ve a put 4 Edition : Z SA cera reecci to the Principles Ca GENERAL SURGERY — dul Wahab DogarJamsheq Ichaw Fimay Yeo v Is-100 A comprehensive approch to the principles of ety VE SURGERY FOURTH EDITION Medicalstudyzone.com Abdul Wahab Dogar Consultant Liver Transplant & Hepatopancreaticobiliary (HPB) Surgeon Doctor's Hospital & Medical Centre Lahore FAROOQ KITAB GHAR Urdu Bazar Karachi- Pakistan Tel: +92 213 2634791Important Note Assalamu alaikum mates This pdf was created by Arshad Ullah ( Final year Mbbs Ayub medical college Abbotabad). This pdf was downloaded from medicalstudyzone.com. You can request a specific book in pdf format. Just go to medicalstudyzone.com and contact us from there. Or you can direct email us at arshadullahbangash@gmail.com Regards Arshad Ullah Owner at medicalstudyzone.comThis book is protected by copy rights in the name of Dr Abdul Wah rules and regulations of Govt of Pakistan under the Copyright act ay is 17218.No part of the book can be reproduced or reprinted a Bistration no written permission of the author. In case of non compliance stri according to copyright act of the Govt of Pakistan, 1 DOB 2s per ind fo. ans without ict action will be taken Title: “A Comprehensive Approach to Principles of General Surgery Author: Abdul Wahab Dogar Consultant liver transplant & Hepatopancreaticobiliary (HPB) Surgeon Doctor's Hospital & Medical centre Lahore Published by: Younas GABA Faroog Kitaab Ghar, Urdu bazaar Karachi Design by: Nazeer Jabbar (Alfalah Graphics) Year of Publication: Ist Edition: Aug 2006 2nd Edition July 2007 3rd Edition July 2008 4th Edition Oct 2016 Number of copies: 2000DEDICATED TO Muhammad ( pheyaleail.ie ) “The Last Prophet and The First soul Created By ALLAH” Medicalstudyzone.comIN THE NAME OF ALLAH CNAs ae The production of new edition is always a labor ot eee eae origin in the ha aha benno ion, many; i am deeply indebted to my beloved wife Afrah Saif for 12 and assistance of help and patience. Constant suppor, This time a lot of contribution was made by different speciatst; andthe hes made the contents nore ata noe pace spective id These include Dr llyas Sadiq, Dr Khuram Niaz, Dr Malik Muhammen ete Sharjeel A Wahid, Dr Ghulam Mustafa, Dr Muhammad Haroon Nee bl Asghar, Dr Shakeel Ahmad Memon, Dr Ehsan Ullah, and Dr Hullidin ame | will like to extend my thanks to Khadija Fazal Karim (BS Zoology, Punjab Unive Lahore) for drawing beautiful sketches to make the book more aie horas and more comprehensive than it was before. | am profoundly thankful to ALLAH Almighty for blessing me with courage and patience to complete such an uphill task. Lastly it is necessary to mention Mr. Muhammad Younas GABA (Farooq Kitaab Ghar, Urdu Bazaar, Karachi) for publishing the book to combat with the international standards and also Mr. Nazeer Jabbar for composing the book in attractive and colorful manner The author alone is responsible for all the shortcomings of this book. He welcome the suggestions for further betterment of the book.CONTRIBUTORS {am greatly indebted to the following seniors and colleagues for helping and contributing for this book. Dr tlyas Sadiq FRCS Assistant Professor of Vascular Surgery Allama Iqbal Medical College Lahore Dr Khuram Niaz MBBS, FCPS Consultant General and Laparoscopic surgeon ATLS Provider Bahawal Victoria Hospital Bahawalpur Dr Malik Muhammad Makki MBBS, FCPS, MD. Dr Zahid Asgher MBBS, MD, FCAP, FASCP Diplomate american board of anatomic and clinical pathology Doctor's Hospital and medical center Lahore Dr Sobia Ashraf MBBS, FCPS (Haematology) Consultant Doctor's Hospital and medical center Lahore Dr Ghulam Mustafa MBBS, FCPS Assistant Professor of Surgery Fatima Memorial Hospital Lahore Dr Sharjeel A Wahid MBBS, FCPS, Uro-oncology Fellow “Chang-Gung Memorial Hospital Kahosiung, Taiwan Shakeel Ahmad Memon FCPS anesthetist of Medical sciences Gambat Dr Ehsan Ullah MBBS, MPhil FRSPH Clinical Effectiveness Advisor f Quality Departement Auckland City Hospital Auckland District Health Board Auckland, New Zealand Dr Adel Asghar MBBS, Chief resident radiology Doctors Hospital & Medical centre Lahore Dr Husnain Ali tlyas MBBS Clinical fellow, liver transplant surgery Doctor’s Hospital & Medical centre Lahore Dr Muhammad Haroon MBBS, MRCS Chief resident surgery Sheikh Zayed Hospital Lahore Dr Afrah Saif MBBS Internee Medicine Sheikh Zayed Hospital Lahore Khadija Fazal Kareem BS Zoology, Punjab University Lahore Roma John Liver transplant coordinator Doctors Hospital & Medical Centre LahorePreface to the first Edition Medical sciences including surgery fs avast and rapidly changing field but th ut the basic level, all that is necessary and what ‘am. During my own preparation of hich would cover all the aspects of ‘ant stimulus in writing this book, concepts remain the same. At the undergraduate | every student desires is to pass the professional ex: final year exam, | really felt the need of a book wi the subject. That has been a motive and const What we have done will not be last to all, everything ripens at its time and becom, fruit at its hour. | am proud of bring out a book after taking a lot from saat juniors and off course my patients. | am really thankful to Ruwan, acd ee Banira Karkie, Sushrusha Arjayal, Abdul Rauf, Samar and Maria Younus who a me a lot during the preparation of first edition, Preface to the fourth Edition The overwhelming response and valuable comments of the readers have been immensely encouraging and source of stimulus for me to bring out the fourthedition in order to fulfill the requirement of the current pattern of professional examination. All the chapters have been updated and references have been added from recent journals and books. Vancouver style has been used for coding the references. The chapters on Shock, Fluids & electrolytes, Acid base disorders, vascular disorders, preoperative and postoperative evaluation and surgical infections have been thoroughly revised and elaborated. A new chapter on Minimal invasive surgery including robotic surgery has been included. In order to impart a long lasting memory and to make the process of learning the art of surgery more convenient colored tables, diagrams and sketches are drawn throughout the book. ‘Abdul Wahab Dogar aticobiliary (HPB) Surgeon & Hepatopancre Consultant Liver Transplant & Hepatop: a edi Cee Hoe Doctor's Hospitalede A ei NO [. os o NTE nS + Radiology _ 2 Pre-operative Evaluation & Managements : 5 Aseptic Techniques & Sterilizations oe [4 Anesthesia & Analgesia _ $60 |uSuturesiNead/estmiiingmmnn 2 een a 6 Post-operative Care a [ae "> Post Operative Complications ——— ‘Surgical Audit | Advanced Trauma L. Thoracic Trauma _ Warfare Injuries 72. Neurosurgical Trauma Oo 73. Burn Injuries Oo ® 74. Plastic Surgery . ge 92 15. Acid Base Disorders se x 100 16. Fluids Therapy “> a Oo 104 17 Hemorrhage & Shock ie _W“V 118 1 Blood Transfusion _ i SV 190 [79. dl a 2). Principles Of Oncology - ~ | me Sin Cesloneme © oo a 23. Surgical infections — GO tl 187 24 Arterial Disorders PS — 204 25. Venous Disorders : 219 26. Lymphatic Disorders AS gee 227, 27. Minimal Access Surgery - 236 | 28. Surgical Anatomy we | 243 | |_29.| Key For Mcqs | 269 | L30.| Index = { | viiRadiology HAPTER Dr. Adeel Asghar O although majority of our diagnosis in surgical practice are based on clinical history and ysical examination. Imaging help to confirm nical diagnosis, resolve uncertainties and helps for legal documentation. Most of our surgical decisions are based on imaging reports but it is very important for the clinician that these should only be requested when there is reasonable chance that it will affect the management of the patient. Basic principle of imaging is that simple and least expensive test (ultrasound, x-rays) should be requested first and if it fails to provide any answer than more complex tests (CT, MRI, MRA) should requested. It is also essential for the clinician to view the imaging results in conjunction with clinical conditions of the patient and to treat the patient rather than to treat the imaging. There are many radiological techniques for imaging the various parts of the body but in this chapter, we will discuss only those which are used commonly and readily available in most of the hospitals. ULTRASOUND Itis the method for examination of a wide ge of clinical problems like abdominal mass, tic, pancreatic, aortic, biliary, urinary tract and gynecological diseases. It is also helpful the diagnosis of diseases of small parts of ¢ body like thyroid, testes and breast. No radiation risks. invasive. No special preparation. Immediate report. Reproducible results. Painless. Sedation is not required. * Inexpensive. Disadvantages * Operator dependant © Long learning curve ‘* Interpretation only possible during the examination * Resolution dependant Mechanism of Action: It is most common method of imaging. The transducer probe is the main part of the ultrasound machine. The transducer probe makes the sound waves and receives the echoes. It is, so to speak, the mouth and ears of the ultrasound machine High frequency sound waves are directed into the body generated by a transducer. As the sound travels through the body, it is reflected by the tissue interface to produce echo which are picked up by the same transducer and are converted into electrical signals and these electrical signals are converted into an image. Medical ultrasound uses frequencies in the range 3-20MHz.The higher the frequency of ultrasound wave, the greater the resolution of the image, but the less depth of view from the skin. Consequently abdominal imaging use transducers with a frequency of 3.5-5MHz, while the higher frequency transducers 5- 10MHz are used for superficial structures such as muscles, breast and testis. B scan (brightness scan): It is the ultrasound of eye ball/ orbit with higher frequencyNT nsducer i.e. 10. dete 5MHz, It t is helpful to choroidal detachment, haemorthge, intraorbital tumours, >reign bodies, ocular measurements, Main method of examination is the ‘act method with patient lying supine and transducer placed directly on the closed eyelid with an. intervening coupling gel mine retinal Vitreous localize fc Proptosis, cont Since >!nce air, bone and other heavily calcified Materials absorb nearly all ultrasound beams, so USG play little part in diagnosis of