Surgical complications and optimizing outcomes

Question 1

What should antibiotic prophylaxis be used?

Answer 1

In pts w/ high-risk cardiac conditions or within 2 yrs of a total joint replacement in the following situations

• Surgery in oral mucosa, groin/leg, wedge excision of lip or ear, nasal flaps, and all grafts.

Question 2

What are considered high-risk cardiac conditions for patients being considered for antibiotic prophylaxis?

Answer 2

Prosthetic heart valve, history of infective endocarditis, unrepaired congenital heart disease, and cardiac transplant patients with cardiac valvulopathy

Question 3

What are considered high-risk joint replacement situations for patients being considered for antibiotic prophylaxis?

Answer 3

Total joint replacements that occurred within 2 years, previous joint infections, type I diabetes, or immunosuppressive states or hemophilia

Question 4

What is the most common timeline for a surgical wound infection?

Answer 4

4-8 days post-surgery

Question 5

What are the sx’s of an infected surgical wound?

Answer 5

Rubor, dolor, calor, and swelling, can also have a purulent discharge, lymphangitic spread, fever, chills

Question 6

What other differential dx items can be considered w/ surgical wound infection and how can they be differentiated?

Answer 6

Contact dermatitis: look for a geometric pattern to bandaid, hx of topical antibx us, and itch > pain

Inflammatory suture reaction: later prevention

Question 7

What sites should antibiotic prophylaxis be considered in any patient (not just high-risk)?

Answer 7

If operating on inflamed skin or high risk areas (lower legs and groin)

Question 8

When is the highest risk of post-operative bleeding present?

Answer 8

First 48 hrs postoperatively

Question 9

How long does aspirin alter platelet function for and when should it be stopped prior to surgery?

Answer 9

Affects platelets for 6-10 days –> can withhold 10 days prior to surgery IF not being used for stroke or myocardial infarction

Question 10

What should the INR ideally be before starting surgery?

Answer 10

<3

Question 11

What are some herbs that increase bleeding risk?

Answer 11

Feverfew, fish oil, garlic, ginger, ginkgo, ginseng, bilberry, chondroitin, vitamin E, licorice, devil’s claw, danshen, dong quai, and alcohol

Question 12

What are the clinical sx’s of a hematoma?

Answer 12

Gelatin-like clot formed in the dead space of a wound: pain, swelling, and red-purple discoloration

Question 13

What is the presentation and treatment of a small hematoma?

Answer 13

Sx’s: pressure sensation

Small and stable can be left to self resolve, can use warm compress

Question 14

What is the presentation of a large hematoma and what should be done?

Answer 14

Acute throbbing pain, expanding size

Requires wound exploration, irrigation, evacuation of hematoma, and/or drain placement

Question 15

What are two areas where hematomas (acute) are considered medial emergencies?

Answer 15

Periorbital and neck

Question 16

How can an early vs organizing hematoma present clinically?

Answer 16

Early (first 48 hrs): Fluctuant

Organizing (≥1 week post-op), thick, fibrous, adherent to adjacent tissue

Question 17

What is the management of early hematoma?

Answer 17

Aspirate w/ a 16-18 gauge needle (or for flaps or enlarging, open and address bleeding)

Question 18

What is the management of organized hematomas?

Answer 18

Cannot be aspirated except @ two weeks postop these undergo liquefaction and can sometimes be aspirated (or left to absorb over months)

Bromelain can also be used to help expedite hematoma resolution

Question 19

What can be given to help expedite the breakdown of a hematoma?

Answer 19

Bromelain (Ananase/Traumanase): oral concentrate of proteolytic enzymes

Question 20

What is the first clinical sign of ischemia?

Answer 20

Pallor

Question 21

What is the difference in flap survival between arterial insufficiency and venous congestion?

Answer 21

Arterial insufficiency: flaps remain viable for 12-14 hrs

Venous congestion: Flaps undergo rapid necrosis (<3-4 hrs)

Question 22

What are the clinical signs of arterial insufficiency?

