surgery Flashcards
hartmanns procedure
removing rectum and/or sigmoid colon and forming a colostomy
three main causes of intestinal adhesions
previous surgery, peritonitis and intra-abdominal infection. Rarely radiotherapy and congenital adhesions.
kocher incision
open cholecystectomy
mercedes benz incision
liver transplant
rooftop incision
liver transplant, Whipples/ pancreatic surgery, upper GI surgery
mcburney incision
open appendicectomy
battle incision
appendicectomy
rutherford morrison incision
renal transplant
pfannenstiel incision
Caesarean section and abdominal hysterectomy
permanent (end) ileostomy
After total colectomy for Inflammatory Bowel Disease (UC/Crohns) or Familial Adenomatous Polyposis (FAP)
Most often in lower right abdomen
covering (loop) ileostomy
To protect distal anastomosis when removing colorectal cancers
Can be reversed at later date
colostomy
After abdomino-perineal resections (APR) for low rectal cancers
Permanent
Most often in lower left abdomen
Produces stools just like an anus
urostomy
To allow draining of urine from kidney, bypassing the ureter, bladder and urethra (e.g cystectomy)
Ileal conduit urinary diversion:
- Section of ileum (15-20cm) is removed and end to end anastomosis is created
- Ends of the ureters are anastomosed to this section of ileum
- The end of the section is brought out onto the skin as a stoma
- This stoma then works to drain urine directly from the ureters into a bag
complications of stomas
Psycho-social impact Local skin irritation around stoma Parastomal hernia Loss of bowel length leading to high output, dehydration and malnutrition Constipation (colostomies) Obstruction Retraction Bleeding Granulomas Prolapse (telescoping of bowel through hernia site) Stenosis
breast exam
BEGINNING
Explain the examination and the reason prior to examining
Obtain consent
Have a chaperone present and document this (along with the chaperone’s name)
Ask about any areas of pain
Allow the patient to get undressed and dressed in privacy
Ask the patient to point out any abnormalities they have noticed
INSPECTION Examine the patient relaxed, while lifting hands overhead and pressing hands into hips (tensing muscles of the chest wall): Scars Cosmetic Augmentation Asymmetry (size/shape) Tethering or fixation of overlying skin Nipple eversion/inversion Nipple discharge Erythema Peau D’orange Paget’s disease of the nipple
PALP
Place flat part of fingers over the area and roll tissue underneath
If necessary support tissue with your other hand
Examine away from the abnormal area first to note patients normal breast tissue and so as not to miss other lumps
Choose a strategy so as not to miss any areas (including four quadrants, subareolar and axillary regions)
LUMP? Location Size Shape (round / oval / irregular) Consistency (soft / firm / hard) Margins (irregular / smooth) Mobile / fixed to skin or chest wall Tenderness Discharge
breast cancer removal surgery
The objective is to remove the cancer tissue along with a 2mm margin (“clear margin”) of normal breast tissue.
Breast Conserving Surgery:
Lumpectomy
Wide Local Excision
Quadrantectomy (removal of a quarter of the whole breast)
Mastectomy (removal of the whole breast)
axillary clearance surg
Offered to patients where early invasive breast cancer has been demonstrated in axillary nodes
Involves removing the majority or all lymph nodes from the axilla
Increases risk of chronic lymphedema in that arm
chronic lymphoedema
Can occur in the ipsilateral arm to the breast undergoing surgery
This can have a large impact on the patient’s quality of life
Patients should be informed of the risk of lymphoedema prior to surgery
Resting the arm post operatively, certain exercises and avoiding injury or infection reduces the risk of developing lymphoedema
Specialist lymphoedema services available
NOTE never take bloods from this arm
breast reconstructive surgery
offered to all having mastectomy
can be done immediately
may not be poss due to radio
types
1. implants - Reasonable appearance but less natural feel (cold, less mobile and static size and shape)
Long term problems include hardening, leakage, and shape change
- latissimus dorsi flap
Portion of the latissimus dorsi plus skin and fat tissue
Tunnelled under skin to the breast area
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location - transverse rectus abdominis flap (TRAM flap)
Portion of rectus abdominis along with blood supply and skin
Either as pedicled flap (tunneled under skin) or free flap (transplanted)
Risk of abdominal hernia due to weakened abdominal wall - Deep inferior epigastric perforator flap (DIEP flap)
- Skin and subcutaneous fat from abdomen (no muscle)
- Transplanted from abdomen to breast
- Transplant the Deep Inferior Epigastric Artery with fat and skin
- Tissue transplanted to reconstruct breast
- Vessels attached to branches of the internal mammary artery and vein
- Very complex procedure with microsurgery
- Less risk of abdominal wall hernia as muscle are intact
breast cancer follow up
surveillance mammography
No screening for women with total mastectomies
Yearly mammograms for 5 years in patients with early breast cancer
After 5 years, screening frequency is based on the risk category for the individual
written care plan All patients have an individual care plan including details on: - Designated contacts and details - Adjuvant treatment review dates - Surveillance dates - Advice on identifying recurrence - Support service details
complications of hernias
incar
ileo-anal anastomosis
restorative proctocolectomy
ileal pouch with J-loop
if a stoma bag had a tap on the end what does this indicate
its a urostomy
post-op comps
ABCDEFGHI -W Anesthetic bed sores chest infection DVT/PE electrolyte imbalance fluids - dehydration or overloa gastritis - stress ulcers haemorrhage infection - urine, wound wound dehiscence
