SURGERY REVIEW

2016
ASEPSIS
History
Definition
Asepsis of surgical instrument and
dressing
Preparation for Dr. and Pt.
Rules and regulations in operating
room
DEFINITION
Aseptic technique:
Basic operational standard
composed with mechanical
sterilization, sterilization,
disinfection and a series of rules
and regulations.
Asepsis:
Absence of microorganisms that
cause disease, freedom of
infection. Sterile: free of all living
DEFINITION
Mechanical sterilization:
To scrub, isolate and filter microorganisms
(bacteria, fungus).
Sterilization
A process capable of destroying all forms of microbial
life (virus).
Disinfection
A process capable of destroying pathogenic
microorganisms but as ordinarily used, not bacterial
spores.
Rules and regulations
To prevent the sterilized people and matter
contamination.
MECHANICAL
STERILIZATION
Scrub, isolate and filter
Scrub: Use water, soap and
antiseptics to scrub the operating
field, hands and instrument. The first
step of aseptic technique.
Isolate: Operation personnal wearing
hat, face mask, operating coat and
gloves.
Filter: Reduce the microparticle and
bacterium in the operating room.
STERILIZATION
Autoclaving
Dry heat
Boiling
Burning
Ultraviolet method
Microwave
Infrared rays
AUTOCLAVING (STEAM
UNDER PRESSURE)
The most completely reliable
sterilization
High pressure (104.0-137.3kPa)
High temperature (121-126C)
30 min
Time depend on T & P
Kill all bacteria (spores of
bacteria)
AUTOCLAVING TIME
Metals (10-15min)
Dressing (30-45min)
Rubber, glass, vitreous enamel
(15min)
Solution in bottle (20-40min)
DRY HEAT
Exposure to continuous dry heat
Avoid being spoilt by wet heat
Temperature (160C)
Time (1 hour)
4 hours for grease
BOILING
Only if autoclaving, dry heat, gas
sterilization is not available (for metal,
glass or rubber stuff).
Minimum period is 20 mins
Period can be decreased to 10 mins safely
in addition of alkali
Not effective against spore unless period
>1hour
Drip in completely
Time calculation (being boiling, start
again)
BURNING
Emergency request, only in special
situation
For metal instrument
95% alcohol
Causing damage to the metal
instrument
Infection of HBV positive, tetanus,
gasgangrene
Single-use stuff could be burnt off.
ULTRAVIOLET METHOD
Kill the microorganism in the air
and surface
Prefer to the OR dressing room
AND isolation ward.
OPERATING ROOM
REGIME
Personnel in operating room must
wear gown, shoes cover, head
cover and face mask.
No permission of upper respiratory
infection or other acute infection
General clean-up per week and air
sterilization
Strict sterilization after operation
or work.
CONCLUSION
Strict aseptic technique is
essential to minimize surgical
infection rate
It is most important to keep
asepsis principle in mind during
any surgical procedure.
AUTOCLAVING
ANNOUNCEMENTS
Storage time ( 2 weeks)
Attention ( 40cm*30cm*30cm,
arrangement, indicate tape,
flammable stuff, liquid rubber
stopper degas)
PREOPERATIVE
PREPARATION
The principle:
Different preparation for different
operation
The classification of operation
according to the characteristics of
operation
Elective surgery
Restrictive surgery
Emergent surgery
Pre operative Assesment
To confirm the diagnosis
To assess the risk of operation
To assess the general condition and function
of important organs (eg jaundice>270/275
pay attention!!)
To evaluate the patients endurance to
the operation and risk of operation
Post-operative
Management
Closely monitor life signs as a
routine
CVP monitoring is necessary if
hemodynamic unstable during
operation
Other items monitored
accordingly
Fluid balance
Wound healing and suture
removal
Classification of incision
Clean incision
Contaminated incision
Infected incision
Types of healing
A- perfect healing
B- some inflammation
C- infected
SHOCK OBJECTIVES
Define shock (syndrome) and describe
its common pathophysiology process
and common clinical manifestation.
Understand the consequences of shock,
e.g., the effect on organ function.
