Questions exam Flashcards
1
Q
List the periods of the history of surgery! What were the milestones!
A
The history of surgery is divided into 3 periods
I. From the primeval times until the middle of the 19th hundred
- Only removal of injured parts was used
II. From the discovery of narcosis (1846) until the 1960s
- Included not only removal of the injured parts, but also their reconstruction
- The milestone was the initiation and application of the principles of asepsis and antisepsis, discovery of blood groups and the development of intensive therapy
III. Lasted from the 1960s until today
- The development of instruments, natural science, researchers, as well as technical development
2
Q
When was the Ether Day? Who did and what on this day?
A
On October 16. 1846 Dr. William T. G. Morton anesthetized a patient with ethyl ether for
the first time
3
Q
When and by whom was the chlorinated lime hand-washing introduced? What were his findings?
A
Ignaz Semmelweis 1847
- To prevent puerperal fever
- Mortality of labor women from 30% to 1%
- “Corpuscles from dead body could enter into blood stream”
4
Q
Who created the antiseptic theory?
A
Sir Joseph Lister
5
Q
Who introduced the antiseptic theory?
A
Ignaz Semmelweis
6
Q
Name 4 surgical instruments which refer to doctors involved in the development of surgery!
A
- Kocher clamp
- Lumnitzer clamp
- Hagar needle holder
- Péan clamp
- Lister bandage scissor
- Véres needle
7
Q
What does the acronym NOTES mean?
A
Use of natural openings to perform surgical procedures
- NOTES: natural orifice transluminal endoscopic surgery
8
Q
What are the synonyms for „ NOTES” technique!
A
- Endoscope
- Transgastric
- Transvaginal
- Transcolonic
- Transvesical
9
Q
What is the definition of surgical intervention?
A
All such diagnostic or therapeutic interventions, in which we disrupt body integrity or reconstruct the continuity of the tissues
- Two types: bloody or bloodless
10
Q
List some examples of bloodless and bloody procedures!
A
- Bloodless: reducing joint translocation or treating closed fracture
- Bloody: abdominal or thoracic surgery
11
Q
What do the septic and aseptic operating theatres stand for?
A
There are two types of operating rooms; septic and aseptic ones
- In the septic operating room the infected parts of the body are operated (e.g. purulent wounds, gangrenes)
- In aseptic operating rooms the danger of bacterial infection does not usually exist (e.g. varicectomy)
There is no need to build the aseptic operating room in a separate area; the two different types can even share a common corridor
12
Q
How shall the staff and the patient enter the operating room?
A
- Before entering into the operating room you should change your clothes in the locker room and wear the surgical cap and the face mask
- Following this, you can enter into the surgical territory
- The patients are brought into the operating room after passing through a separate locker room
13
Q
Describe the structure of the operating room!
A
Se bok
14
Q
List 8 equipments /instruments within the operating room!
A
Operating lamp, operating table, Sonnenburg’s table, supplementary instrument stand, kick bucket, suction apparatus, diathermy, microwave oven, portable X-ray, anesthesia machine, and other instruments required during anesthesia
15
Q
Explain the rules of behaviour in the operating room!
A
1) Only those people whose presence is absolutely necessary should stay in the OR
2) Activity causing superfluous air flow (talking, laughter, or walking around) should be avoided
3) Entry into the OR is allowed only in operating room outfit and shoes worn exclusively in the OR
- This complete change to the clothes used in the OR should also apply for the patient placed in the holding area (i.e. locker room)
4) Leaving the OR in surgical outfit is forbidden
5) The doors of the OR must be closed
6) Movement into the OR out of the holding area (locker room) is allowed only in a cap and mask covering the hair, mouth, and nose
16
Q
Describe the general rules of the aseptic operating room!
A
- Only sterile instruments can be used to perform a sterile operation
- Sterile personnel can handle only sterile equipment
- The sterile instrument will stay so if only the sterile person touch it
- Instruments which are located below the waist are not considered sterile
- If a sterile instrument comes in contact with an instrument of doubtful sterility, it will lose its sterility
- The edges of boxes and pots can not be considered sterile
- A surgical area can never be considered sterile
o However, the applications of aseptic rules of operations are mandatory
17
Q
Explain the definition of asepsis!