lung or bone disease. Fluid is very good conductor of sound waves and is therefore itis good modality ‘or diagnosis of cysts, examination of bladder and biliary system, A recent advance is development of small USG probe which can be placed much closed to region of interest thus producing highly detailed images e.g. trans-esophageal probe can be attached to the tip of endoscope (endoscopic ultrasound: EUS).EUS is gold standard for the local assessment of esophageal tumor. Through EUS it is possible to get FNA of pancreatic lesions. Similarly rectal probe for examining prostate and transvaginal probe for examining pelvic structures provides very promising results. Echocardiography (ECHO) is also a type of ultrasound using high frequency sector probe. It clearly shows the chambers of heart, the valves, the papillary muscles and the interventricular septum. Cardiac function tests can also be calculated by echo. Doppler ultrasound: Reflection of an ultrasound wave from moving objects such as red blood cells causes a change in the frequency of ultrasound waves. By measuring this frequency change, it is possible to calculate speed and direction of the movement of blood. This principle forms the basis of Doppler ultrasound, whereby velocities within major vessels can be measured. Doppler imaging is widely used in the assessment of arterial and venous disease in which stenotic lesion cause an alteration in the normal velocity. Dy lk a Doppler ultrasound with B mode and 2° standard for obtaining vascular flow 8% and for varicose veins. in Limitations Ultrasound waves are absorbed ; therefore ultrasound is not an ideal 2" technique for the bowel. Intestinal gay Bh also prevent visualization of deey such as the pancreas and aorta, Patients who are obese are more ditfcy, image because tissue attenuates the yt! waves as they pass deeper into the by mq Ultrasound has difficulty in penetrat and only the outer surface of bony can be seen per Sut ing | Y tts CONVENTIONAL RADIOGARAPHS (x, In many languages, X-radiation is refereg with terms meaning. Roentgen radiation, wilhelam Roentgen(2), who is credited as discoverer. X-rays are used fr all conventin radiology and for computed tomogra (C1). They are produced by passing very voltage across the two tungsten terminals with, an evacuated tube. One terminal, the cathos is heated to incandescence so that it liberates free electrons. When a high voltage (50-150, is applied across the two terminals, the electrons are attracted towards the anode a high speed. When these electrons hit th anode, x-rays are produced which are allovei to pass through a window in tube causing' make them useful. Ne 9 Figure: 1 Showing mechanism of x 2. a raysechanism of action: While performing Mfventional radiography; x-rays are thrown gam one direction and radiograph film idetecto) placed in opposite direction of ihe patient. When these x-rays are allowed to wes through the body these are absorbed to |) variable extent depending, upon the tissue | gensities and atomic number and shadow id formed on detector. The visibility of normal ind diseased structures depends upon this differential absorption. With conventional radiographs there are four basic densities i.e, sir, fat, all other soft tissues and calcified structures (bones). X-Rays that pass through the air (lungs) are least absorbed and cause most blackening of the radiograph film whereas calcium absorbs the most and so bones and other calcified structures appear virtually white on radiographic film. The soft tissues with exception of fat, e.g. solid viscera’s, muscles, blood, a variety of fluids, bowel wall, etc all have similar absorption capacity and appear same shade of grey on conventional radiographs. Fat absorbs slightly fewer x-rays and therefore appear little blacker than other | soft tissues. Different soft tissues cannot be reliably distinguished as they possess similar densities; despite this conventional radiography has many advantages. It is cheap, universally available and can be compared with the previous examinations. Common Uses: * Chest X-Rays: For detecting abnormalities in thorax e.g pneumothorax, hydrothorax and other lung pathologies X-Ray Abdomen: For detecting abdominal abnormalities e.g. intestinal in and perforation. ‘of bones: For detecting fractures Contrast x rays: As we have already discussed that that different soft tissues cannot be reliably distinguished. In order to overcome this problem administration of contrast material with radiography is used. Contrast can be given intravenously or orally depending upon the viscera to be examined. Intravenous iodinated contrast is used in intravenous urography (IVU).Intravenous contrast results in the opacification of renal excretory system.IVU is discussed in detail in “A practical guide to OSPE/OSCE/TOACS and clinical methods in surgery” by the same author. ; Oral contrast (barium/gastrograffin) is used to delineate gastrointestinal tract. Barium can also be given through rectum for colonic examination Fluoroscopy: In fluoroscopy, a continuous X-ray beam is used to create a sequence of images that are projected on a monitor. When used with a contrast material, which clearly defines the area being examined by making it appear bright white, this special X-ray technique makes it possible for the physician to view internal organs in motion i.e. cine /video radiography Still images are also captured and stored, either on film or electronically on a computer BARIUM STUDIE Various types of barium X-ray examinations are used to examine different parts of the gastrointestinal tract. These include barium swallow, barium meal, barium follow-through, and enema (3). Barium swallows: X-ray examinations are usec to study the pharynx and esophagus. A thict barium mixture is swallowed in supine positior and fluoroscopic images of the swallowin process are made. Then several swallows of thin barium mixture are taken and the passag is recorded by fluoroscopy and standar radiographs. Barium meal examinations are used to stu the lower esophagus, stomach arBarium follow through exam ations are used 1 rium follow through examinal! : eee oa ey, to study the small intestine. Barium enema examinations are used 10 study the large intestine and rectu and are ¢ lassified as lower gastrointestinal series. Barlufh given through rectum by passing 4 small catheter into the rectum and radiographic images are obtained. Double contrast barium studies are done to detect mucosal abnormalities. In double contrast studies, barium !s followed by introduction of air i.e Co2 in case of upper GI studies (by ingestion of some effervescent agent i, e sprite or eno) and room air in case of enema (air is insufflated through the rectal tube). When air is introduced after barium, it he lumen and only clears all barium from t mucosa is outlined. Barium studies are helpful for the diagnosis of the tumor, its location, ulceration or any stricture of the gastrointestinal tract. Figure 2: CC view of right breast MAMMOGRAPHY Mammography is a special type of x-ray imaging, used to create detailed images of the breast. Low dose x-ray is used in this test. Breast compression is necessary to flatten the breast so that the maximum amount of tissue can be imaged and examined. It also allows for a lower x-ray dose and immobilization of the breast to reduce motion blur. Compression also reduces x-ray scatter, which may degrade the image. Mammography plays a major role in the early detection of brest cancer, detecting about 75% Pi cancers at least a year before they can be It. There are 2 types of mammography examinations: screening and diagnostic. Screening mammography: It is done in asymptomatic women. Early detection of small breast cancers by screening mammography tly improves a woman's chances for Figure 3: MLO view of right bre? 7for screening mammography, ¢ ‘ach breas ged separately Dreast is imal for many years, the American Cancer Society (acs) recommended annual screeniay mammograms starting at age 40, but in October 2015, they issued new recommendations ther moved in the direction of those of the medical experts. They now recommend that women at average risk of breast cancer start mammography at 45, that they undergo annual mammograms from 45-54, and continue to undergo mammography every other year after that. Diagnostic mammography: Diagnostic mammography is performed in symptomatic women, such as when a breast lump or nipple discharge is found during self-examination or when an abnormality is found during screening mammography. Diagnostic mammography uses specialized views to determine exact size and location of breast abnormalities and to image the surrounding tissue and lymph nodes Typically, several additional views of the breast are acquired and interpreted during diagnostic mammography. Steps of mammography: * Explain the procedure to the patient * Positioning: Breast should be properly positioned and it should be ensured that entire breast is in the field of x-ray tube. All foreign bodies should be removed from the breast. * Compression: Compression is necessary to flatten the breast, so that the maximum amount of tissue can be imaged and examined and it also reduces radiation exposure. * Exposure settings: Radiation dose should be selected according to the shape and size of the breast of individual patient. * Each breast should be imaged separately and two views (CC,MLO ) of each breast should be performed for screening mammogram and more views (exaggerated Craniocaudal view, axillary tail view, magnification view ) may be needed for diagnostic mammogram Mammographic signs: the cardinal mammographic signs are: * A mass with ill defined or spiculated borders or micro (<0.5mm) can be signs of malignancy Benign masses tend to be spherical with well defined borders and calcification The calcifications in benign lesions di from malignant micro calcifications in that they are rounded, larger, but less in number, involve multiple quadrants and they are usually of similar density Uses or benefits of mammography * Useful screening for breast cancer Surveillance of breast following local excision of breast cancer. Useful for the diagnosis of lumpy breast * Noradiation remains in a patient's body after an x-ray examination Risks and limitations of mammography Mammography isn't foolproof. It does