Title Andre Tan Surgical Notes.pdf ✅

Surgery Notes For the M.B.B.S. By Andre Tan CONTENTS Page I TRAUMA (MULTI-SPECIALTY APPROACH) 2 II APPROACH TO ABDOMINAL PAIN 10 III APPROACH TO ABDOMINAL MASSES 11 IV OESOPHAGEAL DISEASES 12 V UPPER BLEEDING GIT AND ITS CAUSES 21 VI COLORECTAL DISEASES 19 VII LIVER DISEASES 39 VIII PANCREATIC DISEASES 45 IX BILIARY TRACT DISEASES 51 X BREAST DISEASES 60 XI HEAD AND NECK MASSES 69 XII SALIVARY GLAND SWELLINGS 74 XIII THYROID DISEASES 78 XIV PERIPHERAL ARTERIAL DISEASE 85 XV ABDOMINAL AORTIC ANEURYSM 93 XVI PERIPHERAL VENOUS DISEASE 95 XVII UROLOGICAL DISEASES 99 XVIII SURGICAL INSTRUMENTS 110
2 TRAUMA (MULTI-SPECIALTY APPROACH) ADVANCED TRAUMA LIFE SUPPORT ALGORITHM MAIN PRINCIPLES: - Treat greatest threat to life first - Definitive diagnosis is less important - Time is important – the “golden hour” after trauma is when 30% of trauma deaths occur, and are preventable by ATLS APPROACH 1. Primary survey and Resuscitation with adjuncts 2. Re-evaluation of the patient 3. Secondary survey with adjuncts 4. Post-resuscitation monitoring and re-evaluation 5. Optimise for transfer and definitive care PRIMARY SURVEY – ABCDE 1. AIRWAY Assessment of airway patency - Is patient alert, can patient speak? - Gurgling, stridor - Maxillofacial injuries - Laryngeal injuries - Caution: C-spine injury Establishing patent airway - Chin-lift or modified jaw thrust (protect C-spine) - Remove any foreign objects in the mouth where possible - Oro/nasopharyngeal airway - Definitive airway – endotracheal tube, cricothyroidotomy, tracheostomy 2. BREATHING Assessment of breathing - Look, listen, feel: chest rise, breath sounds – rhythm and equality bilaterally - Rate of respiration - Effort of respiration - Colour of patient - Percuss chest - Look for chest deformities e.g. flail chest Management of breathing - Supplemental oxygen - Ventilate as required if patient requires assistance with breathing - Needle thoracotomy for tension pneumothorax, followed by chest tube - Occlusive dressing for open pneumothorax 3. CIRCULATION Assessment of organ perfusion - Level of consciousness - Skin colour and temperature, capillary refill - Pulse rate and character – all major pulses - Blood pressure Classes of haemorrhagic shock I II III IV Bld loss Amt (ml) Percentage <750 <15 750-1500 15-30 1500-2000 30-40 >2000 >40 Ht rate <100 >100 >120 >140 BP Normal Normal Decreased Decreased Cap refill Normal Prolonged Prolonged Prolonged Resp rate 14-20 20-30 30-40 >35 Ur output (ml/h) >30 20-30 5-15 Oliguric-anuric Mental state Sl anxious Mild anxiety Anxious- confused Confused- lethargic Fluid replacement Crystalloid Crystalloid Crystalloid + blood Blood Management - Sources of bleeding  apply direct pressure or pressure on proximal pressure point - Be suspicious about occult bleeding e.g. intraperitoneal, retroperitoneal (pelvic fracture), soft tissue (long bone fracture) - Venous access – large bore, proximal veins - Restore circulatory volume with rapid crystalloid infusion – Ringer’s lactate - Blood transfusion if not responsive to fluids or response is transient - Reassess frequently
3 4. DISABILITY - Glasgow coma scale Eye Verbal Motor Spontaneous opening Opens to voice Opens to pain No response 4 3 2 1 Oriented speech Confused Inappropriate Incomprehensible No verbal response 5 4 3 2 1 Obeys Purposeful Withdraws Flexion response Extension response No response 6 5 4 3 2 1 GCS: 14-15 (minor); 8-13 (moderate); 3-7 (severe) - AVPU score: Alert, Verbal stimuli (responds to), Pain stimuli, Unresponsive - Pupillary reactivity - Call for neurosurgical consult as indicated 5. EXPOSURE - Remove all clothes - Check everywhere for injuries (log-roll to look at the back) - Prevent hypothermia 6. ADJUNCTS TO PRIMARY SURVEY Monitoring - Vital signs – BP, pulse rate, saturation (pulse oximeter) - ECG monitoring - Arterial blood gas Diagnostic tools - Screening X-ray films (trauma series): CXR, AP pelvis, lateral C-spine - Focused abdominal sonography in trauma (FAST) - Diagnostic peritoneal lavage Urinary catheter - Functions: decompress bladder, measurement of urinary output - Caution in urethral injury: blood at urethral meatus, perineal ecchymosis/haematoma, high-riding prostate Gastric catheter (orogastric or nasogastric) - Function: decompress stomach, look at aspirate (bloody? bilious?) - Caution in base of skull fracture: CSF