Short Cases in Surgery by Besong

COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

CHEST TUBE 4. To drain the pleural cavity after thoracostomy Identify = closed tube thoracostomy drainage Procedure with underwater seal.  It is an aseptic procedure.  Fluid in drainage bottle is usually  A chest tube is placed at the 7th intercostal normal saline or distilled water. space midaxillary line for haemothorax or 2nd  Volume of fluid is a minimum of intercostal space anterior-axillary line for 400mls. pneumothorax. However, some modern day How does the chest tube work? teachings advocate 5th intercostals space 1. It is a passive drain that works by a pressure midaxillary line for both haemothorax and gradient between the positive intra-thoracic pneumothorax. pressure in the thoracic cavity and the  Locate the desired intercostal space for negative pressure in the drainage bottle. incision using the sternal angle and counting  The tip of the tube that is connected to the downwards. underwater seal must be submerged in normal  Under LA, a small incision is made at the saline/distilled water inside the bottle. The midaxillary line, parallel to the intercostal function of the fluid inside the bottle is to space chosen, just above the ribs to avoid the dissolve any air that comes in so that it does neurovascular bundle. A tube with side not flow back into the chest. openings is pushed into the pleural cavity.  One end of the 2nd tube is left outside but  The other end of the tube is connected to the tip does not touch the liquid in the the under-water seal. The tube is fixed to bottle. Its function is to equilibrate the the skin using sutures. pressure inside the bottle with atmospheric  Oscillatory movements within the tube pressure. indicate that it is functioning.  (See soft copy of OSCE material)  Increase in the volume of fluid in the Indications for chest tube drainage container is also an indication that 1. Pneumothorax the tube is functioning. 2. Pleural effusions such as; Indications for removal i. Haemothorax  When it drains less than 50mls per day for 3 ii. Pyothorax (Empyema thoracis) consecutive days. iii. Chylothorax  When the symptoms that prompted its iv. Hydrothorax insertion have resolved and evident by v. Haemopneumothorax o Adequate chest expansion vi. Traumatic lung contusion o Adequate air entry into the lungs 3. Oesophageal rupture with gastric leakage into o Absent respiratory distress the pleural space.  Resolved pleural effusion evident by radiological chest x-ray findings.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Sutures sounds and the amount and nature of 1. Anchoring suture: used to hold the chest tube drainage. in place. Chest tube can stop draining in the following 2. Purse string suture: placed loosely on the conditions; skin and is used to close the wound when the  When the tube is blocked chest tube is removed.  If the tube is kinked  If the tube has dislodged Care of the chest tube (STOP)  If the tube has drained all the fluid. S= site Extubation of the tube  Examine the site of insertion for any skin  It is an aseptic procedure excoriation and evidence of infection.  An assistant is needed  Dress the site daily or alternate days.  Remove the anchoring suture T= tube  Ask the patient to take a deep breath and  Must be right enough to prevent kinking and hold it ( to prevent air trapping and not too long or too short. pneumothorax by ensuring a positive  Must be fixed to the dressing to prevent intrathoracic pressure) kinking and undue traction.  Simultaneously remove the tube (the  All junctions must be taped from tubing to assistant pulls it out) while tying the purse tubing to prevent the tubes pulling apart string suture to make the wound airtight.  Must be checked for patency by observing  Dress the wound with sulfratulle gauze (this oscillatory motions. contains an antibiotic – 1% framycetin O = output sulphate + a petroleum jelly lubricant)  Ensure tube is draining  Close the site with plaster and leave it for  Bottle should be large enough to collect fluid 48hrs after which you can start daily of 500 – 600mls and above the initial water dressing of the wound until it heals. content. COMPLICATIONS  The bottle should at all times be well below 1. Infections e.g pleuritis, mediastinitis etc the level of the chest to prevent air or fluid 2. Tube displacement from draining back into the chest. 3. Injury to the intercostal nerves and vessels.  The tube must be clamped at 2 different 4. Damage to soft tissues e.g lungs etc. points especially when patient wants to go and 5. Bleeding urinate or go to toilet. 6. Bronchopleural fistula P= position 7. Subcutaneous emphysema  Position of the tube should be determined 8. Pain at the site of insertion of the tube radiologically whether it is well inserted.  Regularly assess patient for comfort, dyspnea, respiratory movements, breath