have some limitations and potential risks: * Pain and anxiety (due to compression) * Radiation burden in case of false negative results. * Less informative below the age of 35years because of more glandular tissues. Which cause difficulties in interpretation and also glandular tissue is more radio sensitive. * Difficult to perform mammogram of small breast and male breast in case of CA breast in males. * Mammograms in fibrous or dense breast can be difficult to interpret due to obscured details. * Having a positive mammogram may lead to additional testing e.g FNAC or needle / open surgical biopsRGERY * Screening ening mammography can't detect : TS €.8. invasive CA. Ot all of the tumors found by Mammography can be cured. all cance The American Colle established the screening ge of Radiology (ACR) has to guide the breast cancer and diagnostic routine BI-RADS assessment categories can be summarized as follows: - additional imaging Category 0 - Need evaluation Category 1 - Negative © Category 2 - Benign finding, noncancerous * Category 3 - Probably benign finding, short-interval follow-up suggested © Category 4 - Suspicious abnormality, biopsy considered ; «Category 5 - Highly suggestive of malignancy, appropriate action needed Category 6 - Known cancer, appropriate action should be taken. COMPUTED TOMOGRAPHY (CT ACT scan makes use of computer-processed combinations of many X-ray images taken from different angles to produce cross-sectional (tomographic) images (virtual 'slices') of specific areas of a scanned object, allowing the user to see inside the object without cutting. Tomography is from the Greek word ‘tomos" meaning "slice" or "section" and 'graphia" meaning "describing". absorption values can be visualized. Con to conventional radiography, range of den, Hey recorded is increased approximately 10,4 Not only the fat can be distinguished 44 other soft tissues, but gradation of den, m within the soft tissues can be identiiey® brain substance from CSF or tumor from no“ surrounding tissues. However this techn is highly radiation dependent and effect rays dose imparted during CT scan is yen ®t .e.g radiation dose of CT of chests equ). to 400 conventional chest radiopags Mechanism of Action After passing through the axial slice tissues, X-rays are captured by d, analyzed by computer & displayed oa as image. Although other sections can ii used but the axial sections are by the’ frequent. This can distinguish very ae difference in the tissue density. The atten... (absorption) value of the tissue is com with that of water which is given a CT n of zero Hounsfield units (HU). Tissue ranges from +3000(bone) down to -1000j3, Approximately 4000 shades of can appreciated in CT as compared to x-rays in which only 30 shades of Brey ae appreciated. For further understanding aboe CT scan, the reader is referred to “A prac guide to OSPE/OSCE/TOACS and clinics methods in surgery” by the same author, CT also relies on x-rays transmitted through the body. It differs from conventional radiography in that a more sensitive x-rays detection system is used with multiple detectors and the data is manipulated by a computer and 3D image is attained as compared to conventional radiograph where 2D image can be seen. The rs rotate around ing feature in X-rays Figure 4: Mechanism of CT scan ssCommon Uses Best tool for studying the . 8 chest a abdomen. t and « For diagnosis of many different cancers including lungs, liver and pancreatic cancers. » To plan and properly administer radiation treatments for tumors + To guide biopsies and other minimally invasive procedures. «To plan surgery and determine surgical resectability of tumors. «To measure bone mineral density for the detection of osteoporosis. . _ In-cases of trauma, quick identification of injuries to the liver, spleen, kidneys or other internal organs. «Incase of head injury, early detection of epidural/ subdural or subarachnoid haemorrhage. First line investigation for intracranial tumours, infarcts or congenital intracranial malformations. The use of intravenous contrast during CT scan has enabled to get vascular images, vascular anatomy, and vascular malformations. It also helps to diagnose various arterial enhancing lesions, hemangioma etc. Triphasic CT scan of the abdomen is widely used for liver and pancreatic pathologies.(described in detail in “A practical guide to OSPE/PSCE/TOACS and clinical methods in surgery” by the same author) CT angiography (CTA): CTA is a method for obtaining angiogram like images by using the volume acquisition capabilities inherent in spiral CT. A major advantage of CT angiography over conventional angiography is that images resembling arteriogram are obtained relatively oninvasively, by using peripheral intravenous injection of contrast material. In some cases It has replaced conventional angiography. In this technique intravenous contrast is given and “GT scan is performed in arterial phase (5-13 Seconds after contrast injection) when OrCmienc cre Maximum contrast density is in arterial system. The development and widespread availability of helical CT and advanced post-processing techniques has made CTA a practical alternative. CT coronary angiography is good alternative to conventional angiography which is invasive techniqure, require trained interventional cardiologist and fluoroscopy Three-dimensional (3D) reconstruction provides excellent arterial map. This process is becoming easier and faster with the advent of more powerful computer processors and software in commercially available workstations. MAGNETIC RESONANCE IMAGING (MRI) This technique was developed by 1980. The images are obtained as a result of interaction between the radio waves and the atomic nuclei in the body in the presence of a strong magnetic field. As we know, hydrogen atoms are present in vast numbers in every tissue of the body. Hydrogen nuclei (protons) have both charge and spin. When placed in a strong magnetic field, they align with the external field (procession). If a pulse of radio waves of appropriate frequency is then applied to alter the motion of nuclei, the protons are displaced from their alignment. When the radio wave pulse ceases, the protons immediately return to their previous alignment (relaxation). As the protons re-align, they release radiofrequency signals which can be detected by coils placed around the patient. Ancillary equipment converts the radio signals into a digital form which is then processed by the computer into a final image. The specific tissue characteristics define the manner and rate at which nuclei relax. There are large number of image sequence that can be used by applying radiofrequency pulses of different strengths and duration. There can be T1 weighted and T2 weighted pulse sequence (images) Difference between T1 and T2 weighted images is given table 1. ffTable 1 Twi at appears Tes bi saperior i delineaton oF anatorny Sper Te delawatlon OT PSIG Advantages of MRI over CT scan . No radiation. No bony or air artifact Multi-sectional imaging. Highly intrinsic contrast, Specificity & extension of disease is more accurate. Few diseases can be diagnosed early. Figure : MRI machine Benefits/uses of MRI . Images of the soft tissue structures of the body such as the heart, lungs, liver, brain, spinal cord and other organs are clearer and more detailed than with other imaging methods. MRI contrast material (gadolinium) is less likely to produce an allergic reaction than the iodine based contrast (Urograffin) used for conventional X- rays and CT scans. y wy, * MRI enables th: ed abnormalities that might feti9n __ by bones with other imaging ius MRA (Magnetic Resonances thy Angiography) provides noninvasive alternative 42 angiography for diagnosing ton the heart and the cardiovasey * Assessment of biliary tree (me resonance cholangio | rece gi Pancreaatogs, Most recently used in Oncok imaging for staging of rectal can ing and gynecological mali * Exposure to r ‘BNanc;, adiation is Void. Limitation of MRI * Expensive Time consuming (long procedure + Images are easily degraded by mat (respiratory,cardiac, bowel moveme, + Because of high strength magnetic, it cannot be used for patients yj, metallic implants (pacemaker, pros, heart valves, aneurysm clips). Contraindications of MRI Absolute: © Metallic foreign bodies. Pacemakers. e Cochlear implants. * Cranial aneurysm clips. Relative © First trimester of pregnancy. * — Claustrophobia. IMAGING IN ACUTE ABDOMINAL CONDITIONS i d_examinalll After complete history an , following protocol should be lowe abdomen. If one diagnostic test col a diagnosis, then it is not necessa"Y these investigations. ii fat * Ultrasound: It used [0' — |cholecystitis, biliary colic, renal colic, ovarian cysts, ectopic pregnancy, acute pancreatitis, ascites and abscesses. x-Ray chest: erect posture including diaphragm: It is used to see air under the diaphragm. (For detail: A practical guide to OSPE/OSCE/TOACS and clinical methods in surgery” by the same author), X-Ray Abdomen Supine: It is used to see dilated bowel and patterns of gas which are helpful for evaluation of intestinal obstruction (For detail: A practical guide to OSPE/OSCE/TOACS and clinical methods in surgery” by the same author). CT scan: It is used for severe pancreatitis, diverticulitis, small bowel obstruction and bowel infarction. Focused CT scan: It is used for appendicitis and ureteric colic (if there is contrast allergy). Intravenous Urography: It is used to rule out ureteric obstruction by a stone. In addition to these imaging tests, serum amylase, cardiac enzymes, ECG and total leukocyte count are also helpful for acute abdominal conditions. IMAGING IN TRAUMA Head injury: CT scan should be performed only if indicated but it is not necessary to Perform CT scan in every case. The indications Of CT scan in head injury according to NICE (National institute for health and care excellence) UK guidelines are given below: GCS less than 13 at any point. GCS 13 or 14 at 2 hours. Focal neurological deficit. Suspected open, depressed or base of skull fracture. (is More than 1 episode of vomiting Mild head injury in elderly patients (265 yrs) or in patients with coagulopathy/warfarin therapy. Dangerous mechanism of injury Pedestrian or cyclist vs. vehicle, Fall > 1meter or 5 stairs. Ejected from vehicle Amnesia of more than 30 