Explain the therapeutic modalities
available to correct the pathophysiology
in each form of shock, especially for the
hypovolemic shock and septic shock.
Shock
Is a group syndrome rather than a
simple phenomenon
In essence it is inadequate tissue
perfusion and oxygen delivery failure
Three factors to maintain effective
circulation:
Sufficient intravascular blood volume
Adequate cardiac output
Eligible periphera angioasis
Shock
A syndrome that results from
inadequate tissue perfusion of tissues
Insufficient to meet metabolic demands
Lead to cellular dysfunction,
elaboration of inflammatory mediators
and cellular injury
Which may be limited or widespread
Inadequate tissue perfusion can result
in:
Generalized cellular hypoxia
Widespread impairment of cellular
metabolism
SHOCK
A syndrome that results from inadequate
perfusion of tissues.
Insufficient to meet metabolic demand.
Lead to cellular dysfunction, elaboration of
inflammatory mediators and cellular injury
which may be limited or widespread.
Insufficient tissue perfusion can result in:
Generalized cellular hypoxia
Widespread impairment of cellular metabolism
Tissue damage MODS or MOF
Death
ETIOLOGY AND
CLASSIFICATION
Etiology
Hemorrhagic shock
Burn shock
Traumatic shock
Infective shock
Anaphylactic shock
Cardiogenic shock
Neurogenic shock
Classification of shock
Hypovolemic shock:
Hemorrhage-trauma, GI bleeding, ruptured
aneurysm.
Plasma losses- burns, bowel obstruction
Cardiogenic shock:
Intrinsic- MI, cardiomyopathy, valvular HD,
cardiac rhythm disturbance, myocardial
depression
Extrinsic:
Compressive- tension pneumothorax,
pericardial tamponade, high level of positive
pressure ventilation
 Neurogenic shock
Eg- spinal cord injury, severe head
injury, spinal cord anesthesia.
Vasogenic shock
SIRS, toxin
Septic
Traumatic
Anaphalactic and anaphylactoid
PATHOPHYSIOLOGIC
PROCESS OF SHOCK
Cells switch from aerobic to
anaerpbic metabolismlactic acid
productioncell function ceases
/swellsmembrane becomes
more permeableelectrolytes and
fluids seep in and out of
cellNa+/K+ pump
impairedmitochondria
damagecell death
Pathophysiologic staging
of shock
Microcirculatory changes
Metabolic changes
Secondary visceral
impairment
CLINICAL STAGING
1) Shock compensatory stage
-Nervous, restless, agitation
-Cool, pale, thirsty
-Tachycardia, short of breath
-BP normal or increased, pulse
pressure decreased, urinary output
normal or decreased
-Blood loss <20%, <800ml
 2) Shock inhibiting stage
-Serious shock phase
-Faint, dullness, confusion, coma
-Cyanosis, dyspnea
-Extremities cold and wet, pulse fast
and weak
-Oliguria, anuria
-BP decreased
-Blood loss >20%, >800ml
IRREVERSIBLE SHOCK
STAGE
Progressive deterioration become
irreversible at a blood loss of more
than 50% of total blood volume.
Low CO result in stagnant hypoxia of
mitochondria, drastic fall of MAP lead
to filtration diminished or abolished.
Disseminated intravascular
coagulation (DIC)
Terminal condition, all therapy is
frustrating.
The Chinese rule of nines
DEPTH OF BURNS
Method of 4 degrees
-1st: Epidermal injury
-2nd: Superficial 2nd degree
(superficial dermal burns)
deep 2nd degree
(deep dermal burns)
-3rd: Full thickness burns
-4th: Deep structure injury, e.g., bones
and tendons.
Purpose of wound care
To protect the wound
T prevent it from
contamination and infection
To relieve pain
To promote healing with
appropriate medicine.
Burn wound treatment
Dressing therapy
Exposure therapy
Semi- exposure therapy
Operative wound
management
Bathing therapy
Management of different
wounds
1st degree: Cold therapy
(running water)
2nd degree: Dressing (with
medicine)
3rd degree: Protect wound,
skin graft
4th degree: Skin flap
transplantation
SYMPTOMS OF LUNG
CANCER
Fatigue (tiredness)
Cough
Shortness of breath
Chest pain
Loss of appetite
Coughing up phlegm
Hemoptysis (coughing up blood)
If cancer has spread, symptoms include
bone pain, difficulty breathing, abdominal
pain, headache, weakness and confusion.
