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Chapter 2
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Principles of surgery
23
Terminology in surgery 24
History taking and making
notes 26
Common surgical symptoms 28
Examination and investigation of
the patient
Evaluation of breast disease 30
Evaluation of the neck 32
Evaluation of the abdomen 34
Abdominal investigations 36
Evaluation of pelvic disease 38
Evaluation of peripheral vascular
disease 40
Evaluation of the skin and
subcutaneous tissue disease 42
Surgery at the extremes of age 44
Day case and minimally invasive
surgery 46
Preoperative care
Surgery in pregnancy 48
Surgery and the contraceptive
pill 50
Surgery in endocrine disease 52
Surgery and heart disease 54
Surgery and respiratory
disease 58
Surgery in renal and hepatic
disease 60
Surgery in neurological disease 62
Pre-optimization of the patient
Fluid optimization 64
Nutrition in surgical patients 66
Enhanced recovery after
surgery 68
Perioperative care
Getting the patient to theatre 70
Prophylaxis—antibiotics and
thromboprophylaxis 72
In-theatre preparation 74
Positioning the patient 76
Sterilization, disinfection, and
antisepsis 78
Scrubbing up 79
Surgical instruments 80
Incisions and closures 82
Drains 83
Stomas 84
Knots and sutures 86
Post-operative
Post-operative management 88
Drain management 90
Fluid management 92
Acid–base balance 94
Blood products and
procoagulants 96
Transfusion reactions 98
Shock 100
Post-operative haemorrhage 102
Wound emergencies 104
Cardiac complications 106
Respiratory complications 108
Renal complications 110
Urinary complications 112
Gastrointestinal
complications
Neurological complications 116
Haematological complications 118
Deep venous thrombosis and
pulmonary embolism 120
Risk scoring 122
Critical care 124
Commonly used terms in
ITU 126
Invasive monitoring 128
Ventilation and respiratory
support 130
Circulatory support 132
Renal support 134
Enteral support 136
Sepsis, SIRS, MODS, and ALI 138
114
CHAPTER 2 Principles of surgery
24
Terminology in surgery
How to describe an operation
The terminology used to describe all operations is a composite of basic
Latin or Greek terms.
First describe the organ to be operated on
Examples:
lapar-, abdomen (• laparus = fl ank);
nephro-, kidney;•
pyelo-, renal pelvis;•
cysto-, bladder;•
chole-, bile/the biliary system;•
ileo-, small bowel (distal)•
col(on)-, large bowel;•
hystero-, uterus;•
thoraco-, chest;•
rhino-, nose;•
masto/mammo-, breast.•
Second describe any other organs or things involved in the procedure
Examples:
docho-, duct;
•
angio-, vessel (blood- or bile-carrying);•
litho-, stone.•
Third describe what is to be done
Examples:
-otomy, to cut (open);•
-ectomy, to remove;•
-plasty, to change shape or size;•
-pexy, to change position;•
-raphy, to sew together;•
-oscopy, to look into;•
-ostomy, to create an opening in (• stoma = mouth);
-paxy, to crush;•
-graphy/gram, image (of).•
Lastly add any terms to qualify how or where the procedure is done
Examples:
•
percutaneous, via the skin;
trans-, across;•
antegrade, forward;•
retrograde, backward;•
ventral, anterior surface of.•
Examples of terms
Choledochoduodenostomy• . An opening between the bile duct and the
duodenum.
Rhinoplasty• . Nose reshaping.
Pyelolithopaxy• . Destruction of pelvicalyceal stones.
TERMINOLOGY IN SURGERY
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Bilateral mastopexy• . Breast lifts.
Percutaneous arteriogram• . Arterial tree imaging by direct puncture
injection.
Loop ileostomy• . External opening in the small bowel with two sides.
Flexible cystourethroscopy• . Internal bladder and urethral inspection.
25
CHAPTER 2 Principles of surgery
26
History taking and making notes
Making medical notes
All medical and paramedical professionals have a duty to record their
input and care of patients in the case notes. These form a permanent legal
and medical document. There are some basic rules.
•
Write in blue or black ink; other colours do not photocopy well.
Date, time, and sign all entries; always identify retrospective entries.•
Be accurate.•
Make it clear which diagnoses are provisional.•
Abbreviations are lazy and open to misinterpretation; avoid them.•
Clearly document information given to patients and relatives.•
Avoid non-medical judgements of patients or relatives.•
Basics
Always record name, age, occupation, and method of presentation.•
Cover all the principal areas of medical history:•
Presenting complaint and past history relevant to it.•
Other past medical history, drug history, and systematic enquiry.•
Previous operations/allergies/drugs.•
Family history, social history, and environment.•
Presenting complaint
This is a one- or two-word summary of the patient’s main symptoms, e.g.
abdominal pain, nausea and vomiting, swollen leg, PR bleeding.
