exits the skin. Entry and exit points thus
are kept on one side of the wound.

F. Pulley suture
A pulley suture is a modification of a vertical mattress suture. A vertical
mattress suture is placed, the knot is left untied, and the suture is looped
through the external loop on the other side of the incision and pulled
across (see the image below). At this point, the knot is tied. This new loop
functions as a pulley, directing tension away from the other strands.
Pulley stitch, type 1.

G. Far-near near-far modified vertical mattress sutures
Another stitch that serves the same function as a pulley suture is a far-
near near-far modified vertical mattress suture. The first loop is placed
about 4-6 mm from the wound edge on the far side and about 2 mm from
the wound edge on the near side. The suture crosses the suture line and
reenters the skin on the original side at 2 mm from the wound edge on
the near side. The loop is completed, and the suture exits the skin on the
opposite side 4-6 mm away from the wound edge on the far side. A pulley
effect is thus created.
Far-near near-far modification of vertical mattress suture, creating pulley

effect.

H. Horizontal mattress suture
A horizontal mattress suture is placed by entering the skin 5 mm to 1 cm
from the wound edge. The suture is passed deep in the dermis to the
opposite side of the suture line and exits the skin equidistant from the
wound edge (in effect, a deep simple interrupted stitch). The needle
reenters the skin on the same side of the suture line 5 mm to 1 cm lateral
of the exit point. The stitch is passed deep to the opposite side of the
wound, where it exits the skin; the knot is then tied.

I. Half-buried horizontal suture
A half-buried horizontal suture (also referred to as a tip stitch or three-
point corner stitch) begins on the side of the wound on which the flap is
to be attached. The suture is passed through the dermis of the wound
edge to the dermis of the flap tip. The needle is passed laterally in the
same dermal plane of the flap tip, exits the flap tip, and reenters the skin
to which the flap is to be attached. The needle is directed perpendicularly
and exits the skin; the knot is then tied.
Half-buried horizontal suture (tip stitch, three-point corner stitch).

J. Dermal-subdermal sutures
A dermal-subdermal suture is placed by inserting the needle parallel to
the epidermis at the junction of the dermis and the subcutis. The needle
curves upward and exits in the papillary dermis, again parallel to the
epidermis. The needle is inserted parallel to the epidermis in the papillary
dermis on the opposing edge of the wound, curves down through the
reticular dermis, and exits at the base of the wound at the interface
between the dermis and the subcutis and parallel to the epidermis.
The knot is tied at the base of the wound to minimize the possibility of
tissue reaction and extrusion of the knot. If the suture is placed more
superficially in the dermis at 2-4 mm from the wound edge, eversion is
increased.

K. Buried horizontal mattress suture
A buried horizontal mattress suture is a purse-string suture. The suture
must be placed in the mid-to-deep part of the dermis to prevent the skin
from tearing. If tied too tightly, the suture may strangulate the
approximated tissue.
L. Running horizontal mattress sutures
A simple suture is placed, and the knot is tied but not cut. A continuous
series of horizontal mattress sutures is placed, with the final loop tied to
the free end of the suture material.
M. Running subcuticular sutures
A running subcuticular suture is a buried form of a running horizontal
mattress suture. It is placed by taking horizontal bites through the
papillary dermis on alternating sides of the wound. No suture marks are
visible, and the suture may be left in place for several weeks.
Subcuticular stitch. Skin surface remains intact along length of suture line.

N. Running subcutaneous suture
A running subcutaneous suture begins with a simple interrupted
subcutaneous suture, which is tied but not cut. The suture is looped
through the subcutaneous tissue by successively passing through the
opposite sides of the wound. The knot is tied at the opposite end of the
wound by knotting the long end of the suture material to the loop of the
last pass that was placed.
O. Running subcutaneous corset plication stitch
Before the needle is inserted, forceps are used to pull firmly on at least 1-
2 cm of tissue to ensure tissue strength. The corset plication includes at
least 1-2 cm of adipose tissue and fascia within each bite. After the first
bite is tied, bites are taken on opposite sides of the wound in a running
fashion along the defect. The free end is pulled firmly to reduce the size
of the defect, and the suture is then tied.
P. Variations of tip (corner) sutures
Modified half-buried horizontal mattress suture
In a modified half-buried horizontal mattress suture, an additional vertical
mattress suture is placed superficial to the half-buried horizontal
mattress suture. A small skin hook instead of forceps is used to avoid
trauma of the flap.
Deep tip stitch
A deep tip stitch is essentially a fully buried form of a three-corner stitch.
The suture is placed into the deep dermis of the wound edge to which the
flap is to be attached, passed through the dermis of the flap tip, and
inserted into the deep dermis of the opposite wound edge.
Source: Suturing Techniques Technique (Jul 11, 2017)