A
Includes all the procedures, activities and behaviors designed to keep away the microorganisms from the patient’s body and the surgical wound
In other words, the purpose of asepsis is to prevent contamination (maintain sterility)
In a wider sense, asepsis means such an ideal state when the instruments, the skin, and the surgical territory do not contain microorganisms (prevention)
18
Q
Explain the definition of antisepsis!
A
Includes all those procedures and techniques designed to eliminate contamination (bacterial, viral, fungal) present on objects and skin by means of sterilization and disinfection
Because skin surfaces and so the operating field and the surgeon’s hands cannot be considered sterile, in these cases we do not talk about superficial sterilization
- In a wider sense, antisepsis includes all those prophylactic procedures designed to ensure surgical asepsis (treatment)
19
Q
How to prevent the evolution of postoperative wound infections before the surgery?
A
- Careful scrub and preparation of the operative site (cleansing and removal of hair) is necessary
- Wearing sterile clothes in the OR
- Knowledge and control of risk factors (e.g. normalization of the serum glucose level in case of diabetes mellitus)
- In septic and high-risk patients: perioperative antibiotic prophylaxis
20
Q
How to prevent the evolution of postoperative wound infections during the surgery?
A
- Appropriate surgical techniques must be applied
- Change of gloves and rescrub is necessary
- Optimize body temperature of the patient
o Narcosis may worsen thermoregulation
o Hypothermia and general anesthesia both induce vasodilation, and thus the core temperature will decrease - The oxygen tension must be maintained
21
Q
How to prevent the evolution of postoperative wound infections after the surgery?
A
- Wound infection generally evolves shortly (within 2 hours) after contamination
- Hand washing is mandatory and the use of sterile gloves is compulsory while handling wound dressings and changing bandages during postoperative care
22
Q
What is the definition of sterilization!
A
- To sterilize means to kill all microorganisms and spores to create a germ-free environment
- Methods:
o Autoclave (steam with high pressure)
o Gas sterilization with ethylene-dioxide
o Cold sterilization with sprecide chemicals
o Gamma and electron radiation
o Plasma sterilization (low temperature hydrogen peroxide gas plasma – effect of free radicals)
23
Q
What is the definition of disinfection!
A
- The aim is to decrease the number of or inactivate live microbes
- Methods:
o Low temperature steam
o Chemical disinfectants (phenol, chloride containing compounds, alcohols)
24
Q
Explain the steps of the two-phase surgical hand scrub!
A
Se bok
25
What is the purpose of isolation? How do we do it?
- After skin preparation the operating area must be isolated from the non-disinfected skin surfaces, and body areas by application of sterile linen textile or sterile water proof paper drapes
- The main aim is to prevent contamination from the patients skin
- It is generally done with the help of 4 pieces
- The scrub nurse and the assistant use a special specially folded first, big sheet to isolate the patient’ legs
- The second, horizontal sheet is used to isolate the head, and is fixed to the guard
- Placement of the two sided sheets then follows
- The isolated area is always smaller than the scrubbed area
- 4 Backhaus towel clips will fix the isolating sheets
26
List the basic surgical instrument groups!
1) Cutting and dissecting instruments
2) Grasping instruments
3) Hemostatic instruments
4) Retracting instruments
5) Tissue unifying instruments and materials
6) Special instruments
27
What is the function of the dissecting instruments? List some of these dissecting instruments!
- Their function is to cut or dissect the tissue and remove the unnecessary tissues during surgery
- Scalpel
- Scissors
- Hemostats used for tissue preparation (Péan, mosquito, abd Péan)
- Dissector
- Diathermy knife
- Ultrasonic cutting device
- CUSA (cavitron ultrasonic surgical aspirator)
- LASER (light amplification by stimulated emission radiation)
- Amputating knifes, saws and raspatories
28
Explain the use of electric/diathermy knife! What kind of diathermy knifes do you know?
