PRACTICAL GUIDE TO © WITH CHAPTERS ON INSTRUMENTS, SPLINTS AND BANDAGING Fourth Edition _ S.Das_ B.S. (Cal.), F.eC Preface To The Fourth Edition First of all | must apologize for the delay in bringing out this edition. In the interim period | completed three new books on Surgery — (i) A Concise Textbook Of Surgery; (ii) A Textbook On Surgical Short Cases and {ii) Mcgs In Surgery and brought out new editions of ‘A Manual On Clinical Surgery’ and ‘Surgical Short Cases’. The whole process took considerable time. In these few years Surgery has progressed a lot and | have left no stone unturned to cover all the modern concepts in this text. The concept of Operative Surgery has vastly changed in this decade. So I had to revise aif the chapters very thoroughly. With the availability of ‘Minimal Access Surgery’ the trend has moved in that direction. Use of endoscopy has become almost obligatory in majority of surgical conditions. So, in this edition I have offered considerable space on these subjects, A new chapter has been introduced on "Minimal Access Surgery’, Now standard radiology has largely been replaced by Ultrasound Scanning, Computerised Axial Tomography and Radioisotope Scanning. Nuclear Mag- netic Resonance is now increasingly used to get improved quality of imaging. ERCP is more often used nowadays due to increase in acceptibility of Laparoscopic Cholecystectomy. However, the general surgeons of today must be aware of the basic techniques which are available and must possess a sound understanding of the reasons for applying these methods. In each chapter I have continued to provide a section on Anatomy and Phy iology in the beginning. Pathological varieties and their importance in selecting the right operation have been adequately emphasised. Importance of various investigations in chosing the correct operation has been narrated where required. In most cases a total account of treatment has been given to indicate the indication of operation and the type of operation to be offered to the particular case. Recently published works on Operative Surgery are the product of multiple authorship — a number of eminent authorities writing on thelr own specialities. While this type of work will help the postgraduate trying to be specialised on any particular branch, this one-volume book written by a general surgeon is of immense value to the undergraduate and those preparing for postgraduate qualification to acquire a first-hand knowledge on the subject of ‘Operative Surgery’. While writing | have tried to be concise, particular and methodical instead of rambling on which has been the feature of many Western texts. | reiterate that all the chapters have been thoroughly revised in this edition. I must express my sense of gratitude to the great mass of students and teachers of Indian Subcontinent for their spontaneous recommendation of this text. That is why it is the best selling ‘Operative Surgery’ in this subcontinent inspite of freely presence of innumerable Western texts ‘on this subject. Appreciations and reports of acceptance are also coming from other countries outside Indian Subcontinent. My sincere thanks to the DTP composer, processor and printer on whom depend the quality of production of this treatise. 13, Old Mayors’ Court, Caleutta — 700 005, Pebrnary, 1999. S. DAS.Contents ‘cuaPTER PAGE 21. 23. 24. 26. 27. 28. 29, 30. ai. 33. 36. 37. 38. 39. 40. 41. 42, PNRM AN ANAESTHESIA INTRODUCTION OPERATIONS ON ABSCESSES AND CARBUNCLES TUMOURS AND CYSTS OF THE SUPERFICIAL TISSUES SKIN GRAFTING OPERATIONS ON TENDONS AND MUSCLES OPERATIONS ON BLOOD VESSELS AND LYMPHATICS OPERATIONS ON NERVES OPERATIONS ON THE BONES & JOINTS ). OPERATIONS ON THE HAND & FINGERS 1 R 13. 14. 15. 16. 7. 18. 19. AMPUTATION OPERATIONS ON THE SCALP & SKULL OPERATIONS ON THE SPINE & SPINAL CORD OPERATIONS ON THE FACE, MOUTH & JAWS OPERATIONS ON SALIVARY GLANDS OPERATIONS ON THE NECK OPERATIONS ON THE THYROID AND PARATHYROID GLANDS OPERATIONS ON THE BREAST OPERATIONS ON THE THORAX OPERATIONS ON OESOPHAGUS INTRODUCTION TO ABDOMINAL SURGERY MINIMAL ACCESS SURGERY (LAPAROSCOPY) OPERATIONS ON THE STOMACH AND DUODENUM OPERATIONS ON THE LIVER AND SUBPHRENIC ABSCESSES OPERATIONS ON THE SPLEEN PORTAL HYPERTENSION OPERATIONS ON THE GALLBLADDER AND BILE DUCT OPERATIONS ON THE PANCREAS OPERATIONS ON THE APPENDIX OPERATIONS ON THE INTESTINE INTESTINAL OBSTRUCTION OPERATIONS ON THE RECTUM AND ANAL CANAL OPERATIONS FOR HERNIA OPERATIONS ON THE KIDNEY AND URETER OPERATIONS ON THE URINARY BLADDER OPERATIONS ON THE PROSTATE OPERATIONS ON THE URETHRA OPERATIONS ON THE PENIS OPERATIONS ON THE TESTIS AND SCORTUM SURGICAL INSTRUMENTS SPLINTS AND PLASTER OF PARIS BANDAGING INDEX 42a 476 494 526 535 543Published by Dr. S. Das. 13, Old Mayors’ Court, Calcutta - 700 005. INDIA. E-mail - drsomendas@ivsnl.net All Rights Reserved This book or any part thereof must not be reproduced in any form without the written permission of the author, DR. S. DAS. US. $ 12.00 Rs. 330.00A PRACTICAL GUIDE TO OPERATIVE SURGERY WITH CHAPTERS ON INSTRUMENTS, SPLINTS AND BANDAGING Somen Das M.B.B.S. (Cal.), F-R.C.S. (Eng. & Bdin.) Senior Consultant Surgeon AUTHOR OF A MANUAi, ON CLINICAL SURGERY. ‘A TEXTBOOK CN SURGICAL SHORT CASES. A CONCISE TEXTBOOK OF SURGERY & MCOS IN SURGERY. Fourth Epirion CALCUTTA 1999A PRACTICAL GUIDE TO OPERATIVE SURGERY DEDICATED. TO THE MEMORY OF MY FATHER Kate Br. B. Bas Who has taught me how to write a book effectively & TO THE MEMORY OF MY MOTHER: ‘Whose inspiration has always worked with me.Currier T 3 Anaesthesia THE PATIENT The anaesthetist should examine each of his patients before operation, but unfortunately in hospital practice this is not always possible, The anaesthetist should also go through the notes of the patients to be operated on betore they come to the theatre. The anaesthetist should note particularly the efficiency of the patient's respiratory and circulatory system. He must enquire for (i) cough, (ji) sputum, {ily dyspnoea, {iv} orthopnoea, etc. He should also examine for (i) anaemia, (i) jaundice. (ii) any cardiac lesion, {iv) pitting oedema, (v) any lung lesion, (vi) pathological liver, kidney, etc. He should also enquire about the personal history of the patient — whether he is addicted to alcohol, smoking etc. Drug history 's very important. (i) Whether the patient is allergic to any medicine or not. (ii) Whether the patient is having steroid or have had steroids during the preceding 2 years. In these cases the patient is given 100 mg hydrocortisone LM. at the time of premedication. This dose is repeated 8-10 hours later. Gradually the dose is reduced to the patient's normal dose. If high doses of steroids have to be maintained for more than 4 days postoperatively, the risk of infection is increased and an antibiotic must be prescribed. If the blood pressure falls during operation, the anaesthetist must inject a further dose of 100 mg hydrocortisone al once. (il) Whether the patient is having any anti-hypertensive drug, such as reserpine, guanethidine, methyldopa etc. These medicines tend to make the blood pressure very fluctuating — which may shoot up with the administration of vasopressor or fall precipitously with haemorthage. Yet treated hypertension is preferable to untreated. The effects of the above drugs usvatly persist for 2 weeks. But if withheld for 2 weeks. a danger of hypertensive crisis cannot be avoided. A short-acting antihypertensive agent may be substituted. (iv) Whether the patient is having any antibiotic or not. Antibiotics, such as neomycin, streptomycin, polymyxin have a curatiform action. (v) Whether the patient is having phenothiazine group of drugs (psychiatric patients). These drugs, if used in large doses over a long period, may provoke hypertension and prolong unconsciousness. (vi) Whether the patient is having monoamine oxidase (MAO) inhibitors (generally used in mild psychiatric patients}. in these patients pethidine and vasopressors should be avoided. (vii) The anaesthetist should be careful to anaesthetise patients with tong term anticoagulant therapy. Endotracheat intubation should be done very carefully. (vil) If the patient is having ecothiopate (phospholine iodide), which is 2 long-acting anticholinesterase (used in eye department), care must be taken while giving muscle retaxant, par- ticularly suxemethonium, as this may follow protonged paralysis. (ix) If the patient is having massive blood transfusion, anaesthetist must anticipate two conditions — cardiac failure and “citrate intoxica- tion". There may be liberation of large amount of free potassium present in stored blood, which may resull in metabolic acidosis. Some Joss of calcium is also expected by excretion of calcium citrate So adminisiration of calcium gluconate may be advised in these cases. The anaesthetist should also go through the clinical investigations that have been performed such as routine examinations of blood, urine and stool. He can always ask for any special investigation, which may help him to know the state of the patient as a whole or any of his organs. Efficiency of the heart must always be taken into consideration. ‘A patient who can perlorm his usual daily task without distress, is fit for operation. Similarly a patient who can climb a flight of stairs without marked dyspnoea, is also suited for surgery.2 A PRACTICAL GUIDE TO OPERATIVE SURGERY Special mention shoutd be made about chronic anaemia, Preoperative transfusion of whole blood may increase the haemoglobin, but may well overioad the heart. So it is better to prescribe intravenous administration of packed cells rather than whole blood. PREMEDICATION The two functions that premedication is expected lo perform are : (1) to dry up the secretions of the respiratory tract glands and (2) to depress the activity of the patient's central nervous system in order to facilitate the forthcoming anaesthesia. (1) To dry up the secretions of the respiratory tract glands.— Generally atropine or hyoscine {scopolamine} is chesen for this purpose. Atropine dries up the secretions of the bronchial glands by inhibiting the parasympathomimetic action of acety! choline. It also inhibits the secretion of the salivary glands. So the patients invariably suffer from dryness of the mouth, It aiso increases the pulse tate, Sometimes it prevents cardiac arrhythmia mediated by the vagal nerves. The secretions of the gut are decreased, which is an exira advantage in abdominal surgery by preventing vorniting during and after anaesthesia. It also inhibits to certain extent the motility of the gut. Secretion of sweal is alse diminished and loss of heal trom the body by this route is prevented, so body flushing and fever may occur. The pupils will be difated. Alropine is said to cause stimulation of motor centres of Ihe brain. Generally a dose of 1/100 ot S.C. is used for premedication in aduits. Hyoseme (in the dose of 1/150 gr} is more or less similar type of drug as atropine. Their main difference is in the action on the central nervous system. Hyoscine is a cerebral depressant and may cause @ measure of amnesia. So hyoscine does also possess the second ‘unction of premedication while lor the first it stik seems to be a better drying agent than atropine. (2) To depress the activity of the central nervous system.— This is usually achieved by morphine (in the dose of th gr LM) or that group of drug. By depressing the higher centres of the brain an inclination to sleep and uncaring attitude towards the approaching operation are produced. N depresses the respiratory centre and cough centre. Inadvertent respiratory depression, caused by morphine, can be counter-acted by Nalorphan (Lethidrone in the dose of 10-20 mg). It slows the pulse rate, constricts the pupils by stimulating the Grd nerve nucleus. It relieves pain and thus lowers the BMR., which will be advantageous to the anaesthetist. Its main disadvantage is that it stimulates vomiting centre, which may produce nausea end vomiting, even after operation. It depresses the respiratory centre and cough centre. For these disadvantages, pethidine (in the dose of 7-100 mg |.M.} is lending to replace morphine Papaveretum (Omnopon, in the dose of 1/2rd gr) is also preferred to morphine as it gives nse to less postoperative vomiting Sometimes phenothiazine group of drug (chlorpromazine), promezathine (phenergan) etc. may be used. It sedation without depression is wanted, then drug like phenergan is useful. Premedication producing sleep is usually referred to as basal narcosis. Recently phenothiazine group of drugs is being used, which act on reticular system of brain. They cause euphoria without respiratory depression. They also protect against shock and cause some drying of secretions, Some drugs of this group have also an antiadrenergic effect — causing vasodilatation and 4 fall of blood pressure. Chiorpromazine (Largactil), promezathine (phenergan} and promazine (sparing) are the most commonly used members of this group They possess antiemetic and antihisiaminic: properties. Promezathine is moslly preferred because it is less likely to cause incidental hypotension and tachycardia, Either drug in the dose ot 50 mg LM. one hour preoperatively may be given in combination with pethidine. Sometimes hypotension may be invoked deliberately to reduce operative bleeding —- which is known as hypotensive anaesthesia and is only meant for the expert Certain drugs of this category have a specific antiemetic effect and is used for the treatment of postoperative vomiting. These are metoclopramide {maxaion) 5-10 mg or prochlorperazine (Stemetil 12.5 mg) Administration of premedication.— Premedication should be given at least one hour before theANAESTHESIA, 3 patient is due to arrive at the anaesthetic room. Atropine or hyoscine, when subcutaneously given, begins to act after about 30 minutes, whereas morphine starts more slowly, but the effects of both the drugs fast for about 4 hours. if premedication has not been given in right time, it may be given intravenously in the anaesthetic room. If premedication has been given too early, 3 hours may be accepted, But if administered before thal, atropine may be repealed intravenously, when a. vagal- blocking effect is particularly desired DEPTH OF ANAESTHESIA The two functions required of a genera! anaesthetic are (i) the production of narcosis and insensibility to pain and {ii} the provision of a motionless and unvesisting field for the surgeon. The depth of anaesthesia required. varies with the operation. The incision of an abscess or extraction of a tooth may require extremely light anaesthesia, on the other hand operations within the abdominal ‘cavity however require a deeper level of anaesthesia to abolish the tone of the abdominal muscies and to prevent thei: reflex contraction in response to the surgeon's handling of the sensitive peritoneum Classically the depth of anaesthesia is divided into four stages — Stage |. STAGE OF ANALGESIA— Pain is dulied but consciousness is retained. Stage li. STAGE OF EXCITEMENT.— Consciousness is (ost, but there is little change in pain perception. The higher controlling centres are abolished and this allows subconscious manifestations and an over-reaction to all forms of stimulation leading to shouting, fighfing and limb mavements Stage ill, STAGE OF SURGICAL ANAESTHESIA.— This stage is further subdivided into four planes Stage IV. STAGE OF IMPENDING OVERDOSE — gradually leads to failure pf respiration followed by failure of circulation. These stages and planes were described by Guedel in relation to open ether anaesthesia without any premedication. These cannot be strictly applied to modern anaesthetic, administered by a different method and using different drugs. So for modern anaesthesia, following classification is more applicable — (1) inadequate anaesthesia. (2) Surgical anaesthesia — fi) Light; (i) Deep. (3) Deep anaesthesia The depth of anaesthesia is judged mainly from the sespiration, adcitionel information being oblained from the eyes. Respiration — In fight anaesthesia, respiration of the patient may present any character from tachypnoea to breath holding or may appear perfectly regular. When the depth of the anaesthesia reaches the stage of the surgical anaesthesia, aulomatic respiration starts. These automatic respirations are regular, of a little faster rate and greater depth than the respiration of the conscious subject. If the patient's chest is moving, the intercostal muscles are working, the surgical anaesthesia is dight Hf the patient's chest is not moving and the respiration is being catrled out mainly by the diaphragm, the surgical anaesthesia is deep. When the abdominal respirations begin to show a progressive decrease in volume, exhibits loss of regularity and perhaps takes on a jerky character. the stage o! deep anaesthesia has been entered. At this stage, the anaesthesia should be lightened, olherwise respiration will cease. The Pupils. — In the stage of inadequate anaesthesia, the pupils may be observed moving oF fixed in any position of squint. When light surgical anaesthesia has been established, the pupils take up central positions. An overdose of anaesthelic usually produces enlargement of the pupil owing to paralysis of the. 3¢¢ nerve nucleus. The enlargement takes a gradual course. It one gently touches the eyelash of the conscious patient, fefiex winking of the eye resuits. This reflex persists just as far as the onset of surgical anaesthesia. So the presence of this rellex indicates inadequacy of the anaesthesia. is the patient ready for the operation to begin ? As has already been discussed. the operations4 A PRACTICAL GUIDE TO OPERATIVE SURGERY may be divided into two categories — (i) which require light anaesthesia and (ii) which require deep anaesthesia. Light surgical anaesthesia is marked by (a) respiration which is regular and thoracic. (b) The pupils, which are fixed, cenival and nol dilated, (c) Eyelash reflex is absent. When the first incision is made, the tespiralion may quicken, the pulse rate may show a slight rise. But if the patient's respiration suddenly ceases, or becomes highly irreguiar ar the patient becomes violent showing laryngeal spasm, the anaesthesia must be deemed too light for the operation to commence. Deep surgical anaesthesia is marked by (a) respiration, which is regular and abdominal, (b} pupils, which are fhxed, central and not dilated, (c) Eyelash reflex is absent Is the anaesthesia becoming too deep ? An overdose of anaesthesia is marked by (a) respiration, which becomes shallow and irregular, (b) pupils become dilated, {c) abolition of muscular tone, shown by a flaccid abdominal wound. The amount of anaesthesia being administered must be lowered. The anaesthesia should be deep enough, so that the surgeon can carry out his duties unhindered by the patient. THE ANAESTHETIC DRUGS NITROUS OXIDE This is @ gas heavier than air, compressed into cylinders (painted blue) as a quid. Advantages : This is the salest anaesthetic known, provided it is administered with an adequate supply of oxygen. It is non-flammable, nonirritant tc the patient and pleasant to inhale. Postoperative sequelae, including vomiting are almost unknown. Disadvantages : It is impossible to anaasthetise the patient to a plane deeper than very light surgical anaesthesia with nitrous oxide alone. Therelore its use is restricted. Attempts to provide deeper anaesthesia may exceed the limitations af nitrous oxide anaesthesia and often lead to serious cerebral anoxia. Muscle relaxetion is unsatisiactory. Certain amount of rise in blood pressure is noticed resulting in more cozing from the field of operation. Alone or combined with oxygen, it may be used in minor operations, such as the opening of an abscess or setting of a Colles’s fracture. For induction of an anaesthesia, the pure gas is administered at the rate of some & litres per minute by the flow-meter till the consciousness is fost. Then the nitrous oxide is reduced to 6 litres per minule and oxygen is added at the rate of 2 litres per minute, To continue the anaesthesia, a more powerful dug e.g. trichtorethylene or halothane is added Nitrous oxide is available as premixed nitrous oxide-oxygen in equal concentration. it is sutficient for analgesia and is thus of value in obstetrics. It is used increasingly by ambulance men for transporting patients in pain THIOPENTONE This is an ultra-shorl-acting barbiturate, used mainly for the pleasant induction of anaesthesia or for short anaesthesia for minor surgeries, Thiopentone is the commonest of the series in current use. Advantages : Induction with thiopentone is by far the least unpleasant to the patient. The drug ig nonirritant to the iungs and non-explosive. Unpleasant sequelae including vorniting are fare. Muscular relaxation is rapidly achieved. Disadvantages : As othes barbiturates, respiratory depression is the main disadvantage. A fall in blood pressure is not unusual and may be serious in cases of shock. It is a poor anaigesic and relatively Jarge quantity is needed to produce true anaesthesia. The recovery oetiod is rather long and drowsiness persists even after one hour. The use of nitrous oxide for such minor surgery in piace of thiopentone has the advantage of allowing the patient to return home immediately. Thiopentone renders the patient prone to laryngeal spasm. Unlike other general anaesthetics, thiopentone is not excreted by the boay, but it is desiructed by metabolic processes. A dose introduced into the circulation, cannot be recoveredANAESTHESIA 5 and an overdose once given, cannot be detoxicated by the body, it has poisoned. So il must be temembered that the young, old and ill require very much less of the drug than normal adult patients For the beginners, it is better to avoid its use in patients with extemes of age and those enteebled by iliness. it has also got direct depressant effect on the heart. The respiratory depressant effect is much more when injected first, so injection should be given very slowly Bemegride (Megimide) counteracts depressions, caused by barbiturates. A dose upto 50 mg IV. can be given. {tis better to choose a 2.5% solution for induction. Once anaesthesia has been established with thiopentone, its continuance with nitrous oxide and oxygen (in the ratio of 6 : 2) provides a sate anaesthetic suitable for operations requiring tight surgical anaesthesia. A little adjuvant anaesthetic such as trichlorethylene from time to time will assist in maintaining the patient of the required depth of anaesthesia. HALOTHANE Halothane (fluothane} is a volatite anaesthetic and the most expensive. It is a clear, heavy liquid and resembling chioroform in many ways. Halothane is non-flammable. It is non-irritant to the respiratory tract. Anaesthesia is achieved rapidly and smoothly. Recovery is similarly rapid. There is certain fall in blood pressure which may be turned to advantage of hypotensive anaesthesia. Disadvantages — Respiratory depression is common and may require assisted ventilation. Betore anaesthesia has been seached, it has no analgesic properties. It has got some hepatotoxic effect Clinically the condition resembles virus hepatitis. Thal is why halothane should not be giver to one who had previous halothane anaesthetic within the last 4 weeks Halothane is administered with nitrous oxide and oxygen for any operation, not requiring profound muscular relaxation. As anaesthetic agent, it is more powertul than tichlorethylene. It can be used to achieve controlled hypotension anaesthesia. It used with greet care, 2 smooth induction, followed by a ready control of the depth of anaesthesia can be achieved. TRICHLORETHYLENE It is a liquid, whose vapour is heavier than air. Its use as analgesia and light anaesthesia cannot ‘be questioned, but it is useless for deep anaesthesia. Its smell is similar to that of chloroform, that ig why the manufacturers add a blue-dye to assist its recognition. Sometimes tachypnoea and transient cardiac arrhythmias may occur from this anaesthetic agent. ETHER tt is @ potent anaesthetic and may be used for all types of surgery. Advantages — Ether is safe and apparently simple to administer. It has got little, if any, toxic action ‘on the heart. Muscle relaxation is satisfactory and can be used for all abdominal operations Disadvantages.