minutes. Chest trauma: Supine /lateral chest radiograph can detect rib fracture, pneumothorax, hemothorax etc and CT chest is required when there is widening of the mediastinum (aortic rupture). Abdominal trauma: X-Ray chest erect posture including diaphragm to see air under diaphragm, which is representative of bowel perforation. FAST ultrasound and diagnostic peritoneal lavage. If ultrasound is not available (described in detail in chapter on ATLS). If there is some positive finding on ultrasound, then CT scan is needed for hemodynamically stable patients but if the patient is hemodynamically unstable then immediate surgery should be considered. Pelvic trauma: Initial investigation is x-ray anteroposterior and lateral view if fracture is seen then for hemodynamically stable patients CT scan of pelvis is needed to get detail information about the fracture but for hemodynamically unstable patients may need immediate embolization/surgery). intervention (Angio- Renal trauma: Ultrasound abdomen or CT scan abdomen, Single shot IVU can be hel if CT not available. imeMedicine OF substances in th Of disease, Sa involving the application In this “ pene and treatment material is gives Cechnique: the radioactive 8iven to the patient (injection swallowi ng, and inhal. id inhalatior s radioactive material is ion). This radioactiv tharattal is taken up by specific tissue and from ~ ue radiation called gamma rays, which AX* Picked up by special camera called gamma mera and are converted into image. The uptake of radioactive material depends upon the physiological nature of specific tissue. (For example radioactive iodine is taken up by thyroid gland; thalium is taken up by Myocardium and technetium 99 by the bones) Nuclear medicine, in a sense, is "done inside out" or “endoradiology” because it records radiation emitting from within the body rather than that is generated by external sources like x-rays. Nuclear medicine also differ from other means of imaging, which are largely anatomical based, as it also provides functional information Examples of nuclear medicine scan includes + Thyroid scan + Bone scan * DTPA renal scan Myocardial Thallium scan « HIDAscan Positron emission tomography (PET) is an extension of nuclear medicine (described in detail in “A comprehensive approach to principles of systemic surgery” by the same author). POTENTIAL HAZARDS IN IMAGING Contrast media: Intravenous contrast media used in radiology particularly in CT scan can cause life threatening allergic reactions and Nephrotoxicity. The use of low osmolality contrast media is relatively safe and less nephrotoxic. Renal functions should be performed before contrast study and all emergency medications should | Hazards of ionizing radial ions: ay Natural radiation from sun, envio nuclear bombs and other man rae oral contribute a genetic risk over which tly doctor has no control, However, ionising SM for medical purposes is of several tre magnitude than all other sources of radiation and is under the contol qf so avoided. The principle to bat ‘ called ALARA principle "as low as reat 8s achievable”. The tisk of radiation en plain x-ray of chest is very small (1m! however risk considerably increased oo scan of abdomen or pelvis (1:1009) Then’ techniques that do not use ionizing neal (ultrasound,MRI) should be consi” particularly in children. iden Radiations to developing fetus Can h; catastrophic results. It causes incr 3 congenital malformations and chap leukemia and other malignancies wih eg first 10 years of life is increased in ch, exposed to diagnostic x-rays while in utes probably by about 40% compared to nom. population. X-raying the ‘etus therefore shou be avoided INTERVENTIONAL RADIOLOGY (IR) Bre ‘ ea ann, hy IR refers to a range of techniques which eh on the use radiological image guidance (Xr fluoroscopy, ultrasound, computed tomograph [CT] or magnetic resonance imaging (MRI) precisely target therapy. Most IR treatmers are minimally invasive alternatives to ope and laparoscopic (keyhole) surgery. As man IR procedures start with passing a needle through the skin to the target itis se called pinhole surgery Interventional ad's is a therapeutic and diagnostic spec comprises a wide range of i 4 imaging-guided therapeutic ee af well as invasive diagnostic imaging: ae of diseases and organs amenable 0 guided therapeutic procedii and constantly evolving; It inc!4 Bar 3 eo of the vascular, gastrointestinal, Hepatobiliary, ofpitourinary, pulmonary, musculoskeletal art central nervous system piagnostic IR: percutaneous biopsy: Ultrasound or CT Traded biopsy of liver, kidney,pleuta,para- s*rtic lymph nodes can be done jransjugular liver biopsy: In patients with fifuse liver disease, particularly cirrhosis, there nay be problems with blood coagulation with af uncontrolled bleeding after percutaneous “itaneous Angioplasty biopsy. To overcome this problem a biopsy is > technique involves passage of guide wire , ‘ periormed via hepatic vein so if bleeding eens it enters the vascular system. The jugular vous is punctured in the neck and under fluoros a special biopsy catheter is passed tl the superior and inferior vena c&@pand advanced into the hepatic vein whefé g Biopsy Sfliver parenchyma is taken. SNS Catheter Angiography: Aj GBipphy isa type of X-ray that is done to ex. re blood vessels in various parts of the bt .g. heart, brain, liver and kidneys), to determine whether the vessels are diseased, narrowed, enlarged or blocked. Procedure: A small incision is made after cleaning and shaving the skin at the chosen site in order tointroduce the catheter into the artery. The radiologist threads the catheter through the arterial system to the desired location and then injects contrast material. Then X-rays are taken. The whole anatomy of the blood vessels can be visualized with this method. Subtraction angiography: It is possible to subtract the shadows that are present on the plain film or film that has taken aiter the ‘contrast has been injected for angiogram. The fesult is an image containing the detail of pacified structures only. (EE Therapeutic IR Percutaneous dra other fluid collectiggs® drainage cathete& on be ty or fluid percutaneous in scess cavi Thy oie 1 under the of abscesses and scially designed pecially desigt introduced collection Control of imagdagmodality (ultrasound, CT) Once the hater is in the abscess cavity it can be ere for many days to allow continutye Wrainage of the pus. The technique is suf le for most abdominal abscesses eg liver abscess and subphrenic absc ai ogical guid rough the vessel under radiol: which traverses stenosis or occlusion deflated balloon is inserted over the guide wire. When the balloon is the area of blockage, it is inflated to open the arte improving blood flow through the area Angioplasty has been used to treat vasculai stenosis and occlusion at many different sites including coronary, mesenteric, renal and low limb. Complications include haemorrhag: haematoma and false aneurysm formation Vascular stents Stents are expandable metal cylinders that can be embedded in plastic and collapsed to enable them to be inserted through an artery or vein Indication for stenting includes occlusion recurrent stenosis, flow limiting aorti dissection, failure of balloon angioplastyTherapeutic embolization Arteries can be occluded by introducing a variety of materials (glue, gelatin foam, and thrombin) through a catheter selectively placed in the vessel. This technique is used primarily to control bleeding and for aneurysmal coiling. Transjugular intrahepatic portosystemic shunt:(TIPS) Portal hypertension in cirrhotic patient may lead to bleeding esophageal varices. The portal hypertension can temporarily be relieved by creation of an artificial communication between portal and systemic veins of the body. The internal jugular Punctured and a eg through the heart, iv ase < Pt sal Special needle is introduced hone catheter and it passes from the hehe systemic vein) into the portal wer Paha communicatior € Ones, communication is established between ge Portal vein (portosyste, permanent stent can be placed», patent. In this way blood pases fu, gH vein into the hepatic vein and po Py is reduced. The compli ‘one cations procedure are occlusion of the ste, € stent worsening of hepatic encephalo 9. Transarterial chemoembolizati ‘ mbolizati Described in detail in the topic. hepatocellular carcinoma in A compet e e in* A compre approach to principles of systemic surges the same author. 1 mi + Biliary stenting: Percutane transhepatic cholangiography (PTO), Desciie in detail in the chapter under Hepatobike tem “ A comprehensive approach principles of systemic surgery” by the sn author. Figure 5: Demonstration of TIPS Portosysiemin Shuntngerm eer eee References freudenrich C. How ultrasound works. 2002 RASintgen WC. On a new kind of rays. Science. 1896:227-31 British Medical A. BMA Illustrated Medical Dictionary: Essential A? Z Quick Reference ¢© Over 5,000 Medical Terms. Dorling Kindersley Ltd; 2002. Kuo P, Holloway RH, Nguyen NQ. Current and future techniques in the evaluation of dysphagia. Journal of gastroenterology and hepatology. 27(5):873-81. ‘American College of R. American College of Radiology breast imaging reporting and data syste” Reston (VA): American College of Radiology. Bluemke DA, Chambers TP. Spiral CT angiography: an alternative to conventional angiography Radiology. 1995;195(2):317-9. Smits M, Dippel DW], de Haan GG, Dekker HM, Vos PE, Kool DR, et al. Minor head injury: guidelines for the use of CTa[)’a multicenter validation study 1. Radiology. 