- Dissects tissue with the help of heat which is generated by electrical current
- During the dissection the heat can also coagulate the blood from vessels, giving it a strong advantage by cutting and hemostasis simultaneously
- They can be either mono- or bipolar
o Bipolar: the electric current is passing between two parts of the instrument
§ E.g. bipolar forceps
§ There is a need for smaller voltage and amperages making it possible to perform more precise work and smaller size of burned area
o Monopolar: the electric current is passing between the instrument and an indifferent electrode placed beneath the back or one of the limbs of the patient
§ More common in general surgery
§ E.g. electrocauter or electrocautery knife
29
Is it accepted to use electric knife on patients with pacemaker?
In patients with old pacemakers the electrical current may cause arrhythmias, and it must therefore be adjusted prior to surgery
30
What do you know about the ultrasonic cutting device?
- Ultrasonic cutting device (Ultracision) is using ultrasound to cut and coagulate the tissues
- It is working similarly to the diathermy but it does not cause thermic injury
- It makes possible to have more precise movements during surgery
31
Name the non-locking grasping instruments! Explain their functions!
```
Thumb forceps
- Smooth forceps ("anatomical")
- Toothed forceps ("surgical")
- Splinter forceps ("ophtalmic")
- Ring forceps (brain tissue forceps)
- Dental forceps
o They are used to hold tissue during cutting and suturing, grasping and retracting, and remove foreign bodies
o For holding of sponges, bandages, vessels and hollow organs
```
32
List organ clamps!
- Klammer intestinal clamp
- Allis clamp (lung)
- Gallbladder forceps
- Babcock forceps (tube shaped structures)
33
List the hemostatic instruments! Explain their functions!
They act mechanically or thermally to stop bleeding at the site of incision or in the surgical territory
- Vascular clamps: Péan, mosquito, abdominal Péan, Kocher, Lumnitzer, Satinsky, bulldog
- Electrocautery knife
- Various ligation needles and directing probes: e.g. Deschamp ligation needle, and Payr probe)
- Argon beam coagulator
34
List the retracting instruments! Explain their functions!
Retractors are sued to hold tissues and organs aside during surgery in order to improve the exposure, visibility and accessibility
1) Hand-held retractors (by assistant)
- Skin hook, Rake, Roux, Langenback, visceral and abdominal wall retractors
2) Self-retaining retractors
- Weitlaner self-retaining retractor, Gosset self-retaining retractor
35
Explain the application area of metallic clips!
1) They are used to close a skin wound and any luminal structure, vessel, duct etc. (Michel clips)
2) Other uses
- Wound closure
- Hemostasis (can occlude lumen)
- Marker (can be seen on the X-ray- e.g. bed of a tumor)
36
What do you know about the CT and MRI examination of a patient carrying metalic clips?
- CT: the clip disturbs the picture only in the vicinity of it and so examination can be done
- MRI:
o The clips make it impossible to perform the examination because these metals can move in the magnetic field
o The clips can become wandering within the body
o Due to this it has become more common to use the non-magnetic clips like titanium, platinum and absorbable clip
37
What is the Steri-Strip? When to use it?
- Usually produced from fibrin, collagen or thrombin and induces the last phase of blood coagulation producing fine fibrin mesh
- Application
o Hemostasis in operations done on solid organs
o Close the place of air leakage in lung surgeries
o Wound closure
- Disadvantage: can increase the degree of infection in infected wounds and lead to abscess formation
38
List special instruments!
- Volkmann curette
- Instruments used in bone surgery
- Round-ended probe
- Payr clamp
- Suction set
- X-raying set
- Implants, prosthesis
o The metallic screws and pins, joint prosthesis, hernial meshes, vascular grafts and silicon implants
39
Describe the conventional (close-eye, French-eyed) needles!
- Needs to be threaded
- The needle and two arms of the thread goes through the tissue
- Danger of untying
- Re-sterilization
40
Describe the atraumatic needles!
- Has less thickness going through tissue due to no arms of the thread, resulting in less tissue damage
- The thickness of the thread is slightly thicker than the hole made by the needle, making the tissue pack around the thread and avoiding leakage
- No threading time
- No re-sterilization
- No danger for corrosion and untying
- Be careful to not pull to hard, the thread may detach from the needle
41
What are the main groups of the circular needles?