In emergency admissions, do not write a diagnosis here (e.g. ischaemic •
leg). The diagnosis of referral may well turn out to be wrong.
In elective admissions, it is reasonable to write: ‘elective admission for •
varicose vein surgery’.
History of presenting complaint
This is a detailed description of the main symptom and should include •
the relevant systems enquiry.
Try to put the important positives fi rst, e.g. right-sided lower •
abdominal pain, sharp, worse with moving, and coughing, anorexia 24h.
Include the relevant negatives, e.g. no vomiting, no PR bleeding.•
Be very clear about the chronology of events.•
In a complicated history or with multiple symptoms, use headings, e.g. •
‘Current episode’, ‘Previous operations for this problem’, ‘Results of
investigations’.
Summarize the results of investigations performed prior to admission •
systematically: bedside tests, blood tests, histology or cytology, X-rays,
cross-sectional imaging, specialized tests.
Past medical history
Ask about thyroid problems, tuberculosis (TB), hypertension, •
rheumatic fever, epilepsy, asthma, diabetes, ischaemic heart disease,
stroke, and previous surgery, specifi cally.
List and date all previous operations.•
Ask about previous problems with an anaesthetic.•
Asking ‘Have you • ever had any medical problem or been to hospital for
anything?’ at the end often produces additional information.
HISTORY TAKING AND MAKING NOTES
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Systematic enquiry
This is extremely important and often neglected. A genitourinary history
is highly relevant in young females with pelvic pain. A good cardiovascular
and respiratory systems enquiry will help avoid patients being cancelled
because they have undiagnosed anaesthetic risks. Older patients may have
pathology in other systems that may change management, e.g. the patient
with prostatism should be warned about urinary retention.
Cardiovascular.• Chest pain, effort dyspnoea, orthopnoea, nocturnal
dyspnoea (see b p. 58), palpitations, swollen ankles, strokes, transient
ischaemic attacks, claudication.
Respiratory.• Dyspnoea, cough, sputum, wheeze, haemoptysis.
Gastrointestinal.• Anorexia, change in appetite, weight loss (quantify how
much, over how long).
Genitourinary.• Sexual activity, dyspareunia (pain on intercourse),
abnormal discharge, last menstrual period.
Neurological.• 3 Fs: fi ts; faints; funny turns.
Social history
At what time did they last eat or drink?•
Ask who will look after the patient. Do they need help to mobilize?•
Smoking and alcohol history.•
2 Tips for case presentation
Practise• . Every case is a possible presentation to someone!
Always ‘set the scene’ properly• . Start with name, age, occupation, and
any key medical facts together with the main presenting complaint(s).
Be chronological• . Start at the beginning of any relevant prodrome or
associated symptoms; they are likely to be an important part of the
presenting history.
Be concise with the past medical history• . Only expand on things that you
really feel may be relevant either to the diagnosis or management, e.g.
risks of general anaesthesia.
For systematic examination techniques, see the relevant following •
pages.
Always summarize the general appearance and vital signs fi rst.•
Describe the most signifi cant systemic fi ndings fi rst, but be •
systematic—‘inspection, palpation, percussion, and auscultation’.
Briefl y summarize other systemic fi ndings• . Only expand on them if they
may be directly relevant to the diagnosis or management.
Finally, • summarize and synthesize—don’t repeat. Try to group
symptoms and signs together into clinical patterns and recognized
scenarios.
Finish with a proposed diagnosis or differential list and be prepared to •
discuss what diagnostic or further evaluation tests might be necessary.
27
CHAPTER 2 Principles of surgery
28
Common surgical symptoms
Pain
Pain anywhere should have the same features elicited. These can be
summarized by the acronym SOCRATES.
S• ite. Where is the pain, is it localized, in a region, or generalized?
O• nset. Gradual, rapid, or sudden? Intermittent or constant?
C• haracter. Sharp, stabbing, dull, aching, tight, sore?
R• adiation. Does it spread to other areas? (From loin to groin in
ureteric pain, to shoulder tip in diaphragmatic irritation, to back in
retroperitoneal pain, to jaw and neck in myocardial pain.)
A• ssociated symptoms. Nausea, vomiting, dysuria, jaundice?