otorrhoea/rhinorrhoea, periorbital ecchymosis, mid-face instability (grab the incisors and rock), haemotympanum  insert orogastric tube instead of nasogastric SECONDARY SURVEY When to do secondary survey - Primary survey and resuscitation completed - ABCDEs reassessed - Vital functions returning to normal i.e. no need for active resuscitation at the moment 1. AMPLE HISTORY - Allergy - Medications - Past history - Last meal - Events leading to injury, Environment in which trauma occurred 2. COMPLETE HEAD-TO-TOE EXAMINATION Head - Complete neurological examination - GCS or AVPU assessment - Comprehensive examination of eyes and ears for base of skull fractures - Caution: unconscious patient; periorbital oedema; occluded auditory canal Maxillofacial - Bony crepitus/deformity - Palpable deformity - Comprehensive oral/dental examination - Caution: potential airway obstruction in maxillofacial injury; cribriform plate fracture with CSF rhinorrhoea  do not insert nasogastric tube Cervical spine - Palpate for tenderness, any step deformity - Complete neurological examination - C-spine imaging - Caution: Injury above clavicles; altered consciousness (cannot assess accurately); other severe, painful injury (distracts from cervical spine pain) Neck (soft tissues) - Blunt versus penetrating injuries - Airway obstruction, hoarseness - Crepitus (subcutaneous emphysema), haematoma, stridor, bruit - Caution: delayed symptoms and signs of airway obstruction that progressively develop; occult injuries
4 Chest - Inspect, palpate, percuss, auscultate - Re-evaluate frequently - Look at CXR - Caution: missed injury; increase in chest tube drainage Abdomen - Inspect, palpate, percuss, auscultate - Abrasions and ecchymosis – “seat-belt sign” - Lower rib fractures  liver and spleen injury - Re-evaluate frequently - Special studies: FAST, DPL, CT scan - Caution: hollow viscus and retroperitoneal injuries; excessive pelvic manipulation Perineum - Contusions, haematomas, lacerations - Urethral blood - DRE: Sphincter tone, high-riding prostate, pelvic fracture (may feel fragments of bone); rectal wall integrity; blood - Vaginal examination: blood, lacerations Musculoskeletal – extremities - Contusion, deformity - Pain - Perfusion - Peripheral neurovascular status - X-rays as appropriate - Caution: potential blood loss is high in certain injuries (e.g. pelvic fracture, femoral shaft fracture); missed fractures; soft-tissue or ligamentous injuries; examine patient’s back 3. ADJUNCTS AND SPECIAL DIAGNOSTIC TESTS - As required according to suspicion, but should not delay transfer 4. FREQUENT RE-EVALUATION - Have a high index of suspicion for injuries to avoid missing them - Frequent re-evaluation and continuous monitoring  rapidly recognise when patient is deteriorating 5. PAIN MANAGEMENT - Intravenous analgesia as appropriate ABDOMINAL TRAUMA TYPES OF INTRA-ABDOMINAL INJURY IN BLUNT TRAUMA - Solid organ injury: spleen, liver – bleeding (may be quite massive) - Hollow viscus injury with rupture - Vascular injury with bleeding INDICATIONS FOR IMMEDIATE LAPAROTOMY - Evisceration, stab wounds with implement in-situ, gunshot wounds traversing abdominal cavity - Any penetrating injury to the abdomen with haemodynamic instability or peritoneal irritation - Obvious or strongly suspected intra-abdominal injury with shock or difficulty in stabilising haemodynamics - Obvious signs of peritoneal irritation - Rectal exam reveals fresh blood - Persistent fresh blood aspirated from nasogastric tube (oropharyngeal injuries excluded as source of bleeding) - X-ray evidence of pneumoperitoneum or diaphragmatic rupture INVESTIGATIONS - If patient is stable: FAST and/or CT scan - If patient is unstable: FAST and/or DPL FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA (FAST) - Ultrasonographic evaluation of four windows: Pericardial, right upper quadrant, left upper quadrant, pelvis - Advantages  Portable  Can be done quickly in <5min  Can be used for serial examination  Does not require contrast, no radiation risk - Disadvantages  Does not image solid parenchymal damage, retroperitoneum, diaphragmatic defects or bowel injury  Compromised in uncooperative, agitated patient, obesity, substantial bowel gas, subcutaneous air  Less sensitive, more operator-dependent than DPL and cannot distinguish blood from ascites  Intermediate results require follow-up attempts or alternative diagnostic tests