GENERAL SURGERY FOR DENTAL STUDENTS BY Dr. AHMAD K. SHAHWAN PH.D. GENERAL SURGERY
Approach to the Surgical Patient: The management of surgical disorders requires not only the application of technical skills and training in the basic sciences to the problems of diagnosis and treatment but also a sympathy and indeed love for the patient. The surgeon must be a doctor, an applied scientist, an engineer, an artist. Because life or death often depends upon the validity of surgical decisions, the surgeon's judgment must be matched by courage in action and by a high degree of technical proficiency
Approach to the Surgical Patient: • History- • physical Examination - • Investigations- • Pre-operative preparation - • operation - • post-operative treatment- • management of complications.
Approach to the Surgical Patient: • The History : At their first contact, the surgeon must gain the patient's confidence and convey the assurance that help is available and will be provided. The surgeon must demonstrate concern for the patient as a person who needs help and not just as a "case" to be processed. This is not always easy to do, and there are no rules of conduct except to be gentle and considerate.
The History I- The chief complaint :i.e. what the problem that bring the patient to the doctor& its duration . II- The present history: in full detail: 1-when the complaint start exactly ? (day , hour). 2-how it starts? (slowly ,abruptly ) 3-its course ? (increasing , the same or decreasing ). 4- any associated symptoms? (pain vomiting ,fever ,drowsiness ,change in vision ,………..) . 5- the provoking factors: what increase the complaint? 6- the releasing factors;what decrease the complaint ? 7- relieved by medication or not ? 8- constant or intermittent ,its duration & for how long ?
The History e.g. The pain: • The site : • The onset :gradual ,sudden or explosive • The character: burning ,colicky, vague ,heaviness,….. • The severity: mild ,moderate or sever . • constant or intermittent . • relieved by medication or not & what medication ? • Factors increase it :movement ,eating, standing ,…. • Factors decrease it :movement ,eating, standing ,… • Radiation to other site ? • Associated symptoms: vomiting ,fever …..
The History E.g.: vomiting : • What did the patient vomit? Food ,fluid ,…… • How much? • How often? • What did the color of the vomitus ? yellow ,green, brown,…. • Was vomiting projectile? • The taste of the vomitus ?acidic , bitter ,…..
The History III- The past history; • Any same complain before ? How it started & how ended? • Any other complain before? Related to the complaint or not related ? • Any other diseases? hypertension. ,diabetes mellitus , cardiac problem,… IV –The drug history :aspirin ,anticoagulant ,contraceptive pills ,chemotherapy . V- The surgical history :any operation before, type of anesthesia ,any complication?
The History VI- Nutritional history :dehydration . Loss of electrolyte ,protein deficiency. VII- Menstrual history :regularity ,duration , amount,.. VIII-Family history: known disease in the family ,same disease in the family ,hereditary diseases? . IX- Environmental history. X- Habbit history :smoking, alcohol ,drug abuse . XI- Hypersensitivity history .
The physical examination: • All patients are sensitive and somewhat embarrassed at being examined . • The examining room and table should be comfortable ,worm, closed, and drapes should be used if the patient is required to strip for the examination. A female nurse should be present if the patient is female. Most patients will relax if they are allowed to talk a bit during the examination, which is another reason for taking the past history while the examination is being done.
The physical examination: • Inspection :any scar, pulsation, swelling, redness, discharge, asymmetry, hair distribution, ulcers, wound ,…. • Palpation :(superficial palpation for masses, tenderness,….&deep palpation for deep masses ) • Percation :to differentiate between air & solid surfaces. • Auscultation :by use stethoscope to hear normal & abnormal sounds.
E.g. if we find a lump (mass), we should know: • The site . • The size . • The shape . • The edge (cut or rounded). • Tenderness . • Pulsation . • Flactuality . • Consistency . • Mobility . • The surface. • Reducibility . • Regional draining lymph node .
E.g. if we find an ulcer we should know: • The site . • The size . • The shape . • The edge . • The base (what you can feel) . • The floor (what you can see) . • The color . • The secretion . • The vascularity . • Regional draining lymph node .
