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Medicine year 4 ACE > Core procedures 2 > Flashcards

Core procedures 2 Flashcards

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1
Q

Cholecystectomy: recovery

A
  • 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
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2
Q

Cholecystectomy follow up and complications

A
  • 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
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3
Q

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

A
  • 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
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4
Q

Inguinal hernia

A
  • 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
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5
Q

Types of inguinal hernia

A
  • 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
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6
Q

When to repair an inguinal hernia

A
  • 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
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7
Q

Risks and complications of a hernia repair

A
  • 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
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8
Q

Hernia repair: the procedure

A
  • 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.
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9
Q

Hernia repair: recovery

A
  • 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
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10
Q

Hernia repair: When to seek medical advice post surgery

A
  • 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
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11
Q

Mechanism of laparoscopic and open hernia repair

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

Arthroscopy

A

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.

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13
Q

Commonest indication for arthroscopy

A
  • Medial meniscal tear
  • Done if symptoms persist despite 3 months of conservative management
  • Knee is locked (early intervention better)
  • Improves pain and mechanical problems
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14
Q

Benefits of arthroscopic vs open surgery techniques

A
  • 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
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15
Q

Arthroscopy: risks of procedure

A
  • 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
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16
Q

Arthroscopy: pre-operatively

A
  • 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
17
Q

Arthroscopy: the surgery

A
  • 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
18
Q

Imaging carried out prior to arthroscopy

A
  • MRI in younger patients
  • joint XR in elderly patients if signs of co-existing OA (may be better treated with joint replacement surgery)
19
Q

Why is meniscal repair not always appropriate

A

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

20
Q

Arthroscopy: recovery

A
  • 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
21
Q

Arthroscopy: follow up after surgery

A
  • 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

22
Q

Arthroscopy: long term outcomes and different types

A
  • 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
23
Q

Indications for joint replacement

A
  • 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

24
Q

Conservative treatment for hip OA

A

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

25
Q

General and specific risks and benefits: joint replacement

A
  • 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
26
Q

ASA grading for comorbidities

A
  • 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
27
Q

Pre-assessment joint replacement

A
  • 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
28
Q

The surgery: joint replacement

A

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.

29
Q

Joint replacement: immediately after surgery

A
  • 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
30
Q

Joint replacement: recovery

A
  • 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)
31
Q

Complications of joint replacement

A
  • 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

32
Q

Laparoscopic cholecystectomy surgical technique

A
  • 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
33
Q

Laparoscopic colectomy surgical technique

A
  • Midline abdominal incision
  • 12mm port placed at umbilicus for camera and 3 or 4 other working ports
34
Q

Colonoscopy technique

A
  • patient lies on left side with knees to chest
  • care should be taken at the hepatic flexure (short sharp bend)
35
Q

Laparoscopic hernia repair technique

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

Medicine year 4 ACE (9 decks)

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