TREATMENT
Surgery
Chemotherapy
Radiation therapy
Some other therapy (immunologic
therapy, chinese traditional
therapy)
Breast diseases
Anatomy
Physical examination
Acute mastitis
Cystic hyperplasia
Breast tumor
Gynecomastia
Lymph
Pectoralis major
axillary subclavicular
supraclavicular
Medial portion intercostal
lymphatic duct Para
mediastinum
LYMPH
Subcutaneous lymphatic
communication left right
Lymphatic plexus of the rectal
sheath
falciform ligament liver
Imaging study
Mammography
Thermography
Ultrasound
Ductogram
Magnetic resonance (MR)
Positron Emission Tomography
(PET)
Tumor
Benign
-Fibroadenoma 75%
-Intraductal papiloma 20%
Malignant
-Cancer 98%
-Sarcoma 2%
Breast cancer
Pathological procedure
-Tumor site
-Hormone receptor status
-Status of excision margins
-Histologic type
Pathological classification
Type 1 non-metastasizing: inarticulate
carcinoma
Type 2 rarely metastasizing: pure extracellular
mucinous or colloid carcinoma, medullary
carcinoma with lymphocyte infiltration, well
differentiated adenocarcinoma
Type 3 moderately metastasizing:
adenocarcinoma, intraductal carcinoma with
stromal invasion, any other carcinoma not
specifically classified into other groups
Type 4 highly metastasizing: undifferentiated
carcinoma, any tumor that definitely invades
blood vessels.
Lymphatic metastasis
Pectoralis major LN
ipslateral axillary LN
subclavicular supra-
clavicular thoracic duct
venous stream.
Internal mammary nodes
(para-sternal) supra-
clavicular IN
Treatment
Surgical procedure: Curative or
palliative
Radial mastectomy: En block removal
of breast, pectoralis muscle and
axillary LN dissection (ALND).
Extended radial mastectomy: Plus
mediastinal LNs, (2,3,4 rib cartilage
and intra-thoracal A and V LN).
HERNIA OVERVIEW
Inguinal hernia: making up 75% of all
abdominal wall hernias
Femoral hernia: rare and usually
occurring in women
Umbilical hernia (10-30%)
Incisional hernia
Spigellan hernia
Obturator hernia
Inguinal hernia
Direct inguinal hernia
-Proceeds directly through the posterior
inguinal wall
-Direct hernias protrude medial to the
inferior epigastric vessels and are not
associated with the processus vaginalis.
-They are generally believed to be acquired
lesions.
-Usually occur in older males as a result of
pressure and tension on the muscles and
fascia.
Treatment (peptic ulcer
disease)
Medical management:
-ANTACIDS
-H2- RECEPTOR ANTAGONISTS
-PROTON-PUMP INHIBITORS
-SUCRALFATE
-TREATMENT OF H. PYLORI INFECTION: A
standard 2 week bismuth based therapy
comprised pepto-bismol (2 tablets four
times daily) in combination with
metroniadazole (500mg four times daily)
and tetracycline (500 mg four times
Surgical procedure for
peptic ulcer disease
4 classic indications for surgery
Intractability
Hemorrhage
Perforation
Obstruction
Gastric neoplasm
Malignant tumor
Adenocarcinoma

Benign tumor
Gastric polyps
Ectopic pancreas
Acute pancreatitis
Acute pancreatitis is an acute
inflammatory process os the pancreas
with variable involvement of other
regional tissue or remote organ
systems. The disease includes a broad
spectrum of pancreatic diseases which
varies from mild parenchymal edema
to sever hemorrhagic pancreatitis
associated with subsequent gangrene
and necrosis.