Investigations I- Simple blood investigations: • C.B.C. (complete blood count) which reveals hemoglobin, white blood cells, red blood cells, platelets count, • Blood group & Rh-factor. • Blood sugar (fasting or random or post brandial) . • The kidney function tests (Blood urea ,serum creatinine) . • Electrolyte: Na+ ,K+, Ca++,….. • The liver function test (ALT, AST ,serum bilirubin ,serum protein & albumin ) . • P.T. & P.T.T.
Investigations II- urine exam (general & culture). III- Stool exam (general & culture). IV- ultrasonography. V- X-ray: 1- simple X-ray (without dye) e.g. chest X-ray ,abdominal X-ray ,K.U.B. ,skull X-ray ,panorama X-ray, …. 2- X-ray with dye :e.g. barium meal ,barium enema, I.V.P…… 3- C.T. scan 4- M.R.I. VI- E.C.G . (electro cardio graphy )
Investigations • Special Examinations: such as cystoscopy, gastroscopy, esophagoscopy, colonoscopy, angiography, and bronchoscopy are often required in the diagnosis of certain surgical disorders. The surgeon must be familiar with the indications and limitations of these procedures and be prepared to consult with colleagues in medicine and other surgical specialties as required.
Pre-operative preparation • According to the type of operation, we should do: • All the required investigations • Prepare blood . • Shaving the operation site. • The patient take a bath. • Examined by the anesthetist. • Prepare I.C.U. if the patient need. • Give him premedications like diazepam a night before the operation. • Fasting 8 hours before the operation . The patient should enter the operation room in the optimumcondition
Approach to the Surgical Patient: --operation - --post-operative treatment- --management of complications. (according to the type of the operation.)
Postoperative Care: • The recovery from major surgery can be divided into three phases: (1) an immediate, or post-anesthetic phase; (2) an intermediate phase, ( the hospitalization period); (3) a convalescent phase. During the first two phases, care is principally directed at maintenance of homeostasis, treatment of pain, and prevention and early detection of complications. The convalescent phase is a transition period from the time of hospital discharge to full recovery. The trend toward earlier postoperative discharge after major surgery make the 3rd phase more important.
1-The Immediate Postoperative Period • The major causes of early complications and death following major surgery are acute pulmonary, cardiovascular, and fluid derangements. The post-anesthesia care unit (PACU) is staffed by specially trained personnel and provided with equipment for early detection and treatment of these problems. All patients should be monitored in this specialized unit initially following major procedures .
1-The Immediate Postoperative Period The patient can be discharged from the recovery room when cardiovascular, pulmonary, and neurologic function have returned to baseline, which usually occurs 1–3 hours following operation. Patients who require continuing ventilatory or circulatory support or who have other conditions that require frequent monitoring are transferred to an intensive care unit (I.C.U.) . In this setting, nursing personnel specially trained in the management of respiratory and cardiovascular emergencies are available. Monitoring equipment is available to enable early detection of cardio-respiratory derangements.
Postoperative Orders in The Immediate Postoperative Period The nursing team must be advised of the nature of the operation and the patient's condition. Postoperative orders should cover the following: 1- Monitoring the following: A- Vital Signs : Blood pressure, pulse, and respiration should be recorded frequently until stable and then regularly until the patient is discharged from the recovery room. The frequency of vital sign measurements thereafter depends upon the nature of the operation and the course in the PACU. Continuous electrocardiographic monitoring is indicated for most patients in the PACU. Any major changes in vital signs should be communicated to the anesthesiologist and surgeon immediately.
B-Central Venous Pressure Central venous pressure should be recorded periodically in the early postoperative period if the operation has entailed large blood losses or fluid shifts, and invasive monitoring is available. A Swan-Ganz catheter for measurement of pulmonary artery wedge pressure is indicated under these conditions if the patient has borderline cardiac or respiratory function.
C- Fluid Balance The anesthetic record includes all fluid administered as well as blood loss and urine output during the operation. This record should be continued in the postoperative period and should also include fluid losses from drains and stomas. This aids in assessing hydration and helps to guide intravenous fluid replacement. A bladder catheter can be placed for frequent measurement of urine output. In the absence of a bladder catheter, the surgeon should be notified if the patient is unable to void within 6–8 hours after operation.