— Ether possesses a pungent smell and disagreeable taste. The vapour is highly inritant to the upper respiratory tract. Ether is a flammable liquid and vapour. Induction with ether by itse# is slow and unpleasant for the patient. Without other anaesthetic agent it is difficult to produce smooth and untroubled anaesthesia with ether. Indeed the role of ether in abdominal surgery is still important despite the modern increase in ithe number of alternatives. Once induction has been completed, the amount of ether vapour detiverad to the patient may be steadily increased till the respiration has become abdominal. If an overdose has been given, prompt artificial respiration with pure oxygen and air will leave the patient sate CYGLOPROPANE Itis non-iritant, powerful, highly explosive and expensive gas. It is used in closed circuit apparatus.6 APRACAICAL GUIDE TO OPERATIVE SURGERY His @ powerful respiratory depressant and may cause cardiac arrhythmias. It has lost its popularity since inception. CHLOROFORM It is a classical, powerful and non-flammable agent. Though previously used, it should not normally be given because of the danger of primary cardiac faiiure. MUSCLE RELAXANTS These drugs ate often used during anaesthesia to produce relaxation of muscles, particularly in abdominal operations and in reduction of fractures. The advantages ate that the operation can be performed under relatively light anaesthesia with musole relaxants. Operation can be performed easily bnd faster, intratracheal intubation becomes easier. The disadvantage, which an anaesthetist should guard for, is inadequate respiration due to relaxation of the respiratory muscles. The anaesthetist should therefore always be ready to substitute the patient's natural resoisation by squeezing the rese:voir~ inag, The dose should be so adjusted that the patient's breathing will be adequate and normal when he leaves the theatre. Curare is given in the dose of 15-18 mg. It takes about 2-3 minutes to exert full effect and lasts for about 45 minutes. So it may be given just before the peritoneum is opened. Galtamine (flaxedil), a synthetic curare-like drug, is generally given in a dose of 80-120 mg and its effect lasts for about % hour. Suxemethonium (scoline) is generally given in the dose of 50-75 mg. Its action lasts for 5 minutes only and it causes a characteristic muscutar fibrillation before paralysis. Many patients who receive scoling, suffer from postoperative muscular pain. Unlike other relaxant drugs, suxemethonium is not antagonised by neostigmine. This is due to the fact that the ‘curare-like’ drugs are competitive blockers whereas suxemethonium is a depolarising agent. Pancuranlum (pavuion) is 2 recently introduced ‘curare-like’ drug with a steroid structure. It is used in the dose of about 8 mg. Its action starts faster than curare and lasts for about same time as that of curara. It has little effect on pulse, blood pressure and does not liberate histamine as is done by curare on occasions. Neostigmine is the best antidote to the ‘curare-like’ drugs. It is generally given 1.V. and injected slowly, never faster than 1 mg per minute until muscle paralysis has been completoly reversed, The dose needed may be 1.25 to 5 mg depending on the amount and time of muscle relaxant given HYPOTENSIVE ANAESTHESIA During operation, haemorrhage may be reduced by inducing deliberate hypotension. This will help the surgeon ta complete his operation quicker. All general anaesthetics tend to reduce the blood pressure and so does the premedication. But controlled hypotension to reduce haemorrhage can only be achieved by one of the following techniques : (1) Extensive spinal or extra-cural anaesthesia, which will block the sympathetic pathways. {2) Intravenous injection of ganction blocking agents such as methonium compounds and trimetaphan {arfonad). Arionad is used as IV. drip and as the drug induces quick hypotension, is more controliable. Sodium nitroprusside is becoming increasingly popular in this group. (@) Fairly high concentration of halothane produces hypotension but respiration must be assisted with positive pressure, Controlled hypotension has certain risks mainly from impaired cerebral or cardiac circulation ant should be used caly by the expert. Ils use should be restricted to where it is imperative and not just where absence of bleeding is desirable. it is a valuable adjuvant to anaesthesia, but is never justified merely as a means of making an operation easy for the surgeon,ANAESTHESIA, 7 ENDOTRACHEAL ANAESTHESIA introduction of endotracheal tube into the trachea and conveying the anaesthatic vapour directly into the trachea, as also maintaining artificial respiration throughout the course of the operation, is gradually gaining popularity among the anaesthetists, particularly when muscle relaxants are to be used But the followings are the ‘eal indications where endotracheal intubation is most justified (1) When the operation is being performed on the head or face, so that the nose becomes a field of operation without being interfered by the anaesthetist. (2) tn case of ENT and dental surgery, endotracheal ansesthesia provides an uninterrupted airway by use of a throal pack round the tube to seal off the wachea ‘rom blood finding ils way down (8) When the patient is operated on in a position that makes it difficult to maintain a clear airway (e.g. prone position, stiff Trendetenburg position ete.) (4) When secretions from the bronchial tree have to be removed during operation (e.g. in patients with chronic bronchitis, bronchiectasis) (6) To protect the lower respiratory tract from inhalation of vornit in patients who may have [ull stomach, (6) As a route for intermittent positive pressure ventitaticn. Technique ; One of the three means-of inserting a tube into the laryngeal opening may be adopted: (1) The tube is introduced after abolition of reflexes by deep narcosis and extensive local analgesia and a degree of muscular relaxation with muscle relaxant, under direct vision with a laryngoscope. In the hands of the inexperienced, there always remains a chance of trauma by the use of a faryngoscope. (2) Nasal intubation with direct vision by a laryngoscope is assisted by the use of Magill forceps. (3) Blind intubation through the nose which should be practised only by the experts. SHOCK One thing is to be remembered that the anaesthetist accepls the double responsibility of anaesthetising the patient and observing and maintaining the condition of his patient, Most operations are completed remarkably undisturbed, but in certain cases the patients go into the stage ol shock. The pathology of shock is yet to be known thoroughly. it is the condition in which the circulatory system fails to meet the oxygen needs of the tissues and to remove their metabolites. The common causes of shack are : (1) Vasovagal attack: (2) Haemorrhage: (3) Loss of extraceliular fiuid: {4) Toxins and (5} Overdose. The signs of shock are generally — {i) falt in the blood pressure, (ij) rise in the pulse rate. (ii) sweating, (iv) pallor, {v) coldness of the skin. During operation, the anaesthetist should keep a close watch on agpearance of these signs. The anaesthelist should always feel the pulse of the superficial temporal artery, the carotids in the neck, the radial artery or even the dorsalis pedis artery (itis situated just lateral to the extensor tendon of the big toe. When the surgeon is operating on the head and neck region, it will be convenient to feel the pulse of this artery). In ali major operations, a sphyg- momenometer and a stethoscope should be attached to the patient's arm and a ten-minute check ‘of pulse and blood pressure should be recorded on a chart. The anaesthetist should also keep watch ‘on the colour of the nail-bed for cyanosis ot palior. A touch on the skin is very important to note the skin temperature and also sweating. The most important perhaps to note the amount of blood loss trom the field of operation. A rough idea can be gained from the number of blood-soaked swabs. towels, gowns and probably the bottle of the suction machine. A rough estimate of blood joss can be made by weighing the swabs after use and subtracting the weight of equivaient number of dry and unused swabs. Lastly, but not the least, the anaesthetist should keep an eye on what the surgeon is doing. The more vigorous the manipulations of the surgeon. the more likely is the possibility of shock. Moreover, the longer the operation the more is the likelihood of shook. Ill patients are more liable to undergo into the stage of shock than the healthy patients,8 A PRACTICAL GUIDE TO OPERATIVE SURGERY No doubt. earlier the diagnosis of shock is made, more is the chance of recovery. A slight drop In systolic blood pressure and an increase in pulse rate should arouse the suspicion of shock. From shock due to endotoxin, hypotension is associated with fever and rigor. Renal failure may follow. But with drug overdose, there is a loss of vascular tone and hypotension is associated with hypothermia and depressed ventilation. Prevention is always better than cure. So care must be taken not to allow the patient to go into the stage of shock. This can be done by taking following precautions :— {i) Amount of anaesthetic drug should be as small amount as practicable. (i) Fluid loss during operation should be as fittle as possible and if at all takes place, it should be immediately replaced by intravenous infusion. (i It surgeon's manipulation is such as to cause shock, the anaesthetist should be at liberty to advise the surgeon to minimise the vigorous manipulation as far as practicable. if the patient has gone Into the stage of shock, treatment should be done accordingly. The anaesthetist must inform the surgeon first, He should lower the head of the tabie to improve cerebral circulation. The amount of anaesthetic should be decreased and mixture, rich in oxygen, should be administered. Intravenous fiuid infusion to make good the fluid loss requires a more elaborate discussion, which is given below. Somelimes it may be required to administer hydrocortisone even upto 1 gm LV. Of the various points of treatment of shock, as has been discussed in the previous section, intravenous infusion is by lar the most important. The anaesthetist should set up a transfusion set even before the operation if the patient is already shocked or grossly anaemic or is dehydrated or he is anticipating fluid loss during operation. Sometimes the anaesthelist, may have to start intwavenous infusion in operation theatre when the pationt has suddenly started to bleed or has gone into the stage of shock. Generally superficial veins of the forearm and back of the hand are preferred for IV. drip. It is always better to insert the needle as far away from the joint as possible. If it becomes difficull to feet a superficial vein to set a drip up it may be required to start an open drip by cutting open the vein, The drip shauld be started keeping all aseptic precaution, so that the chance of thrambophlebitis, should be minimum. If the patient's condition is due to loss of biood, then whole blood must be administered. The blood of any patient undergoing major surgery, should be grouped and cross- matched beforehand. If massive transfusion is required, the blood should be passed through a warming coll. There is also a provision of making the blood pre-watmed, if blood 1s not available, plasma transfusion or plasma substitutes (Dextran) should be started till the blood is available. If there Is more fluid toss than blood, normal saline or 5% Dextrose {it has got the advanlage of not attering the electrolyte balance) should be administered intravenously BLOOD FRANSFUSION Blood groupa.— The red cells contain agglutinogens named A and 8 and the serum contains agglutinins named anti-A and anti-B. For transfusion, the red cells of the donor are matched against the serum of the recipient. As agglutinins, present in the recipient, are in high-titre, can act on the agglutinogens in the red cells of the donor's blood to produce agglutination and haemolysis. To the contrary, the smail amount of agglutinins, present in donor's serum, is not sufficient to cause aggtu- tination of the recipient's cell as its fire falls on being diluted in the huge blood volume of the recipiont According to the presence or absence of the two aggiutinogens A and B, there are 4 blood groups () group A is one, whose red ceils contain A agglutinogen and the serum contains anti-B agglutinin, {il) group B is one, whose red cells contain 8 agglutinogen and the serum contains anti-A agglutinin; Gi) group AB is one, whose red cells contain both A and B aggiutinogens and the serum contains neither anti-A nor anti-B agglutinin; (iv) group O is one, whose red cells contain neither A nor B agglutinogen and the serum contains both anti-A and anti-8 agglutinins (see table |}. The persons with group AB can receive blood from any group (universal recipient). The persons with group O blood Can give blood to anybody as il has got no agglutinagen in the red cells (universal donot) (see table 3). So in dier emergency, one can use group © blood if the time does not permit to do proper groupingANAESTHESIA 9 TABLE TABLE Il ‘ Cais trom Aggtutnogens | Aggltains ais io ‘Serums from Groups (Recipient) Groups in Red Cells in Serum (onen [A 8 1 | 0 A A Ant a ~ + - * 8 8 Anta 8 + - - * AB AaB Neither AB + + - + ° Noithor Antes &ani-8 | ° - - - - “+ means ‘agglutination’ ;~ means ‘no agglutination’ and cross-matehing or to wait for the availability of the proper cross-matched blood. Belore transtusion, the donor and the recipient must be grouped and cross-matched. For transfusion, the red cells of the donor are matched against the serum of the recipient. There is another factor known as Rhesus (Rh) factor, which is very Important to be considered during cross-matching. Rh, factor.— This is an antigen found in the red cells. Human beings can be divided into Rh positive and Rh negative groups accordingly as the red cells contain Rh factor or nol. Obviously persons with Bh positive blood do not possess anti-Rh antibody in the serum. But when Rh positive cells are injected into Rh-negative persons. the antibady anti-Ah develops. The first transfusion may escape to produce any symptom but further transiusion will definitely produce serious reactions. A similar condition happens when a Ah-negative woman carries Rh-positive foetus. The red celts of the foetus when come in contact with the mother's serum, will form anti-Rh, The anti-Rh will pass into ‘oetal Giculation and destroy the red cells of the foetus, producing haemoiylic reaction. Technique of blood grouping.— On a glass slide, one drop of stock serum from group A and one from group B, are placed side by side, The person, who is to be grouped, Is pricked in his finger tip and a drap of blood is added to each of these drops of serum placed on the slide. After 5 minutes, the slide is examined under the microscope. if agglutination is observed in serum of group A, the person belongs to group 8. If agglutination cccurs in the serum of group B, the person belongs to group A. It aggiutination is seen in both, the person belongs to group AB and if aggiutination is not seen in either of the two, the person belongs to group O. Before the blood is sent for transfusion, direct cross-matching is carried out. One drop of the patient's serum is mixed with one drop of donor's blood (diluted 1 : 20 in safine). The slide is examined under microscope after 5 minutes. I agglutination does not occur. the blood is compatible, if aggtutination occurs the blocd is incompatible. Probable comptications of blood transfuston.— (1) Anaphylactic reaction— This is sometimes seen alter biood transfusion as urticarial rash. dyspnoea, chcutatory collapse, fever ete. The treatment consisis of stopping the transfusion and administering antihistaminic drugs (2) Pyrexial reaction.— Sometimes blood transfusion is accompanied by chill, rigor, restlessness. headache, increased pulse rate, nausea, vomiting etc. With the appearance of these symptoms. transfusion should be stopped immediately (8) Transmission of diseases.— A tew diseases are transmitted via blood. Care must be taken to prevent this occurrence. Malaria, syphilis, some infectious fever, hepatitis may occur due to blood transfusion. (4) Reactions from circulatory overloading — it cannot be over-stressed emphatically that old patient with fess cardiac reserve can be very often overloaded by over-transiusion. Transfusion should be given in slow rate in these palients. Anaemic patients should be given packed cells rather than whole blood as this may cause circulatory overloading. (8) Hemolytic reactions — No doubt this is the most important complication of blood transfusion and every care should be taken to prevent this. Before transfusing the blood, the label of the bottle should be carefully noticed to be sure that this is this patient's blood, otherwise it may cost a life10 A PRACTICAL GUIDE IO OPERATIVE SURGERY Haemolytic teactions include fever, pain in the lumbar region, jaundice with haemoglobinuria, oliguria, renal failure from blockage of the renal tubules with haematin pigment. Treatment consists of immediate stoppage of transtusion. Haematin pigment tends to be precipitated in acid medium, so alkalisation of blood should be done with 10 mi of isotonic solution of sodium lactate and 10 mi of saturated solution of sodium bicarbonate injected intravenously (6) Haemorhagic stage — Sometimes. excessive bleeding may occur from operation site due to massive transfusion. It may be due to prothrombin and fibrinogen deficiencies. Resuscitation When the patient s resuscitated from anaesthesia, care must be taken on two points: (1) Avoidance of the injury to the unconscious patient. (2) Maintenance of efficient respiratory function. () Avoidance of injury.