http://emedicine.medscape.com/article/1824895-technique#c4

BREAST EXAM
THE FEMALE BREAST

A. INSPECTION
 Inspect the breasts and nipples with the patient in the sitting
position and disrobed to the waist.
 Includes: careful inspection for skin changes, symmetry, contours,
and retraction in four views—arms at sides, arms over head, arms
pressed against hips, and leaning forward.
 Adolescent girl – assess her breast development according to
Tanner’s sex maturity ratings
a. Arms at Sides
1. Appearance of the skin, including:
 Color
 Thickening of the skin and unusually prominent pores, which
may accompany lymphatic obstruction
 The size and symmetry of the breasts. Some difference in the
size of the breasts, including the areolae, is common and
usually normal.
 The contour of the breasts. Look for changes such as masses,
dimpling, or flattening. Compare one side with the other.
2. Characteristics of the nipples
 Size and shape, direction in which they point, any rashes or
ulceration, or any discharge
 Occasionally, the shape of the nipple is inverted, or depressed
below the areolar surface. It may be enveloped by folds of
areolar skin, as illustrated. Long-standing inversion is usually a
normal variant of no clinical consequence, except for possible
difficulty when breast-feeding.
b. Arms over Head; Hands Pressed Against Hips; Leaning Forward
 bring out dimpling or retraction that may otherwise be
invisible

B. PALPATION
1. The Breast
 Best performed when the breast tissue is flattened = patient
supine.
 Plan to palpate a rectangular area extending from:
o clavicle to the inframammary fold or bra line &
o midsternal line to the posterior axillary line and well into
the axilla for the tail of the breast.
 A thorough examination will take 3 minutes for each breast.
 Use the fingerpads of the 2nd, 3rd, and 4th fingers, keeping
the fingers slightly flexed.
 Vertical strip pattern - best validated technique for detecting
breast masses.
 Palpate in small, concentric circles at each examining point, if
possible applying light, medium, and deep pressure.
a. Lateral portion of the breast – PX roll onto the opposite
hip, hand on her forehead, shoulders pressed against the
bed or examining table (flattens the lateral breast tissue)
b. Examine the breast tissue carefully for:
o Consistency of the tissues
 Physiologic nodularity before menses.
 Firm transverse ridge of compressed tissue (lower
margin of the breast, especially in large breasts) =
Normal inframammary ridge, not a tumor.
o Tenderness, as in premenstrual fullness
o Nodules
 Lumps or mass that is qualitatively different from or
larger than the rest of the breast tissue = dominant
mass (may reflect a pathologic change)
 Assess and describe the characteristics of any
nodule:
1. Location—by quadrant or clock, with cm from
the nipple
2. Size—in cm
3. Shape—round or cystic, disc-like, or irregular in
contour

4.Consistency—soft, firm, or hard
5.Delimitation—well circumscribed or not
6.Tenderness
7.Mobility—in relation to the skin, pectoral fascia,
and chest wall. Watch for dimpling.
2. The Nipple – elasticity
THE MALE BREAST

 Inspect - nipple and areola for nodules, swelling, or ulceration
 Palpate the areola and breast tissue for nodules
 Gynecomastia
Source: Bates' Guide to Physical Examination and History Taking (11th

edition)

