Core procedures 2

Question 1

Cholecystectomy: recovery

Answer 1

• Observed for a few hours but once able to pass urine can go home with an adult
• First 24 hours: discomfort around the port site or shoulder tip pain, pain killers are prescribed
• Most patients are able to eat and drink 4-6 hours after the operation, and if comfortable walking around will be able to leave hospital the same day. Not followed up in outpatient

Question 2

Cholecystectomy follow up and complications

Answer 2

• Avoid strenuous activity or heavy lifting for 4-6 weeks a can cause hernia. Can return to work after 1-2 weeks
• Can drive after 1-2 weeks but inform insurance company, must be able to do an emergency stop
• Open cholecystectomy; hospital stay is 3-5 days and wont feel normal for 6 weeks
• Can develop pain, bloating and loose stools

Question 3

Cholecystectomy: After the operation patients should seek medical advice if the following happens:

Answer 3

• Develop a fever
• Are vomiting / unable to keep food down
• Develop pain which is not controlled with simple pain killers
• Develop jaundice (yellow skin / eyes)
• Have bleeding, pus or other discharge and redness

Question 4

Inguinal hernia

Answer 4

• The abnormal exit of tissue or organ through the wall of the cavity in which it normally resides
• Presents with lump in groin +/- pain, worsens on activity or standing, palpable cough impulse
• Assess for: reducible, non-reducible (incarcerated), strangulated (pain), bowel obstruction

Question 5

Types of inguinal hernia

Answer 5

• Direct: hernia enters the inguinal canal via a weakness in the posterior wall. Medial to inferior epigastric vessels, usually older people
• Indirect: hernia enters the inguinal canal via the deep inguinal ring. Lateral to the inferior epigastric vessels. More common in children

Question 6

When to repair an inguinal hernia

Answer 6

• Dont if asymptomatic
• If they have pain, discomfort or intermittent obstruction consider repair
• Emergency surgery: incarcerated or strangulated
• Can be done in a young/active person where it is likely to increase in size

Question 7

Risks and complications of a hernia repair

Answer 7

• General: bleeding, infection, scarring, DVT/PE, conversion to open, anaesthetic risks
• Procedure specific: hernia recurrence, chronic pain, testicular atrophy, orchidectomy, injury to bladder or bowel, seroma

Question 8

Hernia repair: the procedure

Answer 8

• Normally elective day case: don’t eat 6 hours before, drink water 2 hours before
• Stop certain medication like anticoagulants
• Either open surgery or laparoscopically: open repair is most common and done under general, spinal or local anaesthesia
• Laparoscopic: done for bilateral or recurrent hernias, performed under general. 2 approaches the Transabdominal Pre-Peritoneal Approach (TAPP) and the Totally Extraperitoneal Approach (TEP). In TAPP abdominal cavity is entered in TEP you go through the peritoneal plane.

Question 9

Hernia repair: recovery

Answer 9

• Observed for few hours: can go home once able to pass urine and if someone can look after them
• Recovery: take it easy for a few days, avoid heavy lifting and straining for 6 weeks incase hernia recurs. Can drive again when you can do an emergency stop comfortably

Question 10

Hernia repair: When to seek medical advice post surgery

Answer 10

• Develop a fever
• Are vomiting / unable to keep food down
• Develop pain which is not controlled with simple pain killers
• Have bleeding, pus or other discharge and redness

Question 11

Mechanism of laparoscopic and open hernia repair

Answer 11

• Open: 8-12cm groin incision over side of hernia
• Laparoscopic: 12mm port at umbilicus, two 5mm ports

Question 12

Arthroscopy

Answer 12

keyhole surgery use to diagnose and treat problems within joints. Mostly used in knees and shoulders. But can be used in ankle, hip, elbow and wrist.

Question 13

Commonest indication for arthroscopy

Answer 13

• Medial meniscal tear
• Done if symptoms persist despite 3 months of conservative management
• Knee is locked (early intervention better)
• Improves pain and mechanical problems

Question 14

Benefits of arthroscopic vs open surgery techniques

Answer 14

• smaller incisions
• improved visualisation of anatomical structures within the knee joint
• less morbidity
• less pain after the operation
• lower risk of infection
• faster healing time and post-operative recovery
• safely go home the same day of surgery
• able to return to work / activities of daily living more quickly

Question 15

Arthroscopy: risks of procedure

Answer 15

• General: DVT, PE, MI, CVA, chest infection
• Specific: superficial wound infection, deep joint infection (septic arthritis), surgical site bleeding, neuro-vascular injury, secondary arthritis, stiffness, swelling, pain
• Use x-ray if detect advanced OA then do knee replacement, arthroscopy is contraindicated in advanced OA

Question 16

Arthroscopy: pre-operatively

Answer 16

• Day surgery: dont eat for 6 hours before and drink water for two hours
• Limb is marked with permanent marker
• General anaesthetic- small minority use a spinal anaesthetic
• Insert endotracheal tube or supraglottic airway

Question 17

Arthroscopy: the surgery

Answer 17

• Knee is examined under general anaesthetic
• A thigh tourniquet is applied and inflated to facilitate a clear view
• Two small incisions are made at the anteromedial and anterolateral aspects of the knee level to joint lines
• The knee joint is insufflated with normal saline to distend joint capsule to allow room for manouvring
• Commonest operation is partial menisectomy (removing damaged meniscal tissue) however can increase risk of secondary OA. New technique of meniscal repair