Has 3 main groups; taper-point, taper-cutting and blunt taper
42
Explain the difference between conventional and reverse cutting needles!
- In the conventional needle the third edge is facing the internal part of the curving body (pyramide-trekant)
- In the reverse needle the third edge is facing the external part of the curving body (opp-ned trekant)
43
What are the main characteristics of the surgical suture materials?
The most important properties are:
o Physical: caliber, tensile strength, elasticity, capillarity, structure, water absorbent capacity, sterilizability
o Application properties: flexibility, capability to slip in tissue, knotting properties, knot security
o Biological properties: absorbent capacity
44
What are the advantages and disadvantages of natural and synthetic suture materials?
Natural materials:
+ Good knotting properties and are easy to handle
- Enzymatic absorption (inflam. reaction)
Synthetic materials:
+ Hydrolytic absorption (less inflam. reaction)
- Harder to handle
45
What does the term “thread memory” stand for?
Thread memory is the capacity of the suture thread to
| return to its former, packaged shape
46
What are the advantages of monofilament threads?
- Smooth surface
- Smaller friction
- Smaller resistance
- Smaller tissue injury
- No spreading of bacteria
- No capillarity
- Not transporting the tumor cells
47
What are the disadvantages of multifilament (twisted or braided) threads?
- Stretching
- Tissue drag, serrating
- Tissue trauma
- Spreading of bacteria
- Capillarity
- Transporting the tumor cells
48
Which one is better: monofilament or multifilament thread?
Monofilament due to less disadvantages, less tissue trauma, no spread of bacteria and no spread of oncotic cells
49
List the advantages and disadvantages of natural suture materials!
Advantages:
- Good handling
- Easy and good knotting
Disadvantage:
- Tissue reaction
- Enzymatic absorption (unpredictable)
- Purchase, screening, controlling
50
List the advantages and disadvantages of synthetic suture materials!
Advantages:
- Economic
- Absorption by hydrolysis (predictable)
- Strength
Disadvantages:
- Handling of synthetic monofilament is difficult
51
Describe the enzymatic and hydrolytic absorption processes of suturing materials!
Enzymatic:
- Active and done by cellular elements, it is characteristic for natural suture materials
- The result can be severe tissue reaction and activation of the inflammatory processes
Hydrolysis:
- Passive and done without participation of cellular elements
- It is characteristic for synthetic suture materials
- The chemical and physical bonds located between the thread fibers will become loose, disintegrating the thread, which will be excreted
52
What do you know about the size classification of the suturing materials?
- The USP (United States Pharmacopoeia) unit is frequently used to determine the diameter of the thread
- It groups the suture materials I groups based on thickness
o Thinnest: 11/0-2/0, 0, 1-7 (thickest)
o Thickest: 7 (1.00 – 1.09 mm)
- The metric system is also accepted
o 0.1 metric = 0.010 – 0.019 mm
o 10 metric = 1.00 – 1.09 mm
53
What do you know about the simple interrupted suture?
- Frequently used to suture skin, fascia and muscle
- After each stitch, a knot is tied
- All sutures must be under equal tension The advantage is that the remaining sutures still ensure an appropriate closure and the wound will not open if one suture breaks or is removed
- The disadvantage is that it is time-consuming since each individual suture must be knotted
54
What do you know about the vertical mattress suture?
- It is a 2-row skin suture
- It consists of a deep suture that involves the skin and the subcutaneous layer (which closes the wound) and of a superficial back stitch placed into the wound edge (this approximates the skin edges)
- The two stitches are in a vertical plane perpendicular to the wound line
55
Where do we use the simple continuous suture line?
This can be applied to suture tissues without tension, the wall of internal organs, the stomach, the intestines, and the mucosa
56
Where do we use the purse-sting suture?