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

CAUSES OF AIR BUBBLES IN CHEST TUBE 2. BBB: tube at the Back (posterior) is Basal  Bronchopleural fistula (7TH ICS) and drains Blood(fluid)  Inappropriate insertion of tube so that one of the fenestrations is not within the pleural cavity  Open pneumothorax NASOGASTRIC INTUBATION Before you pass a chest tube, prepare the bottle by (NG TUBE) washing with jik and pouring normal saline into it. INDICATIONS If the tube is draining fluid, the fluid in the lower A. Therapeutic indications half will be oscillating. The oscillation is produced by i. Feeding in an unconscious Px the movement of the lungs towards the chest wall. If ii. Decompression of the stomach in GIT there is no oscillation, ask the patient to cough to obstruction check for any oscillations. If there is none, then the iii. Administration of drugs tube is blocked. iv. Gastric lavage in GOO/ ingestion of WAYS OF UNBLOCKING THE CHEST TUBE toxic substances 1. Milking the tube. v. After abdominal surgeries e.g in 2. Injecting a sclerosant to dissolve any splenectomy to avoid acute gastric coagulum. dilatation that occurs post-op 3. Pass a sterile NG tube through the chest B. Diagnostic indications tube to dislodge any clot. i. Early morning gastric lavage for 4. Remove the tube, clean the mouth and re-pass collection of samples for AFB (TB in it. But sometimes there may have been children). necrosis around the area where the tube was ii. Massive upper GI bleeding passed previously so you re-pass the tube at iii. Diagnosis of choanal atresia another location. iv. Diagnosis of oesophageal atresia

PROCEDURE CHEST X-RAYS DONE WHEN PASSING A CHEST  Explain the procedure to the patient, and TUBE obtain informed consent. 1. Pre-intubation chest x-ray  Estimate the length needed (from the tip of 2. Post intubation chest x-ray the nose to the tragus of the ear and down to 3. Pre-extubation chest x-ray. the xiphoid process) 4. Post-extubation chest x-ray.  Position the patient so that he or she is N/B sitting upright in the “sniffing” position (neck Normally after a thoracotomy, 2 chest tubes are flexed and head extended). passed for draining air and blood/fluid  Lubricate the tip of the tube with viscous 1. AAA: Anterior tube is Apical (2nd ICS) and lidocaine or a surgical jelly. drains Air

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

 Advance the tube through one nostril and ask vi. Trachea-oesophageal fistula the patient to swallow immediately he feels it. vii. Cancer of the cardia  Advance the tube until the corresponding viii. Corrosive oesophageal stricture length has been inserted. ix. Severe sepsis HOW TO KNOW THAT THE TUBE IS IN THE x. Burns STOMACH CONTRAINDICATIONS  Push air into the tube using a syringe and  Previous gastrostomy listen for boborygmies using a stethoscope  Gastric diseases with impaired emptying placed at the epigastrum.  Intestinal obstruction  Aspirate stomach contents and test with a  Massive ascites litmus paper (blue litmus turns red).  Peritonitis  Put the end of the tube into a bowl of water,  Uncorrected coagulopathy air bubbles will be observed if it is in the  Morbid obesity trachea (tracheal intubation).  Intra-abdominal malignancy.  Do an abdominal X-ray to see the radio- COMPLICATIONS opaque line in the tube.  Infection e.g gastritis, cellulitis CONTRAINDICATIONS  Trauma /perforation of surrounding organs 1. Maxillofacial trauma such as the colon, spleen etc 2. Oesophageal abnormalities  Leakage from gastrostomy site 3. Altered mental status and impaired defenses  Aspiration pneumonitis COMPLICATIONS  Blockage of gastrostomy tube. i. sinusitis,  Haemorrhage ii. epistaxis,  Gastric ulcer