T• iming. Does it occur at any particular time?
E• xacerbating or relieving factors. Worse with deep breathing,
moving, or coughing suggests irritation of somatic nerves either in
the pleura or peritoneum; relief with hot water bottles suggests
deep infl ammatory or infi ltrative pain.
S• urgical history. Does the pain relate to surgical interventions?
Dyspepsia (epigastric discomfort or pain, usually after eating) What is the
frequency? Is it always precipitated by food or is it spontaneous in onset? Is
there any relief, especially with milky drinks or food? Is it positional?
Dysphagia (diffi culty during swallowing) Is the symptom new or long-
standing? Is it rapidly worsening or relatively constant? Is it worse with
solid food or fl uids? (Worse with fl uids suggests a motility problem, rather
than a stenosis.) Can it be relieved by anything, e.g. warm drinks? Can
the patient point to a ‘level’ of hold-up on the surface (usually related to
the sternum)? This often accurately relates to the level of an obstructing
lesion. Is it associated with ‘spluttering’ (suggests tracheo-oesophageal fi stula or inhalation of food/fl uid).
Oesophageal refl ux (bitter or acidic tasting fl uid in the pharynx or
mouth) How frequently? What colour is it? (Green suggests bile whereas
white suggests only stomach contents). When does it occur (lying only, on
bending, spontaneously when standing)? Is it associated with coughing?
Haematemesis (the presence of blood in vomit) What colour is the
blood (dark red-brown ‘coffee grounds’ is old or small-volume stomach
bleeding; dark red may be venous from the oesophagus; bright red is arterial and often from major gastric or duodenal arterial bleeding)? What
volume has occurred over what period? Did the blood appear with the
initial vomits or only after a period of prolonged vomiting (suggests a
traumatic oesophageal cause).
Abdominal distension Symmetrical distension suggests one of the ‘5
Fs’ (fl uid ascites, fl atus due to ileus or obstruction, fetus of pregnancy, fat,
or a ‘fl ipping big mass’). Asymmetrical distension suggests a localized mass.
What is the time course? Does it vary? It is changed by vomiting, passing
stool/fl atus?
COMMON SURGICAL SYMPTOMS
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Change in bowel habit May be change in frequency or looser or more
constipated stools. Increased frequency and looser stools is more likely
than isolated constipation to be due to a pathological cause. Is it a persistent or transient? Are there associated symptoms? Is it variable?
Frequency and urgency of defecation New urgency of defecation
is almost always pathological. What is the degree of urgency—how long
can the patient delay? Is there associated discomfort? What is passed—is
the stool normal?
Bleeding per rectum What colour is the blood? Is it pink-red and only
on the paper when wiping? Does it splash in the pan? (Both suggest a case
from the anal canal.) Is it bright red on the surface of the stool (suggests
a lower rectal cause)? Is the blood darker with clots or marbled into the
stools (suggests a colonic cause)? Is the blood fully mixed with the stool
or altered (suggests a proximal colonic cause)?
Tenesmus (desire to pass stools with either no result or incomplete
satisfaction of defecation) Suggests rectal pathology.
Jaundice (yellow discoloration due to hyperbilirubinaemia; b p. 312)
How quickly did the jaundice develop? Is there associated pruritus? Are
there any symptoms of pain, fever, or malaise (suggests infection)?
Haemoptysis (the presence of blood in expectorate) What colour is
the blood? (Light pink froth suggests pulmonary oedema.) Are there clots
or dark blood (infection or endobronchial lesion)? How much blood?
Moderate bleeds quickly threaten airways: get help quickly.
Dyspnoea (diffi culty in or increased awareness of breathing) When does
the dyspnoea occur—quantify the amount of effort. Is it positional?
Orthopnoea.• Diffi culty in breathing that occurs on lying fl at; quantify
it by asking how many pillows the patient needs at night to remain
symptom-free.
Paroxysmal nocturnal dyspnoea.• Intermittent breathlessness at night.
Both orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac
failure.
Claudication (the presence of pain in the muscles of the calf, thigh, or
buttock precipitated by exercise and relieved by rest) After what degree
of exercise does the pain occur (both distance on the fl at and gradients)?
How quickly is the pain relieved by rest?
Rest pain (pain in a limb at rest without signifi cant exercise) How long
has the pain been present? Is it intermittent? Does it occur mainly at night?
Is it relieved by dependency of the limb involved?
Dysuria (pain on passing urine) When does the pain occur (beginning, end,
or throughout the stream)? Is if felt in the penis or suprapubically? Is it associated with frequency? Is the urine discoloured or does it contain debris?