- The openings of the GI tract (e.g. in appendectomy) are closed by this suture
- An atraumatic needle and thread are used
- It is a suture for a circular opening, running continuously around the opening
- The wound edges are then inverted into the opening with dressing forceps and the threads are pulled and knotted
57
When it is suggested to remove the stitches? What are the influencing factors?
Usually within 3-14 days
- BUT depends on location (tension), blood supply and general condition of patient
- Face: 3-5 days
- Head+abd wall: 7-10 days
- Hand+arms: 10 days
- Leg+foot: 8-14 days
- Trunk+joints: 10-14 days
58
What is a wound?
- A wound is a circumscribed injury which is caused by an external force, and it can involve any tissue or organ
- It can be mild, severe, or even lethal
- Wounds can be divided into:
o Simple or compound wounds
§ In simple wounds, skin, mucous membrane,
subcutaneous tissue, superficial fascia, and the
muscles (partially) can be injured
§ In compound wounds, there are additional injury
to the muscles, tendons, vessels, nerves or bones
o Acute or chronic wounds
59
What areas are injured in case of a simple wound?
Skin, mucous membranes, subcutaneous tissue, superficial fascia, and the muscles (partially)
60
What areas are injured in case of a compound wound?
The components of the simple wound + additional injury to the muscles, tendons, vessels, nerves or bones
61
What kind of wounds do you know based on their origin?
- Mechanical
- Chemical
- Wounds caused by radiation
- Wounds caused by thermal force
- Special wounds
62
List the wounds of mechanical origin!
- Abraded wound (vulnus abrasum)
- Punctured wound (v. punctum)
- Incised wound (v. scissum)
- Cut wound (v. caesum)
- Crush wound (v. contusum)
- Torn wound (v. lacerum)
- Bite wound (v. morsum)
- Shot wound (v. sclopetarium) - slo pet tar
63
What do you know about the incised wound?
- Caused by a sharp object
| - Best healing of all the wounds
64
What do you know about the shot wound?
- Consist of an aperture, a slot tunnel and possibly an output
- If the shot is close (e.g. contact shot), burn injury is present
- Caused by foreign materials which may remain in the patient
65
Classify the wounds according to bacterial contamination?
- Clean
- Clean-contaminated
- Contaminated
- Heavily contaminated
66
What does the primary wound managements stand for?
```
- Temporary wound management (first aid)
o The aim is to prevent infection
o Clean wound, hemostasis, covering
- Final primary wound management
o Clean => anesthesia => excision => sutures
- Less than 12 hours after injury
```
67
What does the term „primary delayed suture” stand for?
- Clean, wash with saline, cover, and leave for 4-6 days
- If there are no signs of infection after the delay (4-6 days):
o Anesthesia => excision of wound edges (refreshing the edges) => suture
68
What is the „early secondary wound closure”?
- If following the first management of the wound, the excised wound (after inflammation and necrosis) starts to proliferate, then there is a need to refresh the wound edges
- 2 weeks after the injury:
o Anesthesia à excision of wound edges à suturing à
draining
69
What is the „late secondary wound closure”?
- The proliferating parts and scars of the former wound should be excised
- With greater defects, plastic surgery solutions should also be considered
- 4-6 weeks after the injury:
o Anesthesia => excision (of the secondarily healing
scar) => suturing => draining
70
What holding positions of the scalpel do you know?
- The fiddle-bow holding grip, used for long, straight incisions
- The pencil grip, used for short or fine incisions
71
Describe the phases of wound healing!
- Hemostasis-inflammation (0-2 days)
- Granulation-proliferation (3-7 days)
- Remodeling (lasts from day 8 => months)
72
What is happening in the granulation-proliferation phase of wound healing?
- Formation of granulation tissue and fibroblasts
- Fibroblast migration => collagen deposition
- Angiogenesis
- Granulation tissue formation
- Epithelization
- Contraction
73
What is happening in the remodeling phase of wound healing?
- Regression of many capillaries
- Physical contraction (by myofibroblasts)
- Collagen degeneration and synthesis – the fibers become smaller and stronger
- New epithelium is produced
- The final tensile strength of the wound is ∼ 80 % of the initial strength of the tissue
74
Describe the types of wound healing!