2007;245(3):831-8 Newman B, Callahan MJ. ALARA (as low as reasonably achievable) CT 201 1()"executive summary Pediatric radiology.41:453-5. de Gregorio MAn. Global Statement Defining Interventional Radiology. ntervencionismo 12 Medicalstudyzone.comPre-operative Evaluation & Managements | e goals of preoperative medical The ultimat fe the patient's surgical assessment are to reduc and anesthetic perioperative morbidity or mortality, and to return him to desirable functioning as quickly as possible(1).Surgery situation and many metabolic and is a stressful endocrine changes occ depending upon the type surgery. It is important to particular patient can will surgery and anesthesia or ni other co-morbidities, it can produce fatal effects and rather curing from one disease; we may deteriorate the patient by another. It is mandatory that patient's condition should be optimized before any elective surgery. In some situations it might be wiseable to delay the surgery for optimization. ur during surgery and severity of the know whether that hstand the stress of ‘ot. If patient has preoperative The following primary goals of have been evaluation and preparation identified(2, 3) = Documentation of the condition(s) for which surgery is needed. « Assessment of the patient's overall health status. * Uncovering of hidden conditions that could cause problems both during and after surgery. « Perioperative risk det Optimization of the condition in order patient’s surgical perioperative Developm hope of r i hop a arniety and facia, + Reduction of costs, short hospital stay, reduction of car and increase of patient Satisfactn ening Pre-operative assessment should be by the anesthetist and the surgical te: it has following components. es. «Taking detailed history * — Clinical examination. « — Routine and target oriented investigations. e — If any abnormality is found, i it be treated to its optimal level. = A. Preoperative History The history most important component of the a evaluation. The history should include a pa and current medical history, a surgical ison a family history, a social history (use of tobacx alcohol and illegal drugs), a history of allege current and recent drug therapy, unuswa reactions or responses to drugs and an problems or complications associated wi previous anesthetics. The history should inc a complete review of systems to look f undiagnosed disease or inadequately con chronic disease. Diseases of the cardiovasct and respiratory systems are the most rele in respect of fitness for anesthesia # surgery(3). The key topics in history includes: eee Cardiovascular: rnyocadi a (<6weeks) Hypertension: : disease, arthythmias In general pat —_—rs who can climb a flight of stairs with getting short of breath or chest nat have lower risk of perioperrin morbidity and mortality of cardlowneeul, origin. \ Respiratory: COPD, asthma. Gastrointestinal: hepatitis, pepti ulcer,gastroesophageal reflux, chroni ag liver disease, obstructive jaundice 1, | + Neurological: CVA.epilepsy,psychiatric By illness. tig) =, Renal: renal dysfunctions, UTIs ti, Endocrine: diabetes, thyrotoxicosis, phaeochromocytoma : My Previous surgery, anesthesia, Malignancy, a medicatons. : smoking, alcoholism, bleeding disorders, drugs allergy. B. Physical examination: The physical examination should build on the information li gathered during the history. Ata minimum, a focused preanesthesia physical examination includes an assessment of the airway, lungs : and heart, with documentation of vital signs(4). © Unexpected abnormal findings on the physical | examination should be investigated before elective surgery. Airway examination Air way examination is done to identify the predictors of difficult mask ventilation and difficult intubation. The Samsoon and Young modified Mallampati test(5) is performed with dinician sitting in front of the patient with the patient’s mouth open and tongue protruding, without speaking or saying: | + Grade |: Soft palate, fauces, uvula, pillars visible. * Grade Il: Soft palate with some part of uvula seen * Grade Ill: Soft palate seen. * Grade lV: Only hard palate seen. Iz Pri Managements | W Mt \V Highest the grade, the higher the risk obtaining and securing airway. Other parameters of difficult Intubat includes: + Long upper incisors * Aprominent “overbite’ + The patient cannot protrude mandibular incisors anterior to maxillary incisors. * Inter incisor distance is less than 3cm when mouth is fully opend «© Uvula is not visible when tongue is protruded with patient in sitting position. «Shape of palate is highly arched or very narrow. + Mandibular space is noncompliant + Thyromental distance is less than three fingerbreadths. « Neck is short or thick. » Patient lacks normal range of motion of head and neck.id accepted that the clinical history oa Routine laboratory tests in patient Xam, cPParently healthy on clinical ‘amination and history are not beneficial or ost effective. A clinician should consider the risk-benefit ratio of any ordered lab test. When studying a healthy population, 5% of patients will have results which fall outside the normal range. Lab tests should be ordered based on information obtained from the history and physical exam, the age of the patient and the complexity of the surgical procedure(6). No routine laboratory or diagnostic screening test is necessary for the preanesthesia evaluation of patients but the investigations are needed in major surgery which can cause organ system dysfunction. In our practice it is common to perform CBC, Urea, creatinine, HBsAg, Anti HCV before surgery without any indications. Various Indications for specific tests are given below: + Full blood count (CBC): * For all major operations * Those with anemia or ongoing blood loss = Any chronic disease or malignancy « Asicke cell trait in patient with afrocaribian origin. * Electrolytes and creatinine * Forall major surgeries Patients over age of 60 with cardiovascular, renal or endocrine disease * Patients on diuretics, digoxin, antihypertensive therapy. * Echocardiography « All those patients with age 60ye + Cardiovascular, renal ¢ respiratory involvemeny = Diabetes mellitus * Clotting screen * Bleeding diathesis + Liver disease + Eclampsia ‘+ Patients on anticoagulati therapy z © Chest x-ray * Cardiac history Respiratory symptoms * COPD Pulmonary cancer ,metags SPECIFIC THEIR M If a patie ; than sur effusion level wi The ben © Pregnancy test the risk Specific = All women of child beating oa ee to the b + Blood glucose and HbAtc but em © Diabetes and endocrine pte Wh*'EY Cardic «Liver function tests College Heart * Jaundice report + Hepatitis rie = Cirrhosis surger a i Depending upon findings on history ¢ ; examination and initial lab results; ® advanced tests may be needed int coronary angiogram, cardiac perfusion® pulmonary functions tests, ABGs and brain, . ion On the basis of history, examina investigations, American sot Anesthesiologists (ASA) has develope “d for the classification of physical statu! patients (7) as described in table 2No organic, phy Mild to moderate systemic dc Examples: Heat disease th sashcass 1 Asdcass 2 Ipsaciass 3 | Severe systemic disturbance thet map oe Examples: Heat di that limits activity complication, chronic pulmonary dis, Severe systemic disturbance thats asnclass 4 jasaclass5 | Moribund patient who has ite chance of con ASA class 6 SPECIFIC PRE-OPERATIVE PROBLEMS AND THEIR MANAGEMENT. Ifa patient is suffering from any disease other than surgical issue, it should be treated to a level where it does not complicate surgery. The benefits of the surgery should outweigh the risk of surgery and risks of anesthesia specific medical problems encountered during pre-operative assessment should be corrected to the best possible level for elective surgery but emergency surgery is a different entity where you have to operate as early as possible. Cardiovascular diseases: The American College of Cardiology (ACC) and the American Heart Association (AHA) published a task force report on Guidelines for perioperative cardiovascular evaluation for noncardiac surgery(8). Patients’ risk factors are usually (Table 3) "4 ‘Major clinical predi ‘Mayocardial infarction <6 weeks Unstable or severe angina (lass I-1V) Decompensated congestive heart failure Significant arrhythmias (e.g. causing hemodynaris Severe valvular disease (e.g, aortic or mira stenosis i CABG 04 PTCA <6 weeks Previous myocardial infarction pathologic Q waves Mild angina (class 1-0) Silent ischemia ( Holter monitoring) Compensated congestive heart failure, Post CABG or PICA >6 weeks ant Diabetes mellitus Kena insufficiency = estvestening wth o athout Examples: Congestive hea (lire persistent angie paca aoe al but sented Examples: Uncontrolled hemorrh: “ A declared brain-dead patent vines organs ae bein eng 4 ‘ ‘An “E" added 10 the status number to designate av everyone oo ic italy? ith valve area=1.0m") ejection fraction £0.35, Mh 3 months of >6 yf, oF wth ant-ang i subdivided into three categori¢ intermediate and minor (Table period is necessary for the myocard) after an infarction and for the t resolve. Patients with coronary r done within the preceding 40 de be classified as high-risk patient major predictors have 2 g perioperative risk. Only vi surgical procedures shou considered for these patients operations should be postponed anc patients properly investiga Intermediate-risk factors ref independent risk factor for perioperative mortality. esent an Minor tisk factors are markers of an increased probability of coronary artery disease, but not of an increased perioperative risk Jictors (markers of unstable coronary artery disease) Tntermadiate clinical predietors (markers of stable coromary artery disease) gaitad ina eer oteal 3 months (<3 months it complicated) based onthe history othe presence of inal therapyclinical predictors (increased prob Familial history of coronary artery disease Age >70 yr ECG abnorm Low fu Histon Uncon hypertension Jemic hypertensi Smokin lity of coronary artery disease) es (arrhythmia, LVH, left bundle branch block) hypertrophy Post infarction (>3 month), asymptomatic without treatment Post CABG or PTCA 3 month and 56 yr and no symotoms of angina nor anti-anginal therapy CABG = coronary artery Bypas grafting PICA percutaneous transluminal coronary anglopasty, LVI vec Myocardial infarction: In patients with previous myocardial infarction (MI), the risk of perioperative MI decreases with the time from infarction as shown in table below: Time elapsed after MI_| Incidence of postoperative MI >6months 596 4-6months [10-20% < 3moths 20-30% This contrasts with patients without a history of MI whose risk is around 0.2%. “A postoperative/ perioperative MI is a lethal lesion with a >50% mortality rate(9)."In general, a delay of six months for elective surgery is recommended. Post-infarction coronary artery angioplasty, stenting or bypass surgery reduces the risk of perioperative MI and advice from cardiologist should be considered. The factors increasing the risk of ischemic heart disease (smoking, hypertension, diabetes, obesity) should