DIGITAL RECTAL EXAM
 Suitable patient positions for conducting the examination:

o Patient to stand and lean forward with his upper body resting across
the examining table and hips flexed
o Side-lying position – satisfactory and allows good visualization of the
perianal and sacrococcygeal areas.
 Ask the patient to lie on his left side with his buttocks close to the edge of
the examining table near you. Flexing the patient’s hips and knees,
especially in the upper leg, stabilizes his position and improves visibility.
Drape the patient appropriately and adjust the light for the best view.
Glove your hands and spread the buttocks apart.
 Inspect the sacrococcygeal and perianal areas for lumps, ulcers,
inflammation, rashes, or excoriations. Adult perianal skin is normally more
pigmented and somewhat coarser than the skin over the buttocks. Palpate
any abnormal areas, noting lumps or tenderness.
 Examine the anus and rectum. Lubricate your gloved index finger, explain
to the patient what you are going to do, and tell him that the examination
may trigger an urge to move his bowels but that this will not occur. Ask him
to strain down. Inspect the anus, noting any lesions.
 As the patient strains, place the pad of your gloved and lubricated index
finger over the anus.
 As the sphincter relaxes, gently insert your fingertip into the anal canal in
the direction pointing toward the umbilicus. If you feel the sphincter
tighten, pause and reassure the patient. When, in a moment, the sphincter
relaxes, proceed.

 Occasionally, severe tenderness prevents entry and internal examination.
Do not try to force it. Instead, place your fingers on both sides of the anus,
gently spread the orifice, and ask the patient to strain down. Look for a
lesion, such as an anal fissure, that might explain the tenderness.
 If you can proceed without undue discomfort to the patient, note:
o The sphincter tone of the anus. Normally, the muscles of the anal
sphincter close snugly around your finger. Initial resting tone reflects
the integrity of the internal anal sphincter. To check external sphincter
tone, ask the patient to bear down and squeeze the rectal muscles.
o Tenderness, if any
o Induration
o Irregularities or nodules
 Insert your finger into the rectum as far as possible. Rotate your hand
clockwise to palpate as much of the rectal surface as possible on the
patient’s right side, then counterclockwise to palpate the surface
posteriorly and on the patient’s left side.
 Note any nodules, irregularities, or induration. To bring a possible lesion
into reach, take your finger off the rectal surface, ask the patient to strain
down, and palpate again.
 Then rotate your hand further counterclockwise so that your finger can
examine the posterior surface of the prostate gland. By turning your body
somewhat away from the patient, you can feel this area more easily. Tell
the patient that examining his prostate gland may prompt an urge to
urinate.

 Sweep your finger carefully over the prostate
gland, identifying its lateral lobes and the median
sulcus between them. Note the size, shape, and
consistency of the prostate, and identify any
nodules or tenderness. The normal prostate is
rubbery and nontender.
 If possible, extend your finger above the prostate
to the region of the seminal vesicles and the
peritoneal cavity and sweep the anterior wall.
Note any nodules or tenderness.
 Gently withdraw your finger, and wipe the anus or
give the patient tissues. Note the color of any fecal
matter on your glove, and test it for occult blood.
FEMALE
 The rectum is usually examined after the female genitalia while the woman
is in the lithotomy position. This position allows you to conduct the
bimanual examination and delineate a possible adnexal or pelvic mass. It
allows you to test the integrity of the rectovaginal wall and may help you to
palpate a cancer high in the rectum.
 If you need to examine only the rectum, the lateral position is satisfactory
and affords a much better view to the perianal and sacrococcygeal areas.
Use the same techniques for examination that you use for men. Note that
the cervix is readily palpated through the anterior wall. Sometimes a
retroverted uterus is also palpable. Do not mistake either of these, or a
vaginal tampon, for a tumor.
Source: Bates' Guide to Physical Examination and History Taking (11th

edition)

PCS CPG

EVIDENCE-BASED CLINICAL PRACTICE
GUIDELINES ON THE DIAGNOSIS AND
TREATMENT OF ACUTE APPENDICITIS
Philippine College of Surgeons (2002)
Operational Definitions:
 Uncomplicated Appendicitis - includes the acutely

inflamed, phlegmonous, suppurative or mildly
inflamed appendix with or without peritonitis.
 Complicated Appendicitis - includes gangrenous

appendicitis, perforated appendicitis, localized
purulent collection at operation, generalized
peritonitis and periappendiceal abscess.
 Equivocal Appendicitis - a patient with right lower

quadrant abdominal pain who presents with an
atypical history and physical examination and the
surgeon cannot decide whether to discharge or to
operate on the patient.