1) Healing by primary intention (Sanatio per primum intentionem):
- The wound edges are brought together so that they are adjacent to each other
- Minimizes scarring
- Most surgical wounds heal by primary intention healing
2) Healing by secondary intention (per secundum):
- Granulate – the wound may be packed with a gauze
- Abacterial or purulent inflammation, the wound is -
Connective tissue => scar
- Larger clot, more necrotic, involves wound contraction
- Examples: gingivectomy, tooth extraction sockets
Not: (3) Healing by tertiary intention:
- The wound is initially cleaned and observed, typically 4-5 days before closure
- The wound is purposely left open
- Examples: healing of wounds by use of tissue grafts)
75
List the influencing/delaying factors of wound repair!
```
Se bok
Local factors:
- Ischemia
- Infection
- Foreign bodies
- Edema, elevated tissue pressure
```
Systemic factors:
- Age and gender
- Sex hormones
- Stress
- Ischemia
- Diseases (e.g. DM)
- Obesity
- Medication (e.g. glucocorticoids and some antibiotics)
- Alcoholism and smoking
- Immunocompromised conditions
- Nutrition
76
What early complications of wound healing do you know?
- Seroma
- Hematoma
- Wound disruption
- Superficial wound infection
- Deep wound infection
- Mixed wound infection
77
What are the characteristics of the seroma?
- The wound cavity is filled with serous fluid, lymph, or blood
- Signs: fluctuations, swelling, redness, tenderness, subfebrility
78
What are the characteristics of the hematoma?
- Occurs due to insufficient bleeding control, short draining time, or anticoagulant therapy
- Signs: swelling, fluctuations, pain, redness
- High risk of infection
79
What are the characteristics of the wound disruption?
- Subdivided into partial, superficial (dehiscence), and complete separation (disruption)
o First, the deeper layers are involved and finally the
skin
- Can be caused by surgical error, increased intra-abdominal pressure, would infection, or hypoproteinemia
80
What forms of superficial wound infection do you know?
- Diffuse: a diffuse and superficially spreading inflammation located below the skin
o E.g. erysipelas and lymphangitis (caused by hemolytic streptococci)
- Localized: localized (circumscribed) infection
o E.g. abscess
81
List the local and general symptoms of wound infection!
- Local signs:
o Rubor, tumor, calor, dalor, and functio laesa
- General signs:
o Rapid sedimentation rate of RBCs, leukocytosis,
fever, shivering, depression
82
What are the late complications of wound healing?
- Hypertrophic scars
- Keloid
- Necrosis
- Inflammatory infiltration
- Abscesses
- Foreign body-containing abscesses
83
What are the characteristics of hypertrophic scar?
- Hypertrophic scars develop in areas of thick chorium
- They are composed of non-hyalinic collagen fibers and fibroblasts, and are confined to the incision line
- They usually regress spontaneously within 1-2 years
84
What are the characteristics of keloids?
- Keloids are over-proliferations of collagen fibers in the subcutaneous tissue
- They have well-defined edges, with pinkish-brown, emerging tough structures
- They particularly affect scars o the presternal and deltoid areas, and the ear
- They are characterized by subjective complaints (e.g. pain, itching) and constant development
85
What is hemostasis and what are the factors of it?
- Hemostasis is the process which causes bleeding to stop
- Factors:
o Vascular hemostasis (vasoconstriction)
o Platelet hemostasis
o Clotting
86
What are the characteristics of diffuse bleeding?
Oozing of blood from bare (denuded) or cut surfaces (can become serious if uncontrolled)
- Capillary bleeding
- Parenchymal bleeding
87
What could be the direction of bleeding from clinical point of view?
- External (e.g. by trauma or surgical incision, resulting in visible bleeding)
- Internal:
o In a luminal organ (e.g. hematuria, hemoptoa,
melena)
o In body cavities (e.g. hemothorax,
hemopericardium, hemascos)
o Among the tissues (e.g. hematoma, suffusion)
88
What methods of surgical haemostasis do you know?
