87241087 Clinical Surgery Notes PDF

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Summary

Revision Podmedics to these notes on the basics of surgery for undergraduates. Learning in an age where in the clinic and the library, is so accessible, the authors have often felt a little overwhelmed. texts are excellent, we feel that none currently provide a good summary to get students the harde...

Description

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The Podmedics’

Surgery Revision Notes

© Podmedics 2010

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Introduction Welcome to these notes on the basics of surgery for undergraduates. Learning in an age where information, both in the clinic and the library, is so accessible, the authors have often felt a little overwhelmed. While many texts are excellent, we feel that none currently provide a good summary to get students started. Often the hardest toil in studying medicine is figuring out how precisely to get started. In these notes we outline some of the common processes that are used to break down both presentation of the disease and the processes that drive it. Having done this, we then use these techniques as a schema for our notes. The notes are based upon a series of podcasts written by Jonny and Ed during early 2008 (the podcasts are available at the site). While they are clearly aimed at the level required for UK final MBBS, they should be useful to students at any stage of their training. It is our belief that these notes, together with the supporting podcasts, make up a definitive and useful revision tool for students. A considerable amount of work has gone into preparing these notes. Please support us by telling you friends and pointing them in our general direction.

Thank you and good luck.

The Podmedics Team

Contact us The Podmedics constantly aim to improve the quality, accuracy and consistency of their content - please do get in touch if you have any questions or comments.

Ed Wallitt: [email protected] Jonny Manley: [email protected]

Please do not reproduce these notes without prior permission. All images remain the property of their original authors.

DISCLAIMER: No responsibility is taken for errors/omissions from these notes. They are written by students for students. © Podmedics 2010

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Podmedics’ Recommended Texts/Links/Courses

Websites www.podmedics.com Please forgive us the indulgence of being placed first.

www.onexamination.com You must answer questions from this site!

Google images Fantastic for practising presentations of just about anything you can think of.

Texts Surgical Talk Probably the only medical book ever written that is possible to read in bed.

Lecture Notes on Surgery Harold Ellis was one of the finest surgeons and medical educators of his time. His book is great (...if you want to be a surgeon)!

Courses The 10-week Surgery Revision Course

Hosted by the MDU and the mighty Mr Barry Paraskevas

© Podmedics 2010

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Table of Contents Key Principles ! Surgical Fluids and Nutrition!

8 12

Fluids!

12

Nutrition!

15

Trauma Surgery! Advanced Trauma Life Support (ATLS)!

18 18

Chest Trauma !

24

Head Trauma !

28

Burns!

32

Peri-operative Care !

35

Pre-operative!

35

Post-operative!

38

Skin Disorders!

42

The Oesophagus!

47

Clinical Anatomy!

47

Dysphagia !

48

Oesophageal Tumours!

50

Gastro-oesphageal reflux disease!

52

Hiatus Hernia and other conditions!

53

The Stomach! Clinical Anatomy!

57 57

Acute Upper GI Bleed !

59

Peptic ulcer!

61

Perforated Peptic Ulcer!

63

Gastric Cancer!

65 © Podmedics 2010

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Gallstone and Biliary Disease!

68

Clinical Anatomy!

68

Introduction to Gallstones!

69

Gallbladder Complications!

70

Biliary Tree Complications!

73

Intestinal Complications!

75

The Spleen!

77

Clinical Anatomy!

77

Hypersplenism & Hyposplenism!

78

Splenectomy !

79

Splenic Trauma !

80

The Pancreas!

83

Clinical Anatomy!

83

Pancreatitis !

85

Pancreatic Tumours!

90

Basic Principles of the Lower Gastrointestinal Surgery!

92

Important Clinical Anatomy!

92

Intestinal Obstruction !

95

Colon Cancer and Stomas!

100

Colorectal carcinoma !

100

Emergency bowel operations !

103

Stomas!

104

Inflammatory Conditions!

105

Appendicitis!

105

Diverticular Disease!

107

Surgical Ulcerative Colitis! Crohn’s Disease!

Peri-Anal Disease! Clinical Anatomy!

109 111

113 113 © Podmedics 2010

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Haemmorrhoids!

114

Anal Fissures!