Executive Summary:
 When should one suspect appendicitis?

Consider the diagnosis of acute appendicitis when a patient
presents with right lower quadrant abdominal pain.
 What clinical findings are most helpful in diagnosing acute

appendicitis?
Acute appendicitis should be suspected in any patient
(especially male) who presents with a high intensity of
perceived abdominal pain of at least 7-12 hours duration, with
migration to the right lower quadrant, and followed by
vomiting.
Although symptoms alone have a low discriminating power,
the diagnosis of acute appendicitis becomes more certain when
the physical examination findings include right lower quadrant
tenderness, guarding, rebound tenderness and other signs of
peritoneal irritation.
 What diagnostic tests are helpful in the diagnosis of acute

appendicitis?
Although the diagnosis of acute appendicitis is primarily
based on the clinical findings, the following examinations may
be helpful:
A. All Cases
1. White blood cell differential count
B. Equivocal Appendicitis in Adults
1. CT Scan
2. Ultrasound

Whenever feasible, CT scan should be preferred over
ultrasonography in clinically equivocal appendicitis in adults
because of its superior accuracy.
C. Equivocal Appendicitis in the Pediatric Age Group
1. Ultrasound (graded compression)
2. CT scan
Although CT scan and ultrasound have comparable
accuracy in the diagnosis of acute appendicitis in the pediatric
age group, ultrasound is preferred because of its lack of
radiation, cost-effectiveness and availability compared to CT
scan.
D. Selected Cases
1. Diagnostic Laparoscopy
Despite its statistically significant favorable effects,
diagnostic laparoscopy should be viewed as an invasive
procedure requiring anesthesia and having risks similar to
appendectomy. It should be utilized at this time only in
selected cases.
The following examinations are generally not useful in the
diagnosis of acute appendicitis:
1. Plain Abdominal X-ray
2. Barium Enema
3. Scintigraphy
 What is the appropriate treatment for acute appendicitis?

Appendectomy is the appropriate treatment for acute
appendicitis.

 What is the recommended approach to the surgical
management of acute appendicitis?
Open appendectomy is the recommended primary
approach to the treatment of acute appendicitis in our
setting.
Therapeutic laparoscopic appendectomy is an alternative
in selected cases.
 What is the role of laparoscopic appendectomy in the

management of acute appendicitis in children?
Laparoscopic appendectomy may be recommended as an
alternative to open appendectomy in the pediatric age group.
 What is the role of antibiotics in the management of acute

appendicitis?
A. Is antibiotic prophylaxis indicated for uncomplicated
appendicitis?
YES. Antibiotic prophylaxis is effective in the
prevention of surgical site infection for patients who
undergo appendectomy and should be considered
for routine use.
B. What antibiotic/s is/are recommended for prophylaxis in
uncomplicated appendicitis and what is the appropriate
dose and route of administration?
The following antibiotics are recommended for
prophylaxis in uncomplicated appendicitis:
o Cefoxitin
 2 g IV single dose (Adults)
 40 mg/kg IV single dose (Children)

Alternative agents:
o Ampicillin-sulbactam
 1.5-3 g IV single dose (Adults)
o Amoxicillin-clavulanate
 1.2-2.4 g IV single dose (Adults)
For patients with allergy to β-lactam antibiotics:
o Gentamicin 80-120 mg IV single dose plus
Clindamycin 600 mg IV single dose (Adults)
o Gentamicin 2.5 mg/kg IV single dose plus
Clindamycin 7.5-10 mg/kg IV single dose
(Children)
C. What antibiotic/s is/are recommended for the
treatment of complicated appendicitis and what is the
appropriate dose, route and duration of
administration?
The recommended antibiotics for therapy of
complicated appendicitis in adults are:
o Ertapenem 1 g IV every 24 hours
o Tazobactam-piperacillin 3.375 g IV every 6 hours
or 4.5 g IV every 8 hours
For adults with β-lactam allergy:
o Ciprofloxacin 400 mg IV every 12 hours plus
o Metronidazole 500 mg IV every 6 hours
The recommended antibiotic for therapy of
complicated appendicitis in pediatric patients is
ticarcillin-clavulanic acid 75 mg/kg IV every 6 hours
Alternative agents for pediatric patients include:
o Imipenem-Cilastatin 15-25 mg/kg IV every 6 hours