Clinical presentation
Pain of abdomen is diffuse
Hypotension
Metabolic derangement
Sepsis
Fluid sequestration
Multiple organ failure
Death
Differential diagnosis
Intestinal perforation
Peptic ulcer
Choleocystitis
Acute intestinal obstruction
Renal colic
Myocardial ischemia
Acute gastroenteritis
Treatment
1) Non-operative management
Dietary control
Nasogastric suction
IV fluid therapy and electrolyte
replacement
Nutritional support
Antibiotics
Analgesia
Pancreatic exocrine secretion
suppression
Pancreatic enzyme inhibitor
2) Surgical procedure
Peritoneal lavage: remove toxins and
various metabolites
Pancreatic drainage
Debridement of necrotic tissue
Biliary procedure:
-Endoscopic sphincterotomy
-Cholecystectomy
-Remove the CBD stone
3) Operative indication
Secondary pancreatic infection
Correction of associated biliary
tract disease
Progressive clinical deterioration
Surgery is contraindicated in
uncomplicated pancreatitis.
Complications
Systemic complication:
-ARDS
-Renal failure
-Cardiovascular failure
-MOSF
 LOCAL COMPLICATIONS:
-Pancreatic abscess
-Pancreatic pseudo cysts
-Pancreatic phlegmon
-Pancreatic ascites
-Pleural effusion
-Pancreatic fistula
-Intestinal fistula
Appendicitis symptoms
Pain in the abdomen, the lower right
area classic pattern of migratory pain is
the most reliable symptom of acute
appendicitis
Loss of appetite
Nausea
Vomiting
Constipation or diarrhea
Inability to pass gas
Low fever that begins after one
symptom
Physical examination
Location and tenderness
Rebound tenderness and guarding
Psoas sign
Obturator sign
Rovsings sign
Differential diagnosis
General surgery: perforation of peptic ulcer/
perforation of cholecyctitis
Urinary surgery: RT, ureteral calculus
Department of gynaecology: Ruptured ectopic
pregnancy, Ovaries follicle rupture, Torsion of
the pedicle of ovarian cysts, Pelvic
inflammation, Appendagitis
Digestion: acute gastroenteritis
Other: cancer of ileocecal junction
Hemorrhoid classification
3 types of hemorrhoids according
to the origin of H.
External
Internal
Prevention
Add fiber to prevent constipation and
diarrhea
Drink lots of water
Do not ignore the urge to go
Do not strain
Limit time on the commode to 2
minutes
Remove the library from the bathroom
Avoid obesity
Colorectal cancer
(etiology-risk factors)
High fat diet
Family history of polyps or cancer FAP
Personal history: IBD, colon polyps, or
cancer of multiple organs
Age: ore than 90% of the patients are
over 40
Other factors: alcohol, smoking,
obesity
Pathology cytology
Adenocarcinoma
(most common type)
Mucinous carcinoma carcinoid
Undifferentiated carcinoma
Squamous carcinoma
Spread of colorectal
cancer
Direct spread: Invade the surrounding
tissue or organ (Sigmoid colon cancer
can spread into the left ureter)
Lymphatic spread: CRC, cells frequently
spread to mesenteric lymph nodes
Vascular spread: CRC invades the
vascular system and spread to distant
organs (liver, lungs)
Spread by implantation
Symptoms and signs
Right colon cancer: anemia, occult
bleeding, abdominal mass in right illiac
fossa
Left colon cancer: often feel colicky
pain, rectal bleeding, bowel obstruction
mass in left illiac fossa, constipation or
diarrhea, never feeling relieved mucous
discharge
Rectal cancer: the most common
symptom is bleeding with defecation,
thin stools, increased bowel movement
frequency, feeling of incomplete
Diagnosis
Digital examination very important
examination for lower rectal cancer
Endoscopy: Sigmoidscopy, Colonscopy
Tumor marker: CEA (carcinoembryonic
antigen)
Tests for spread (liver ultrasound, CT,
MRI, PET)
Types of treatment
Surgery: Laproscopy vs open
surgical resection, colostomy
(temporary or permanent)
Chemotherapy: Adjuvent,
neoadjuvent and palliative, Oral
versus intravenous
Biological therapy (targeted agents):
VEGFR inhibitors, EGFR inhibitors
Chemo radiation (rectal cancer)
Post-op follow up
CEA
Colonscopy
Ultrasonography
CT
Trans-rectal ultrasound
Bacterial liver abscess
Clinical manifestations:
-Shakes, high fever, hepatic region pain
-T 39-40*C, usually be remittent fever
-Toxic symptoms such as profuse
sweating, nausea, vomit, loss of
appetite.
