General Surgery Notes

General Surgery Notes

Healing:

1. Healing by primary intention occurs in a wound that is

• Clean and uninfected
• Surgically incised
• Without much loss of cells and tissue
• Edges of the wound are approximated by surgical sutures

2. Primary closure of incised wounds must be done within 6 hrs.

3. Healing by secondary intention occurs in a wound that is

• Open with a large tissue defect and infected
• Not approximated by sutures but is left open
• Having extensive loss of cells and tissues.

Rule of nines:

The ‘rule of nines’ may be used to estimate the total body surface area burnt in adults.

• Head: 9%
• Right upper limb: 9%
• Left upper limb: 9%
• Right lower limb: 18%
• Left lower limb: 18%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Genitalia: 1%

The effects of burn injury are:

1. Local:

• Cell necrosis
• Collagen denaturation
• Infection
• Inflammation

2. Systemic:

• Hypovolemia
• Gastric or duodenal ulcer
• Multiple organ failure
• Hypoxia.

Types of grafts:

Ulcers:

Sinus and fistula:

Common tumors and their location:

Common staphylococcal skin infections:

Fluid management:

Carcinoma of lip and tongue:

• The majority of tongue cancers occur in the middle third of the lateral margins followed by posterior and anterior thirds of the tongue.
• Early lymph node metastasis and invasion of the floor of the mouth are common.
• It is mostly epidermoid carcinoma and accounts for more than half of the intraoral carcinomas.

• Commando operation – Block dissection of lymph nodes along with Hemiglossectomy.
• Brachytherapy – Interstitial (or) intracavitary radiotherapy when the growth is more than 1 cm in diameter in the anterior 2/3rd of the tongue.
• Teletherapy – External beam radiation is used when the growth is more than 2 cm in the posterior third of the tongue.

Types of Lymph nodes:

Buerger’s Disease:

• Thromboangitis obliterans (Buerger’s disease) is an occlusive disease of small and medium-sized arteries of both upper and lower limbs.
• The disease commonly occurs in men who are chronic smokers.
• The disease is characterized by gangrene of toes and fingers with characteristic corrugation of femoral arteries and distal arterial occlusions.

• Deep vein thrombosis is a serious life-threatening condition characterized by the development of the postthrombotic limb and venous ulceration.
• The frequent location is the lower limb and the commonest complication is pulmonary embolism.
• The signs and symptoms are swelling, pain, dilated superficial veins, calf tenderness, and redness.

Risk factors for deep vein thrombosis are:

• Old age
• Recent orthopedic surgery of lower limbs
• Oral contraceptives
• Thrombophilia
• Nephrotic syndrome
• Sedentary lifestyle.

Venous ulcer:

• Venous ulcer is the most common ulcer of the leg.
• The Basic cause of venous ulcers is abnormal venous hypertension in the lower third of the leg, ankle, and dorsum of the foot.
• This ulcer may be associated with demonstrable varicose veins or may follow thrombosis and phlebitis in the deep and perforating veins.

Blood transfusion:

• Massive blood transfusion-350 mL/5 min.
• SAG-M blood-deficient in albumin.
• Stored plasma is deficient in factors V and VIII.
• Post-transfusion hepatitis is most common in packed cell volume transfusion.
• Plasma transfusion is indicated when the area of burns exceeds 10%.
• The most common cause of pulmonary edema is circulatory overload from parenteral therapy.
• The most common reaction after blood transfusion is pyrexia.
• Hypocalcemia- below 2.5 mg/100 mL of calcium in blood inhibits blood coagulation.
• Clot retraction-abnormal Inpolycythemia, prothrombenimia, and multiple myeloma.
• Bleeding time gives the reaction of blood vessels to hemostasis.
• Clotting time to 15 mm.
• Prothrombin time-raised in warfarin treatment, liver disease & vitamin K deficiency.
• Prothrombin time-11 to 12.5 sec
• Deficiency of factors I, II, V, VII, and X increase prothrombin time.
• Partial prothrombin time for integrity and activation of the intrinsic system.
• Clot retraction to half of its mass occurs by 1 hr and is completed by 24 hr.
• Bleeding time-2.5 to 9.5 min (method). Duke method-1.5 to 4.5 minutes
• Surgery is contraindicated when PT is more than double the control.
• For factor IX deficiency, factor conjugate (II+VII+IX+X) is given.
• Von Willebrand disease is characterized by normal prothrombin time and increased partial prothrombin.
• Long-term use of phenytoin is associated with gum hypertrophy, osteomalacia, and folate deficiency.
• One stage of prothrombin tissue is an index of the function of the intrinsic pathway.
• Treatment for hereditary spherocytosis-splenectomy.
• Desferroxamine-indicated in iron overload following transfusion as seen in thalassemia etc.
• The commonest site of hemorrhage in hemophilia-knee.
• Conversion of celcius scale to Fahrenheit: Cel +32= Fahrenheit x (5/9).