For children with β-lactam allergy:
o Gentamicin 5 mg/kg IV every 24 hours plus
Clindamycin 7.5-10 mg/kg IV every 6 hours
For gangrenous appendicitis, the recommended form
of management is to treat in the same manner as
uncomplicated appendicitis.
The duration of therapy may vary depending on the
clinician's assessment after the operation. The therapy
may be maintained for 5-7 days. Sequential therapy to
oral antibiotics may be considered when gastrointestinal
function has returned.
The absence of fever for 24 hours (temperature
<380C), the ability to tolerate oral intake and a normal
WBC count with 3 % or less band forms are useful
parameters for the discontinuation of antibiotic therapy.
 Should gram stain and culture and sensitivity be routinely

done?
Gram stain and culture and sensitivity testing for
intra-operative specimens (purulent peritoneal fluid or
tissue) should not be routinely performed except in high-
risk and immuno-compromised patients.
 How should localized peritonitis be managed?

No necrotic tissue or purulent material should be
left behind as much as possible. General peritoneal
lavage is not recommended for localized peritonitis.
Intra-peritoneal drains, while most useful in patients
with a well-established and localized abscess cavity,
should be selectively utilized.

 What is the appropriate method of wound closure in
patients with complicated appendicitis?
The incision may be closed primarily in patients
with complicated appendicitis.
 What is the optimal timing of surgery for patients with

peri-appendiceal abscess?
A patient with a peri-appendiceal abscess should
undergo surgery as soon as the diagnosis is made.

EVIDENCE-BASED CLINICAL PRACTICE
GUIDELINES ON THE DIAGNOSIS AND
TREATMENT OF CHOLECYSTITIS
Philippine College of Surgeons (2004)
Operational Definitions:
 Symptomatic Cholecystitis – include bot acute and chronic

cholecystitis
 Acute Cholecystitis – acute upper abdominal pain with
tenderness under the right costal margin accompanied by
fever, laboratory markers of inflammation and scintigraphy or
sonologic evidence.
 Complicated Cholecystitis – refers to emphysematous
cholecystitis, cholecystitis with perforation and secondary
peritonitis, pericholecystic abscess formation and generalized
peritonitis
 Early Cholecystectomy – cholecystectomy performed within
72 hours of administration
 Delayed Cholecystectomy – initial conservative treatment
with antimicrobials followed by cholecystectomy 8-12 weeks
later
 Standard Open Cholecystectomy – transverse subcostal skin
incision greater than 6cm in length to provide comfortable
exposure of the gallbladder
 Mini-incision/ Minilaparotomy Cholecystectomy –
transverse subcostal skin incision less than or equal to 6cm in
length

 Laparoscopic Cholecystectomy – use of 10mm subxiphoid
and 5 mm lateral trocars for cholecystectomy
Executive Summary:
 What clinical findings are most helpful in diagnosing

symptomatic cholecystitis?
No single clinical finding is sufficient to establish or exclude
the diagnosis of symptomatic cholecystectomy.
 What ancillary tests are helpful in the diagnosis of acute

cholecystitis?
The most accurate imaging test in suspected acute
cholecystitis is hepatobiliary scintigraphy. For practical
purposes however, ultrasonography is the appropriate imaging
procedure.
 What ancillary tests is the most helpful in the diagnosis of

chronic calculous cholecystitis?
Ultrasonography is the most helpful diagnostic test for
chronic calculous cholecystitis.
 Is cholecystectomy indicated for asymptomatic gallstone?

Routine cholecystectomy is not recommended for
asymptomatic gallstones. However, cholecystectomy may be
considered in selected group of patients.

 What is the recommended surgical approach in the
management of acute cholecystitis?
The recommended surgical for acute cholecystitis are open
cholecystectomy (standard or mini-cholecystectomy) or
laparoscopic cholecystectomy.
 What is optimal timing of surgery for acute cholecystitis?

