Instruments in Surgery

Pradeep Chopra, MBBS,MS,FRCS Ed

Life saving

Life Saving

Tracheostomy

Obstruction of upper air passages

Improve respiratory function
Respiratory paralysis
Operations on upper airway
Prolonged ETT, ICU

Tracheostomy

Obstruction of upper air passages

FB impaction
Acute infections
Odema of the glottis
Bilateral abductor paralysis
Tumours of the larynx
Trauma, crushed larynx
Congenital webs or atresia
5

Tracheostomy

Improve respiratory function

Reduce dead space, anatomical

Aspiration of bronchial secretions

Bronchopneumonia
Chronic bronchitis with emphysema
Chest injuries, flial chest

Tracheostomy

Respiratory paralysis

Helps in PPV and toilet

Unconsciousness, head or facio-maxillary injury

Coma
Bulbar polymelitis
Tetanus

Endotracheal intubation

Tracheostomy

After care

Bedside; tracheal dilator, oxygen

Humidifier
Suction with sterile catheter
Inner tube care, crusting

Tracheostomy

Complications

Crusting
Surgical emphysema
Mediastinal emphysema
Tracheal stenosis

Percutaneous tracheostomy
Used in the ICU

10

Endotracheal intubation

Substitute for tracheostomy, respiratory

paralysis
Less desirable in long term:

Toilet is easy with tracheostomy

Intubation granuloma of vocal folds and
subsequent stricture

11

Life Saving

12

13

Treatment of massive haemorrhage

3rd stopped
3rd oozing
3rd heavily bleeding

Resuscitation

Blood Tx
Avoid sodium
Care with opiates

Arrest of Haemorrhage

Tamponade
Drugs
Sclerotherapy
Operations
Devascularisation
Transection
Shunt operations*
*best avoided

General Management

Decrease protein load- bowel

Lactulose
Clears bowel
Bacteria
Neomycin
Blood cathartic

Prevention

Repeated Sclerotherapy
2 weeks,1m,6m
nonthrombosed, new
Operations

14

Life Saving

15

Intercostal Drainage

Indications:

Trauma: Haemothorax, Pneumothorax

Surgery: Entering pleural space
Pleural Effusions:

Transudate- CCF
Exudate- infections (turbid) and tumours
Blood stained- trauma, tumour, Tb, infarction,
pancreatitis
Chyle
16

Intercostal drainage

Site
Space
Procedure
Direction
Removal
Precautions

17

18

Intercostal drainage
underwater seal

19

Pneumothorax

Spontaneous
Rupture of bulla
Trauma: penetrating, # ribs, iatrogenic
( lung Bx, Central line)

PPV
Rare: asthma, cystic fibrosis, resuscitation &
ventilation of new born.

20

Haemothorax

Indication for thoracotomy

Initial drainage > 1000 ml

Continued bleeding of > 250 ml/ hr first 4-5 hr or >
2000 ml in 24 hrs.

21

Life Saving

Central Venous
Pressure Monitoring
Haemodialysis
TPN
Chemotherapeutic
drugs
TIPPS
IVC filters

22

23

Limb/Life Saving

Embolectomy
catheter (Fogarty)

Acute Ischaemia of
the limb
Embolus retrieval
Acute on chronic
Pulmonary embolus
Endoscopic retrieval
of CBD stones

24

25

26

Essential

27

Essential

28

29

Drains

Types:

Open: gloved, penrose, corrugated

Closed:

Gravity
Suction
Sump

30

Drains and indications

Nonfunctioning GI tract
Extensive dissection in closed space
Large flaps
Abscesses that do not communicate
Difficult abdominal surgeries
Certain operations: LN dissection, thyroid,
pancreatic, pelvis, peritonitis etc.,
Peritoneal lavage: peritonitis, pancreatitis,
peritoneal dialysis
31

Drains and complications

FB reaction and isolation

Colonisation by bacteria
Not a substitute for hemostasis
Erode: blood vessel, intestines (rigid)
Excessive suction: necrosis (intermittent love
level suction safer)
Break, dislodge (radio-opaque marker)
32

When to remove the drain

Fulfilled their purpose

No further drainage is present or if the
drainage is minimal
Document
Note the completeness of removal
C/S if indicated

33

Essential

34

Essential

35

Nice to Know

Condom catheter

36

Nice to Know

Cluttons urethral
dilators

37

Essential

T tube

CBD exploration
Injury to the CBD
Traumatic
Iatrogenic
Surgery on CBD ie.,
anastamosis
Size at least 14F
MTBE
Removal after 3-4 weeks
38

Essential

Isotonic Solutions

39

Essential

Hypertonic Solutions

40

Essential

41

Table
solution

Na

0.9%saline

154

0.45%saline

77

RL

130

5% dext

Cl

Hco3

Hyponatremia
ECF replace

154

Na maintenance,
gastric replace

77
4

109

Uses

28

Isosmolar deficit
Maintenance,hyperosmolar dehydration
42

Essential

Colloids

43

Nice to Know

44

Complications of TPN

Insertion related

air embolism
arterial puncture
arrhythmias
catheter embolus
chylothorax
Haemo/hydro
pericardium

Hematoma
Hemothorax
Hydro-TPN-othorax
Malposition
Pneumothorax

Late complication

infection/sepsis
thrombosis
displacement

45

Essential

TED Stockings
SCD

46

Essential

Colostomy

Temporary (loop/end)
Defunction anastomosis
Injury to colon / rectum
High fistula in ano
Hartmans procedure
Mucous fistula
Permanent (end)
APR for ca rectum

47

Colostomy complications

Prolapse
Retraction
Necrosis
Stenosis
Parastomal hernia
Internal herniation intestinal obstruction
Bleeding granulomas around margin
Diarrhoea
48

Other ostomies

Loop ileostomy
Caecostomy

Impeding perforation, colonic obstruction

49

50

51

52

53

Essential

54

Haemorrhoids Treatment

55

56

57

58

59

60

61

Nice to Know

Laparoscopic
instruments
Indications
Insuffulation
gases
Techniques
Contraindication

62

Nice to Know

64

65