Tracheostomy:

• Done at the level of the 2nd and 3rd tracheal ring.
• Emergency-vertical incision – Scarring – lower border of cricoid to sternal notch.
• Elective-horizontal incision – No scan -5 cm long about 2 finger breadth above sternal notch.
• If done at 1 string or cricoid-stenosis
• At the 5th to 7th ring -the trachea is difficult to reach due to the presence thick layer of fat.
• Cricothyrotomy through the cricothyroid membrane.
• Primary hemorrhage-during surgery
• Secondary hemorrhage after 7 to 15 days due to infection.
• Reactionary-within 24 hr (1 to 5 hr)-due to loss of clot/ligature step.
• Burns-albumin transfused.
• Hypovolemic shock-Ringer’s lactate.
• Patients under shock should have legs elevated 20 degrees with the head remaining elevated.
• Tachycardia and tachypnea represent the earliest signs of shock.
• HCO3 ion is absent in Ringer’s solution and Darrow’s solution.
• K+ rich-Darrow’s solution.
• SAG-M blood-blood-plasma + mannitol
• Ringer’s lactate-resembles plasma; IV fluid of choice in cholera, and prevention of hemorrhagic shock.
• IV fluid that reduces cerebral edema-mannitol
• 1 liter dextrose-200 calories of energy.
• Vascular space-5% of the body weight.
• Extravascular space-20% of body weight.
• Hyperglycemia in trauma is due to:
  • Catecholamine release
  • Gluconeogenesis
• Rule of nine-Wallace
• To calculate the severity of burns
  • Head and neck-9%
  • Upper limb (R&L)-9×2-18%
  • Thorax (front & back)-9 x 2= 18%
  • Abdomen (front and back) = 18%
  • Lower limb (front & back, right & left) = 9×4 = 36%.
  • External genitalia -9%.
• Muir and Barclay formula for determining fluid replacement:
• 1 ration = % of burn x body wt/2
• The head and trunk in severely burned patients account for 45% of the total body surface.
• Fluid replacement in burns
  • Fluids-for >10% burns in children and > 15% burns in adults.
  • Through nasogastric tube->35% burns.
  • Blood replacement therapy burns 25 to 50% burns.
• Cleft lip-treated surgically at 3 months of age.
• Cleft palate treated surgically at 15 months to 2 years of age.
• Rule of 10-for cleft lip repair Hemoglobin->10% Age-10 weeks
• Weight->101b Total count-<10,000/cubic mm of blood.
• The salmon patch disappears by the first year of age.
• Port wine stain is present at birth and persists through life.
• The tensile strength of a wound reaches that of normal tissue by 2 years and 50% of normal within 6 weeks.
• Crushed and devitalized wounds should be sutured by delayed primary suturing 4 to 6 days after injury.
• The greatest retarder of wound healing is residual infection.
• Enzymatic debrirna of a wound-hyaluronidase.
• Pyrexia due to wound infection on the 5th postoperative day.
• Nerve repair in an infected wound occurs by secondary intention.
• Gaping of scalp wounds occurs due to injury to the galea aponeurotica.
• Growth of epithelium over an ulcer and growth of nerve after nerve suturing- 1 mm/day.
• Structure preserved in Crile’s operation-phrenic nerve; and in functional neck dissection-accessory nerve and SCM, IJV.
• Raynaud’s phenomenon is associated with atherosclerosis, scleroderma, and Buerger’s disease.
• Signs and symptoms-increased vasospasm of peripheral arteries (hands), more in women, occurs in response to beta-blockers and cold exposures.
• Treatment is the use of nifedipine.
• Buerger’s disease is seen in men and affects lower limbs.
• The common site of an aortic aneurysm is the abdominal aorta below the level of the renal arteries.
• Brodie’s Trendelenburg test-sapheno femoral delay.
• Lumbar sympathectomy is done for rest pain and ulceration.
• Virchow’s triad of venous thrombosis:
  • Changes in the vessel wall.
  • Reduced rate of blood flow.
  • Increased coagulability of blood.
• Charcot’s triad pain, jaundice, and fever as seen in acute cholangitis.
• Universal antidote-charcoal, tannic acid, milk of magnesia.
• White leg-femoral vein thrombosis+ lymphatic obstruction.
• Painless effusion of joint in congenital syphilis is Charcot’s joint.
• Congenital lymphoedema-Milroy’s disease.
• Meleney’s ulcer-infected post of wounds.
• Martorell’s ulcer-ulcers in hypertensive patients.
• Everted edges-squamous cell carcinoma.
• Raised and rolled out pearly edges-rodent ulcer/basal cell carcinoma.
• Flask-shaped femur-Gaucher’s disease.
• Hormone increased in pituitary adenoma-prolactin.
• Burst open periosteum-osteosarcoma -> Sunburst appearance
• Blowout distension-aneurysm.
• Cigarette paper appearance-pytriasis rosea.
• Rope sign-acute poliomyelitis is associated with weakness in the larynx and hyoid muscles.
• Branchial cyst removal/Sistrunk operation involves damage to the accessory and hypoglossal nerve.
• Cystic hygroma-usually seen in the lower 1/3rd of the posterior triangle.
• Trench foot-frostbite.
• Most common primary bone tumor in children-osteosarcoma.
• Cardinal feature of parkinsonism-akinesia.
• Vomiting is associated with hypochloremic and hyponatremic alkalosis.
• Surgical risk for patients with organic heart disease depends on the cardiac reserve.
• In tetanus-period of onset is the time interval between the first symptom and first reflex spasm.
• The median nerve is the least involved in leprosy.
• Critical value of serum calcium-4mg%.
• Serum lactates-elevated in metabolic acidosis.
• Bee venom-neutralized with the application of soda bicarbonate.
• Third space-transcellular fluid.
• The commonest complication of surgical removal of ranula is injury to the lingual nerve.
• Eschrisch’s sign-protrusion of lips due to tapping of skin at angle of mouth-tetany.
• The commonest site of thyroglossal cyst-subglottic level.
• Neuroblastoma tends spontaneous regression.