Question 18

Imaging carried out prior to arthroscopy

Answer 18

• MRI in younger patients
• joint XR in elderly patients if signs of co-existing OA (may be better treated with joint replacement surgery)

Question 19

Why is meniscal repair not always appropriate

Answer 19

depends on blood supply to location of tear (tears within inner third have poor blood supply)

Question 20

Arthroscopy: recovery

Answer 20

• Allowed to weight bear and walk immediately after recovering from anaesthetics
• Wear knee brace for 6 weeks
• Discharged same day as surgery and receive outpatient physiotherapy rehabilitation programme

Question 21

Arthroscopy: follow up after surgery

Answer 21

• Surgical wound check by district nurse at 2 weeks
• See surgeon at 6-8 week post discharge for clinical review
• Driving is usually permitted at 4 weeks for menisectomy and 6 weeks for meniscal repair
• Sedentary join can return at 2 weeks whilst physical jobs around 4-6 weeks

Pain: some patients continue to have pain in knee due to loss of shock absorber effect

Question 22

Arthroscopy: long term outcomes and different types

Answer 22

• Partial meniscectomy: removes the torn part of the meniscus, preserving the healthy part
• Sub-total menisectomy: when there is large and extensive tearing of the meniscus, a large volume of meniscal volume is removed
• Risk of secondary OA is proportional to how much tissue is removed. Occurs several years after
• Meniscal repair is less likely to cause OA

Question 23

Indications for joint replacement

Answer 23

• Patients with advanced OA and symptoms despite 3 months of conservative treatment
• OA on x-ray without symptoms is not an indication for surgey
• Most patients considered are ASA I or II

Benefits: pain relief of the affected joint, can improve walking distance

Question 24

Conservative treatment for hip OA

Answer 24

analgesia (escalating up the analgesic ladder), glucosamine / chondroitin supplements, physiotherapy, walking aids, intra-articular steroid injection, advice on activity modification and weight loss.

Question 25

General and specific risks and benefits: joint replacement

Answer 25

• General: DVT/PE, MI, CVA, UTI, chest infection
• Specific: superficial wound infection, deep prosthetic joint infection, surgical site bleeding, neuro-vascular injury, stiffness, swelling, numbness around the scar, loosening and / or gradual wear of the prosthesis, leg length discrepancy, dislocation of the prosthetic hip joint, unexplained chronic pain, peri-prosthetic hip fracture

Question 26

ASA grading for comorbidities

Answer 26

• ASA I - normal healthy patient
• ASA II - patient with mild systemic disease
• ASA III - patient with severe systemic disease
• ASA IV - patient with severe systemic disease that is a constant threat to life
• ASA V - moribund patient who is not expected to survive without the operation
• ASA VI - declared brain-dead patient whose organs are being removed for donor purposes

Question 27

Pre-assessment joint replacement

Answer 27

• Majority are inpatient but rarely day cases
• Don’t drink water for 2 hours or eat for 6 hours
• Limb is marked with permanent marker.
• General or regional (spinal) anaesthetic. Regional used more commonly as reduces need for postoperative analgesia

Question 28

The surgery: joint replacement

Answer 28

You remove the arthritic surface of the acetabulum and implanting a new artificial (metallic or polyethylene plastic) acetabular cup component. You then remove the femoral head and replace it with new artificial metallic femoral head and stem components.

Question 29

Joint replacement: immediately after surgery

Answer 29

• Allowed to fully weight bear after recovery from anaesthetics
• Post operative blood tests (check haemoglobin) and hip x-ray
• Discharged from hospital after 2-3 days
• Progress with outpatient physiotherapy rehabilitation programme

Question 30

Joint replacement: recovery

Answer 30

• Surgical wound check by district nurse at 2 weeks
• Attend physio to wean off crutches
• See surgeon 6-8 weeks post discharge for review
• Driving permitted at 6 weeks
• Sedentary jobs can return 6-8 weeks whilst more physical jobs its 3-6 months
• All patients receive thrombo-prophylaxis (self-administered subcutaneous low molecular weight heparin for 2 weeks followed by 28 days of aspirin)

Question 31

Complications of joint replacement

Answer 31

• Leg length inequality: may need heel raise
• Leaky wound or haematoma: treat by omitting some doses of thrombo-prophylaxis medication
• Prosthetic hip dislocation: important to follow the pre-cautions set by physiotherapist and occupational therapist
• Deep prosthetic joint infection: requires joint washout and debridement. Given prophylactic antibiotics

THR lasts 10-15 years

Question 32

Laparoscopic cholecystectomy surgical technique

Answer 32

• 12mm port at umbilicus to allow insufflation of abdo with CO2
• 12mm port just below xiphisternum
• two 5mm ports in RUQ
• The gallbladder is extracted through the umbilical port
• Assess CBD is high suspicion of stones. If stones perform ERCP

Question 33

Laparoscopic colectomy surgical technique

Answer 33

• Midline abdominal incision
• 12mm port placed at umbilicus for camera and 3 or 4 other working ports

Question 34

Colonoscopy technique

Answer 34

• patient lies on left side with knees to chest
• care should be taken at the hepatic flexure (short sharp bend)

Question 35

Laparoscopic hernia repair technique

Answer 35

• 8-12cm groin incision over side of hernia
• 12mm port at umbilicus, two 5mm ports