— The patient must be handled carefully as he is semi-conscious and cannot take care of himself. (i) Maintenance of efficient respiratory function —~ Three things are closely related in this respect :— (a) A clear airway, (b) a clear chest and (c} adequate respiratory exchange. A guaranteed airway must be assured and where unconsciousness is expected to persist for 48 hours or more, an elective tracheostomy should be performed, In that case a suction catheler should be passed to the lower respiratory tract for removal of secretions. The chest must be kept clear for gaseous exchange to take piace efficiently. This means preventing aspiration of vomit, pharyngeal secretion, blood etc. These should be done by emptying the stamach with nasogastric suction, physiotherapy to encourage coughing, postural drainage of the lungs, aspiration of secretion by passing @ suction catheter through a tracheostomy or endotracheal tube, bronchoscopy or bronchoscopic aspiration eic, But the most important is the Patient's own ability to cough eftectively. Adequate respiratory exchange, if at all required, can be performed by artificial respiration. It may be intermittent positive pressure infiation under manual control alone or by means of a specially designed purrip and an ‘iron-tung’. Post-anaesthe' The common postoperative complications, following general anaesthesia, are (1) Vomiting, (2) Chest complications, (3) Thrombosis of teg-veins, (4) Carbondioxide retention, (5) Postoperative pain, (6) Mechanical injuries, (7) Delayed toxic effects of the anaesthetic drugs. (1) VOMITING.-- Modern techniques have definitely reduced the incidence of this distressing complication, but its occasional appearance cannot be denied. We shall now consider the probable causes of vomiting and their prevention, Betore the anaesthesia — (a) Premedication of morphine increases the incidence of vomiting. About 30% of cases with this premedication complain of nausea and 10% of vomiting. The incidence of vomiting atter morphine premedication can be reduced by giving promezathine or some other specific antiemetic along with morphine. {b) Women and children are more prone to this complication than men. Assurance is the best treatment in these cases. During the anaesthesia — {@) Certain anaesthetic agents like ether, cyclopropane etc. are liable to cause this complication. Halothane and intravenous barbiturate cause least vomiting of all the anaesthetic agents. (b) Inrtation of the stomach with swallowed anaesthetic vapour, swallowed blood or even hypoxia may initiate vomiting tendency. complicationsANAESTHESIA W {©} Operations on the gut or on the gonads increase vomiting tendency Postoperatively — {@) Ingestion of large emount of fluid after being recovered from anaesthesia may well produce vomiting. A sip of plain water may be permitted followed by 4 suitably {lavoured mouthwash and then the patient may be offered a fruit juice or even a cup ol tea. This will definitely reduce the incidence of vomiting. If the possibility of dehydration arises, the patient should be given an intravenous drip before proper drink is allowed {o) If vomiting is persistent, one must always consider the possibility of presence of a cerebral tumour oF so, as probable cause of postoperative emesis. (2) CHEST COMPLICATIONS,.— Certain chest complications are liable to follow general anaesthesia — {i) Atelectasis, localised or raroly massive, is probably the most important in this list. (ii) Bronchopneumonia — very common particulary in the elderly Gil) Acute bronctitis. (iv) Lung abscess — usually due to inhalation of foreign bodies of acid regurgitation. Locatised atelectasis, which seems to be the commonest. is pessibly due to a plug of mucus being lodged in some of the smaller bronchi. This leads to collapse of the lobule distal to the block The patients sometimes fail to cough out the mucus due te pain in the abdomen following abdominal operations. Chest complications are more corner fallawing operations on the upper abdomen and or hernias, In those who smoke heavily, with pre-existing respiratory cisease, with heavy pre- and postoperative sedation ete (3) THROMBOSIS OF LEG VEINS.— This is actually due to unconsciousness of the patient during operation rather than due to the anaesthetic agent. The teg muscles remain flacby and the leg veins asa liable to get thrambosed. Subcutaneous heparin in the dese of 5000 units 8 hourly, starting with premedication, is a good method of prevention. This may be continued ‘or 2 days followed by oval anticoagulants, controlling the prothrombin time and gradually tailing off. Venous stasis can be prevented by using crepe bandage or elastic stockings in the leg betore the operation is started {) CARBONDIOXIDE RETENTION. — Inadequate ventilation, most cammon alter athoracic operation or in an emphysematous patient, steadily increases carbondioxide in the body. This has a nercotie eifect and prolongs the anaesthesia. So this condition should be at once suspected if the patient Femains unconscious for unusually longer period or reverted to unconsciousness after temporary recovery. Cyanosis may develop, the pulse may become slow and bounding with a raised blood pressure, Circulatory collapse may occur later, Treatment is efficient artificial respiration to wash out the carbondioxide. It may be necessary to continue this for 2 hours or more. (5) POSTOPERATIVE PAIN.— This is fairly a common complication and it is more often due to surgery than anything else. Those, who undergo thoracctomy, upper abdonrinal operations or haemorthosdectomy, are more liable to suffer {rom this complication. Injection pethidine is commonly employed medicine jor this complication. Sometimes tong acting local analgesia, such as mercain, may be used (6) MECHANICAL INJURIES.— Postural nerve palsies or minor physical injuries, resulting from careless handling of the patient, are not uncommon. Care must be taken to prevent this (7) DELAYED TOXIC EFFECT OF THE ANAESTHETIC DRUGS.--- Delayed hepatitis following halothane: administration or delayed renal damage following administration of methoxyflurane is not unknown Berbiturates are notorious to harm liver. The possibility cf these toxic effects should always be kept in mind wherever these anaesthetic agents ate administered SPINAL ANAESTHESIA Spinal anaesthesia is a disagreeable form of anaesthesia to many patients and is potentially dangerous unless employed with great care and attention. This is certainly nat to be regarded as simple Substitute of general anaesthesia. The indications lor spinal anaesthesia are mainly @ matter of opinion. Bul it should be avoided on the following lypes of patients12 A PRACTICAL GUIDE TO OPERATIVE SURGERY (i) Chitdren, (2) Il and feeble patients. (3) Patients with severe abdominal distension. {4} Patients with diseases such as labes, disseminated sclerosis or syringomyelia. ) Patients with unsound cardiovascular systern ADVANTAGES : — {i} The advantage of spinal anaesthesia is profound relaxation (without need for a reasonably skilful general anaesthesia). (i) Retention of consciousness, (ii). Non-irritation of the tungs by the general anaesthetic agent — so no chance of postoperative chest complications. (iv) Operative haemorrhage is less due to overall fall in blood pressure — of course there remains @ possibility of bleeding when the blood pressure rises again. DISADVANTAGES -— (i) Fall of blood pressure is usually related to the level of the spinel block. This is due to paralysis of the sympathetic nervous system. (i) Technical difficuities due 10 administration by the inexpert Gil) High incidence of postoperative headaches. (iv) Meningitis — if sterilisation is not properly maintained. (v) Postoperalive neurological complications, e.g. cauda equina lesions. (vi) Above all, postoperative vomiting is not less common than general anaesthesia. TECHNIQUE OF INJECTION.— It may be performed with the patient sitting or lying down. in both, the patient is asked to bend forward so that the chin touches the knees. This is done to open the inter-laminar spaces. The anaesthetist should scrub properly. He should don sterile gown, cap, mask and gloves. He should then see that alt his instruments are ready for use. A wide area of the patient's back shoutd be carefully cleaned with iodine and spirit. A sterile towel is now draped. The site of puncture is selected. An imaginary line through the highest points of the iliac orests passes through the 4th lumbar spine oF through the 4/th lumbar interspace. The injection is made generally through the space above, i.e. through the 3/4th interspace. A small bleb of solution is injected subcutaneously A coarse needle is passed through the skin at the point of solution, The coarse neadie is taken out and the spinal needle Is passed through the same hole in a slight upward direction. One should not touch the shatt of the neadie. fit is touched at all to facilitate smooth insertion of the spina! needic, it should be done with sterile gauze swab. After inserting about 5 mm or so, resistance of the duramater will be felt, It is pierced with sudden loss of resistance. Removal of the stilette will be followed by 2 flow of C.S.F. Sometimes the needle may not go straight into the subarachnoid space but will go astray to cause damage to the surrounding structures. if three attempts fall, a space higher or lowet should be chosen. If three endeavours in the altemate space are unsuccessful, it is advisabie to abandon the project. Once the tip of the needle has reached the sub-arachnoid space, the syringe containing the anaesthetic agent is fixed to the needle. Ginchocaine (Nuparcaine) is generally used for spinal anaesthesia. The maximum dose is generally 150 mg_and duration of anaesthesia is generally 120 minutes. C.S.F. has an almost constant specific gravity of 1.004. It is obvious that a solution with higher specific gravity will fall and a solution with a lower specific gravity will rise in the dural sac in an upright position. Another important point to be remembered is that T6 is the iowest point in the thoracic curve when the patient lies on his back and heavy solution cannot run uphill, so that the anaesthesia cannot Teact above the level of Ta Cinchocaine has got a specific gravity of 1.025. Two more recent introductions — mepivacaine (carbocaine) — which has a rather brief duration and Prifocaine are gradually altaining popularity. The principal difference between these agents and cinchocaine is that the onset of anaesthesia with cinchocaine is about 15 minutes, but with Prilocaine is about 5 minutes. The duration of anaesthesia is equal with these drugs. These drugs are fixed in about 19-15 minutes after injection, so that further movement will not alter the level of analgesia :ANAESTHESIA 13 Dosage scheme — Operation site Dose Position of the patient Perineum 0.5 mb Sitting _ Lower atidomen upto umbilicus: 4.5 mt Lateralty Upper abdomen 2mi Laterally with 5° Trendelenburg tilt Care of the patient under spinal anaesthesia- (1) Preoperatvely — the preparation is same as that of general anaesthesia except that the premedicalion may be given in heavier dose. (2) During Operation — the patient must be comfortable on the table. The surgeon must not be allowed to describe his progress in audible tones. Nor he will be allowed to use the patient's chest as an instrument tray. In case of abdominal operation, it is advisable to administer oxygen. If the patient becomes too apprehensive and too concerned about the operation, he should be properly sedated with a dose of 10 mg diazepam IV In extreme cases, a small dose of thiopentone followed by nitrous oxide and oxygen may be used. (3) Postoperatively — the patient should lie with the foot-end of the bed raised. He should be in semni-darkness for 8 hours. Reading and smoking should be prohibited for 12 hours. If the patient complains of headache even with these measures, injection pethidine may be prescribed. EXTRADURAL BLOCK Extradural space is the space outside the duramatet and within the bony vertebral canal, which extends from the base of the skutl to the sacral hiatus. So in this technique, anaesthetic sotution works: ‘on the nerve roots in the extradural space outside the dural sheath. By preserving the integrity of the Guramater, headache and neurological complications, which may follow spinal anaesthesia, are avoid- ed Its disadvantage is that the solution teaks out through the intervertebral foramen and prevents accurate assessment of how far a given volume will spread. Technique.— The extradural space may be reached at any level. The technique is similar to that of an intrathecal injection for spinal anaesthesia, But the needle having penetrated the ligamentum flavum, stops short of uramater. That the tip of the needle is in the extradural space. is marked by sudden loss of resistance of ligamentum flavum, ease of injection of a fttle air and presence of negative pressure which is indicated by withdrawal of hanging drop of saline on hub of the needle. A larger volume of lignocaine (1.5%) solution is used. It produces its effect in 10 minutes and lasts for 1% to 2 hours depending on the strength of the solution. Amethocaine in 1% strength, when added to lignocaine. increases the curation of anaesthesia by 50%. Prilocaine is also a good agent for extradural block Complications — Fall in blood pressure, paralysis of the respiratory muscles, inadvertent spinal injection, toxic reactions of the injected analgesia are its complications. which have limited its use CAUDAL ANALGESIA This is @ form of analgesia, in which extradural space is reached through the sacral hiatus. This is definitely a sate anaesthesia. This hiatus fies between the two cornua of the sacrum and is identified by direct palpation. This form of analgesia is particularly usetul when the sacral nerves are to be anaesthetised as in cystoscopy, haemorthoidectomy and during labour. LOCAL ANAESTHESIA Local anaesthesia can be divided into the following categories14 A PRACTICAL GUIDE TO OPERATIVE SURGERY (1) Surface analgesia. (2) Infitration analgesia (3) Nerve block (4) Field block (1) Surtace analgesia. — Here the surface of the skin is anaesthetised with an anaesthetic agent used in a spray or in an ointment or cream or painted on the mucous membrane directly. This is commonly used in (a) laryngoscopy and bronchoscopy; (b) incision of quinsy: (c) cystoscopy; (4) urethral dilatation; (@) incision of an abscess etc. The drugs used are cocaine — 1-4%, lignocaine or prilocaine — 4%. This is the only occasion in which this high concentration is used. (2) Infiftration analgesia.— In this, local anaesthetic solution is injected subcutaneously beneath the skin to be incised. The drug is injected fanwise through as few needle pricks as possible. The point of the needle is kept moving as the fluid is ejected — thus minimising the possibility of inadvertent intravenous injection, as the advancing stream of fluid will push away small blood vessels. This technique is simple, effective and does not require any anatomical knowiedge. This is used in minor operations, such as excision of a lipoma, polyp, dermoid cyst etc. This is also used for extraction of tooth. in combination with genera! anaesthesia or major nerve block, a bloodless field may be met with the vasoconstrictor effect of adrenalin in the solution Drugs mostly used are lignocaine (1 — 2%), Prilocaine (0.25 — 0.5%) and Marcain. (8) Nerve biock.— Here the nerve, which supplies sensory twigs to the operating field, is blocked by local anaesthetic. This technique requires greater accuracy than the foregoing, for the nerves concemed must be located exactly. So knowledge of anatomy is required. Some of the common nerve blocks used are (a) Brachial block for operation to be performed on the arm and forearm, The nerves concamed are biocked in the axillary region. (b) Finger block for operations upon the finger. The solution is infiltrated on the two sides of the finger at its base, where the digital nerves reach the finger. (¢) Intercostal nerve block for the relief of pain (e.g. tractured ribs) which is reached just below the respective rib. (d) Block of the inferior dental and Jingual nerve in the region of the mandibular foramen for extraction of the molar tooth The drugs used are lignocaine oF prilocaine in the strength of 1 - 2% solution. (4) Fletd block.— In this, a barrge of focal an- algesic solution is laid across the path of the nerves supplying the operation field. This can ‘only be used where the anatomy of the operating field permits it, such as in the upper paramedian, midiine incision, in ‘operation for hernia or in excision of the benign tumours ‘of the skin and subcutaneous tissue (see Fig. 1.1) INDICATIONS.— The indications for local analge- sia are briefly » (a) minor surgery; (b) where the life of the patient may be endangered by unconscious- ness; (c} where skilled anaesthetist is not avaitabte; (d) where the patient has had meal recently to preclude the possibilily of general anaesthesia CONTRAINDICATIONS — are (a) sepsis near the fieid of injection; (b) when the patient is non-co-oper- ative; (c) where the amount ef iocal anatgesic solution required, may risk the possibility of toxic reaction. DANGERS. — (1} The dangers are mainly where Flgd.t.— Showing "lid block to) aneesineseANAESTHESIA 15 the neighbouring structures ate important and may run the risk of being damaged by the point of the needle {2) Overdosage |s another lethal danger, which should always be borne in mind. The maximum safe dose of each local anaesthetic should be remembered and obviously this dose will be tess in the young, the old and the ill. A relatively small amount in a highly vascular area is more dangerous than a larger dose in a relatively Jess vascular area. The toxic reactions due to overdosage will be heralded by bradycardia, restlessness, convulsions etc. The treatment is immediate stoppage of administration of local anaesthetic. The patient’s airway is checked anc! ertificial respiration is started with oxygen, if necessary. The convulsions are controlled by LV. injection of minimum quantily of thiopentone, but it has got the disadvantage of depressing the heart. So injection of Suxemethonium with assisted respiration by endotracheal tube may be betler. Sometimes the reaclions of over-dosage are due to adrenalin it contains ratner than proper overdosage. In this case, the patient will be pale, the pulse will be rapid, there will ba rise in blood pressure and imegularity in heart beat (8) Inadvertent intravenous injection of focal anaesthelic may be lethal. Before injecting the local anaesthetic, it is a good practice to draw back the syringe plunger to see if any blood is coming within the syringe (4) Sometimes sudden collapse, immediately following injection of local anaesthetic, is ascribed to idiosynerasy. There are a number of local analgesics, found in the market. But followings are the most commonly used drugs — Maximum dose Concentration Duration Main uses. (1) Lignocaine 500 mg 05 — 2% 90. minutes Extradural, Tropical, Netve block 2) Prilocaine 600 mg 05 — 2% 9° Tropical, Nerve block, Extradural (3) Procaine 1000 mg 05 — 2% oo Nerve block, Infiltration, (4) Bupivacaine 150 mg 05% 300, Extradural, (Marcain) Nerve block (5) Cinchocaine 150 mg 0.02% 120, Spinat Adrenatin is sometimes used with local analgesic drugs. It counteracts the effect of vasodilatation of the local analgesics. It gives two fold advantages — (a) the drug remains at the site of injection longer, which prolongs analgesia and (b) its vasoconstricting effect will reduce haemorthage at the site of operation Adrenalin should never be used in @ concentration stronger than 1/2,00,000 but can be effective in a solution of 1/6,00,000 HYPOTHERMIC ANAESTHESIA A brief suspension of circulation, which may be required in cardiac, vascular or brain surgery, will lead to hypoxia and great damage to the vital organs. But if the body temperature is lowered, the metabolic activity is reduced and demand for oxygen is consequently less. Methods of inducing hypothermia are : {i) Surface cooling — Generally in infants and children this method is applied. The patient is first anaesthetised and intubated and {hen immersed in a tub filled with ice and waler so that the entire body except the head, remains inside water. Operation is performed when the desired level of temperature is reached. After the operation, the body is rewarmed by immersing in warm water16 A PRACTICAL GUIDE TO OPERATIVE SURGERY {i) Body cavity cooling.— This is mainly performed in pleural cavity, which is performed with ice-cold saline alter thoracotomy. (ii) Direct cooling of bloed.