Bacterial liver abscess
Examination:
-Blood routine: WBC
-X-ray: raise of diaphragmatic
muscle and limitation of
movement; liver shadow increased.
-B-USG and CT scan
Bacterial liver abscess
Diagnosis
Differential diagnosis:
-Amoebic liver abscess
-Right subphrenic abscess
-Liver cancer
-Infection of biliary tract
Bacterial liver abscess
Treatment:
-Antibiotics
-Correct fluid and electrolyte
balance
-B-USG, CT guiding puncture drain
-Drainage by operation
-Lobectomy of liver is reasonable if
there is chronic local thick wall
abscess
Liver Cancer: Pathologic
type
Nodus: most common, usually
with hepatic cirrhosis
Huge lump: less with hepatic
cirrhosis or with level hepatic
cirrhosis
Diffusion: least seen, hard to be
recognized with hepatic cirrhosis.
Clinical type
Micro HCC: T</= 2cm
Small HC: 2cm<T</=5cm
Middle end stage HCC:
5cm<T</=10cm
Huge HCC: T>10cm
Clinical manifestations
Lack of typical symptoms in the
earlier stage
Frequent clinical manifestations:
-Pain in the hepatic region,
decreased appetite
-Debility, abdominal distension
-General and digestive symptoms
-Metastasis symptoms
Diagnosis of PLC (primary
liver cancer)
History
Physical examination
Laboratory examination
- Tumor marker: AFP
- USG
- CT, CTA
- MRI
- DSA
- ECT
- PET
- Liver biopsy
Types of operation
Local excision,sub hepatic
segmentectomy, segment, lobe,
half liver, right three lobes and
irregular excision.
Remain 30% of the normal liver
tissue
Remain 50% of the cirrhotic liver
tissue
Portal hypertension
Normal portal pressure is 1.27
2.35 kPa (13-24cm H2O), average
1.76kPa (18cm H2O)
4 collateral pathways
Esophageal and gastric venous
plexus
Umbilical vein from the left portal
vein to the epigastric venous
system
Retroperitoneal collateral vessels
The hemorrhoidal venous plexus
Clinical manifestations
Upper gastrointestinal
hemorrhage
Ascites
Enlarged spleen, hypersplenia
Hepatic coma
Acute abdomen
Acute abdomen refers to abdominal pain that
begins suddenly and is severe in nature. There are
many causes for acute abdomen, ranging from
appendicitis to peritonitis and ectopic pregnancy.
Many of the causes require surgery.
It is a condition that requires a fairly immediate
judgement or decision as to management.
- Does this patient need surgery?
- Is it urgent, or can wait?
In other words, is the patient unstable or stable?
The assessment of the acute abdomen pain is an
art form that all surgeons must master.
Causes of abdomen pain
4 main causes of abdominal pain:
-Inflammation: appendicitis
-Obstruction: Biliary colic, intestinal obstruction
-Ischemia: mesenteric ischemia
-Perforation (any of the above can progress to organ
perforation)
-Diseases that can progress to organ perforation
include mesenteric ischemia, diverticulitis,
appendicitis, bowel obstruction, cholecystitis, hernia,
and peptic ulcer disease.
Important signs in
patients with abdominal
pain
Diagnostic work-up
History-PE X-rays Ultrasound
CT scans Exploratory
laparotomy or Diagnostic
laparoscopy
Clinical patterns of acute
abdomen
Abdominal pain and shock
Generalized peritonitis
Localized peritonits (confined to
one quadrant of the abdomen)
Intestinal obstruction
Medical illness
Important medical causes
Acute Appendicitis
Acute Cholecystitis
Small Bowel Obstruction (SBO)
Perforated Peptic Ulcer
Acute Pancreatitis
Mesenteric Ischemia
Diverticulitis
Abdominal Aortic Aneurysm
 THE END. GO REVISE AGAIN.