116

Anal abscess/Anal sepsis!

117

Anal Fistula !

118

Rectal Prolapse !

119

Anal Carcinoma !

120

Breast Disease !

123

Clinical Anatomy!

123

Diagnostic Principles in Breast Disease !

124

Benign Breast Disease!

125

Malignant Breast Disease!

127

Neck Lumps !

131

Clinical Anatomy!

131

Lymphadenopathy !

134

Solitary Lumps in the Neck!

135

Thyroid Surgery!

139

Hernias !

143

Vascular Surgery !

149

Clinical Anatomy!

149

Venous Disorders!

151

Arterial Disorders!

154

Orthopaedics!

167

Basic Fractures!

167

The Hip!

170

Important other fractures for finals !

175

The Knee!

179

Neurosurgery !

183

Clinical Anatomy!

183

Spinal Cord Compression!

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Neurological Tumours!

186

Hydrocephalus!

187

Urology !

189

Clinical Anatomy!

189

Common presentations!

190

Kidney and Bladder!

197

Prostate Disease !

202

The Scrotum!

206

Testicular Cancer!

Appendix!

210

212

Common abdominal scars!

212

Common drugs!

213

© Podmedics 2010

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Key Principles Here we outline some of the different common techniques that can be applied throughout the field of surgery.

General approach to defining a disease 1. 2. 3. 4.

Definition (and classification) Epidemiology (and risk factors) Aetiology Clinical features a. Symptoms/Signs (further split each into general and specific) 5. Investigations 6. Management 7. Complications

Common techniques Aetiology When thinking about aetiology try to think in terms of... 1.

2. !

Anatomy - i.e. what are the surrounding structures/associated pathologies that could be causing the given problem. Surgical sieve - what pathological processes could be occurring?

THE “VINTA MEDIC” SURGICAL SIEVE

Process

Sub-split

Process

Vascular

Heart Blood vessels

Metabolic/Nutritional

Infection

Bacterial Viral Fungal Protozoal

Electrolytic

Neoplastic

Primary Secondary

Degenerative

Trauma

Penetrating Non-penetrating

Iatrogenic

Autoimmune

Gel and Coombs classification

Congenital

Sub-split

Anions Cations Non-charged

Drugs Interventional procedures

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Clinical features

This should be split into symptoms and signs and each of these should be sub-divided into general and specific. Have this table memorised in your head and go through it logically when you are thinking of investigations to do. Investigations

Modalities Cultures

Bloods - ABG Bloods - Venous Imaging

Scopic/Biopsy Functional

Tests + Findings Blood Urine MC & S, dipstick / pregnancy test CSF Joint aspirate Pleural/peritoneal fluid NB: usually justified if the patient is ill For each test you must be able to justify why you are performing it Plain X-ray e.g. chest, abdomen, bones Plain X-ray series + contrast USS CT/MRI PET/radio-isotope Specific tests for a given system that do not fit into the above. e.g. ECG, lung function test, pH manometry

Treatment

If an emergency you must first talk about RESUSCITATION e.g. Airway, Breathing, Circulation etc.

Modalities

Specifics

CONSERVATIVE

Always think about: 1. Basic things e.g. analgesia, fluids, 2. Risk factor management

MEDICAL

This is surgery..but we still use drugs

SURGICAL

What techniques can be used, what do they involve and when are they indicated

© Podmedics 2010

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Complications These are split into general (applicable to any surgery) and specific (applicable to the described surgery). GENERAL

Think in terms of: Airway e.g. difficulties with management Breathing e.g. hypoxia Circulation Drugs e.g. allergies, anaesthetic reactions Exposure to the theatre environment e.g. hypothermia, accidental injury

Specific - Immediate

At time of surgery e.g. primary haemorrhage, visceral damage

Specific - Early

1-3 days post-surgery e.g. pyrexia, SOB, reactionary haemorrhage, urinary retention, oliguria

Specific - Late

3-10 days post-surgery e.g. infection, DVT/PE, C. diff colitis

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© Podmedics 2010

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Surgical Fluids and Nutrition Fluids Fluid and Electrolyte Distribution Average 70kg man - 42L (60-70%) - ⅔ INTRACELLULAR - ⅓ EXTRACELLULAR (plasma, interstitial, transcellular e.g. ocular, fluid, pleural)

! !

