Surgery - principles

Question 1

Halsted’s principles (8)

Answer 1

Aseptic technique 
Anatomical/technical knowledge
Gentle tissue handling
Control haemorrhage
Preserve blood supply
Accurate tissue apposition
Minimise tension
Eliminate dead space

Question 2

Principles of tissue dissection & handling

Answer 2

Dissect along tissue planes
Blunt + sharp dissection
Lighting, retraction & suction
Tension at right angles to dissection plane
Keep tissues moist - lavage + sponges

Question 3

What are the consequences of blood in the operative field?

Answer 3

Obscures structures
Irritant to tissues
Prevents tissue apposition
Delays healing
Potentiates infection

Question 4

Types of haemorrhage

Answer 4

Primary = at the time of Sx
Delayed = post-op (e.g. dehiscence)

Question 5

What are the clinical signs of haemorrhage?

Answer 5

Tachycardia
Hypotension 
Peripheral vasoconstriction/hypoperfusion/cold extremities
Weak pulse
Pale MM
Long CRT
Mental depression
Delayed recovery from Ax

Question 6

Methods of haemostasis

Answer 6

Careful surgery/dissection
Haemostats
Electrocautery
Topical haemostatic agents (AgNO3)
Vessel sealant devices
Tamponade (30s --> 2-3mins)
Ligation (3 forceps, transfixing ligatures)

Question 7

Indications for exploratory laparotomy

Answer 7

GI disorders - FB, rupture, torsion
UGT disorders
Penetrating trauma 
Acute abdomen - GDV
Peritonitis
PSS
Splenic disorders - haemangiosarcoma
Unknown origin abdo disorders

Question 8

What equipment is required for ExLap?

Answer 8

General sx kit
Balfour self-retaining abdominal retractors
Suction
Sponges
Sample tubes
Suture material

Question 9

What are the 4 approaches for ExLap?

Answer 9

Ventral midline
Paracostal (extension to expose liver)
Flank = OVH, grid gastropexy
Retroperitoneal = adrenals, kidneys

Question 10

4 layers of the abdominal wall

Answer 10

Transversus abdominus
Rectus abdominus
Internal abdominal oblique
External abdominal oblique

Question 11

External landmarks for ExLap

Answer 11

Xiphoid process
Pubis
Umbilicus

Question 12

Internal landmarks for ExLap

Answer 12

Falciform ligament
Duodenocolic lig (at caudal duodenal flexure)
Mesenteric root
Omentum + omental bursa
Kidneys
BVs - aorta, CdVC, portal v.
Ileum w anti-mesenteric vessels

Question 13

What 4 quadrants are explored in an ExLap?

Answer 13

Cranial/Cr L quadrant
Cranial R quadrant
Caudal L quadrant
Caudal R quadrant

Question 14

What organs are assessed in the Cranial/Cr L quadrant?

Answer 14

Diaphragm
Liver
Stomach
Gastro-oesophageal sphincter

Question 15

What organs are assessed in the Cranial R quadrant?

Answer 15

Duodenum
Pancreas
Portal v.
CdVC
R kidney/adrenal

Question 16

What organs are assessed in the Caudal R quadrant?

Answer 16

Urinary bladder/uterus
Uterus + ovaries
Prostate
Open omental bursa to visualise L limb of pancrease

Question 17

What organs are assessed in the Caudal L quadrant?

Answer 17

Spleen
Rectum, colon, caecum --> follow prox to duodenocolic lig
Mesenteric root + LNs
Ileum
Jejunum
Duodenum at duodenocolic lig
L kidney/adrenal
Aorta

Question 18

What types of samples should be taken during ExLap?

Answer 18

Swabs = C&S
Fluid samples = peritoneal fluid, bile, urine
Tissue Bx

Question 19

What biopsy technique is used for the liver, pancreas, GIT, & adrenal?

Answer 19

Liver = guillotine or punch Bx
Pancreas = guillotine suture Bx 
GIT = skin punch Bx (full thickness)
Adrenal = FNA

Question 20

Steps involved in closure of the abdominal cavity

Answer 20

Lavage until clear (0.9% NaCl) + no bleeding
Linea alba closure (Cd > Cr) (simple continuous w absorbable monofilament PDS)
SQ closure
Intradermal/skin closure (non-abs monofilament)

Question 21

Complications of laparotomy

Answer 21

Hypothermia (intra-/post-op)
Seroma
Dehiscence/evisceration
FBs left in abdomen
Adhesions
Peritonitis
Infection 
Self-trauma (dt tight suture knots)
Skin irritation

Question 22

What type of suture should be used in skin sutures & why?

Answer 22

Monofilament = no wicking of bacteria into wound
Non-absorbable = good knot security
- absorbable may be used but will not be absorbed as no contact w body fluids/enzymes

Question 23

What type of suture should be used in SQ sutures & why?

Answer 23

Absorbable = cannot remove