Surgery 2 Module 2 Flashcards
How to close reduce a dislocated hip?
Most commonly craniodorsal dislocation with luxation of the coxofemoral joint - 50% effective if corrected unless dysplastic
- Adequate depth of anaesthesia to give
necessary muscle relaxtion - Assisstant loops a strap or towel under the affected leg in the groin and applies counter-traction from the dorsal side of the patient
- Externally rotate the leg (stifle pointed at the ceiling) to allow the femoral head to clear the ilial body
- Apply steady traction to the limb in a caudo-ventral direction for a few mins to fatigue the muscles
- Whilst maintaining traction internally rotate the limb and concurrently push medially on the greater trochanter to push the femoral head in to the acetabulum
compare the greater trochanters on both legs
put thumb behind the greater trochanter and externally rotate the limb - this should push out finger between the trochanter and ischium
Once reduced repeatedly move the hip with firm downward pressure on the hip to squeeze out haematoma/damaged joint capsule from the joint cavity - 5-10mins
How to diagnose a cranio-lateral hip luxation?
Femoral head lies over the ilial body
- Limb will be held off the ground and turned
inwards - On palpation : the greater trochanter of the luxated hip will be higher than the contra-lateral side and have an altered position relative to the wing ilium
- The affected limb will appear shortened if both hips are gently extended and examined and assessed from behind
- Under GA/Sedation lack of thumb displacement confirms the luxation (place thumb into gap between the greater trochanter and ischial tuberosity, then externally rotate hip)
- x-ray orthogonal views
When is joint flushing suggested for?
- Post op wound infection
- Septic joints that hav ebeen untreated for 72hrs or
more - Septic joints that hav enot responded to conservative
treatment after 48-72hrs - Penetrating wounds to the joint
Indications for emergency thoracic surgery?
- Repair of diaphragm rupture
- Traumatic injury to the thoracic wall/lung
- Open chest CPR
How to drain the chest effectively?
- Avoid aggressive use of large (50ml) syringes as they
create substantial negative pressure that can damage
the lungs - Moving patients in to several different positions to
remove all accumulated fluid - If tube blocked: flushing with a small volume of saline
When to remove a thoracostomy tube?
- When negligible (<20-30mls) production of air in the last 24 hours or fluid production is equal to or less than what is expected by the tube being present itself
- 2-5mls/kg/day
What are the surgical approaches to the thorax?
Lateral intercostal thoracotomy: only allows a one sided narrow view
Median sternotomy: complete thoracic exploration
What is the pathophysiology of diaphragmatic rupture?
Rupture occurs when there is a blow to the abdomen in the presence of an open glottis –> the lungs deflate as the air is force through the airway and the force of the abdominal organs moving cranially exceeds the strength and distensibility of the diaphragm - creating a tear
Strangulation of organs within the thoracic cavity
Stomach being trapped in the thorax and a gastric dilation in the pleural space can occur
How to diagnose a diaphragmatic rupture?
- Borborygmi may be detected
- Heart and lungs sounds may be dull
- Abdo cavity feeling empty
- Radiography: line of diaphragm cannot be followed
across the entire body and abdominal viscera seen in
the thorax
What is the best to explore the neck?
Neck exploration is carried out by midline approach
Trachea is displaced to the side and the oesophagus is identified slightly to the left of midline
Post op care for a thoracostomy?
- Analgesia
- Opioids
- Local analgesia: intra operative intercostal blocks,
post operative bupivacaine down the chest drain
every 6-8 hrs - wound soak catheters
- lidocaine patches
- CRI: lidocaine/ketamine/opiate
- Chest tube care
- Drained hourly for the first 2-4 hrs then every 4
hours - If minimal production of air/fluid can be removed
- Cytology of fluid can be useful to monitor response
to antimicrobial therapy - Submit catheter tip for culture
- Drained hourly for the first 2-4 hrs then every 4
Common causes for hepatic surgery?
- Masses: Adenoma, HCC
- Hepatic abscesses
- Liver lobe torsion (LL most mobile)
Ways to improve hepatic exposure?
- Packing swabs behind liver to lift up
- Cut triangular ligaments
- Diaphragm myotomy
Liver biopsy options?
Guillotine technique
Artery forcep crush
Wedge resection - overlapping sutures around the area of interest
Punch biopsy
Lap biopsy
Reason for nephrectomies?
- Trauma
- Masses
- Persistent infection
- Obstructive calculi with hydronephrosis
- Renomegaly
How to do a nephrectomy?
Incise peritoneum around kidney
elevate medially
ligate renal A and V
Tie ureter at level of bladder and incise
Surgery options for prostatic abscesses and cysts?
- Marsupialisation
- Partial or complete prostatectomy
- Abscess/cyst debridement/resection and omentalisation
How to deal with haemorrhage of liver?
Capsular bleed
- Pressure
- Topical haemostatic agents
Severe bleeding
- Pringle manoeuvre - 20 mins max: hepatoduodenal ligament is clamped through epiploic foramen reducing blood into hepatic artery
- Occluding vena cava cranial to liver
- Hepatic artery ligation
Indications of dystocia?
- Lack of progression from stage 1 –> 2 in 12-24 hrs
- More than 4hrs between pups
- Strong contractions more than 30mins with no pup
- Rads to aid foetal malposition and counting
- If inter-uterine gas = foetal death
Treatment of dystocia?
- Rule out birth canal obstruction
- U/S foetal heartbeat - Normal 220, 180-150 if distressed
- Oxytocin q30mins
- Finger repositioning with finger
- C - section
How to resus a neonate?
- Clear oral and nasal cavities of excretions
- Vigorous external rubbing
- Intubate only if all else fails
- Naloxone - sublingual
- If asystole - adrenaline and gentle lateral thoracic
compressions
Indications on radiographs of obstruction
Up to 1.6x body of L5
>2 indicative of obstruction
Most common stomach tumors?
Adenocarcinoma - mets likely at diagnosis 70-80%
Sarcoma/GIST/Leiomyoma
Lymphoma