be addressed. After coronary stenting, elective surgery should be further delayed until after dual antiplatelet therapy is stopped (6weeks). ative MI increases oms of angina. imum medical erative MI (25%) be referred to lasty, stenting or story of coronary ing, the risk of ificantly, even Congestive heart failure: failure (oedema, paroxysmal nace he or orthopnoea) is associated ii . perioperative risk and should be ie prior to elective surgery. “Left cca ejection fraction as determined by yo- Scan, has been shown to be an imi” predictor of survival in patients with mo infarction and congestive heart failure, 4 with ejection fraction of less than a 19.5% mortality as compared to 2.2% ,. ejection of more than 55% (who » undergoing non cardiac surgery). Hypertension: Prior to elective surgery, tk: pressure should be controlled to 160/90mmHsg.If a new antihypertensive introduced, a stabilization period of ates weeks should be allowed. Volvular heart disease: Appropriate rele" to cardiologist and anesthetist should be m* In patients with mechanical heart vale warfarin should be stopped 5 days bet surgery and infusion of unfractionated he should be started once INR is < 1.9 and : should be maintained 1.5times of normal? this infusion should also Ds Sve before surgery. Heparin and warfarin a in Rae aaa and heparin is ot once full effect of warfarin has been a" ) ithermy sol Pacemakers: Monopolar dial in patiem avoided during surgery ! pacemakers. = J5 emia: preoperative anemia sl Abated with iron and vitamins Rees atient undergoing major surgery w th hremoglobin level of less than 8g/dl should nsidered for transfusion. - respiratory diseases: Anesthesia and surgery have deleterious effects on respiratory system. patients with pre-existing respiratory disease amnuch more prone to have respiratory roblems. In addition, respiratory diseases have effects on other systems; most importantly, rocardiovascular system. For example, if the lungs are working sub optimally and arterial weturation is low, this may cause an increase sa ediac output which in turn may precipitate an ischemic cardiac event. ifthe vital capacity is less than three times of tidal volume then respiratory insufficiency is very likely after a laparotomy or thoracotomy, because pain and muscle cutting reduces the pal capacity. By performing pulmonary functions tests (PFTs) pre-operatively this can be pre-empted so it may be possible, to use minimal invasive surgery and regional anesthesia to prevent respiratory complications. if PFTs show, pre-existing bronchospasm. Asthma: There is an increase risk of sputum retention and pneumonia. This risk can be frinimized by optimal medical therapy before surgery (bronchodilators, steroids).Patients taking more than 10mg of prednisolone and undergoing high risk surgery will need peri- operative steroids therapy: Patients with pre-existing restrictive lung disease are at risk of postoperative respiratory failure because of fatigue. These patients should be evaluated by pulmonologist and minimal invasive surgery should be preferred. on monoxide reduces 5 .Nicotine increases ause peripheral iary function is also helps to reduce monoxide and of smoking: Carb n delivery to tissue: art rate and can © striction.Bronchocil ired. Smoking cessation complications. Carbon nicotine levels return to normal within 12-24 hours.Ciliary functions starts to improve within 2-3 days. After three months of abstinence lungs functions return to normal, Infections: elective surgery should be postponed in the presence of chest infection. It should be treated with antibiotics and physiotherapy and the operation reschedule d after 4-6 weeks Coagulation disorders Thrombophilia: patients with previous history nse at risk should be of thrombosis or the ided with identified, they should be prov thromboprophylaxis. Oral contraceptive P and hormone replacement therapy incre the risk of thromboembolism and s stopped 6 weeks before surgery Anticoagulation therapy: Those warfarin therapy; it should be st before surgery and infusion of heparin should be started once INR and APPT should be maintained 1.5 normal and this infusion should also be 2 hours before surgery. Heparin anc are started in postoperative period is stopped once full effect of warfarir achieved. Vitamin K can be used to the effects of warfarin in patients req emergency surgery; it takes 24-48 he reverse anticoagulation. For more rapid correction FFPs and prothrombin complex concentrate can be used aemophilia A is associated Haemophilia: H and haemophilia B with factor VIII deficiency is associated with factor IX deficiency. These patients require infusion of these factors to achieve haemostatic level at the time of surgery and in postoperative period until risk of bleeding subsides: Obstructive Jaundice: Patients having obstructive jaundice are at a high risk for surgery as they may develop Hepatorenal shut aEN elas down, bleeding diathesis, cholangitis and sepsis. Patients with obstructive jaundice can develop deficiency of Vitamin K dependant clotting factors (II, V, VI, IX and X) as these are fat soluble vitamins and require bile salts for their absorption from gut mucosa. So Vitamin K should be given to these patients before an operation to minimize the risk of bleeding. Adequate hydration should be maintained to avoid acute renal shut down. Prophylactic antibiotics are also needed to prevent cholangitis and septicem!a. METABOLIC DISORDERS Diabetes patients are ata are prone to have sepsis, delayed wound healing, CVA and diabetic Ketoscidosis. So, close monitoring and pre operative treatment is required. HbA1C level should also be checked. Diabetic patient may be either non insulin dependent (taking oral hypoglycemic agents) or insulin dependent. Nan insulin dependent: These are at risk of hypoglycemia which if un-noticed, could lead to severe brain injury, coma and death. They should © Be first on list = Stop the morning dose of oral hypoglycemic agents * Have regular sugar check (1-2 hourly) Have intravenous canula with slow infusion of dextrose saline mixture Restart their medications as soon possible after surgery * As hypoglycemia is more dangerous than hyperglycemia, moderate nyperalycem Diabetes Mellitus very high risk and For patients who ar on afternoon ty } can be given with half of thei insulin. : normal dog Methods of insulin administrati patients with poor glycemic control. scale insulin is normally administered, scale insulin consist of intravenous glucose and potassium that can be gi’ Single mixed infusion(10) (The Albert ne or it can be given’as.a separate iniy insulin and glucose with: potent’ This prevents the disproportionate na" insulin and glucose administration, Inka! continued until the patient redunneall diet; where upon routine insulin me reintroduced, Potassium is added as ag therapy can lead to hypokalemia, Patients taking long term corticosteroids. normal healthy conditions, the adrenal go. produces 30 mg cortisol per day, the equiv of 7.5 mg prednisolone or 30 mg hydrocortin, The stress response to surgery doubles or tis the daily prcductions. Those taking longtey corticosteroid therapy may not be able toc» with such a response (adrenal suppress and may suffer acute adrenocortical insufcen which can manifest as hypotension, bradyeari: confusion and hypoglycemia. These patients require supplemes! corticosteroid therapy in perioperative pens the amount depends upon the extent of sug? and the length of time that the patient is um! to take oral medications (Table 4). Thyrotoxicosis: Life threatening thyrotox® may be precipitated by any surgery espe after thyroid surgery which accentuates hy release. It is therefore preferable (° hyperthyroid patients into euthyroid be —7 ol ry qable 4) Guideline for steroids administe, ip ut con the morning of surgery. The in ew enteral eae ge ett od the surgery become prolonged ar more extensive: nes hivher usual glucocorticoid dosage orally if possible) on the morning yoo Dane surgery.Carbimazole 30-40mg is drug of choice for preparation, when euthyroid (after 8-12 wweeks) dose may be reduced to Sme 8 hourly The last dose of carbimazole may be given on the evening before surgery. Alternatively beta blockers may also be used to abolish toxic slate Beta blockers have no effect on the gland itself but they act on the target organs and inhibit peripheral conversion of T4 into T3.This results in a rapid control and operation may be arranged within a week or two. The appropriate drug is propranolol 40mg thrice a day. During pregnancy, propylthiouracil should be preferred as carbimazole can cross placental barrier and cause fetal hypothyroidism. Hypothyroidism: Hypothyroidism should also be corrected before surgery as it may cause ute hypotension, shock, hypothermia and ntilation .This hypoventilation can cause retention post-operatively. Myxoedema a should be suspected in patients who fail awake promptly from anesthesia. It is sable to treat Myxoedema patients with yroxine before elective surgery. In incy cases, levothyroxine can be given sly or by nasogastric tube. : Dehydration can occur in intestinal obstruction and V before the operation, Therein hydrocotone 1V during the ‘operation; then the dose should be rapidly tapered over 48h Rae sal slucoconicoid dooge orally tt posible) on the morning on, hen 10mg necosone WY dring he 1¢ administered and then rapidly tapered (over i done the pastoperatve course is uncomplicated, peritonitis; proper fluid resuscitation is mandatory before operation. Otherwise, it may lead to hypovolemic shock or acute renal shut down. Renal failure: Patients who have chronic renal failure but are not on dialysis, end stage renal failure can occur due to intra-operative hypotension or inadequate fluids postoperatively Those patients who are dependent on dialysis should undergo dialysis 24 hours before surgery, so that the electrolytes are normal and the effect of heparin wears off. Similarly postoperative dialysis should be delayed for 24 hours, if possible. Obesity: Obesity (>30% above ideal weight) increases the risk of cardiovascular and pulmonary complications and it may be the causative factor in some diseases (e.g. umbilical or paraumblical hernia). The elective surgical procedures should be delayed while the patient attempts to lose weight. Preoperative fasting: Pre-operative fasting is necessary to reduce the aspiration of gastric contents at induction of anesthesia, during surgery or in the immediate period afte surgery. Fasting guidelines for adults anv children are given below(11). ——NERAL SURGERY Adults Pre-operative fasting in adults undergoing elective surgery - ‘the 2-6 rule’ «6 - Formula milk, cow’s mpi upto 6hbefore. ka. * The anaesthetic team shou further interventions for ma higher risk of regurgitation ang ae * ‘2’ - Intake of water up to 2h before induction of anaesthesia * ‘6'- A minimum pre-operative fasting, Preoperative assessment in ¢, time of 6 h for food (solids, milk and surgery: The principles of assessment t8 milk-containing drinks. The anaesthetic team should consider further interventions for patients at higher risk of regurgitation and aspiration as for elective surgery except i opportunity to optimize the condition tt by time constraint. Some risks can be but other persists and these fe ty 9 hou! Post-operative resumption of oral intake in explained to the patient. 