Osmolality (280-295 mosmol/l) - should be equal between IC and EC CHARGED + UNCHARGED

∴ (Na++K++Cl-+HCO-) + (urea+glucose) = 2(Na++K+) + urea + glucose

INPUT

OUTPUT

Oral

1.5L

Urine

1.5L

Food

1L

Stool

0.5L

Oxidative water

0.5L

Skin

0.5L

Lungs

0.5L

TOTAL

3L

3L

Total insensible = skin loss + lung loss.

Daily Requirements Water • 40ml/kg/day ~ 3 L per day Electrolytes • Na+ = 100 mmol/day • K+ = 60 mmol/day

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Indications for Intravenous Fluids Pre-operative resuscitation Replacement of normal loss Replacement of additional loss Postoperative resuscitation Electrolyte disorders

1. 2. 3. 4. 5.

Types of Fluids

Types CRYSTALLOIDS

Normal saline

154 mmol Na+ in 1L

Dextrose saline

30 mmol/l Na+ + 40g dextrose

5% dextrose

50g dextrose in IL

Hartmannʼs (lactated Ringerʼs solution)

Anions + Cations + Ca + lactate

- “Electrolytes in water that form a true solution and pass through semi-permeable membrane.”

COLLOIDS - “Fluid with high molecular weight molecules that does not form a true solution and does not pass through a semi-permeable membrane.”

Contents

Natural e.g. blood, albumin

Synthetic e.g. Gelofusin, Haemaccel

Dextran compounds

Fluid Regimes 1L normal saline + 2L 5% dextrose OR

3L dextrose saline

+ 20mmol/l of K+ per bag

Important caveats: • Always replace ADDITIONAL LOSSES e.g. vomiting, diarrhoea, ileostomies, 3rd space • If fever (20% extra/day or 500ml/degree above 37) • No potassium 24-48 hours post surgery (non-cardiac)

Hartmannʼs is also known as LACTATED RINGERʼS SOLUTION and should be avoided in liver and renal failure.

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Assessment of volume status • Check fluid charts and other bedside charts, quick history. • Observation: awake/orientated or confused, shortness of breath. • Inspect for: • Cap. refill (> 3 secs) • Temperature of the hands • Increased skin turgor • Tachycardia/tachypnoea • Blood pressure (late sign) • Low JVP • Sunken eyes • Dry mucous membranes

Features of JVP: • • • • •

Falls on inspiration Falls on standing Non-pulsatile Lies between the 2 heads of the SCM Has a double waveform

• Examine chest and peripheries for oedema

URINE OUTPUT: Should be 0.5 ml/kg/hr (= 30ml/hr for 70kg man) If no output/anuria: 1. SIMPLE STUFF e.g. check catheter & bag, flush the catheter with 50 mL saline using a bladder syringe 2. Fluid challange (250ml colloid - repeat a couple of times) 3. Senior review and consider CVP monitoring

A central venous pressure line is often used in order to gauge the response to a fluid challange. • If the patient is UNDERFILLED the CVP will not increase with the challange or will increase the fall again • If the patient FILLED then the CVP will rise (> 10mmHg) and stay elevated

© Podmedics 2010

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Nutrition Nutrition is important as it affects outcome 1. Impaired immune system 2. Delayed/poor wound healing 3. Longer rehabilitation (so increased cost, nosocomial infections, DVTs)

Assessment

HISTORY EXAMINATION

ANTHROPOMETRIC

BLOOD TESTS

Eating habit, diet, recent changes in weight/appetite Regular weights BMI Waist circumference (>102 cm in men, > 88 cm in women) Upper arm circumference Ulnar length Grip strength Skin fold thickness Albumin Pre-albumin Phosphate Transferrin Lymphocyte count

BMI = weight (kg) / height (m)2

Normal

18.5 - 25

Overweight

25 - 30

Obese

30 - 40

Morbidly obese

> 40

Waist circumference is a better representation of omental fat + better predicts development of metabolic syndrome.

Daily Requirements Calories:! Protein:!! Nitrogen:!