D- Other Types of Monitoring Depending on the nature of the operation and the patient's pre-existing conditions, other types of monitoring may be necessary. Examples include measurement of intracranial pressure and level of consciousness following cranial surgery and monitoring of distal pulses following vascular surgery or in patients with casts.
2- Respiratory Care In the early postoperative period, the patient may remain mechanically ventilated or treated with supplemental oxygen by mask or nasal prongs. These orders should be specified. For intubated patients, tracheal suctioning or other forms of respiratory therapy must be specified as required. Patients who are not intubated should do deep breathing exercises frequently to prevent atelectasis.
3- Position in Bed and Mobilization The postoperative orders should describe any required special positioning of the patient. Unless doing so is contraindicated, the patient should be turned from side to side every 30 minutes until conscious and then hourly for the first 8–12 hours to minimize atelectasis. Early ambulation is encouraged to reduce venous stasis; the upright position helps to increase diaphragmatic function. Venous stasis may also be minimized by intermittent compression of the calf by pneumatic stockings.
4- Diet Patients at risk for emesis and pulmonary aspiration should have nothing by mouth until some gastrointestinal function has returned (usually within 4 days). Most patients can tolerate liquids by mouth shortly after return to full consciousness. 5- Administration of Fluid and Electrolytes Orders for postoperative intravenous fluids should be based on maintenance needs and the replacement of gastrointestinal losses from drains, fistulas, or stomas.
6- Drainage Tubes Drain care should be included in the postoperative orders. Details such as type and pressure of suction, irrigation fluid and frequency, and skin exit site care should be specified. The surgeon should examine drains frequently, since the character or quantity of drain output may herald the development of postoperative complications such as bleeding or fistulas. 7- Medications Orders should be written for antibiotics, analgesics, gastric acid suppression, deep vein thrombosis prophylaxis, and sedatives. If appropriate, preoperative medications should be reinstituted. Careful attention should be paid to replacement of corticosteroids in patients at risk, since postoperative adrenal insufficiency may be life-threatening. Other medications such as antipyretics, laxatives, and stool softeners should be used selectively as indicated.
8- Laboratory Examinations and Imaging The use of postoperative laboratory and radiographic examinations should be to detect specific abnormalities in high-risk groups. The routine use of daily chest radiographs, blood counts, electrolytes, and renal or liver function panels is not useful.
The Intermediate Postoperative Period • The intermediate phase starts with complete recovery from anesthesia and lasts for the rest of the hospital stay. During this time, the patient recovers most basic functions and becomes self-sufficient and able to continue convalescence at home.
1- Care of the Wound : Within hours after a wound is closed, the wound space fills with an inflammatory exudate. Epidermal cells at the edges of the wound begin to divide and migrate across the wound surface. By 48 hours after closure, deeper structures are completely sealed off from the external environment. Sterile dressings applied in the operating room provide protection during this period. Dressings over closed wounds should be removed on the third or fourth postoperative day. If the wound is dry, dressings need not be reapplied; this simplifies periodic inspection. Dressings should be removed earlier if they are wet, because soaked dressings increase bacterial contamination of the wound.
1- Care of the Wound: Dressings should also be removed if the patient has manifestations of infection (such as fever or increasing wound pain). The wound should then be inspected and the adjacent area gently compressed. Any drainage from the wound should be examined by culture and Gram-stained smear. Removal of the dressing and handling of the wound during the first 24 hours should be done with aseptic technique. Medical personnel should wash their hands before and after caring for any surgical wound. Gloves should always be used when there is contact with open wounds or fresh wounds.
1- Care of the Wound : Generally, skin sutures or skin staples may be removed by the fifth postoperative day and replaced by tapes. Sutures should be left in longer (eg, for 2 weeks) in incisions that 1- cross creases (eg, groin, popliteal area); 2-for incisions closed under tension; 3-for some incisions in the extremities (eg, the hand); 4-with incisions of any kind in debilitated patients. Sutures should be removed if suture tracts show signs of infection. If the incision is healing normally, the patient may be allowed to shower or bathe by the seventh postoperative day.