Haematuria (blood in the urine) Does the blood occur at the start
(suggests bladder origin), during, or end (suggests prostatic or penile origin) of the stream? Is there associated pain (suggests infection or stone
disease)?
29
CHAPTER 2 Principles of surgery
30
Evaluation of breast disease
Positioning and inspection
Breasts are best examined semi-recumbent and then sitting upright.
Initially, the arms are by the side, semi-recumbent. After initial inspection,
they should be positioned ‘hands on hips’, sitting upright (initially relaxed
and then with forced pressure on the hips to tense the pectoral muscles), and fi nally abducted slowly above the head. For palpation, the hands
should return to the hips and the patient may lie back semi-recumbent
again.
Inspection is critical and should concentrate on the following.
• Are the breasts the same size? Is there
Overall symmetry and position.
deformity due to underlying disease? Is the position normal?
Skin appearance.• Is the skin erythematous or oedematous? Is there
fi xed lymphoedema of the skin (‘peau d’orange’)? Are there scars from
previous surgery?
Skin tethering.• Does the skin move freely as the arms are raised?
(Tethering is suggestive of underlying intraparenchymal scarring or
tumour.)
Nipples.• Are the nipples indrawn, deviated, or ulcerated (suggestive of
retroareolar tumour or infection)? Is there any evidence of discharge?
Palpation
Use the fl at of the fi ngers and use all four fi ngers at once. Palpate the
‘normal’ breast fi rst. Be methodical and don’t ‘knead’ the breast. A common routine is: upper outer quadrant; lower outer; lower inner; upper
inner; central (retroareolar); supraclavicular fossa; axilla. Features to look
for include the following:
Palpable mass.• Is it hard, irregular, and tethered (cancer) or smooth,
rounded, and mobile (cysts or fi broadenoma)?
• Typical of benign disease.
Diffuse nodularity.
Nipple discharge.• On palpation of the central area. Blood suggests
tumour; pus suggests infection; serous or milky may not be relevant.
Axillary and supraclavicular lymphadenopathy.• Is it multiple and tethered
(cancer)?
Investigations
Ultrasound
•
Easy to perform and painless—often done in breast outpatient clinic.
Avoids radiation dose in young women.•
Highly sensitive for differentiating between solid tumours and cysts.•
Mammography
•
Used both for population screening and diagnostic testing.
Uncomfortable for most women and involves a low radiation dose.•
Able to identify impalpable lesions.•
Able to identify premalignant lesions (e.g. ductal carcinoma • in situ).
Mammographic features of malignancy include: spiculated •
microcalcifi cation; irregularity; stellate outline.
EVALUATION OF BREAST DISEASE
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Aspiration cytology
Well tolerated, easy to perform, and quick to report on—often done •
in one half day during breast outpatient clinic.
Does not provide histology: provides only cellular information and •
relies upon cellular atypia for a diagnosis of malignancy.
Does not differentiate between invasive and • in situ carcinoma.
Occasionally therapeutic for cysts.•
Good sensitivity and specifi city.•
Guided core biopsy
•
Performed under ultrasound or mammographic guidance using a
®
needle or similar device.
Trucut
Can be done under general or local anaesthetic.•
Provides actual histology information—allows cancers to be graded.•
Able to differentiate between invasive and carcinoma • in situ.
Highly sensitive and specifi c.•
Computerized tomography (CT) scanning
•
Relatively non-specifi c for local breast pathology.
Useful for assessment of extensive local invasion and regional and •
systemic staging.
CT positron emission tomography (PET) scanning
Occasionally used to assess indeterminate lesions identifi ed on plain •
CT and identify unsuspected metastatic disease.
Magnetic resonance imaging (MRI) scanning
Occasionally used for the assessment of local breast pathology.•
Key revision points—anatomy of the breast
Breast comprises epithelial ductal tissue, epithelial secretory lobules, •
fat, and connective tissue.
It is divided into four ‘quadrants’ and a peri/retroareaolar central
•
zone for clinical description of abnormalities.
The • areola is the pigmented area around each nipple.
The • arterial supply is from segmental perforators from the internal
thoracic artery (ITA).
Lymphatic drainage• —important in breast cancer management.
Non-pathological lymph drainage is almost entirely to the axillary •
nodes.
Medial half can occasionally drain to internal mammary nodes.•
Lymph nodes are divided into three levels (1, below; 2, behind; 3, •
above pectoralis minor).
31
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