Wounds, Stomas, Fistulae, Anastomoses, Tube and Drain

Question 0

Describe how wounds heal

Answer 0

Primary intention:
occurs if wound edges are brought together immediately
scarring is minimal

Secondary intention:
occurs if wound edges are not brought together (irreparable skin loss, wound infection, wound brreakdown). Wound fills up with granulation tissue from the base upwards.
slower than primary intention and produces more scarring

Question 1

Name the different types of wounds and how to treat them

Answer 1

Incised - clean caused by a sharp object
- treat with sutures
Lacerated - contaminated with jagged edges
- treat by excising the edges and then suturing
Crushed and devitalised - seen often in RTAs and industrial accidents
- treat by debridement and healing by secondary intention

Question 2

What factors have adverse effect on wound healing?

Answer 2

VITAMINS A, B, C, D, E

Vitamin deficiency 
Infection 
Technique 
Arterial supply 
Malnutrition 
Icterus (secondary to hepatobiliary disease, haemolysis or uraemia)
Necrotic tissue 
Sugar (diabetes)
Anaemia, Age 
Blood clot (haematoma formation)
Cancer
Drugs (cytotoxic agents or steroids)
Edge tension

Question 3

What abnormalities of scarring are there?

Answer 3

Hypertrophic:
excessive scarring which remains within the margins of the wound edges.
occurs in young people and after burns
treat with compression

Keloid:
excessive scarring which extends beyond the wound edges.
common in dark skinned races and on the sternum and deltoid
do not treat with excision - makes it worse. treat with steroids.

Question 4

Name the indications for stoma formation:

Answer 4

FLEDD

Feeding - gastrostomy, jejunostomy
Lavage - caecostomy (rarely)
Exteriorisation - colostomy, illeostomy
Decompression - caecostomy (in gross bowel obstruction)
Diversion - illeostomy, colostomy, duodenostomy (rare)

Question 5

What are the differences between an ileostomy and a colostomy?

Answer 5

Ileostomy:
Site: RIF
Shape: spouted, due to the high enzyme content of the contents
Effluent: liquid to semi liquid
Output: Low = 500ml/ day, High = 1 litre/ day

Colostomy:
         Site: LIF 
         Shape: flush to the skin 
         Effluent: Semi - solid to solid 
         Output: 200 - 300ml/ day

Question 6

When would you use an ileostomy?

Answer 6

To protect a distal (colonic) anastomosis - temporary

Following a panproctocolectomy - permanent

Question 7

When would a panproctocolectomy be performed?

Answer 7

1. Ulcerative colitis
2. Familial adenomatous polyposis
3. Severe Crohn’s disease
4. Multiple colonic cancer

Question 8

When would you use a colostomy?

Answer 8

To protect a distal anastomosis - temporary
Following a abdominal perineal resection - permanent
After colonic resection if primary anastomosis is not feasible immediately

Question 9

What are the different types of colostomy?

Answer 9

Loop colostomy:
A loop of colon is brought to the surface and secured with plastic/ glass rod; bowel is opened and edges sewn down.
Diversion
Easily reversible

End colostomy and rectal stump (hartmann’s):
Proximal end of colon is brought up as end colostomy and distal end is stapled and dropped back into the cavity.
Mucus produced by it passed PR
Reversible but can be difficult to find the stump

Double barrelled colostomy (Paul- Mikulicz)
Both ends are brought up to the surface.
Proximal end is functional and the distal end is a mucus fistula
Easily reversible

Question 10

When would you reverse a colostomy?

Answer 10

After 6 weeks - after 12 weeks reversal is more difficult due to adhesions

Question 11

What are the complications of stomas?

Answer 11

Fluid loss
Odour 
Ulceration of skin 
Leakage 
Stenosis 
Hernia 
Ischemia
Terminal ileum loss - B12
Sexual/ psychological

Question 12

What is an ileal conduit?

Answer 12

A loop of ileum is used for urinary diversion after cystectomy.
Both ureters are anastomosed to one end of the loop and the other end is brought to the surface as a spout.

Question 13

What is a fistula?

Answer 13

An abnormal connection between two epithelial or endothelial surfaces

Question 14

What are the different types of fistulae?

Answer 14

Blind - connects two structures but open on one end only
Complete - has external and internal openings
Incomplete - a fistula from the skin that is closed and does not connect to any internal structure
Horse-shoe - connects the anus to the surface of the skin after going around the rectum

Question 15

What conditions prevent the closure of a fistula?

Answer 15

FRIEND

Foreign body 
Radiation 
Infection
Epithelialisation 
Neoplasia 
Distal obstruction

Question 16

When would a primary anastomosis not be feasible in bowel surgery?

Answer 16

In the presence of perforation, sepsis, ischemia, intestinal obstruction or disease at the site of anastomosis .
These all increase the chance of anastomotic leak (usually happens day 5 post op)

Question 17

What does french mean when describing a tube?

Answer 17

The diameter - the larger the number the wider the diameter.
Divide by ~ 3 to get the diameter in mm (12F = 4mm)

Question 18

What structures does a urethral catheter transverse through in male catheterisation?

Answer 18

1. urethral meatus
2. penile (spongy) urethra
3. membranous urethra
4. prostatic urethra
5. bladder neck
6. bladder

Question 19

What are the indications for a chest tube?

Answer 19

1. pneumothorax
2. haemothorax
3. pneumo- haemothorax
4. chylothorax
5. empyema
6. large pleural effusion

Question 20

Where would you insert a chest tube?

Answer 20

5th intercostal space in the mid axillary line.

Go over the rib to avoid the neurovascular bundle

Question 21

What are the indications for a central line?

Answer 21

CHIPS

CVP monitoring
Cardiac pacing 
Haemodialysis 
Infusions (TPN, chemo)
Pulmonary artery catheterisation 
Shoddy peripheral venous access

Question 22

What are the complications of a central line?

Answer 22

Catheter tip embolus or thrombotic embolus 
Arrhythmias
Pneumothorax
Haemothorax
Plural effusion 
Air embolism 
Infection 
Bleeding 
Subclavian vein thrombosis

Question 23

What are the indications for an NG tube?

Answer 23

1. emptying the stomach contents (emergency surgery preop)
2. rest bowel (pancreatitis)
3. feeding

Question 24

What is a flatus tube?

Answer 24

A large bore, flexible tube used to decompress obstructed large bowel by allowing passage of flatus.
Passed PR
Used in sigmoid volvulus

Question 25

What is a cholecystostomy tube?

Answer 25

A tube inserted to drain the gallbladder.
Inserted under USS guidance.
Placed either surgically or percutaneously

Question 26

What is a T tube?
What is the min time it can be left in?
When is it safe to remove?

Answer 26

A tube place into the biliary tree usually after it has been surgiclly explored.
It drain bile percutaneously.

It must be left in 10days. a fibrous tract forms in this time, around the tube, which then scleroses on removal, preventing bile leak.

It can be removed if clinically there are no signs of cholangitis on clamping, there is not derangement of LFTs on clamping and the T tube cholangiogram is normal.

Question 27

What are the indications for drainage?

Answer 27

Removal of infected foreign material
Obliteration of dead space
Monitoring - for leakage post bowel anastomosis