7 healthy adults, Consent: All the conditions should be with patient and with the close reg 8 written consent of the procedure sho." taken, The diagnosis, procedure ¢ explained, likely complications sho described. If two different procedy, available for the same conditions, these, be described with prone and cones, should be allowed to ask if any question consent implies that it is given voluntsc, a competent person. Everything discussej, agreed should be documented. + Patients should be encouraged to drink when ready, providing there are no | contraindications. Children Pre-operative fasting in children undergoing elective surgery - ‘the 2-4-6 rule’: * /2/- Intake of water and other clear fluid up to 2h before induction of anaesthesia. + '4°- Breast milk up to 4 h before. References 1. Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokate 2007;11(1):13-21. Kitts J8, The preoperative assessment: who is responsible? Canadian Journal of Anesthesiajoand 2: canadien danesthA@sie. 1997;44(12):1232-6. 3. Roizen Mf, Foss JE, Fscher SP Preoperative evaluation. 1990. 4. Aplelbaum jt, Connis RT, Nickinovich DG. American Society of Anesthesiologists Task Fore ® I ‘Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation. Anesthesiology.116():5228 ificult tracheal intubation: a retrospective study. Anaesthesia. 1987;425)487% tory testing: What is needed. 54th ASA Annual Refresher Course ects ttigrew RA, Plank LD, Van Rij AM. American Society ‘of Anesthesiologs® ‘a predictor of wound infection. ANZ journal of surgery. 2007;77091:73841 1 Chaitman BR, Ewy GA, Fleischmann KE, et al. ACCIAHA gui ovascular evaluation for noncardiac surgerya “executive ssummaty® ge of Cardiology/American Heart Association Task Force on Pa, ite the 1996 Guidelines on Perioperative Cardiovascular Evaluation the American College of Cardiology. 2002;393):542-53: | IC, Hurlbert Bj, Sink BJ, Mpas PAC, et al. Recommendation, tion of the surgical patient with emphasis on the cardiac patien! Medical Center. 2006. a ent of diabetes during surgery. British journal of nae& Sterilizations Aseptic Techniques CHAPTER vy jston (1794-1847 was a reputable surgeon and was able to do amputation in 2 and half minutes. Keeping in mind the lack of anesthesia, the patient spent the entire rocedure fighting as hard as they could, the Pltiple medical "assistants" whose job was to hold the screaming patient down. One day Liston amputated much more than he needed to. While amputating the patient's leg at the hip, Liston accidentally sliced through the fingers of one of his assistants. That would have been bad enough, but it proved disastrous when the patient's stump turned gangrenous. The saw must have been contaminated, because the assistant became ill and infected, too. Within a few days, both the patient and the assistant died. The procedure was being observed by an elderly doctor in a dress coat with long tails. In the confusion, Liston cut through the man's coat. The man wasn't cut, but because blood was spurting around, the old gentleman didn't know that Feeling the tug, and seeing himself covered in blood, the man collapsed on the floor, had a heart attack, and died, Liston, therefore, had performed a surgery with a 300% mortality rate(1). wf. SlESES seri sk Health care-associated infections are an important source of morbidity and mortality. All invasive procedures involve contact by a medical device or surgical instrument with a Patient's sterile tissue or Mucous membranes. A major risk of all such procedures is the introduction of pathogenic microbes leading to infection, Failure to properly disinfect or sterilize equipment may lead to transmission Via contaminated medical and surgical devices. To prevent cross infections only sterile rents are used. sterilization is usually undertaken in Sterile Services Department (SSD) in hospitals. Various terminologies used in SSD are given below. DECONTAMINATION Decontamination aims to eliminate or reduce the levels of vegetative micro-o! other unwanted materials medical devices, equipmer The purpose is to minimize infectio bacterial colonization, to make such items sate for reuse on patients and for handling by staf This can be achieved through a combination of cleaning, disinfection and sterilization ym reusa ind surfaces. Cleaning The aim of cleaning is to remove visib! blood, tissues, body fluid residues, degrad products, pyogens, soil and dust) from reusa medical devices and equipment. However, i does not necessarily destroy micro-organisms. Cleaning prepares medical devices for disinfection or sterilization and involves warm water and a solvent (usually detergent). Most equipments can be cleaned using manual or mechanical methods ion Disinfection Disinfection can be defined as a process intended to kill the micro organisms with the exception of bacterial spores. Classification of Disinfection Low: Reduces the overall number of micro- organisms but does not destroy tubercle bacilli or bacterial spores. Intermediate: Kills tubercle, viruses and fungi, but only some spores.GENERAL SURGERY High: Kills most forms of microl some spores, Methods of disinfection: Th chemical or physical Chemical Agents * Alcohol: it is used to clean the skin before venipuncture. Alcohol wipes principally used for disinfection of telephones, thermometers, stethoscope inated object, and other lightly conta * Formaldehyde: Equipment is exp to circulating formaldehyde gas in an t cabinet at 50°C. It is used for therapy equipment It is ten dehyde air respiratory 2%Glutaraldehyde (Cidex): times more effective than formal It destroys micro-organisms rapidly and is active against vegetative bacteria. However, it has low efficacy against spores and has little effect against tubercle bacilli 0.1% Sodium hypochlorite: It acts by releasing chlorine to damage bacterial cell wall; most bacteria are killed within 30-60 seconds. Fungi and viruses are extremely susceptible but tubercle bacilli are more resistant. It is commonly used to disinfect baths, cradles, and furniture and lavatory seats. Physical Agents * Low temperature steam: Exposure to dry saturated steam at 73°C for 20 minutes at sub atmospheric pressure is used for heavily contaminated instruments. * Boiling Water: Soft water boiled at 100°C for 5 minutes is also effective. STERILIZATION By definition the process destroys all forms of microbial life including bacteria, viruses, spores and fungi. Sterilization can be achieved either with heat or with chemical agents Sterilization with heat: Moist or dy for this purpose. Y hey » Moist heat (autoclaving): jr», the instruments in boiling water produces disinfection. The the heat (steam) under pressure can o,™ ery high temperature, desiratyt terilization. Autoclave is like a pre. cooker in which steam under 2 is passed. The temperature ofthe depends on the pressure. A press 15 pounds achieves a temperat, a 121°C and 15 minutes are enoys achieve effective sterilization wh pressure of 30 pounds can ach, temperature of 134°C and with « temperature and pressure effec: sterilization can be achieved jn », minutes. This is most commonly method of sterilization in Operas, Theater and all forms of bacteri heat resistant spores are kills © Dry heat (Sterilization by hot air oven It is used for the sterilization instruments with fine cutting edges sy as ophthalmic instruments. A dry, h environment is created, with temperatur as high as 180°C. Sterilization with chemicals * Ethylene oxide: Ethylene is a high penetrative non corrosive gas. It is us to sterilize heat and moisture sensi materials such as lenses, electri components, sutures and single vs items before packing(2). + 2% Glutaraldehyde: It is used often disinfectant but can be used ! sterilization if exposure time is increas * Combination of low temperalu steam and formaldehyde: |! combination of dry saturated steam" formaldehyde has the advantage tw sterilization is achieved at @ iq temperature of 73°C. This melha thus suitable for heat sensitive oan and instruments with integral P By components.sterilize ‘on by irradiation: AL industrial level, res yringes catheters and intravenous cannulas sterilized by using gamma rays(3) or ed electrons. The articles are packed carton is passed under gamma are celeral nd the whole radiations n by peracetic acid: It is effective against spores, bacteria, viruses, yeasts and j, This sterilization technology uses room e vaporized peracetic acid (VPA), which is injected into a pressurized chamber(4). Room tem erature VPA delivery greatly roves over other sterilization methods that incorporate heat such as hydrogen peroxide, ide, and gamma/E-beam irradiation tu emperatur Monitoring of sterilization: Sterilization is monitored by placing heat sensitive strip on each pack of instruments. They change their color if the required level of temperature is achieved. Sterilization methods of various objects are: Steam under pressure (by autoclave) Dressing materials and loves Catheters, syringes and | Gamma rays W cannulas Hot air Fine cutting edge instruments €.8. ophthalmic instruments Tea sensitive materials | Ethylene oxide (plastics) Endoscopes {STERIS) peracetic acid ‘Skin of patient pyodine, alcohol, dettol Steam under pressure Surgical instruments like and temperature. ry forceps, forceps, Tormaldehyde re Wr ecu The term aseps!s refers to the ing contamination of wound that only sterile act with them. ASEPSIS: methods of preventi her sites by ensuring and oth come into cont objects and fluids use of solutions sepsis is the alcohol for ANTISEPSIS: Anti iodine or such as chlorhexidine, disinfection of skin. hemicals used to kill micro- ace of skin and mucus antiseptics -8- alcohol, ANTISEPTIC: organisms on the surf membrane are called iodine, chlorhexidine FACTORS CONTRIBUTING TO ASEPSIS IN OPERATION THEATRE (A) _ Patient Preparation Bacterial flora of the patient is the principal source of infection in surgical wounds. Patient preparation begins with pre-operative sessment. A focal source of sepsis should be treated before surgery, particularly ‘osthetic implants are to be used. An infection o' after 72 hours stay in the hospital is term nosocomial. Following measures should be taken for patient preparation : Preoperative showering « Showerin ic solution has shown with an antisepti to reduce wound infection. Shifting: Patient should wear clean jown and transferred ina clean bed or trolley to the theatre. Shaving: Do not remove preoperatively unless the hair at or around the incision site will interfere with the operation; if hair is to be removed, remove immediately before the operation, preferably with electric clippers.