—- This is carried out by passing. blood trom a vein through an ice- cold coil and returning it to the another vein, After operation, the blood is rewarmed.CHAPTER 2 7 Introduction ANTISEPTIC AND ASEPTIC SURGERY Antiseptic surgery means killing the bacteria, which are already present in the wound by the use of chemicals known as antiseptics. Aseptie surgery means the technique of preventing the organisms from entering the wound by various methods. So in the former, no attempt is made to prevent the organisms from enering the wound ard only when they have gained access to the wound, they are Killed by antiseptics. But aseptic surgery, which is the vend of modern surgery, is to prevent the access of the organisms into the wound. This can be done by various ways such as sterilising all the materials which are used during operation, preparation of the skin, which is incised etc. The organisms get entry into the operating wound through various sources PREOPERATIVELY, (j) By nasal carriage — about 14.9% of patients harbour staph. pyogenes in thelr anterior nares. These patients act as carriers. (ii) From the ward — either by carrier nurses, carrier patients oF cross-intection from other surgical wounds, infected linens, bed-covers, blankets, utensils alc. DURING OPERATION, (i) From improperly prepared skin, which may harbour organisms in the ducts of sweat glands, sebaceous glands and in the sides of hair follictes. (i) From operation theatre ‘self — it would appear to be the general agreement that modem operation theatre provides a reasonably safe environment for routine genetal surgery. yet lower standard operation theatres may provide organisms to infect the wound during operations. (ji) From surgical gloves — danger to leak and tears in the gloves are about 30%, in this context hexachlorophene detergent cream is an effective agent for preoperative scrubbing, (iv) From the masks — there should be an impervious insert within the mask, which will prevent direct contamination of wound with salivary droplets or mucus expelled by inadvertent sneezing. (v) From the drainage of the wound — the longer the drainage is maintained, the greater is the likelihood of infection. (vi) From foreign bodies, suture material, tissue trauma, devitalised tissue, haematoma ete. POSTOPERATIVELY, wound may get infected if the dressings are not sterilized. In case ot clean operating wound without a drainage, the dressing should not be removed unnecessarily before the removal of stitches. STERILIZATION Sterilization means making @ substance free from living micro-organiem Methods of sterlization are three ‘by chemicais, by heat and by gamma irradiation Chemical Sterilization is effected by means of antiseptics, e.g. iodine, carbolic acid, lysot etc. These kill the protoplasm of the bactetia, This is of valug in small emergency operation theatres, where needles, scalpel, scissors fic. are dipped in these chemicals, Belore using, they are thoroughly rinsed in stenile water Other metnods of chemical sterization which are presently used are as follows — Ethylene oxide.— This is mainly used for sterilizing causable materia that are intolerant to heat mainly the suture materials. It is the gas which is used, Its main isadvantage is that it forms an explosive mixture with ait. It is al60 toric carcinogenic. The gas is mixad in the sterilizing chamber with carboncioxide, nitrogen, methy! bromide oF 218 A PRACTICAL GUIDE TC OPERATIVE SURGERY chlorofivecarbon. A relative humidity of 80% to $0% is maintained. The material is exposed upto 12 hours at room temperature or 2 hours at 40°C, The biological indicator is Bacitis subtifs NCTC 10073. Ethylene oxide can be used 4m polyglycolic acid (Dexon), polyaropylene, linen and cotton, but it may be usetul for catgut and polyethylene too. Giutaratdenyde — This is mainly used for starilising tibreoptic endoscope. The instrument is slertised by this method just before using it with 10 minute exposure. The endoscope is again sterilised alter its use. This solution is used as @ 2% aqueous solution butfer to pH 7.5 to 8.0, It is more active than formaldehyde, Endoscopes should bbe sterilised both before and alter use, Low temperature gas plasma with hydrogen peroxide — A vacuum is produced in a sterilizing chamber and hydrogen peroxide is introduced, Gaseous H,0, is produced. If a radio trequency discharge is passed through this 923 it dissociates into active oxygen anti hydroxyl radicals. These are immensely toxic to micro-organisms. Gut this is rapicly converted to molecular oxygen and water whea the discherge Is terminated. The discharge 1s continued for 60 minutes. All metals, polymers and rubber can be sterilised by this method, But this method is unsuitable for cotton, finer or liquids. Hoat Sterilization is much more important and very widely used. Dry heat in the form of flame, red-hot cautery ‘or hot ir is not very popular Wet Neat in the form of boiling water or steam is sti tne most popular method or sterilization, The best method of sieriizing materials, which are tolerant to heat, is sterilization by steam in an autoclave. The air is evacuated and steam is intcaduced under pressure, The temperature is maintained at 132°C for 20 minutes. Hot air is not as effective as steam It hot air 8 used, higher temperature (180°C) for longer period 460 minutes) should be used. The temperature is monitored by thermometer and by biological indicator such as spores of Bacilus stearotharmophitus NCTC 10007 on pager strips. The boiling is used for all blunt instruments and rubber goods. Generally 45 minutes boiling is necessary for this purpose. Steam is used tor dry materials like towels. gowns and Gressings. Autoclave or pressure steriizer in which steam is further heated to 120°C is mostly used in all institutions At this high temperature and 16Ib por sq, inch pressure all spores and bacteria are killed in 39 minutes, Sharp instruments like knives, scissors, chisels, osteatomes, razors etc. ate lable to become blunt on boiling, Thay in tack ‘are Kept i9 antiseptic solution and whenever required. rinsed properly in sterile water 25 the solution is very much injurious to skin and then used. But today, even these instruments are carefully wrapped and autoclaved in many institutions, a8 the chemical sterlizetion is of doubtful efficacy. Gamma (rradlation is used where toth chemical and heat slerlizalions are inctiective. This is meinly used for plastic and suture materials. The source is usually Cobalt 60, which emits gamma rays. The dose is 25 milion rads It must be remembered that higher casas may cause degradation of polymars. The biological indicator is baciius pumius NCTC 8281. Mainiy, suture materials are steriized by gemma-iradiation. tis a cry process caried out after the material is packed and sealed. A single cose of 2.5 Mrd is monitored chemically and physically. It is used for ceatgut, silk, nyion, polyester and polyethylene, but is contraindicated in polyglycolic acid (dexon}, polypropylene. linen and cotton LIGATURE AND SUTURE MATERIALS ‘The term "Ligature” denates tying something auch as blood vessel o* a pedicle. whereas “suture” denotes sewang by means of @ needle and a thread, made up ct suture matetial. Suture materials are required to keep the wounds together unti thay hoid sufficiently well by themselves by natural fibres (collagen) to form a strong scar. They are mainly divided into two groups — absorbable and nonabsorbable. These ave again may be of natural or synthetic variety. Oniy the commonty used materials are described below. ABSORBABLE SUTURE NATURAL Catgut.— The surgical catgut today is preparad trom the submucosa of the first one-thita of the small intestine of government inspected sheep or cow. Excised intestine is mechanically cleared and they are subjected to a stoping [process which removes the muscle trom cne side and the mucous membrane from the other. Casings of 16-18 metre diameter are preserved in ice or salt and iransperted 10 the suture factory where they are split fongkualinally into two or three ribbens. Further mechanical cleaning ensures that the final ribbon is pure submucosal collagen The ribbons are then chromed {it a chromic svture is desired), twisted together and slowly dried uncer tension. Chromic catgut is made by treating catgut with chromic acid salt tc elfect cross linking, which delays Aydrolysis. Absorption 8 unpredictable particularly in contamineted or infected wounds, so predictable synthetic absoroables ¢ 9. polyghactin is more prefered nowadays vy majority of the surgeons, This is now polished and sorted for size. Il is sieriised by gamma itradiation or ethylene oxide and packod in Mluid containing 70% alcohol with glycerol an¢ water to maintain flexibility. Plain catgut is ebsorbec in a week, whereas chromic catgut lasts for 10-40 days. The catgut is suppliedUGATURE AND SUTURE MATERIALS 18 in sealed glass tubes already sterilised and ready for use. A that is necessary is the sterilization of the outside of the glass container. ft cannot be boiled, as it denatures the catgut. It is immorsed in 20% lysol solution or 1 in 20 carbolc lotion for 24 hours for sterilization, it can be quickly sterilised by keeping it under pure lysol tor 30 minutes. The catgut has been graded according to thickness and strength from 0000 (4/0) to 4. The fine catgut is used for tying subcutaneous blood vessels and fat: No. 0 i used for peritoneum, of course, in emergency when one finds ificully in closing the peritoneum, it is better to use No. 1. Catgut No. 1 is also used for suturing muscles, fasciae and named blood vessels, it (s pethaps appropriate here to remember that “plain” catgut is far from innocuous. 2s its tile might suggest. Chvoming not only delays absorption but significantly reduces the tissue irtation The great advantage of caigut 's thal being absorbable it can be used even in the presence of infection, where non-absorbable suture cannol be used. So far as chromic catgut is concemned, the presence of infection does not cause the catastrophic fall ia. strength The aisadvantages are :~— (1) As with all absorbable sutures, tensile strength Is lost much faster than the material is absoroed. Indeed litle effective tensile strength can be expected from catgut after 8 to 9 days, (2) It is «ntant to some extent and should be used as title a8 possible in presence of germs in the wound. {3} The knot holding ig alll not ideal. The metariel becomes more elastic and i swel's sell loose. (4) The source is undeniably seotic and the purity of the product is subject to doubt. if not properly sterilised it itselt can initiate virulent infection like tetanus. (5) Though very commonly used, yet it is net very cheap. (6) Immune responces were Invoked to explain some of the variations ia its behawour Collagen.— This was evolved to overcome the disadvantages of conventional catgut. In 1964 a “catgut” variant became available. The flexor tendons of beet were converted into dispersed fibrils, Tne cispersed fibrils were then exttudod and re-constituted to form collagen sutures. ‘The range of sizos paraleled the existing catgut. It seems to be no different from regular catgut in tissue reaction, tensile stvengtn and histochemical enzyme profile. i may be thal the tissue reaction Is slightly less than that of the chromic catgut, This has found some acceptance in ophthaimic surgery but filtle elsewhere. SYNTHETIC Polyglycolie acid (Dexon).— It is a synthetic absorbabie suture material. It is made-up of polymenzed hycroxyacetic acid (polyglycolic acid). It is absorbed by hydrolysis in a slower and more predictable fashion than caigut. This material is liquefied, extruded as filaments, siretched and braided to form a suture. Size 0 contains 192 filaments, while 3/0 contains 80 filaments. It is sterilized with ethylene oxide Its agventages are — (}) Great tonsila strangth in the order of Dacron polyester; (2) it handles like silk: (3) very Intie tissue reactivity; (4) It disappears at 60-90 days, much laler than catgut by a process of slow hydrolysis and it knots well The only disadvantage is that the tensile strength falls in 15 days Co-polymer.— This synthetic absorbable suture overcomes the only disadvantage of polyglycolic acid that its tensile strength does nol fall before 4-6 weeks. i's full absorption takes about 3 months. So it is the most idest among the absorbable sutures, Polyglaetin (Vieryl).— i is a braided synthetic polymeric suture. It retains its strength and integrity for a long time in tissues. 1 is ideal for bowel anastomosis. It hancles well and the knots are secured as it 1s braided. There are other polymeric synthetic absorbable sutures such as polydioxanone and polycarbonate, which are used in menofilanent form, These sulures can be used for subcuticular skin closure sc removal of suture is not raqurad. This may also be used for abcominal wall closure NON-ABSORBABLE SUTURE NATURAL Silk,— It is a natural suture presented as a silicore-coated non-absorbabie braid, It has great strength and can be handled well with secure knols. Its the continuous prctein thread spun by silkworm larva in making its cocoon. The fibre consists of a central core of fibroin (a protein-keratin} covered with a thin layer of serecin (the silk-albumin) Which is usually removed. Most surgical sik is braided to give it added strength anc better holding qualities. Floss Sik ts a loosely twisted sitk fibre believed to enccurage the infitration of fibreSlasts and incorporation with collagen to provide @ slrong repair of hemias. Repeated boiling cr autoclaving does not reduce the tensile sirenglh although the knot becomes more friabie. Its aavantagos are — (1) Size for size slik is stronger than catgut, (2) it is the best handling materials. {9} it knots well anc it dees not sip even if the ends are cut short. lis disadvantages aro — (1) Silk is capilary, It allows the passage of tissue Hluid along the strand. so acts as awk fo conduct infection from one place to another. It can, of course, be made non-capillary by ether wax oF20 A PRACTICAL GUIDE TO OPERATIVE SURGERY silicone. But unfortunately the knot becomes less secure in this sik (2) It is more irritating to the tissue than ihe synthetic sutures and is specially troublesome if infection presents. The wound refuses 20 neal until the offending sfitch comes out. (3) It loses ait its effective strength after 6 months in the tissues. (4) Its capillary encourages intecuon ‘and for that it Is losing popularity as a skin suture. Suture abscesses more often accur following silk suture Skworm gut— This is sometimes called “unspun silk*. The sitkworm is killed belore it is ready to spin its cocoon. The (aw silk precursor is removed from the silk sac and is hardened to form strands of 12 inches length We cannot be more than 18 inches. Il is a monofilament. Its advantages are thal it is smooth, strong ang inet. It can be autoclaved without damage, its disadvantages are that it lacks flexibility and ties with difficulty it does not fave any advantage over the synthetic monofilament. Cotton.— It is a vegetable material composed of the unicellular hairs from the seeds of the plant. Its main aovantage is that 1 is lass irritant. Yet it needs meticulous aseptic technique during use. its disadvantage is that itis ne weekest suture material, I gains strength when wet. When combined with polyester il is a stronger material Linen.-- It is a cellulose material, made from the twisted long staple fiax fibres. It handles well and is cheap. Us use Is largely restricted to gastrointestinal surgery and practically has no advantage over silk SYNTHETIC Polyamidea (Nylon) — There are wide range of synthetic non-absorbable sutures now available which olfer great sirength and are relatively inert in tissues. Monofilament nylon is ditficuit to tle, but Is ideal for closure of the abdominal muscular aponaurosis, Braided nyton is much easier to handle and is sultable for hernia repair. Nylon is a synthetic polyamide and widely used in skin suture. Its advantages are that it is rather inert and can be used in presence of infection, itis stronger than silk. It can be autoclaved thrice before it loses its strength. Its disadvantages 21@ that it does nol Knol nicely and it requires mustiple throw of knots for security, I is difficult to handte. Like silk it loses strength as time passes off. Polyester. — It is « braided suture. It is better known by ils trade names of Dacron and Terylene. Its advantages are that it handles well, maintains high tensile strengtn in tissue indefinitely, is serum procs, can be aulociaved several times without damage. In cardiovascular surgery it has its own ground. Here it requires extra smoothness and fibres ‘ace costed with Teflon for this purpose. The disackantage is that the kaot is not vary secure. Polyethytene.— This high molecular weight polymer provides a strong inert suture material. It nas high tensie strength end is pliable. It cannot be autociaved, so sterilized by ethylene-oxide. Its quality, of Deing absolutely inert has given birth to mesh, which is widely used In the operation ct nernia repair, It gradually toses is strength and Litimately breaks so it iS unsuitable for cardiovascular surgery. Polypropylene.— It is a polymerised propylene, extended into monofilament and coloured right blue for its recognition in the tissue, It is very much inert, $0 often used in mesh for hernia repair. Tensile strength is high and well maintaried upto 24 months, ft can be autoclaved at least three times without any loss of strength. Its only disadventage is difficulty in knotting, but at least better than nylon. This is ideal for vascular anastomosis, Stainless stoo!.— The soil iron alloy containing chromium, nickel and molybsonuim is the best. Its aovantages are that it has high tensile strength, itis fiexible and may be tied into a knot which has the highest security of all the suture materials and that it 1s extremely inert and can be safely used even in presence of infection. Last but rot the least it can be autoclaved indefinitely without any harm to the sulure material. Only disadvantage is that may break if the material is kinked. Tantalum.— Though not much used 2s suture material yet it can stand repeated flaxion and extension oetter than the stool-and is as strong as the falter. It is particularly uselul as @ gauze tor herria repalr. Sliver.— It is also used very occasionally particularly as @ perianal subcutaneous stitch for intractable rectal prolapse in the elderly. It is very inert and usualy prepared as a monofilament. Staple 4. Michel clips nave been used for skin closure for many years. See Plate tl in Chapter on ‘Surgical Instruments’ 2. A number of elreular staples aro now avaitable for uniting bowel end-to-end, A single or double concentric tow of metal staples are held in a circular cartridge. This is apposed to a circular anvil with the edges to be unites trapped between ther. When ihe stapler is actuated, a single or double ring of staptes is extruded from the cartridge and strike the anvil. These staples are then bent over and closed. Al the same ime a circular knite blade cuts off ‘excess tissue Creating a cifcuiar ‘umen between the two viscera. Before using first ensure that the safely catch is applied so that the instrument will not be inadvertently apposed. First insed the cartridge and separate the anvil from the cartridge, A purse-string suture ef 2/0 monofilament prolene is applied around the edges ol the tube and tie the purse-siring to craw the edges of the tube over the cortridge towards the spindle, The end of the second tube is now drawn over the aril and insert a similar purse-siring suturePREPARATION OF THE SURGEON AND HIS ASSISTANTS at te hold the end against the spindle. The anvil and the cartridge are apposed tc trap the double layers of tube ends between them, Before doing that check that no extra tissues are inadvertently enclosed. The safety catch is now released and the stapler 1s actuated. The two ends of tne bowel are united with the staples and the excess tissue is timmed off. The anvil is naw separated tom the cartridge and 1s rotated through 360° and with a gently twisting motion the stapler Is withdtawn, The anvil is now removed and the intact circular ‘doughnuts’ of tissues can be seen ‘on the spindle confirming that the circular anastomosis is complete. If @ hole has bean specially created to insert the stapier, clase it with sutures. Sophisticated developments have been made xith curved instrument and detachable, rotatable anvil to allow anastomosis in cifficul areas of access e.g. transabdominal cesophagojejunostomy after total gastrectomy, afier low antenor resection of rectum ete. Side-to-side staplers can be used to insert four linear parallel rows of staples and at the same time the bowel Is cul between the two middie rows. First the two parts of the gut which are to be anastomosed are put together. Ahole is made on each tube of gut so thal the separated jaws ‘of the stapler can be inserted. The two jaws are locked after being ‘ure thal no extraneous tissue has been inadvertantly trapped, The stapler is Gow actuated and the two halves are then separated lor wilndrawal Ensure that the edges are conectly stapled and i there Is a gap rainlorcing sutures are inserted. The hole through which the machine is withcrawn is closed in each tube. PREPARATION OF THE SURGEON AND HIS ASSISTANTS The surgeon should take a refreshing bath in the doctor's room of the operation theatre. Then he should put on the vest, the trouser and the shoes, particularly kept for him in the operation theatre. He should also wear the cap and the mask. Then he will enter the anaesthetic room and will alk to the patient. This is important nat only from the psychological aspect of the patient, but also the surgeon knows that this is the right patient he is going {to operate on. Al that time he should make a quick look at the history sheet of the patient to correlate the name and address as also to know some precise points which he may require to know at the time of operation. White the patient is being anaesthetised the surgeon with his assistants will move to the scrubbing room. Scrubbing or washing should be done in running water with the liquid soap and chlorhexidine upto well above the elbow. Brush should be used for scrubbing with particular care to the nails, creases and webs of the hands. It should take at least ten minutes. The hands should be dried with starite towels. He wilt take some spirit and smear that on the hands and forearms. For surgical hand disinfection the present custom is to use lathering with 4% chlorhexidine in a detergent base for minutas fellowed by application of alcohofic chlorhexidine {or 70% isopropanoloi). This preparation eliminates tran- sient bacteria and resident bacteria in the hands. i hardly causes irritation of the skin. To prevent hand scrubbing repeatedly, many surgeons use two gloves before starting the operation. The superticial gloves are changed before “Figs. 2.1, 2.2 & 2.3.