1- Care of the Wound : Fibroblasts proliferate in the wound space quickly, and by the end of the first postoperative week, new collagen is abundant in the wound. On palpation of the wound, connective tissue can be felt as a prominence (the healing ridge) and is evidence that healing is normal. Tensile strength is minimal for the first 5 days. It increases rapidly between the fifth and twentieth postoperative days and more slowly thereafter. Wounds continue to gain tensile strength slowly for about 2 years. In otherwise healthy patients, the wound should be subjected to only minor stress for 6–8 weeks. When wound healing is expected to be slower than normal (e.g., in elderly or debilitated patients or those taking corticosteroids), activity should be delayed even further
1- Care of the Wound : When a wound has been contaminated with bacteria during surgery, it is often best to leave the skin and subcutaneous tissues open and either to perform delayed primary closure or allow secondary closure to occur. The wound is loosely packed with fine-mesh gauze in the operating room and is left undisturbed for 4–5 days; the packing is then removed. If at this time the wound contains only serous fluid or a small amount of exudate, the skin edges can be approximated with tapes. If drainage is considerable or infection is present, the wound should be allowed to close by secondary intention. In this case, the wound should be packed with moist-to-dry dressings, which are changed once or twice daily. The patient can usually learn how to care for the wound and should be discharged as soon as his or her general condition permits. Most patients do not require visiting nurses to assist with wound care at home.
1- Care of the Wound : Wound healing is faster if the state of nutrition is normal and there are no specific nutritional deficits. For example, vitamin C deficiency interferes with collagen synthesis and vitamin A deficiency decreases the rate of epithelialization. Deficiencies of copper, magnesium, and other trace metals decrease the rate of scar formation. Supplemental vitamins and minerals should be given postoperatively when deficiencies are suspected, but wound healing cannot be accelerated beyond the normal rate by nutritional supplements. Wound problems should be anticipated in patients taking corticosteroids, which inhibit the inflammatory response, fibroblast proliferation, and protein synthesis in the wound. Maturation of the scar and gain of tensile strength occur more slowly. Extra precautions include using non-absorbable suture materials for fascial closure, delaying removal of skin stitches, and avoiding stress in the wound for 3–6 months.
2-Management of Drains : Drains are used either to prevent or to treat an unwanted accumulation of fluid such as pus, blood, or serum. Drains are also used to evacuate air from the pleural cavity so that the lungs can reexpand. When used prophylactically, drains are usually placed in a sterile location. Strict precautions must be taken to prevent bacteria from entering the body through the drainage tract in these situations. The external portion of the drain must be handled with aseptic technique, and the drain must be removed as soon as it is no longer useful. When drains have been placed in an infected area, there is a smaller risk of retrograde infection of the peritoneal cavity, since the infected area is usually walled off. Drains should usually be brought out through a separate incision, because drains through the operative wound increase the risk of wound infection.
2-Management of Drains : • Closed drains connected to suction devices are preferable to open drains (such as Penrose) that predispose to wound contamination. The quantity and quality of drainage should be recorded, and contamination minimized. When drains are no longer needed, they may be withdrawn entirely at one time if there has been little or no drainage or may be progressively withdrawn over a period of a few days.
2-Management of Drains : • Sump drains (such as Davol drains) have an airflow system that keeps the lumen of the drain open when fluid is not passing through it, and they must be attached to a suction device. Sump drains are especially useful when the amount of drainage is large or when drainage is likely to plug other kinds of drains. Some sump drains have an extra lumen through which saline solution can be infused to aid in keeping the tube clear. After infection has been controlled and the discharge is no longer purulent, the large-bore catheter is progressively replaced with smaller catheters, and the cavity eventually closes.
3-Postoperative Pulmonary Care • The changes in pulmonary function observed following anesthesia and surgery are principally the result of decreased vital capacity, functional residual capacity (FRC), and pulmonary edema. These changes are accentuated in patients who are : • obese, • who smoke heavily, or • who have preexisting lung disease. • Elderly patients are particularly vulnerable because they have decreased compliance, increased closing volume, increased residual volume, and increased dead space, all of which enhance the risk of postoperative atelectasis.