General Anesthesia:

General Anesthesia Halothane:

1. Sensitizes heart to adrenaline
2. Used in patients with bronchial asthma, the requirement of a bloodless field, and plastic surgery. Disadvantage-causes CVS depression.
   • Seizures, hemorrhagic shock, muscle relaxation – cyclopropane.
   • N₂O causes Megaloblastic anemia
   • Ketamine used in shock
   • Thiopental administered by rectal route
   • % of N₂O used to produce adequate dental anesthesia but maintain adequate patient cooperation -35%. Etonox -50% O₂ + 50% N₂O
   • Antagonist to succinylcholine – neostigmine
   • Diethyl ether, if used alone, produces the most reliable eye signs

Color coding of storage cylinders:

Clostridium diseases:

Cleft lip and cleft palate:

• Cleft lip repair:
  • Millard’s rotation advancement flap surgery
  • Tennison – Randall triangular flap method.
  • Cleft lip repair is commonly performed between 3 – 6 months of age, whereas cleft palate repair is frequently performed between 6-8
    months i.e., before the child acquires the bad habit of nasal speech.
  • A cleft lip is repaired according to the rule of tens i.e. when the baby is 10 lbs, 10 weeks old, and has haemoglobin more than 10 gm%.
  • Usually, clefts of soft palate are repaired at 6 months whereas hard palates are repaired at 12-15 months.

• Cleft palate – Ward wills operation, Y-V push-back palatoplasty.

Xerostomia and Sialorrhea:

Signs and symptoms of hypo and hyperthyroidism:

Carcinoma of the thyroid:

Commonest Site Of Lesion

Erysipelas: Face and scrotum

Cellulites: Scrotum and scalp

Sebaceous cyst: Scalp, face, scrotum

Keloid: Sternum Face, neck

Lymphangioma & Hemangioma: Tongue, Lip

Carbuncle: Back, Nape of neck and shoulders

Implantation Dermoid: Hand and finger

Dermoid cyst: External angle of the eye, any line of fusion

Kaposi’s sarcoma: Limbs

Granuloma pyogenic: Face, fingers, toes

Corn: Toes, feet

Malignant melanoma:

• Males – trunk
• Females – leg

Hyperpigmentation in:

• Exposed areas and creases
• Addison’s disease of palms

Pregnancy tumor: Gums and Tongue

Signs:

Battle’s Sign:

In the posterior cranial fossa fracture, behind foramen magnum, Ecchymosis appears at the tip of Mastoid in 3-4 days

Acute appendicitis:

• Rovsing’s sign – Pressure in the left iliac fossa causes pain in the right iliac fossa
• Murphy’s sign – Catch of breath in inspiration
• Moyniham’s sign: in acute cholecystitis

Chvostek’s sign:

• Tapping the side of the facial nerve
• Elicits spasm in latent tetany

Trousseau’s sign:

• Eliciting carpal spasm in latent
• Tetany by raising the pressure in the cuff around the arm.

Rope sign:

• Acute poliomyelitis
• And larynx due to weakness of Hyoid muscles.
  • Kerning sign is seen in Meningitis – Brudginski’s sign
  • Flag sign – Seen in Kwashiorkor
  • Coleman’s sign – A hematoma seen in the floor of the mouth due to fracture of the body of the mandible.”