— Showing the tech- starting the next operation. nique of putting on the gloves withaut touching Now he will wear the gown. He must not touch the ‘he Suter surfaces ofthe gloves with tare fingersA PRACTICAL GUIDE TO OPERATIVE SURGERY Fig, 2.4.— Lithotomy postion. 2.2). Finally the sleeves of the gown are pulled down and the culfs of the gloves are pulled up above the sleeves. thus the sleeves are fixed (Fig. 2.3). At this time care must be taken not to touch the bare wrist. Now the hands should not be al- lowed to hang down, lest they should touch any unsterile ‘object. They are held in front ‘of the chest with flexed al- bows. Fig. 2.6.— Knee-chest position. outside of the gown. The tapes and the waist-belts will be tied by the nurses at the operation theatre. Then he should put on the gioves. He must know the exact size of the gloves, While putting on he must not touch the outside of the gloves. First the hands are well powdered. The turned out cuff of the left hand glove is held with the right hand. The left hand is slipped in without touching the outside of the glove (Fig. 2.1). With the left Rand now hold the glove of the right hand so that the fingers of the former will be inside the tured out cuff of the latter giove and while slipping in, the right hand will neither touch the outside of the glove of the left hand nor the glove of the right hand (Fig. Fig. 2.5.-~ Trendetenburg position. POSITION OF THE PATIENT ‘The position of the patient will of course depend upon the type of operation. Dorsat position (lying on the back) is the common- est but while local operations jike excision of the tumours, cysts etc. are carried out the position of the patient is made in such an order as to help the exposure. Laierat position flying on the side) is adopted in operations on kidney and related region. Prone position is for operations on the back. Lithotomy position (see Fig. 2.4) (lying on the back with the legs suspended in stir rups) is for operations on the perineum. Head dependent position (head is extendedINCISION 23 ‘over the edge of the table) is for operations inside the mouth e.g. tensiliectomy, cleft palate etc. Neck extended position (by using sand bags or pillows below the shoulder blades while the head rests on a ring) is for operations on the anterior aspect of the neck including the thyroid gland. Trendelenburg position (see Fig. 2.5) (head end of the table is iowered down, the shoulders are supported with shoulder guards fixed to the table, the leg piece Is also lowered ¢o that the legs hang fram the knees at the edge of the lable] is used for operations on the pelvis including prostate. Reversed Trendelenburg position is used! for operations on the upper abdomen and brain. Knee-chest position (see Fig. 2.6) of the patient is or introduction of the proctoscope oF sigmoidoscope. In this position the patient lies in such 2 position that the knees and the chest remain in contact with the bed and the head is supported ‘on his hands. PREPARATION OF THE SKIN (See ‘Routine preoperative preparation’ — Preparation of the field of operation). After the gatient arrives at the operation theatre being anaesthetised, the sister-in-charge cuts the bandage and takes afl the sterile towel from the operating site to expose it. Two gauze pieces are taken and each is fixed to one sponge-holding forceps for painting. Firstly the operation site with good surrounding area (i.e. for abdominal operations, area from the nippies to mid-thigh should be painted) is painted with 30% cetavion or 1% iodine and then with another sponge holding forceps the area is painted with methylated spirit, Then the patient is draped. In certain institutions to prevent wound infection from the surrounding skin, steri-drape (a sticky paper) is used. itmust be remembered, that however rigorously one follows aseplic rilual, it is difficult 10 overcome slight contamination by exogenous bacteria. The patients who are going tor cardiac, arterial or joint prosthesis insertion, the result may be disastrous in these cases. For this reason it is essential to give the patient an antibiotic intravenously with induction of anaesthesia. The choice of antibiotic ‘depends on the advice of department of microbiclogy of that hospital. Flucloxacillin is a sensible choice it may be added wilh cephalosporin to take care of the gram-negative rods. There is ample evidence that a single preoperative dose is enough and there seems to be no jusiilication for continuing the antibiotics for more than 24 hours. Attempts have also been made to incorporate antibiotics into prosthetic materials. But these have not proved to be effective in clinical practice itis now accepted that patient's skin around the operation site shouid not be shaved the day betore operation. The present tren is that the skin should be shaved or chemically depilated immediately before operation. Since the skin is trealed only once before operation, stronger antiseptic solution should be used. Tincture of iodine 2% in §0% ethanol is probably the best choice. it should better be avoided in case of babies and on the scrotum INCISION incisions are designed firstly for proper access to the pathology to be operated on. Secondly it must o@ adequate. Thirdly, if possible, It should be along the Langer lines or natural creases for cosmetic reason. That is why in certain operations in nack though longiludinal incision would have been better for proper access, the transverse incision along the natural crease is prefewed. This will diminish the likelihood of keloid formation. Fourthiy, when there is a possibilily of existence of any named vessel or nerve just beneath the incisional area, the incision is made paraitel to those structures. The incision is made with the belly of the knife in one stroke through the skin and underlying soft tissues along the length of the incision. it should neither damage any important structure in the depth nor make tailings {shallow incisions at the end). Ail bleeding paints should be clamped with artery forceps. Small superficial vessels are occluded by pressure only (that means the palr of forceps should be kept for a while) or by torsion (that means the pair of forceps is twisted) or by coagulation with diathermy. Larger vessels are tied with fine catgut While holding the vessels, care must be taken to take as iiltle surrounding tissue as possible in the24 A PRACTICAL GUIDE TO OPERATIVE SURGERY artery forceps. Alter ligations, we leave two non-living matters inside the wound, one is the sulure material and the other is the strangulated tissue distal to the ligature. Bleeding from the vessels of the muscles are sometimes troublesome. This is tackled by suturing the muscle with needie and catgut. KNOTS Different types of knots.— The knot, which is most frequently used by the surgeons, is the “Reet Knot”. This is a very reliable knot as well While tying the knot care musi be taken to draw the ends in the right direction (see Fig. 2.7), otherwise the knot will be insecure. Have the ends cut 2 to 3 mm long beyond the knot when tying with fine catgut, inen or sik thread. For monofilament nylon, have the threads cut about 5 mm long. in the passing it may be mentioned that "Granny" knot, which mimics the “Reef” knot is in fact unsafe and should never be used. For a few slipping suture materials “Triple” knot may be used. This means an extra helf hitch on the tra- ditional “Reet” knot (see Fig. 2.7) When thicker suture material is used for tying farge vessels or when the suture material is very much slippery “Surgeon's” knot is the ideal (see Fig. 27) Tying keot only with the left hand is very useful to expedite the process. The needle and the catgut or the reel of the suture material is held with the tight hand and the left hand is used for knotting. Fig. 2.8 shows the exact method of knotting with the left hand alone. METHOD OF WOUND CLOSURE AND DRAINAGE After operations, the skin margins of the wound must always be apposed for proper healing of the wound by first intention. Of course, in presence of sepsis or potential sepsis this cule should be violated and the wound is kept open. Two points are to be remembered be- fore closing the wound. One, to obtain perfect haemostasis. This is very impor fant and haematoma in the wound is the commonest caiuse of non-healing of the wound, This also initiates sepsis. The second point is that one should not leave any dead material or dead space inside the wound. This wil prevent wound healing. Drainage to be used or not? SEL GRANNY'S KNOT REEF KNOT TRIPLE KNOT SURGFON'S KNOT Fig. 2.7,— Different knots Fig. 2.8.— Showing the exact method of knotting with the eft hand aloneMETHOD OF WOUND CLOSURE AND DRAINAGE 25 The principies of drainage are that (1) all septic wounds should be drained, (2) of the aseptic wounds (a) those which will have oozing vessels of will have large area which will continuously ooze serous discharge should be drained, (b) those where there are chances of collection of the natural ftuid inside the wound e.g. bile after cholecystectomy or urine afler ureterolithotomy should be drained or (c) those wounds where there are possibilities of leakage from anastomosis should be drained. Unnecessary drainage should be avoided as its presence initiates infection. As a rule, unless there is a definite reason, the drainage should be taken off within 48. hours Drains may be of corrugated rubber sheet, a rubber tube, a cigaretle drain (je. a gauze wick inside @ split rubber tube} or a modern suction drain (Redivac}, where a perforated polythene tube is pushed into the wound by means of a special needle through healthy skin outside the wound, thus making an air-tight junction. The other end of the tube is altached to a bottle. There must not be any space between the lube and the surrounding skin for effective suction. This closed suction device taxes off the cozing olood or serum from the wound. Deep stitches for the muscles and fasciae are used to obliterate any Gead space at the depth of the wound. Always absorbable sulure material particularly No.0 chromic catgut is used. Superficial stitches are employed for the suparficial fatty layer if this layer is quite thick. In fat, fine plain or chromic catgut can be used. For skin, non-absorbable suture material like silk or nylon is mostly used. For skin, cutting needle is used and the suture is not i90 tightened as ischaemia, thus produced, will delay healing. Only apposition of the skin margins is required. Michel clips may be used instead of suture materiais. Where the superficial fatty layer is not too thick and the skin margins are vary well apposed before suturing. a type of sticky papier called staristrip may be used for wound closure This is of areat cosmetic value and pig, 2.9... Shows the method of introducing continuous subeuicuar sche. may be used after operations on thyroid where platysma has been carefully sutured. Cosmetic subcuticular stitches are often used nowadays. It is a continu- ‘ous suture picking up alternate sides ‘of the wound just beneath the surface (Fig. 29) Mis better 10 avoid this suture when the wound is infected or perlect haemostasis is not achieved TYPES OF SUTURE (Fig. 2.10).— continuous suTURE Various types of suture may be used as required in various situations. The deep sutures are made usually inter- mupted. (1) Continuous suture is gan- erally used for anastomosis of the guts, deep fascia, extemal oblique aponeurosis EVERSION INTERRUPTED SUTURES CONTINUOUS: etc. The advantage is that the suture pene can be quickly applied and that it is a also haemostatic. The disadvantage is coer ese ANKE INTERRUPTED warstes? that should haematoma or infection occur, ‘one cannot remove a part of the suture and drain the wound. In this process Fig. 2.10.— Showing the types of suture commonly use.26 A PRACTICAL GUIDE TO OPERATIVE SURGERY the whole suture will be undone and the wound will gape. So this is not used in presence of infection, (2) Imerupted suture, in contradistinclion to the continuous suture, takes much time and does not have the disadvantage as the previous suture. (3) Blanket or Button-hole suture is a type of continuous sulure, where the needie is passed through the loop of each stitch. This can be used in skin in old individuals after the operation of pin and plate fixation of the tracture neck of femur. {4} Mattress sulure is the type of suture where the neadle starts from one margin Wravels to the other margin and then comes back to the same margin through separate punctures. This may be continuous oF interrupted; horizontal or vertical. A type of mattress suture called Halsted’s suluse is often used where the suture is passed through the skin margins to evert the margins. PREOPERATIVE PROCEDURES A proper, routine, well-planned preoperative procedure is essential for safe operation and uneventful recovery. For this, the patients should be admitted 2 days prior to operation in cases of elective operations. Where bowel surgery is required the patient is admitted earlier for bowel preparation House-Surgeons should take proper history of the case and carry out thorough examinations. Special attention is given on the generat examination. Is the patient anaemic ? What is the blood pressure of the patient 2 How is the cardiac condition of the patient 7 An E.C.G, may be done in this respect. How are the lung conditions 7 Routine blood examination for Total Count, Differential Count of W.B.C., Hb%, P.C.V.. MCHC, ESR. should be done. Bleeding Time, Coagulation Time, grouping anc cross matching are also very important. Routine urine and stool examinations should also be performed. 1. On admission, the patient should take a hot bath and ciean himself thoroughly. 2. Junior residentiat staff should be informed. 3. Medicine. — if the patient is having any medicine or he is supposed to take any medicine after admission, this should be properly prescribed. Hf the patient is very much apprehensive, he may be n sleeping tablet at night 4, Anaesthetist should be informed by the house-surgean, who will leave a note to the anaesthetist narrating in nutshell the salient features in history, examination and the type of operation to be performed He must also mention if the patient is allergic to any drug and aiso if the patient is having or had any drug, which is of anaesthetic importance (see page 1) ROUTINE PREPARATION FOR THE ‘GOOD RISK’ (a) Dlet.— The patient is given a light diet on the day befcre the operation. On the day of operation. he is nat allowed to take anything by mouth from the early moming if the patient is to be general anaesthetised (b) Steeping tablets,— These should not be used as a'routine practice. But its necessity cannot be over-exaggerated in case af apprehensive patients for a good sleep at night before the operation {c) Bowel.— If the palient’s bowel habit is quite regular, a soap-water enema in the morning of the operation is ali that is required. In case of constipated patients, laxatives should be prescribed 36 hours before the operation and the patient mus! have morning enema before he goes to the operation theatre, (d} Oral hyglene.— Patient's teeth and gums should always be examined. Presence of pyorrhoea is contra-indication to operation, as this may lead to postoperative parotitis and pulmonary compli- cations So pyorthoea should be treated first before the patient is readmitted for operation. {e) Preparation of the fietd of operation.— The field of operation should always be examined carefully to exclude any seplic spot. If present, it should be treated first and operation should be postponed til ils proper healing The skin is prepared in the evening before operation. Only in cases of bone and joint operations,PREPARATION FOR THE "BAD RISK’ 27 the preparation is commenced 48 hours before operation and sepeated every 12 hours. it is very impodant to know the extent of skin preparation which must be well beyond the field of operation. For instance, in case of abdominal operation, the skin is prepared from the level of the nipples down to the middie of the thighs and for operation on the knee, skin is prepared from the groin to the ankle. Preparation. The skin is first scrubbed thoroughly with scap and water taking special.care for the folds and crevices. The skin is then shaved with razor avoiding any cuts or scratches, as this will provide an opening for infection. If the skin is very dirty, spirit turpentine or ether shouid be used to remove the dist. The skin is then dried with sterile towel. It is customary to apply some antiseptic such as spifit or:acfiflavine on the prepared skin. The part is now covered with a sterile towel and bandage. This bandage is only opened in the operation theatre. PREPARATION FOR THE ‘BAD RISK’ (@) Obesity.— In addition fo the technical difficuities of operation, the obese are bad risks for many reasons. Their muscles are flabby with poor cardiac reserve. The chance of wound infection is more. Healing takes time. So except in emergency operations, the patient is advised to lose some weight by dieting betore operation. (b) Cardiac and respiratory disease: gestion ftom the physician, whether operat should be treated first. (c) Matnutritian.— There are certain conditions which give rise to malnutrition as such. They are pyloric stenosis, malignancy, ulcerative colitis etc. Besides these conditions, patients in this country often suffer from mainutrition. For a normal individual nothing tess than 1 gm of protein per kilogram of body weight per day can be considered as a safe sation. The average requirement for the sick and injured is 150 gram of protein daily. When malnutrition is present, plasma protein should be estimated It should be remembered that dehydration may mask hypo-proteinaemia. So dehydration must be cortected before taking sample for protein estimation. Hypo-proteinaemia may lead to shock. abdominal distension {due to oedema of gastro-intestinal tract), lower resistance to infection, delayed wound healing etc. Protein replacement can be done orally or parenterally, Orally by giving high protein diet, one can replace protein. Parenterally, one can infuse whole blood, plasma, or plasma substitutes or protein hydrolysate (aminosol). (d) Anaemia.— Like malnutrition, anaemia is aiso quite common in this country. Anaemia may ‘occur from bleeding peptic ulcer, malignancy etc. This should be detected as early 23 possible and should be corrected by iron preparation, folic acid or even blood transfusion. (@) Vitamin deticlency.— This is also quite common in this country. Of all vitamins, the general surgeons are more concerned with vitamin C, B & K. Vitamin C is concerned with collagen formation and hence wound healing. Vitamin B is concemed with carbohydrate matabolism and vitamin K is concerned with synthesis of prothrombin by the liver, hence its deficiency will lead to defect in coagulation. Vitamin K is absorbed from the distal part of the smal! intestine and being fat-soluble. presence of bile is extremely essential for its absorption. So deficiency of vitamin K is seen: in obstructive jaundice cases. i) Diabetes. — Estimation of blood sugar and examination of the urine will give @ clue to the severity of the disease. Barring the emergency cases, diabetes should be controlled first before any operation is contemplated. It is not that the blood sugar should be brought down to normat fevel, but may be accepted at a bit higher level. But there should not be any sugar and ketone body in the urine. The glycogen reserve in the liver should be increased by injecting glucose and insulin which is very important. When the patient is moderately diabetic, he should be admitted al least 24 hours before operation. 3. or 4 samples of blood and urine should be taken to astimate sugar content and to assess whether the diabetes is controlled or not. If it is controlled, one half of the patient's total daily requirement Presence of these complications should invite sug- justified or not. Whenever possible, these conditions28 A PRACTICAL GUIDE TO OPERATIVE SURGERY of insulin is given in the morning of the day of operation. Then an 1.V. drip with 10% glucose is started. Throughout the day blood sugar estimation is done 2 hourly and insulin dose is calculated in the way it the blood sugar is 150 mg/100 ml — 8 units, if from 150-200 mg/100 ml — 12 units and when 200-300 mg/i00 ml — 16 unils is administered. Generally 200-400 Gr of glucose is given throughout the day in 2000 to 3000 mi of flvid. When there is a change to ketoacidosis, blood electrolytes, pH and CO, combining power should be determined. Gradually the patient shoud be transferred to his noimal diabetic regime. When the patient is on oral hypoglycaemic drug, the corresponding insulin dose is calculated as follows — 250 mg of chlorpropamide is equivatent to 25 units of soluble insulin, 100 mg of phenformin is equivalent to 15 units and 1500 mg of tolbutamide is equivalent te 15 units of insulin In case of abscess formation, drainage must be made without delay. as diabetes may not be possible to control in presence of infection. As regards anaesthesia, local or spinal anaesthesia is the best. If this becomes impracticable, ‘cyclopropane is the anaesthetic of chaice as this will allow a high concentration of oxygen to be administered. Nitrous-oxide-oxygen is the next best. Intravenous anaesthesia may be emptoyed for short ‘operation. Ether and chloroform are contraindicated in diabetes, as the former raises the blood sugar and produces acidosis, whereas the latter has got hepatotoxic offect. (g) Fluid and electrotyte Imbatance.