1) Mechanical: Digital pressure, Torniquet, ligation, suturing, preventive hemostasis, clips, bone wax, expedients, others
2) Thermal: hypothermia, heat, electrosurgery, diathermy, laser
3) Chemical: aethoxysclerol, absorbable gelatin, absorbable collagen, microfibrillar collagen, oxidized cellulose, oxytocin, epinephrine, thrombin, novel hemostatic agents (HemCon, QuikClot)
89
List the mechanical methods of surgical haemostasis!
- Digital pressure (direct pressure)
- Tourniquet (constricting or compressive device, specifically a bandage)
- Ligation
- Suturing
- Preventive hemostasis (occurs in ligatures)
- Clips
- Bone wax
90
List haemostatic methods based on thermal effects!
Low temperature:
- Hypothermia
- Cryosurgery
High temperature:
- Electrocauterization
- Monopolar diathermy
- Bipolar diathermy
- Laser surgery
- Local electrosurgery
91
What are the mechanisms of haemostasis based on chemical and biological materials? List 3 materials!
Mechanisms:
- Vasoconstriction (e.g. epinephrine, oxytocin)
- Coagulation (microfibrillar collagen, thrombin)
- Hygroscopic effect (absorbable collagen, absorbable gelatin, oxidized cellulose)
92
Give examples of vital, absolute, and relative indications!
1) Vital indications: Ruptured aortic aneurysm
2) Absolute indications: Mechanical ileus, ebolectomy
3) Relative indications: Hernia repair
93
What are the components of surgical risk?
Risk of surgery itself + anesthesiological risks
94
What factors increase surgical risk?
- Acute surgery
- Duration > 2 hours
- > 65 years old
- Pregnancy
- Malignant diseases
- Malnutrition
- Alcohol consumption
- Smoking
- Acute disturbances (hypovolemia, dehydration, shock)
- Acute inflammations (respiratory, urinary, GI, sepsis)
- Thrombosis
- Acute organ insufficiencies (heart, lung, kidney, liver)
- Acute endocrine disorder
- Organ insufficiencies (heart, lung, kidney, liver)
- Endocrine disorder
- Immunological disorders
- Hemophilia
- Organ alterations (see below)
- Chronic disorder (hypovolemia, anemia)
- Chronic inflammations (respiratory, urinary, GI)
- Allergy
95
What kind of organ alterations increase surgical risk?
- Cardiorespiratory
- Hypertension
- Nervous system alterations
- Diabetes mellitus
- Chromic uremia
- Cirrhosis
- Susceptibility for infection
- Immunosuppression
- Thromboembolic predisposition
96
In what way does overfeeding increase surgical risk?
- Respiratory disturbance (usually restrictive):
o Deteriorating the gas exchange, increased
respiratory function
- Decreased cardiac reservoirs
- Difficulty with intubation (regurgitation)
- Disturbances with wound healing
- Thromboembolism
97
List the organs and systems whose preoperative examination is essential from the point of view of
the assessment of surgical risk!
- Cardiovascular system
- Respiratory system
- Metabolic state
- Renal function
- Liver function
- Endocrine balance
- Homeostasis
- Immune system
98
What can be applied for trombosis prophylaxis during pre-, and postoperative phase?
Drugs:
- Heparin derivatives (Na-heparin, Ca-heparin, low molecular weight heparins)
- Platelet aggregation inhibitors (e.g. Aspirin, Colfarit)
Physical:
- Early mobilization
- Compression (elastic bandages)
- Bed-side bicycle
- Keeping the lower extremities at a high level
99
List the forms of vertical laparotomy!
- Median laparotomy
- Paramedian laparotomy
- Vertical transrectal laparotomy
- Pararectal laparotomy
100
List the forms of transverse and oblique laparotomy!
Transverse:
- Horizontal transrectal laparotomy
- Pfannenstie
Oblique:
- McBurney incision
- Paracostal (Kocher) laparotomy
- Subcostal laparotomy
101
What abdominal approaches would you suggest in case of open cholecystectomy, appendectomy, or gynecological surgery?
