1.6 Indications and contraindications of surgery. Surgical incisions.

Question 1

Classification of surgical indications by urgency of surgery

Answer 1

vital:
- immediately
- life threatening situation, disease can be cured only with immediate operation
- ie. bleeding, perforation, obstruction of blood supply etc.

acute:
- urgent, within a few hours
- ie. ileus, appendicitis

planned:
- elective
- ie. hernia

Question 2

Classification of surgical indications by therapeutic possibilities

Answer 2

absolute:
- disease can be cured only with surgery
- time can be chosen
- ie. tumorous diseases, gallstones with complaints

relative:
- disease can be cured with or without surgery
- delay of operation does not risk the patient’s life expectancy
- ie. hernia without complains, low extremity varicositas, gallbladder stones w/o complaints

prophylactic:
- ie. Meckel diverticulum

social:
- ie. inappropriate medication

Question 3

Classification of surgical indications by therapeutic aim

Answer 3

• diagnostic: biopsy
• ablative (curative): removal of sick parts (ie. appendectomy)
• palliative: improving symptoms (ie. bypass)
• reconstructive: reconstruction of damaged parts or parts with malfunction (ie. plastic surgery)
• transplantation
• constructive: reconstruction of abnormalities patients are born with

Question 4

Classification of surgical indications by effects/impacts

Answer 4

• curative: complete healing
• palliative: improving quality of life (ie. cancer)
• preventative (ie. familial adematous polyposis patients, proctocolectomy to preven cancer development)

Question 5

Absolute contraindications of surgery

Answer 5

personal, material, professional and legal criterions are not met

• patient has not given consent, except in life-threatening situations
• patient is not suitable for the operation at the moment (inoperable)
• disease is not suitable for the treatment (ie. irresectable cancer)
• severe cardiorespiratory failure, hemorrhagic shock, sever metabolic/hemostatic imbalance

Question 6

Relative contraindications of surgery

Answer 6

• moribund (dying) patient
• manifested cardiomyopathy not responding to therapy
• shock, except if surgery is the solution
• bleeding disorder is out of control

Question 7

What is operability?

Answer 7

• operability is about whether the patient is in appropriate condition fro operation
• operability is influenced by the patient’s general condition, age and comorbidities
• patients in bad conditions can be successfully opperated on if proper preparation is combined with modern anesthesia, good surgical skills and postoperative intensive care

Question 8

What are the resectability options?

Answer 8

if complete removal of the disease/tumor is possible or not

resectable: if the removal is compatible with life of the patient
irresectable: if removal is not compatible with life of the patient (subjective, depending on the surgeon’s skills and technical possibilities)

Question 9

What are the common surgical symptoms?

Answer 9

• pain (site, onset, character, radiation, associated symptoms, timing, excerbating factors, surgical history)
• indigestion, dysphagia, reflux, hematemsis, altered bowel habits
• abdominal distention: fluid ascites, flatus (ileus/obstruction), fetus, fat, “flipping” big mass
• bleeding per rectum, tenesmus (feeling of incomplete defecation), jaundice, hemoptysis (coughing up blood), dyspnea, claudication, dysuria, hematuria

Question 10

What is the nomenclature of operations?

Answer 10

-tomy: incision made into a body cavity (laparotomy, thoracotomy), or organ cavity (gastrotomy, colotomy)
-stomy: creation of an opening into the outside world (gastrostomy, tracheostomy)

Question 11

What are the types of surgical interventions?

Answer 11

amputation
- total or partial removal of an extremity or a body part
- indicated in severe infections and necrosis

anastomosis
- making connection of luminar organs with suturs (ie. gastro-esophageal anastomosis, vascular sutures etc.)
- indicated when the tubular organ integrity is disrupted either by trauma or intentionally, such as when removing a tumor from the intestines

bypass
- stopping an organ system (ileo-transverso-stomy)
- getting around a stenotic vessel (coronary bypass)

desobliteration
- opening of an obstructed vessel

enterostomy
- creating a permanent opening through the abdominal wall into the intestines
- indicated where the intestine has lost it’s function due to ie. Crohn’s, excessive gluten exposure in Celiac’s, or cancer

enucleation
- removal of capsulated organs, such as benign tumors

excision
- removal of diseased tissue without extending beyond the borders of the organ/tissue

extirpations or […]-ectomy
- removal of sick organ or a sick part (ie. rectum extirpation, appendectomy)

incision
- opening of a pathological lesion/cavity, opening of a body cavity

reconstruction
- restoration of anatomical structures ie. sphincter reconstruction, breast reconstruction

resection
- partial removal of an organ, only the diseased parts

osteosynthesis
- synthesis of bones with screw, nails and plates for stability during motion

transplantation

Question 12

What are the types of surgica incisions?

Answer 12

1. Kocher’s collar incision
2. median sternotomy
3. thoracotomy: posterolateralis, anterolateralis, axillaris
4. subcostal incision
5. median laparotomy: upper, medial, lower, total
6. transrectalis laparotomy
7. pararectalis laparotomy
8. transverse laparotomy
9. suprapubic incision (Pfannestiel)
10. McBurney incision
11. oblique inguinal incision

Question 13

What are the main steps of any operation?

Answer 13

1. incision:
   - parallel to Langer’s skin lines
   - follow physiological skin wrinkles
   - perpedicular to muscle movements
   - pay attention to nerves and vessels
2. opening
3. exploration: confir the suspected diagnosis (ie. with frozen-section biopsy to check if problem is resectable)
4. substantive operation
5. anastomosis and wound revision
6. hemostasis