— The total body water, as measured by deuterium oxide dilution, accounts for 57-62% of body weight in normat men, 53-55% in women and 77% in new born infant, Water does not seem to exist free and unattached, but that as water o! hydration it forms part of the complex ionic equilibria, which make up cell substance and the body fluids. The total quantity of water is related to the total quantity of cations, particularly of sodium and potassium, which in their turn govern the total content of anions and their associated water. The largest subdivision of the water of the body is that of intra-cellular fluic (70% of total body water). The intra-cellular water forms part cof the proteplasm of the cells and is associated with potassium, the most important intra-celtular cation and with phosphate, the main intra-celtular anion. The extra-ceilular water of the body amounts to about 30% of the tolal body water and forms the environment of the cells. It is sub-divided into intra- vascular fluid (7% of body water), which is situated within the blood vessels, interstitial fluid, which lies outside the blood vessels and belween the cells of the tissues of which it forms the immediate environment and transcellular fluid (6% of total body water), which includes tluid, which is extra-ceflular but not interstitial, such as cerebrospinal and synovial fivids, urine in the collecting tubules and urinary tract, fluid in the ducts of glands and in the elementary tract as well as in the eyas and ears, The most important cation in extra-cellular fluid is sodium and the content of potassium is very small: while the predominant anions of this fluid are chloride and bicarbonate. Water loss.— Water loss may be divided into (i the extra-renat loss in the form of insensible water loss as vapour in the expired alr or through the skin or as liquid in the faeces and sweat and (i) the renal joss as the urine. Insansible water joss amounts to about 1000 ml of water daily, 200 ml is lost in faeces and about 1500 mt as urine. If the patient is losing fluid by vomiting, diarthoea or through drainage (2.9. from the bile duct), this amount of fluid should be given in addition to the insensible water toss and loss by urine. A clinicalty dehydrated patient of about 70 kg weight will require 3600 mi of fluid which has already been lost plus 2500 ml as his daily requirement, i.e, about 6 litres a day. It nas been seen that loss by vomiting, diarrhoea or from intestina/ fistula is associated with potassium joss, in these cases potassium has to be administered. The striking features of severe potassium deficiency are profound apathy, muscular weakness and neuromuscular inco-ordinalion Deep reflexes may be absent. The patient may feel difficulty in swallowing, there may be drowsiness or even coma. Sometimes potassium deficiency may be associated with ileus and abdominal distension Peripheral blood pressure may be lowered and the pulse rate may be slow. These may be increased QT interval, decreased height, inversion or rounding of T wave, depression of ST segment in elec trocardiography. In these cases replacement of potassium is the treatment. Potassium salts should be administered by mouth, if possible. It may also be necessary to administer saline to restore theROUTINE POSTOPERATIVE CARE 29 extracellular tluid volume, but the amount of sodium should be minimum as excess sodium may be wansterred into potassium-deticient cells. When the patient is comatose, he will require intravenous potassium. In this case cate must be taken not to reach the toxic level (about 7 mEq/lite) which may cause cardiac arrest. In this context, one must be sure of adequate outflow of urine, for which it should be the practice to introduce 500 mi of 5% glucose solution IV. before administration of potassium. The type of potassium salt which is to be administered in potassium deficiency, depends on whether it is associated with acidosis or alkalosis. With associated acidosis, the Intravenous solution should contain sodium acetate in addition to potassium chloride. If the patient is able to ewallow, potassium citrate should be administered by mouth in 2 gm doses every 4 hourly. In intravenous solution, potassium content should not exceed 70 to 80 mEqjfitve and the rate of infusion should not exceed 20 mEq potassium per hour, With associated alkalosis, potassium chioride should be given upto 2 ‘am over a period of 4 hours by intravenous route containing potassium concentration 70-80 mEgfitte provided the urinary output is normal. This may be followed by a further 2 gm administration, preceded it necessary, by 500-1000 ml of 5% glucose solution to maintain urinary volume. Alternatively, potassium chioride may be dissolved in glucose solution and administered accordingly. During’ potassium replacement, serum potassium concentration drops down to a very low level and gradually increases till i returns to normal level. One must be very careful not 10 administer too much of potassium as this is dangerous and may cost a life, The best indication of a dangerous rise in extracellular potassium is slowing of the heart and pulse rate, when the solution of potassium chioride should al once be teplaced by 5% glucose solution. Metabolic acidosis. —- This may be due to loss of bicarbonate in intestinal secretion by vomiting and diarmhoea. It may also occur from cardiac 8ypass, pulmonary hypo-ventilation during cardiac arrest of due to sudden restoration of an adequate blood tlow to any large mass of tissue which has been poorly perfused for sometimes, as for example, when an aoitic embolus is removed or a volvulus of the intestine is untwisted, Treatment is the administration of a balanced electrolyte solution, which contains sodium acetate and some potassium chloride as well as sodium chloride. This provides bicarbonate and potassium as well as sodium and water, which are the most important components of the lost secretions. Sodium bicarbonate may be administered as a 4.2% solution, which contains 0.8 mEq bicarbonate per ml. This solution is hypertonic and is usually mixed with other solutions. Respiratory acidosis is usually due to pulmonary hypo-ventilation and the treatment is restoration of normal respiration. Metabolic aikalosis — in surgical practice, this condition is commonly found in pyloric stenosis with loss of acid by repeated vomiting. if it continues for a long period, there will oe also potassium. deficiency as iarge amount of mucus of the gastric juice contains potassium. This along with partial starvation due to vomiting and daily loss in the urine will cause potassium deficiency. Aikalosis with potassium deficiency may also be found in some types of Cushing's disease with adrenal cortical neoplasms and after prolonged administration of cortisone. The treatment is to ensure restoration of exta-cetlular fluid volume by intravenous administration of sodium and chloride, It there is associated potassium deficiency, adequate amount of potassium chloride should be given. Respiratory alkalosis, which is sometimes come across during anaesthesia due to hyperventilation, can be corrected by insutllation of carbondioxide. ROUTINE POSTOPERATIVE CARE By proper postoperative care, the patient is brought back to his normal condition after operation This care starts immediately after operation in the operation theatre and ends when the patient resumes his normal active life. This care is more important in case of the patients who had undergone operations under general anaesthesia. The patient is gently lifted from the operation table to the trolley. Special care is given to the operating field. Rough handling shoutd be avoided since it may introduce postoperative shock. In the trolley, the patient will lie without pillow on his side. He should be well covered from the neck to the toes. The patient should be fully conscious before he leaves the operation theatre.30 A PRACTICAL GUIDE TO OPERATIVE SURGERY Resuscitation from ariaesthesia.— This has already been discussed in the chapter of ‘Anaesthesia’ Position of the patlent.— As soon as the patienl becomes fully conscious, pillows should be given underneath his head. He is better propped up with a back-rest in the next morning. The traditional * Fowler's position has lost its popularity as it encourages formation of thrombosis in the leg veins. It is of no use giving pillows beneath the knees of the patient, on the contrary the patient is instructed to move his legs as much as possible. Propped up position will help in better respiration and coughing. Fowler's position was also aimed at localisation of the peritoneal exudate or pus in the pelvis from where they can be easily drained through the rectum or vagina. But it is now realisad that gravity plays litte role in the movement of the peritoneal exudate, it is the capillary suction and difference ot pressure that helps in the movement. When the patient expires, the diaphragm rises creating a negative pressure by which the exudate is drawn upwards into the subphrenic space. So, from ali aspects Fowler's position has lost its foothold. Diet.— if the operation is not performed on the gastro-intestinal trect, fluids may be allowed from the evening of the day of operation. The fluid must be given in a very sestricted manner — started with a sip of water and gradually increased to a glass of fruit juice. In the first few hours following recovery trom anaesthesia, the patients always show a tendency of vomiting. This will definitely be aggravated if the patient is allowed to quench his thirst properly. On the next day of operation semi- solid foods are allowed and from the 3rd day onwards normal diet is allowed. Any protein or vitamin deficiency must be corrected during convalescent period the operation is done on the gastro-intestinal tract, the patient Is always given an IV. drip and the drip is continued til his intestinal peristalsis returns to normal. Then fluid is started by mouth and gradually replaced by semisolid and solid foods. The course taken for this replacement should be according to the operation performed, more slowly in case of upper gastrointestinal tract operations than operations on the iower Gl tract and galibladder region. Oral hyglene.— !t was very important in the pre-antibiotic era, when incidence of parotitis and respiratory infection, following oral infection and drying, was very high. But even in this age of antibicties, importance of oral hygiene cannot be over-emphasised. Rellef of pain.— As soon as the patient comes round from anaesthesia, he will invariably compiain of pain in the operation site. Some sort of hypnotic and analgesic should be prescribed. Injection pethidine is a very popular drug in this respect. Injection morphine has got certain disadvantages such as depression of respiration, vomiting, intestinal spasms etc. Injection Baralgan and Siquil are also good substitutes of pethidine. These have got added advantage of antiemesis. Micturition.— Normal urination is always expected within 24 hours after operation. Nature tries to conserve water and sodium after operation and this may be one of the reasons of delay of normal micturition, After certain operations as on hernia, on perineum etc. normal micturition may be well- delayed. Hot and cold applications on the suprapubic region or making the patient sit up on the bed may help in normal micturition. If these measures fail, the patient should be helped to stand up by the side of the bed for urination. Sometimes injection carbachol (1 mi) may be required, but the drug should not be used if there is any organic obstruction in the outflow of urine. If these procedures do not come out successful, there will be no way out but to catheterise the patient Bowel.— If operation is not performed on G.I. tract, it is a good practice to give an enema on Ihe 3rd day as bowel becomes /eluctant to move after operation. Clearance of the bowel by enema will not only cure the abdominal discomforts but aiso will restore appetite. But enema should not be given 50 reluctantly and so routinely when the operation has been performed on G.I, tract. In these circumstances, each case should be judged according to its merit. Early mobilisation.— This has become the modern trend of postoperative care. The patient is often asked to get up on the very next day, if it does not hurt the site of operation much. Early mobilisation will not only decrease the incidence of leg vein thrombosis, but aiso will keep the patient free from chest complications. In minor abdorninal operation, such as appendicectomy or herniotorny, the patient is encouraged to get up i the evening. He is even allowed to stand by the side of the bed for micturition if he cannot do so in the bed. It will be a great psychological benefit on the partROUTINE POSTOPERATIVE CARE at of the patient not to ask for bed pan all the time. After appendicectomy or hernictomy, young patients may be discharged on the 4th postoperative day i{ they remain otherwise normal. They will report to the out-patient department on 7th or 8th day for removal of stitches. Care of the wound.—- If there Is no soakage or infection in the operating wound, the dressing should not be changed til the time of removal of the stitches. if the dressings become very much soaked with discharge, they should be removed, a good inspection to the operating wound is made and the wound is redressed according to the circumstances. If the patient is running temperature and there is brawny induration around the operation wound one should suspect possibility of wound sepsis and the dressing should be immediately removed to see the condition of the wound. Presence of pus underneath the wound should be let out by removing one or two stitches from the most dependent part and @ corrugated rubber sheet drain is intraduced through the opening, The wound is redressed. The wound is dressed every alternate day or if the soakage is too Mnuch, it can be dressed every day. N these complications do not arise, dressings should not be removed till the removal of the stitches. Unnecessary change of dressing may start infection of the wound. There is no set rule as to when the stitches shouid be removed. It depends on the surgeon, depends on the condition of he patient, depends on the type of the operation and depends on the type of postoperative complications that might have occutred. Normally, in healthy adult, without any postoperative complication, the stitches are removed on Sth day for operations on the head and neck, on &th day for operations on the thorax and abdomen and on the 10th day for orthopaedic operations. But obviously, in presence of abdominal distension and malnutrition, the stitches for abdominal operations should be removed much later. AS a ule, tension sutures are removed on the 14th day or soCuarrer 3 32 Operations On Abscesses And Carbuneles OPERATION ON AN ABSCESS ‘An abscess is a collection of pus in the body. tt is said, where there is pus, let it out. So the principle of ireatment of such an abscess is (j) to drain the pus, {i} to send a sample of pus for culture aed sensitivity and (ji) 10 give proper antibiotic. Drainage of pus can be obtained by tree incision oF By Hilton's methed. When presence of abscess is obvious, do not rely on antibiotic only. Administralian of antibiotic continuously in this case may lead to chronicity, even to @ hard lump, which is so popularly known ae ‘antibioma’, This has been found in breast, when breast abscess was not drained and was faled on antibiotic only. Incision has got one more advantage in these cases as the pus, which is tefeased by incision, is sent for culture and sensitivity and the definite antibiotic for that particular case ig known and hence administered. This will avoid beating about the bush. ‘Pee incision — The idea is to drain all the pus, that is lying within the absoess cavity. For this, the incision is made on the most prominent part so as to cause least damage to the surrounding heallny tissue and on the most dependent part so that gravity wilt help drainage. Incision must be adequate for easy drainage of pus and to avold chronicity. If any important structure, like nerve or sosacl is liable to be present in the depth, the incision should be parallel to those structures. Incision should be bold. through the skin, subcutancous tissue and deep fascia, Muscle should be incised along the line of the fibres. Exoloration — Afier the incision has been made up to the abscess cavity anc some amount ci pus has been extruded, a finger is inserted into the abscess cavity anc ail the walls of tne loculi are broken. There must mot be any loculus unbroken, as this will lead to chronicity. ‘Counter-incision — When the most prominent part is not the most dependent part, complete drainage of pus ig not possible. So a counter-incision is required at the most dependent part to facilitate drainage by gravity. Through the first-made incision on the most prominent part, an artery forceps is pushed to the most dependent part. The biades are slightly made apart, then with a knife a fresh incision is made on the skin between the fips of the artery forceps Closure. ~ After the pus has been thoroughly drained, a roller gauze is packed inside the wound There is always bleeding from the surrounding granulation tisaue. if the bleeding is slight, the roles gauze is taken out, but if the bleeding is troublesome, it can be kept for 48 hours, after which it is Solaced by simple corrugated ruber sheet drain. Proper systemic antibiotic should be started as early as possible. Some surgeons believe in local antibiotic, but its piace is still controversial. ‘ratlow-up.— Alor 48 hours, the dressing is removed. Fresh dressing is done every day wit aosilinine jotion and sterile gauze. Il required. proper local antibiotic may be used. Rest to the affected partis very important postoperative measure to be adopted in al cases. This expedites healing. Visine Should be given to the subjects, who are thought to be sutlering from this deficit. Vitamin © should be given to all cases — 500 mg tab. once daly, as this helps in wound healing, Vitamin @ complex should always be given with tetracycline when this antibiotic is the choiceOPERATIONS ON ABSCESSES AND CARBUNCLES 33 Hilton's method.— This method is chosen when there ate plenty of important structures like nerves and vessels around the abscess cavity. The skin ard subcutaneous tissue are incised. A pair of artery ferceps or sinus forceps is insinuated through the deep fascia into the abscess cavily. The blades are fow gradually opened and the pus is seen to be extruded out. The forceps is taken out with the jaws open to increase the opening. Now a finger is introduced to explore properly as described above. OPERATIONS ON DIFFERENT ABSCESSES Abscess of the Neck.-- This is usually drained by Hillon's method. Abscess of the neck usually results from supputation of the regienal Iympht nodes. 't may, however, occur from extension of the alveolar abscess. For cosmetic reason, the horizontal incision along the nalural crease is preferred But occasionally when the aoscess runs along the direction of the stemomastoid. the incision along anterior border is made. Abscess of the Axilla— As the previous one, this also results from suppurative lymphadenitis of the regional lymph nodes. The incision is made half an inch behind the anterior fold of the axilla 10 avoid the major vessels and the nerves (Fig. 3.1). The drainage is usually done by Hilton's method Abscess of the Groin.— This is also a sequel of the sup- purative condition of the regional lymph nodes. The lymph nodes here are cisiributed in twa sets. The medial group of the horizontal. 4 lymph nodes is involved trom infection of the extemal genitalia, whereas the vertical group is involved from infection of the lower limb, For the former condition, ¢ horizontal incision along the mos? prominent and dependent part of the abscess is made. For the letter condition, a vertical incision along the auscess is preferred as the wound is fikely to gape when the thigh is bent. thus — Fig. 3.1.-— Shows the incision for providing betler drainage. drainage of axillary abscess Popliteai Abscess.— This abscess usually results from three condilions ~~ (1) Suppuration of the regional lymph nodes. (2) Osteomyelitis of the lower end of the femur or upper end of the tibia and (3) Infection of the local cellular tissue. In clinical examination, one must exclude the possibility of popliteal aneurysm. Cases are aot unknown when lecking aneurysm with surrounding inflammation was incised with mistaken diagnosis of abscess with disastrous result. The incision is made slightly medial to the lateral border of the popliteal space, Care must be taken not to injure the lateral popliteal nerve. The drainage is made by Hillon’s method. liac Abscess.