Open cholecystectomy:
- Right paracostal laparotomy
Appendectomy:
- McBurney incision
Gynecological surgery:
- Lower median muscle-splitting incision (Pfannenstie incision)
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What do you know about the muscle-splitting incisions? What are the advantages and
disadvantages?
In these types of incisions the fibers of the abdominal wall muscles are not cut but separated from each other alongside their courses
Advantage:
- The possibility for development of postoperative hernia is rare
Disadvantage:
- It gives a limited exposure and is helpful only in case of a sure diagnosis
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What does thoracolaparotomy mean? When it is used?
Creating a large incision from the lower axilla to the supra-umbilical area (thoracoabdominal incision), opening the thoracic and abdominal cavities and exposing the diaphragmatic region
- Used in case of big tumors of the liver, renal tumors, possibly total gastrectomy, operations around the cardia region, esophageal tumors
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What factors did contribute to the spreading of laparoscopic operations?
The technical development, training operations and the patient’s increased demands for the minimally invasive surgeries contributed to the wide spread
105
What are the disadvantages of open surgery?
- Big exposure, more trauma
- Postoperative pain depends mostly on the size of the surgical wound
- It is harmful to keep the body cavity open for a long time (due to vaporization, drying, etc.)
- Danger of secondary injuries during exposure (e.g. intestines, spleen, lungs)
- Increased possibility for later adhesions
- The bigger the wound, the bigger is the possibility for postoperative complications (e.g. infections, hernias)
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What are the advantages of laparoscopic surgery?
- Less postoperative discomfort
- Much smaller scars
- Less internal scarring
- Quicker recovery time
- Shorter hospital stays
- Earlier return to full activities
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What does pneumoperitoneum mean?
Insufflating the peritoneum with gas to create a workspace for the laparoscopic surgeon
108
What kind of gas can be used for pneumoperitoneum?
Carbon dioxide and nitrous oxide are the preferred gases nowadays
- The first gas used was filtered room air, but this supports combustion, and so does N2O (so it is not used for prolonger procedures)
Helium can also be used, but it does not have any advantages over CO2
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Introduce the usage of the Veres needle!
- The Veres needle is used to create a pneumoperitoneum with the closed access technique
- It is inserted blindly through the sub-umbilical area and then used to create the pneumoperitoneum
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How and on what level of pressure can the pneumoperitoneum be used safely?
The best operating intra-abdominal pressure is between 10-15 mmHg
- 15-20 mmHg is suboptimal, and actual pressures above 20 mmHg are dangerous
The insufflator will maintain an optimal actual pressure by constantly monitoring and make small changes in pressure to maintain the optimal pressure
111
What type of telescope is popular in laparoscopy?
Hopkins rod lens system:
- The advantages are greater light transmission, better image quality, wider field of view and image magnification
- It utilized longer rods of glass and smaller air spaces between the lenses
112
What do you know about the laparoscopic light sources?
- Illumination of the abdominal cavity is important for orientation
- Currently a 150-300 W fan-cooled xenon light source is used to provide color-corrected light for extended period of time
- The illumination is transmitted to the laparoscope via a flexible fiber-optic light guide
- The camera is connected to the optic, which transmits it to the monitor
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List the difficulties of the laparoscopic technique!
- Limited visual field
- Lack of hand-eye coordination
- Lack of depth perception (2D images on monitor)
- Requires a great amount of training
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In which surgical fields do we use microsurgical techniques?
- Microsurgery is surgery with the use of a microscope
- Neurosurgery
- Traumatology
- Ophthalmology
- Maxillo-facial surgery
- Plastic surgery
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What kind of special instruments are needed for microsurgical interventions?
1) The iris forceps
- Used to grab soft tissues
2) Needle holders
3) Scissors with blunt tips
4) Approximator: a hemostat with two tips, which can be slipped along a single axis toward each other and fixed
5) Bipolar coagulator
- The electricity passes only through the tissue located between the tips of the forceps
6) Microsurgical needles and threads (8/0, 9/0, 10/0 and 11/0)
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How would you describe the main caracteristics of patient safety in ambulatory surgery?
What are the contraindications of ambulatory surgery? FUCK THIS SHIT
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