3-Postoperative Pulmonary Care • Pain is thought to be one of the main causes of shallow breathing postoperatively. Complete abolition of pain, however, does not completely restore pulmonary function . The principal means of minimizing atelectasis is deep inspiration. Early mobilization, encouragement to take deep breaths (especially when standing), and good coaching by the nursing staff suffice for most patients.
4-Postoperative Fluid & Electrolyte Management Postoperative fluid replacement should be based on the following considerations: (1) maintenance requirements, (2) extra needs resulting from systemic factors (e.g., fever, burns), (3) losses from drains, and (4) requirements resulting from tissue edema and ileus (third space losses). Daily maintenance requirements for sensible and insensible loss in the adult are about 1500–2500 mL depending on the patient's age, gender, weight, and body surface area. A rough estimate can be obtained by multiplying the patient's weight in kilograms times 30 (e.g., 1800 mL/24 h in a 60-kg patient). Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic rate.
4-Postoperative Fluid & Electrolyte Management • For patients requiring intravenous fluid replacement for a short period (most postoperative patients), it is not necessary to measure serum electrolytes at any time during the postoperative period, but measurement is indicated in more complicated patients (those with extra fluid losses, sepsis, preexisting electrolyte abnormalities, or other factors). Assessment of the status of fluid balance requires accurate records of fluid intake and output and is aided by weighing the patient daily. • As a rule, 2000–2500 mL of 5% dextrose &/or normal saline & / or lactated Ringer's solution is given daily. Potassium should usually not be added during the first 24 hours after surgery, because increased amounts of potassium enter the circulation during this time as a result of operative trauma and increased aldosterone activity.
4-Postoperative Fluid & Electrolyte Management In most patients, fluid loss through a nasogastric tube is less than 500 mL/d and can be replaced by increasing the infusion used for maintenance by a similar amount. About 20 meq of potassium should be added to every liter of fluid used to replace these losses. However, with the exception of urine, body fluids are isosmolar and if large volumes of gastric or intestinal juice are replaced with normal saline solution, electrolyte imbalance will eventually result. Whenever external losses from any site amount to 1500 mL/d or more, electrolyte concentrations in the fluid should be measured periodically, and the amount of replacement fluids should be adjusted to equal the amount lost.
5-Postoperative Care of the Gastrointestinal Tract In the immediate postoperative period, the stomach may be decompressed with a nasogastric tube. Nasogastric intubation was once used in almost all patients undergoing laparotomy to avoid gastric distention and vomiting, The nasogastric tube should be connected to low intermittent suction and irrigated frequently to ensure patency. The tube should be left in place for 2–3 days or until there is evidence that normal peristalsis has returned (e.g., return of appetite, audible peristalsis, or passage of flatus).
5-Postoperative Care of the Gastrointestinal Tract Once the nasogastric tube has been withdrawn, fasting is usually continued for another 24 hours, and the patient is then started on a liquid diet. Opioids may interfere with gastric motility and should be stopped in patients who have evidence of gastro-paresis beyond the first postoperative week. After most operations in areas other than the peritoneal cavity, the patient may be allowed to resume a regular diet as soon as the effects of anesthesia have completely worn off.
6-Postoperative Pain Severe pain is a common sequela of intrathoracic, intra-abdominal, and major bone or joint procedures. About 60% of such patients perceive their pain to be severe, 25% moderate, and 15% mild. In contrast, following superficial operations on the head and neck, limbs, or abdominal wall, less than 15% of patients characterize their pain as severe. The factors responsible for these differences include duration of surgery, degree of operative trauma, type of incision, and magnitude of intraoperative retraction. Gentle handling of tissues, expedient operations, and good muscle relaxation help lessen the severity of postoperative pain.
6-Postoperative Pain • While factors related to the nature of the operation influence postoperative pain, it is also true that the same operation produces different amounts of pain in different patients. This varies according to individual physical, emotional, and cultural characteristics. Much of the emotional aspect of pain can be traced to anxiety. Feelings such as helplessness, fear, and uncertainty contribute to anxiety and may heighten the patient's perception of pain.