— Linlixe the previous ones. it is usually 2 sequel of a haematoma within the iliac muscle. Clinically it mimics very closely an appendicular abscess. But It is a bit lateral to the usual position of appendicular abscess. moreover Rovsing's sign is absent here. The incision is made just above and parailel to the iliac crest, The structures are cut right up to the abscess along the line of incision. The peritoneal cavity is not opened as it is obliterated by adhesions Ischio-rectal abscess.— See under ‘Operations on the Rectum and Anal Canal’. Mammary Abscess.— See uncer “Operations on the Breast’ OPERATION ON A CARBUNCLE Indications. — (i) Carbuncle is only ingised when the toxaemia and pain persist even after a course of proper antibiotics [il) When the carbuncle is move than two and half inches in diameter. incision is never made unless ihere is softening in tne centre, Operation.—- tncision is always made under antibiotic cover. A large crucial incision is made extending upto the margin of the inflammatory zone. Sloughs should be cleared with a piece of gauze. Apices of the four flags are generously excised The wound is covered with vaseline gauze or solratulie dressing. The part should be kept in perlect resi ior a week. 3Cusrrer 4 24 Tumours And Cysts Of The Superficial Tissues BENIGN TUMOURS Benign tumours are as a rule excised with or without surrounding heaithy tissue as the case may be. in adults this is done under local anaesthesia. In case of children general anaesthesia may be required as it is very diffoull to contrat them under local anaesthesia LOGAL ANAESTHESIA. — Generally lignocaine — ¥% to 2% is used for local anaesthesia. This may be used atong with adrenalin to enhance the action as well as to reduce bleeding {rom the operating site. Marcaine has got a longer action (4-6 hrs.) than lignocaine and may well be used where longer acting local anaesthesia is required. Local anaesthesia can be used by two methods — (4) Infiltration anaesthesia and (2) Field biock. infiltration anaesthesia aims at paralysing the nerve endings lo the actual site ‘of operation. The injection is mace to the nerve supplying the operation site in the subcutaneous tissue. Field Block aims at anaasthetising the operation site by injecting tocal anaesthetic all around it This is done by raising small skin wheals by fine needles at some distance from the operation site ‘and subsequently introducing tong subcutaneous needles through these skin wheals and injecting the local anaesthetic through it (Fig.1.1) Paplliomata — This can be classified into (1) True papilloma and (2) Inlective warts. True papiltorne.— Excision is the treatment for this condition. Excision should be done along with healthy surrounding skin margin of % inch. Inadequate excision may lead to malignant change. lf the wart has suddenly enlarged, been painful and/or ulceraled, malignant change should be suspected and immediate excision with % inch of surrounding hea'thy skin should be performed. In the passing it may be mentioned here that amelanotic melanoma often resembles a simple wart. Infective warls.— These are actually exorbitant granulation tissues which occur in ciops, These are best treated with CO, snow or by diathermy coagulation. Only occasionally excision may be called tor. Haemangiomata,— These are actually hamartoma rather than true tumour, These may oocur from. capillary — when it is called capillary haemangioma or trom veins — venous (cavernous) haemangioma or from arteries — artenal haemangioma. Capiilary haemangioma — These are of three varieties :— (1) Post Wine Stain.— These are present at birth. They remain as they were throughout life, Occasionally they may become nodular. Treatment is purely cosmetic. Excision and grafting are usually performed. (2) Strawberry Angioma— These are usually seen at the age of 3 weeks as ted marks. TheyTUMOURS AND CYSTS OF THE SUPERFICIAL TISSUES 35 gradually increase in size with immature vascular tissue up to 1 year of age. After this. they gradually flatten and complete regression occurs at the age of 7 or 8 years. Treatment is ‘wait and watch’ as natural involution is the rule (3) Salmon Patch— These also present at birth and disappear before the first birthday Venous (Cavemous) haemangioma_— These are also congenital, but they show no sign of regres- sion. Treatment is surgical excision, though application of the freezing probe (cryosurgery) is of soma. value, Radiotherapy is not liked by the surgeons as necrosis and skin pigmentation mar the result Surgical excision is not very easy. Al first the feeding vessels are lied. Subsequently the dilated and tortuous vessels ate dissected carefully from the skin and deeper structures. At this time one must be cautious that intermuscular extensions of haemangioma may be present and cause excessive haemosthage if the complete removal is not possible. Arterial Haemangioma (Cirsoid Aneurysm)— This tumour is actually a network of interwoven arteries. Al operation again Ihe feeding vessels are tied first and the network of the vessels are gradually dissected carefully from the skin and deeper structures. Troublesome haemorrhage may sometimes occur. Lipoma.— This circumscribed tumour of the adipose tissue is excised as a rule. This tumour has gol 2 capsule which helps in its removal. The skin and subcutaneous tissue up to the tumour are incised along the line of the nalurat crease. The capsule of the tumour has got fibrous prolongation upto the skin. These are incised and made the capsule free from the surrounding tissue. Then the tumour is very easily shelled out. The dead space is now packed with gauze and kept for a few minutes. The gauze is then removed, the oozing vessels are electrocoagulatad and the dead space is obliterated with the needle and catgut. If the tumour is very large a cubber sheet drain may be used. The skin is closed as usual MALIGNANT TUMOURS Squamous cell carcinoma or epithetioma.— ft is a malignant tumour arising from the epidermis or its appendages. The peculiarity is that tha cells show some degree of maturation towards keratin formation. It is a less common tumour, but more malignant and more rapidly growing tumour than a basal celt carcinoma. TREATMENT,— The choice fies. between surgical excision and radiotherapy. As a general guide one must remember that a weil differentiated tumour is belter suited for surgery, whereas poorly differentiated tumours are suitable for radiotherapy. Other factors, however, should be considered e.g site and size of the tumour, age of the patient and general condition. Surgery is the treatment of choice when the lesion has invaded the bone or cartilage or there is lymph node metastasis. Surgery — Excisional surgery should be carried out with 1 to 2 om of clearance on all sides of the tumour. The skin incision is first marked with a skin pencit before the patient is anaesthelised. In face fess clearance is kept to offer better cosmetic result. Radiotherapy — it is more often used in case of less differentiated tumours, when the tumour is mobile and the patient is pasticutarly elderly. It is more used in case of tumours of the head and neck and is more often avoided in tumours of the extremities and trunk, Particularly in the latter situation it often causes necrosis. In case of both surgery and radiotherapy the 5 year cure rate is approximately 95%. Treatment of secondaries.— There is no place of prophylactic lymph node clearance in this condition. When the regional lymph nodes are involved, they are excised by block dissection as these secondaries are not radiosensilive. When the lesion is very near to the lymph node metastasis monoblock excision is advised. Lymph node enlargement may not be due to metastasis and in 50% of cases it may be due to simple infection. If there is doubt about the nature of enlarged lymph node, afine needle aspirate may be used for cytological examination of biopsy may be taken for histopatholagicat examination. Radiotherapy is only advised for palliation when the nodes are inoperable.38 A PRACTICAL GUIDE 70 OPERATIVE SURGERY Basal cell carcinoma or rodent ulcer.— This is a malignant tumour arising from the basal area cf the epidermis and its appendages. I is by far the commonest form of skin cancer. It is @ Gisease of old males. As the name suggests it gradually invades the surrounding tissues and even bone, but seldom disseminates to the lymph nodes. Over 90% of lesions are found on the face, usuelly above a line from the lobe of the ear to the comer of the mouth. The commonest site is around the inner canthus of the eye TREATMENT — The choice of treatment lies between radiotherapy and surgery. Radiotherapy. — It is very radiasensitive, so radiotherapy is quite effective. The only problem of sing'e dose treatment is necrosis and scarring. Modem techniques of fractioning the dose over several weeks have decreased the incidence of scarring and necrosis, Radiotherapy is avoided in certain areas like the pinna, overlying the lacrimal glands or close to the lacrimal canaliculi Surgary.— Excisional surgery which includes a margin of § mm on all sides including the deep surface, is still preferred by most of the surgeons. it is followed by primary closure or sliding or full Ibickness skin graft over the defect, This is usually performed by a piastic surgeon and the scar which follows this procedure is ao worse than following radiotherapy. Excision however has the problem of inadequate removal, particularly in the deep aspect of the lesion. Recurrence is not revealed till the deeper structures are involved. If this occurs radiotherapy should be used ‘Oniy in case of very superficial crusting lesion, shave excision through the mid-dermis is curative and produces a good cosmetic resutt. Bolh these modes of treatment i.e. radiotheraphy and surgery offer a cure rate of over 95%. Chemotherepy.—in case of small superticial lesions S-fluorouracil may be used topically. Recur- rence nas been noticed following this treatment Cryasurgery.— Small lesions particularly in the elderly is quite suitable for this treatment and offers ‘gecd cosmetic value. Malignant Melanoma.— It often arises from a lentigo or frequently without any previous lesion. The signs of malignant change are that the lesion becomes darker, suddenly increases in size, spreads with surrounding inflammation and/or becomes ulcerated. This tumour is highly malignant, it infiltrates the dermis and metastasizes through lymphatics and biood vessels. Ai times it becomes very difficult to say with certainty whether the tumour is benign or malignant When the tumour locks very much innocent, yet suspicion still exists, complete excision with a margin of 7 mm (% inch) of healthy skin should be performed. This excised tumour is nistologically examined and when tie tumour comes out to be a malignant one. wide excision of the previous wound is carried out as suggested betow Clinical Steging— Stage — presence of only tumour. Stage i! — presence of satellites or ‘in transits’ make the stage of the lesion as tla. When regional lymph nodes ere enlarged the slage of the lesion becomes IIb. When the lesion has both satellites ‘and enlarged lymph nodes, the slage is Hab Stage lif — presence of wider dissemination than the regional lymph nodes I must be remembered that tumour thickness ‘s the best measure of prognosis. Lesions less than 1mm in thickness have very favourable prognosis. The thickness is measured by an optical micrometer from the top of the granular layer of the epidermis to the deepest melanoma cells in the dermis Paradoxically if areas of segression are present, thin melanomas may have appreciable risk of metastasis, as the lesion may have in the past the sufficient thickness which is missing in the specimen now. TREATMENT OF THE PRIMARY TUMOUR. — The treatment of malignant melanoma is ‘wide excision’ The area is first mapped out with ink. A 2 cm margin of healthy tissue around the primary malignant melanoma should be excised, That means when the tumour is just palpable, 2 cm margin is sufficient W the tumour is more than { mm in thickness, excision with 3 cm around the lesion with the underlying subcutaneous tissue but not including the deep fascia should be performed. All suspicious lesions should be subjected to excision bfopsy with a margin of al least 1 cm. Only in case of a lerge fesionTUMOURS AND CYSIS OF THE SUPERFICIAL TISSUES 37 and one is not very certain about the diagnosis, incision biopsy may be acceptable. Once the diagnosis ‘is conimed definitive wide excision should be performed within 3 weeks. Any lesion suspacted to be malignant melanoma should never be shaved, cauterised or curetted to prevent dissemination In case of face the amount of skin excision is reduced with 1 to 2 om of clear heaithy margin around the tumour. On the tunk, where the melanoma is more aggressive, a clear margin of 5. em in al! directions shoutd be excised. Both in the trunk and in the limbs the excision is commenced at the proximal margin (relative to lymphatic drainage) and carried round the periphery. The excision includes the subcutaneous tissues but not the deep fascia. This fascia acts as a barrier to deep invasion. Melanoma on the foe or finger is treaied by amputation of the digit at a level to allow appropriate wide excision of the skin depending on the thickness of the tumour. Melanoma of the mucosa of the mouth, vagina or anal canal is more malignant. In case of anal canal, abdominoperineal excision is carried out After excision perfect haemostasis must be attained. The defect is re-surfaced by split skin graft This is better than a transposition or rotational flap because of the fact that it takes easily and acts 28 a window to watch for recurrences. The graft should be taken from the conialateral limb as the tumour ceils have a precilection for the ipsilateral donor site. MANAGEMENT OF lia LESIONS.— Laser. cryoprobe or superficial electron radiotherapy is quite beneficial in this stage of diseese. Isolatad limb perfusion is quite effective when the disease involves the limb. Melphatan is used for perfusion of the limb whose femoral artery and vein have been isolated and have been cannulated. The drug is passed through @ heat exchanger and it is infused into the arlery at a temperature more than 40°C. 50% complete response has been claimed and further 40% partial response may be expected. MANAGEMENT OF STAGE tld DISEASE— Prophylactic removal of the regional lymah nodes is unjustified and unnecessary. Lymphatic tissues play a major part in the defence mechanism of the body and it seems reasonable to leave the nodes for the natural function and only to operate when thay fail, Excision of the clinically invelved lymph nodes should only be performed when the nodes remain enlarged after a period of approximately 4 weeks observation. Cases are on record when clinically enlarged lymph nodes regressed after excision of the primary tumours. These may be examples of spontaneous immunofogical regression or examples of cure from transient episode of infection Where the primary lesion is adjacent to the regional lymph nodes. excision may be carried out en bloc, only when these lymph nodes are clinically involved or are included in the desirable margin of excision. Recently radioactive isotopes such as radioactive phosphorus is injected along with dye into the subcutaneous lymph channels for lymphagraphy. This is called ‘endolymphatic therapy’. This hhas got the edvaniage that it not only shows the presence of malignant tissue within the lymph nodes which may be even clinically not enlarged but also it may act on the metastalic tissue and cure them 4 the metastatic lymph nodes are fixed to deeper structures and inoperable in ihat sense, ablation af the lymph nodes by fore-or hind-quarter amputation should be considered MANAGEMENT OF STAGE il DISEASE — Radiotherapy has gol very little place in the treatment of this radio-resistant tumour. It has only a palliative value in the not infrequent extremely painfut bone secondaries occurring at the late stage of this disease Chemotherepy has been used both with single and multiple drugs. Vindasine, which is almost similar to Dacarbazine, has almost 25% response rate Vindesine has very few side effects and is often used as a first line of treatment in disseminated cases. Systemic administration of drugs such as chlorambucil or cyclophosphamide is disappointing. Dosage to the limit of leucocyte deprassion does not prevent occurring of recurrence. More recently interleukin- 2has been used with approximately 40% of response. Cytotoxic drug can probably be mora efficiently used in Isolated limb perfusion as mentioned above. Whatever may be the mode of treatment, the prognosis of this stage of the disease is extremely poor and 50% of patients die betore completion of 1 year from the first metastasis38 A PRACTICAL GUIDE TO OPERATIVE SURGERY CYSTS Sebaceous Cysts.— The cyst as a rule should be removed completely, thal means the cyst: wall along with its contents should be removed. If a portion of the cyst-wall remains, there is a possibility of recurrence, For sebaceous cysts, a tinear incision is made on the protuberant skin. The skin margins ase carefully undermined up to the margins of the cyst. Then the cyst is held with Lane's tissue forceps and gradually freed from the underlying tissue. Thus excision is completed. The skin margins are sutured if there are no oozing vessels at the bed. if the cyst is a large one, an elliptical incision is made on the skin and the portion of the skin within the ellipse including the punctum is removed. An alternative method is to incise the cyst, to remove the contents and carelully dissect off the two halves of the cys! wall Infected Sebaceaus Cyst.— When the sebaceous cyst is associated with inflammation, the operation is deferred until infection has been cured. Dermold Cyst— This is operated on in the same manner as the sebaceous cyst. This cyst often produces indentation on the underlying bone and at times may be connected with the duramater through the cranial bones. These cases require special attention during deeper dissection and at times osteoplastic flap may need be removed for proper dissection of the intracranial connectionCusriEer § ES Skin Grafting Though it comes in the domain of plastic surgery, Only the basic points of skin grafting, which a general surgeon should know, will be discussed here. Indications.— (1} Skin is toe best possible dressing for a raw surface, that is why extensive raw wound should always be covered with skin. In surgical practice extensive raw wound can resull from many conditions, of which trauma and ourn deserve special mention. If this raw wound is not grafted it scars easily with the blemishes and deformities. (2) Contracted scars in the vicinity of the joints require excision and skin gratting. (3) Skin loss from surgically removed malignant growths should be made good with immediate skin cover. TAKING OF A SKIN GRAFT DEPENDS ON VARIOUS FACTORS.— (1} The recipient area must not be avascular. (2} There should not be any excess blood, serum or exudate to separate the graft from the recipient area. For this, a pressure bandage is always required after skin grafting, (3) The recipient area must be free from infection. (4) The part after skin grafling should be immobilised !0 prevent displacement. (6) The nutritional status of the individual should be satisfactory. PREPARATION OF THE RECIPIENT WOUND.— The area is frst washed with soap and water. A soft brush may be used tq clean the dirt from the surrounding skin. Then diluted cetavion solution is used fo clean the area with sponge-holding forceps. Any slough in the wound should be removed with great care, There should not be any crevices or hypergranulation tissue in the wound. Hf present, they should be scraped off to expose a fiat healthy granulation tissue as the bed for skin graft. Ii there is any bleeding this should be tackled by pressure of hot saline pack. PREPARATION OF THE DONOR SKIN — This atea is shaved at least 24 hours before the operation, Then the area is cleaned with ether soap and spiril. Strong antiseptics like tinct. iodine must be avoided. The area is now dressed with sterile gauze and bandage, which will be opened only in the operation theatre. METHODS OF SKIN GRAFTING Skin loss can be made good -— () By local adjustments (by fiaps) from the surrounding skin (2) By tree skin gratts taken from other parts of the body. (3) By pedicle grafts, where the flap remains attached to the original site on one end and the other to the piace to be grafted. Occasionally an intermediate "host" may be used where the distance between the denor area and the recipient area is too long to be bridged. Suppose a wound in the face is to be grafted from the abdominal! wall. In this case as the distance is too much the fiap from the abdominal wall is first transferred to the forearm and then from the forearm to the face, So the forearm acts as an intermediate “host” 1. Local adjustments from the surrounding skin (by flaps).— Geing physiological this is the est method. This metnod has an obvious advantage that as the blood supply of the flap