Answer 22

Decreased skin temperature, lack of bleeding following pinprick test

Question 23

What are the clinical signs of venous congestion?

Answer 23

Cyanotic-purple skin color, increased dark purple bleeding after pinprick test

Question 24

What things can cause ischemia/necrosis after surgery?

Answer 24

Hematoma, infection, high wound tension

Question 25

What are some patient-related risk factors for ischemia/necrosis?

Answer 25

Smoking, nicotine-containing products

Question 26

What procedure-related risk factors exist for ischemia/necrosis?

Answer 26

To much undermining (especially too superficial), postoperative edema, sutures tied too tightly, and insufficient or excessive electrocoagulation

Question 27

Should necrotic tissue be debrided?

Answer 27

NO! Unless there are signs of infection (serves as a biologic dressing)

Question 28

How can ischemia/necrosis risk be minimized?

Answer 28

Suture replacement to decrease tension, the elevation of the surgical area (decrease edema), heat application (increased circulation), hyperbaric oxygen

Question 29

When is a wound at the highest risk of dehiscence?

Answer 29

Time of suture removal

(can remove sutures in stages if more support is needed)

Question 30

What is the treatment for dehiscence?

Answer 30

Classic teaching/boards: Resuture if <24 hrs after surgery, if >24 hrs then secondary intention healing

Newer studies suggest that if there is no infxn, hematoma, necrosis then resuturing can be done

Question 31

If surgery is performed on the ear and significant pain is noted after surgery what is this? and how is it treated?

Answer 31

Chondritis, very painful, can occur on any ear procedure involving cartilage. Can be associated with pseudomonas

Tx w/ NSAIDs for pain, quinolone if suspected infection

Question 32

What is a risk factor test for ectropion that can be done?

Answer 32

The “snap test” (lower eyelid is pulled down, this should snap back normally, but if it takes a while (or doesn’t) go back to being against the eye this is a risk factor). Medial and lateral canthus test as well (these are pulled, there should not be much laxity here, more is abnormal)

if these are abnormal, higher risk

Question 33

What degree of eyebrow lift is ok for the closure of surgical wounds?

Answer 33

≤3mm is ok, > 3mm should be avoided (wont self resolve)

Question 34

What surgical sites are most common for keloids?

Answer 34

Anterior neck, chest, and scars crossing jawline

Question 35

What are some risk factors for trapdoor/pincushioning defects?

Answer 35

Often from concentric forces, so curved incision lines like bilobed flaps, nasolabial fold transposition flaps

Question 36

How can pincushioning/trapdoor defects be avoided?

Answer 36

Wide undermining, sizing the flap properly, and good flap adherence to the wound base

Question 37

What sutures have the highest risk of spitting?

Answer 37

Vicryl sutures placed superficially

Question 38

When do spitting sutures usually occur and how can they be addressed?

Answer 38

1-3 months postop, can be removed if possible

Question 39

How can ectropion be prevented when working near the lower eyelid?

Answer 39

Periosteal tacking sutures, Frost suspension sutures (a stitch is thrown in the lower eyelid, near the medial canthus, and attached to the skin of the upper eyelid suspending/holding the lower eyelid up)

Question 40

What is the highest risk suture for suture granuloma?

Answer 40

Vicryl (polyglactin-910)

Question 41

When do suture granulomas generally occur postop and what should be done?

Answer 41

1-3 months, resolves itself but can use intralesional triamcinolone to help things along

Question 42

How are post-surgical telangiectasias treated?

Answer 42

Pulsed dye laser

Question 43

How can thickened scars be treated?

Answer 43

Massage or intralesional steroid

Question 44

What can be done to treat webbed or contracted scars?

Answer 44

Z-plasty revision

Question 45

How can motor nerve damage be avoided when operating on the face?

Answer 45

Staying above the SMAS

Question 46

What can be done to minimize abnormal sensation issues after surgery on the forehead?

Answer 46

Orienting excisions vertically rather than horizontally if possible, can decrease the number of sensory nerve branches transected