Patients with acute cholecystitis should undergo
cholecystectomy within 72 hours of admission.
 Is antibiotic therapy indicated in the management of acute

cholecystitis?
A. Empiric antibiotic therapy for uncomplicated acute
cholecystitis:
1. Cefazolin 1 gram IV every 8 hours
2. Cefuroxime 1.5 gram IV every 8 hours
3. Cefoxitin 2 gram IV every 8 hours (if at risk for
anaerobic infection)
For patients with allergy to beta-lactam antibiotics:
Fluoroquinolone 100 mg IV every 12 hours +
Metronidazole 500 mg IV every 6 hours
B. Recommended for therapy in complicated acute
cholecystitis:
1. Cefoxitin 2 grams IV every 8 hours
2. Ertapenem 1 grams IV every 24 hours
Beta-lactam/ Beta-lactamase inhibitors:
3. Ampicillin-sulbactam 1.5-3 grams IV every 6 hours
(add Gentamicin 240 mg IV every 24 hours if with risk
for enterococcal infection)

For patients with allergy to beta-lactam antibiotics:
Fluoroquinolone 400 mg IV every 12 hours +
Metronidazole 500 mg IV every 6 hours
The duration of therapy may vary depending on the
clinician's assessment after the operation. The therapy may
be maintained for 5-7 days. Sequential therapy to oral
antibiotics may be considered when gastrointestinal function
has returned.
The absence of fever for 24 hours (temperature <380C),
the ability to tolerate oral intake and a normal WBC count
with 3 % or less band forms are useful parameters for the
discontinuation of antibiotic therapy.
 What is the recommended surgical approach in the

management of chronic cholecystitis?
Laparoscopic cholecystectomy is the recommended
surgical approach in the management of chronic cholecystitis.
 Is antibiotic therapy indicated in the management of

chronic cholecystitis?
Antibiotic prophylaxis is the recommended for patients
who will undergo open cholecystectomy for chronic
cholecystitis. For patients who will undergo laparoscopic
cholecystectomy, antibiotic prophylaxis is likewise
recommended.
The following antibiotics are recommended for prophylaxis
in chronic cholecystitis:
1. Cefazolin 1g IV single dose within 2 hours pre-operatively

Alternative agents:
2. Cefuroxime 1.5g IV single dose within 2 hours pre-operatively
3. Gentamicin 80mg IV single dose within 2 hours pre-
operatively
 Should an intra-peritoneal drain be routinely placed after

cholecystectomy?
An intra-peritoneal drain need not be routinely placed after
cholecystectomy.


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SURGERY

SURGERY CLINICS Page 1 of 53

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ACUTE & UNCOMPLICATED APPENDICITIS:

CEFAZOLIN 2 g IV single dose

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INGUINAL HERNIA SURGERY:

Antibiotic prophylaxis is NOT recommended in

CEFAZOLIN 1 g IV single dose

SURGERY CLINICS Page 7 of 53

GASTRIC & DOUDENAL SURGERY:

CEFAZOLIN 1 g IV single dose

ERTAPENEM 1 g IV single dose

SURGERY CLINICS Page 8 of 53

Harrison's Principles of Internal Medicine (19th edition)

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Purpose of surgical hand scrubo:

SURGICAL SCRUB TECHNIQUES

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1. Pick up the cuff of the right glove with your

2. Slide your fingertips into the folded cuff of

3. Use gloved left hand pick up folded cuff of

SURGERY CLINICS Page 15 of 53

TWO HAND TECHNIQUE

2. Purple strand held in right hand

3. Left hand turned inward by

4. Purple strand crossed over white

SURGERY CLINICS Page 16 of 53

6. Purple strand released by left

7. Left index finger released from

8. Purple strand brought toward the

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10. Left hand rotated inward by

11. Horizontal tension applied with

12. The final tension on the final

SURGERY CLINICS Page 18 of 53

2. Purple strand brought over white

3. With purple strand supported in

4. The first half hitch is completed

SURGERY CLINICS Page 19 of 53

6. Purple strand held in right hand

7. As the middle finger is extended

8. Horizontal tension applied with

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Various types of sutures. From Dorland's, 2000.

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The suture should be tightened sufficiently to approximate the wound

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C. Running locked suture

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E. Half-buried vertical mattress suture

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