You might also like

• The Hobbit

  

  From Everand

  The Hobbit

  J. R. R. Tolkien

  Rating: 4.5 out of 5 stars

  4.5/5 (24727)
• Freakonomics Rev Ed

  

  From Everand

  Freakonomics Rev Ed

  Steven D. Levitt

  Rating: 4 out of 5 stars

  4/5 (7837)
• The Handmaid's Tale

  

  From Everand

  The Handmaid's Tale

  Margaret Atwood

  Rating: 4 out of 5 stars

  4/5 (13185)
• • Magazines
  • Podcasts
  • Sheet music
• The 7 Habits of Highly Effective People

  

  From Everand

  The 7 Habits of Highly Effective People

  Stephen R. Covey

  Rating: 4 out of 5 stars

  4/5 (353)
• Pride and Prejudice: Bestsellers and famous Books

  

  From Everand

  Pride and Prejudice: Bestsellers and famous Books

  Jane Austen

  Rating: 4.5 out of 5 stars

  4.5/5 (19653)
• The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  

  From Everand

  The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  Mark Manson

  Rating: 4 out of 5 stars

  4/5 (5794)
• The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  

  From Everand

  The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  Mark Manson

  Rating: 4.5 out of 5 stars

  4.5/5 (20003)
• Art of War: The Definitive Interpretation of Sun Tzu's Classic Book of Strategy

  

  From Everand

  Art of War: The Definitive Interpretation of Sun Tzu's Classic Book of Strategy

  Stephen F. Kaufman

  Rating: 4 out of 5 stars

  4/5 (3321)
• The Art of War: A New Translation

  

  From Everand

  The Art of War: A New Translation

  Sun Tzu

  Rating: 4 out of 5 stars

  4/5 (3044)
• American Gods: The Tenth Anniversary Edition

  

  From Everand

  American Gods: The Tenth Anniversary Edition

  Neil Gaiman

  Rating: 4 out of 5 stars

  4/5 (12943)
• The 7 Habits of Highly Effective People: The Infographics Edition

  

  From Everand

  The 7 Habits of Highly Effective People: The Infographics Edition

  Stephen R Covey

  Rating: 4 out of 5 stars

  4/5 (2475)
• The 7 Habits of Highly Effective People

  

  From Everand

  The 7 Habits of Highly Effective People

  Stephen R. Covey

  Rating: 4 out of 5 stars

  4/5 (2564)
• Wuthering Heights (Seasons Edition -- Winter)

  

  From Everand

  Wuthering Heights (Seasons Edition -- Winter)

  Emily Brontë

  Rating: 4 out of 5 stars

  4/5 (9486)
• Habit 6 Synergize: The Habit of Creative Cooperation

  

  From Everand

  Habit 6 Synergize: The Habit of Creative Cooperation

  Stephen R. Covey

  Rating: 4 out of 5 stars

  4/5 (2499)
• The Iliad: A New Translation by Caroline Alexander

  

  From Everand

  The Iliad: A New Translation by Caroline Alexander

  Homer

  Rating: 4 out of 5 stars

  4/5 (5700)
• Oscar Wilde: The Unrepentant Years

  

  From Everand

  Oscar Wilde: The Unrepentant Years

  Nicholas Frankel

  Rating: 4 out of 5 stars

  4/5 (10242)
• Habit 3 Put First Things First: The Habit of Integrity and Execution

  

  From Everand

  Habit 3 Put First Things First: The Habit of Integrity and Execution

  Stephen R. Covey

  Rating: 4 out of 5 stars

  4/5 (2506)
• How To Win Friends And Influence People

  

  From Everand

  How To Win Friends And Influence People

  Dale Carnegie

  Rating: 4.5 out of 5 stars

  4.5/5 (6510)
• The Iliad: The Fitzgerald Translation

  

  From Everand

  The Iliad: The Fitzgerald Translation

  Robert Fitzgerald

  Rating: 4 out of 5 stars

  4/5 (5341)
• The Odyssey: (The Stephen Mitchell Translation)

  

  From Everand

  The Odyssey: (The Stephen Mitchell Translation)

  Stephen Mitchell

  Rating: 4 out of 5 stars

  4/5 (7769)
• Never Split the Difference: Negotiating As If Your Life Depended On It

  

  From Everand

  Never Split the Difference: Negotiating As If Your Life Depended On It

  Chris Voss

  Rating: 4.5 out of 5 stars

  4.5/5 (3270)
• The Picture of Dorian Gray: Classic Tales Edition

  

  From Everand

  The Picture of Dorian Gray: Classic Tales Edition

  Oscar Wilde

  Rating: 4 out of 5 stars

  4/5 (9752)
• The Picture of Dorian Gray (The Original 1890 Uncensored Edition + The Expanded and Revised 1891 Edition)

  

  From Everand

  The Picture of Dorian Gray (The Original 1890 Uncensored Edition + The Expanded and Revised 1891 Edition)

  Oscar Wilde

  Rating: 4 out of 5 stars

  4/5 (9054)
• Anna Karenina: Bestsellers and famous Books

  

  From Everand

  Anna Karenina: Bestsellers and famous Books

  Leo Tolstoy

  Rating: 4 out of 5 stars

  4/5 (7086)
• Life of Pi: A Novel

  

  From Everand

  Life of Pi: A Novel

  Yann Martel

  Rating: 4 out of 5 stars

  4/5 (13455)
• Stardust

  

  From Everand

  Stardust

  Neil Gaiman

  Rating: 4 out of 5 stars

  4/5 (8114)