(Razor shaving has been associated with increased surgical site infections attributed to microscopic cuts in the skin that serve as foci for bacterial multiplication. hair + Painting and draping: ; g: Preoperative preparation of skin with antiseptic ——(€.8. 10 % aque is aqueous iodin ae eae: acl double door exi cor it to the cor The solution is applied with a sponge from the area of incision outwards in a circular manner. The most heavily contaminated area is cleaned last and the sponge is discarded. Multiple sponges are used for this purpose. Sterile surgical drapes are used to isolate the prepared surgical site. * Prophylactic antibiotics should be given at the time of induction of anesthesia, (B) Preparation Of Surgical Instruments Surgical instruments used during procedures ared by cleaning, disinfection and are prep: ave already been discussed. sterilization which hi (© Preparation Of Surgeon Hand washing: Preoperative washing from fingertips us to the elbows using a bactericidal agent reduces the resident flora of the surgeon's hands. Gloves: Use of surgical gloves is vital part of asepsis. Studies suggest that between 50 - 70 % of the gloves are punctured during surgery. About 40,000 organisms can pass through a pinhole puncture in twenty minutes and increase the infection of clean wounds from 1.7% to 5.7%. Wearing two pairs of gloves offers a greater protection. «Masks and hair cover Disposable/sterile masks and caps are essential. «Surgical Gowns: Surgical gowns reduce the transmission of bacteria from skin surface. TidOr. Ade Present, ah, the thea’ q erature tet to so aye as Adu “dirty area” should be entrance should connect scrubbing area. The tem regulated between 19% humidity between 45% lights should be present, One of the key factors i infection\isithd number of bea air. Most ofthe bacteria are catch personnel, the medical stage te outdoor patients. So, ait changes 2 can reduce micro-organisms sprit” ventilation systems filter the air sry bacterial load in the air. There meet ue flow and air should be filtered thes filter (HIPA filters) and cycled thee theatre 20-25 times in an foil oot bacterial flux; the aim isto keep ya” count at < 180 colony forming wad Y 4 y (E) Surgical Techniques Poor tissue handling and inadequate result in devitalization of tissues and hemos formation. Necrotic tissues and hema. provide material for bacterial growth» increase the rate of wound infection, SURGERY IN HIGH RISK PATIENIS The concerned patients fall in two categire those carrying hepatitis B antigens or Ani? antibody and those who are HIV poste These diseases can be transmitted io* surgeon by a needle prick so follow precautions should be taken while pee these patients: + Any member of the staff com contact with the patient should ' plastic apron, visor and double 5 » Disposable gowns and drape essential. rt] Boots rather than open shoes i”) worn to protect feet when 5” sharp is dropped: boa? Ifthe assistant’s position ey i the operating surgeonration while changes are being 2 operat sharp instruments like sealnel, should be minimum. Rather, diathermy and scissors should be used for dissection and stapling devices are helpful to avoid the use of needles Round body needles should be preferred over cutting ones. Passage of sharp instruments should not be hand to hands, rather via a dish, ‘At the end of operation, disposable items should be gathered and labeled The operation theatre should be cleaned using diluted hypochlorite. When the patient is in the ward, any discharge of the body fluids or an open wound should be handled after wearing double gloves and goggles. The patient may be isolated. itis B exposure in surgery if surgeon is accidently pricked by a needle which was used upon a patient who was postive for hepatitis B surface antigen the following protocol should be followed. If the surgeon is not vaccinated for hepatitis B, he should be given hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine at two different sites. HBIG is considered efficacious if administered within 7 days of exposure If surgeon is vaccinated previously and his hepatitis B surface antibody level is more 10mIU/ml then no treatment Is needed but if this level is less than 10mIU/ml then he should be given HBIG and one dose of hepatitis B active vaccine Currently there are no such recommendations for immunization against HCV. Measures against HIV exposure are discussed at page 201ow Anesthec} wl nesthesia & Analgesia & x <= Oo Until the advent of anesthesia, surgeries were quick and brutal. Patients were fully conscious and there are many sketches and depictions to be found of surgery before this discovery illustrating what would look to anyone else like torture. With its use anesthesia allowed for much safer, longer, and more invasive surgical procedures. Of all milestones and achievements in medicine, conquering pain keel Ahmad Memon importance for good surgical There are two types of anesthesia : Utcon General anesthesia: It effects body and is characterize. a he unconsciousness (amnesia) 2"! and muscle relaxation which wf induced and reversible. must be one of the very few that has potentially affected every human being in the world It was in 1846 that one of mankind's greatest fears, the pain of surgery, was eliminated. The true birth of modern anesthesia should include the discussion of two gases: Ether and Chloroform. One name stands out amongst all others when discussing the founder of modern anesthesia, William T.G. Morton (1819 - 1868). In modern day there is no concept of surgery without anesthesia. Safe anesthesia is of utmost General anesthesia is a drug: sate characterized by tria (amnesia), analgesia (los and muscle relaxation. T which anesthetic drugs in gener. biggest mysteries © 2. Regional anesthesia: Only part ol body is affected, patient rem! conscious. GENERAL ANESTHESIA induced, reves! d of unconsciows® s of pain sensi! he mechanism duce the state’ af al anesthesia are considered ore f modern me adNg os uases OF GENERAL ANESTHESIA —— Induction of anesthesia Maintenance of anesthesia Reversal and Extubation \ 1, Induction of anesthesia: Induction means putting the patient to sleep, The ment can be induced either with Pralational or intravenous drugs + Intravenous induction: Induction is frequently done by intravenous agents Propofol has replaced thiopentone as most widely used induction agent; it has rapid induction and recovery. No hang over effect. Other infrequently used intravenous agents include etomidate and ketamine. « Inhalation induction: It includes gases such as isoflurane halothane, sevoflurane etc. It is useful in children, needle phobics or in patients with risk of pulmonary aspiration. Inhalational agents should have sweet smell and | rapid onset of action. Sevoflurane is the drug of choice for this purpose followed by Halothane (induction is delayed as compared to sevoflurane). Isoflurane is a pungent gas and is not used for induction. 1 2 3. Airway management and ventilation during anesthesia: After induction airway management is mandatory which can be achieved by supra- lotic devices (LMA, I-gel) or by endotracheal intubation. “Good airway means safe anesthesia. Loss of muscles tone as a result of general anesthesia, the patient become unable to keep their airway open so they require some techniques or procedures to keep their airway Open. The use of long acting muscle relaxant (required for surgery) means that they cannot breathe themselves so will require artificial Ventilation. once short acting muscle relaxant is gives; muscles tone is reduced and eflex become absent ,Manual methods ion chin lift and jaw thrust aryngeal mask airway or endotracheal tube is then inserted and patient is allowed tc breathe spontaneously or ventilated Laryngeal mask airway (LMA): It is inserted via mouth and produces a seal a glottis opening method of maintain airway. Its placement less irritating and less traumatic and technic can be taught to non anesthet Paramedical staff. LMA is useful for procedures and provides reliab Muscles relaxation and intubation Before Intubation, it is necessary to complete relaxation of muscle: larynx can be visible and there is 1 reflex. This can be achieved by giving very short acting muscle relaxant e.g suxamethonium (depolarizing agent) at a dos of 1.5mg/kg body weight. Its action starts within seconds and remains for a few minutes. The patient is intubated with the help o laryngoscope through the lar visualizing the vocal cords. The correc endotracheal placement is checked by direct Visualization of equal chest movement and auscultation of chest for equal air entry on both sides. ngeal inlet by Q: why suxamethonium is used before intubation. Answer Adequate muscle relaxation facilitates endotracheal intubation and suxamethonium has very good muscle relaxing property and it has very rapid onset of action (30 sec to 1 min) e It isshort acting (action last for 2-5 min) so if endotracheal intubation fails due ee eee