25-35 kcal/kg/2 hrs (usually ~ 2500 per day for men and ~ 2000 per day for women) 1.5 kg/24 12g per day

© Podmedics 2010

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Nutritional Therapy

Basic definitions:

• ENTERAL - “Nutrition that is delivered via the normal enteral route” • PARENTERAL - “Nutrition that is delivered directly through the venous system.”

1. Enteral Nutrition

To use this form of nutrition it is necessary for patients to have some degree of functioning bowel. There are 3 types of feed: 1. POLYMERIC • Near to normal e.g. food-supplements (Nsure, Fortisip), OSMOLITE 2. DISEASE SPECIFIC • Gluten-free diets in coeliac disease, liver disease feeds 3. ELEMENTAL • Basic AA and saccharides e.g. chronic multiple fistulae in Crohns

This may be administered: 1. ORAL 2. Fine-bore NG tube (check for aspirate, CXR) [< 6 weeks] 3. Gastrostomy (surgical/PEG) 4. Jejunostomy

Complications of enteral nutrition:

Feed itself

Method of delivery

Too much feed/too little feed Intolerance (nausea/vomiting and diarrhoea) Electrolyte + glucose imbalance Malposition of NG tube Tube obstruction Infection around gastrostomy/jejunostomy

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2. Total Parenteral Nutrition

This should be avoided if at all possible. The main indication is NON-FUNCTIONING BOWEL • e.g. short bowel syndrome, prolonged ileus, severe Crohnʼs disease

May be administered through: 1. Large peripheral line 2. Central line (tunnelled = Hickmann line)

Complications of parenteral nutrition:

Feed itself

Method of delivery

Reactive hypoglycaemia Fatty liver Vitamin deficiencies Complications of inserting a central line e.g. pneumothorax, bleeding Infection around site Sepsis Malposition

© Podmedics 2010

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Trauma Surgery

Advanced Trauma Life Support (ATLS) Trauma is the leading cause of death due to injury worldwide, and may be defined as: “A body wound or shock caused by a serious and life-threatening injury.”

The trimodal death distribution describes death due to injury in three peaks or periods. The first occurs within seconds to minutes of injury and is due to severe injuries where only prevention can reduce deaths. The second occurs within minutes to hours, where the golden hour of care with rapid assessment and resuscitation can save lives. The third peak occurs after several days to weeks and is often due to sepsis and multiple organ dysfunction. When treating traumatised patients we use ATLS Principles:

1. Primary Survey/Resuscitation • ABCDE 2. Secondary Survey • AMPLE • Top-to-toe examination 3. Definitive treatment

TRIAGE is the process of prioritising care based upon available resources and the extent of injuries sustained.

The Primary Survey This basically is RESUSCITATION and may be remembered using the familiar mneumonic ABCDE.

1. Airway and C-spine

The C-spine must be secured with in-line immobilisation. Unknown trauma to this area could lead to severe spinal injury and breathing compromise. Initially this may require manual immobilisation, but eventually inline support of the C-spine needs triple immobilisation with: 1. Hard collar 2. Blocks or sandbags 3. Tape over chin and forehead

Airway and C-spine

Breathing

Circulation

Disability

Exposure

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The airway must be assessed and treated.

ASSESSMENT

TREATMENT

1. If orientated and speaking...AIRWAY IS SECURE. 2. If obtunded or gurgling/stridor...AIRWAY NEEDS SECURING. 3. If complete obstruction...OPEN and SECURE. Chin lift or jaw thrust Remove foreign bodies with fingers Suction with a Yanker tube e.g. vomit, blood Secure the airway e.g. nasopharyngeal, oropharyngeal - Guedel, ET tube, surgical

Types of Airway

The best person to manage the compromised airway is an anaesthetist. Airways may be divided into: NON-SURGICAL and SURGICAL and NON-DEFINITIVE and DEFINITIVE A definitive airway is an adequately secured, cuffed tube in the trachea. An ETT and tracheostomy are definitive airways. Note that an LMA is not a definite airway, as patients are still at risk of aspiration. The indications for a definitive airway are: • • • • •

Apnoea Inability to maintain a patent airway Risk of aspiration or obstruction GCS < 8 Inadequate oxygenation via...