iii. sore throat.  Gastrocolic fistula iv. esophageal perforation,  “Buried bumper syndrome” (the gastric part v. tracheal intubation of the tube migrates into the gastric wall) vi. aspiration pneumonitis, vii. pneumothorax, TYPES A. Temporary a. Serous-lined GASTROSTOMY b. Stamm’s Indications c. Kader-sem i. Nasopharyngeal tumours d. Percutaneous-endoscopic gastrostomy (PEG) ii. Oral cancers B. Permanent iii. Bronchogenic tumours affecting the a. Mucosa-lined oesophagus b. Janeway’s iv. Oesophageal cancers v. Oesophageal atresia.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

PROCEDURE d. Perforation of left colon  A supraumbilical midline incision (ideal one is e. Left sided colonic cancers left paramedian incision) is made. f. High anal fistula  Choose the site, usually lower anterior part of g. Trauma to the left sided colon. stomach and make an opening ii. Permanent  Through a stab wound in the left a. Abdomino-peritoneal resection of hypogastrium, pass the tube (Foley’s or rectum for a carcinoma Malicot’s catheter) into the stomach and put b. Cancer of anal canal two purse strings around the tube. c. After Hartmann’s operation  Anchor the stomach to the anterior COMPLICATIONS abdominal wall. 1. Mucosal prolapsed 2. Stoma Retraction 3. Skin excoriation COLOSTOMY 4. Stoma necrosis 5. Stoma stenosis Types 6. Para colostomy hernia  Temporary (defunctioning and loop colostomy) 7. Colostomy diarrhea  Permanent (end colostomy) 8. Social isolation (See soft copy of OSCE material) 9. Mental depression. Temporary colostomy 10. haemorrhage  Site is right hypogastrium and left iliac fossa TREATMENT OF COMPLICATIONS  Could be ;  Skin excoriation: use zinc oxide cream and . Loop colostomy colostomy bag to collect discharge. . Or Defunctioning colostomy (double  Mucosal prolapse: make the stomach tight barreled colostomy. But never say  Haemorrahge: use pressure or diluted double barrel because Dr. Ekenze will adrenaline penalize u if u say double barrel)  Stoma stenosis: colostomy revision or Permanent colostomy recanalization  Site is lateral edge of the rectus sheath, 6cm  Parastomal hernia: re-exploration and closing above and medial to the anterior superior iliac lateral space spine (left iliac fossa)  Colostomy diarrhea: metronidazole or change  Commoner in adults. to high fibre diet. Oral metronidazole = Indications 200mg tds. i. Temporary CAUSES OF SKIN EXCORIATION a. Hirchsprung’s disease  Leakages b. Anorectal malformations  Wet skin b4 placing the appliance c. Sigmoid volvulus  Inadequate stoma hole

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

 Improper and inadequate adhesive sheet  In a fracture over a long bone the plaster usage should start proximal to the proximal joint  Allergy and stop distal to the distal joint (see above  Infection knee cast for fracture of the tibial shaft).  Altered weight of the patient Instructions to patients in POP 1. Watch out for tightness 2. Observe swelling of distal limb 3. Keep the limb elevated for 2-3 days PLASTER OF PARIS (POP) 4. Do not walk on plaster unless advised to do so.  Plaster of Paris is hemihydrated calcium 5. Avoid wetting the plaster sulphate which occurs naturally as a mineral 6. Return to the Doctor in case of rock - gypsum. First discovered near the city complications.

of Paris in France. 2(CaS04. 2H2O) + Heat

2 (CaSO4. ½H2O) + 3H2O. TYPES OF POP SPLINTS  POP bandages are made by commercially i. Casts:- These are encircling POP splints used heating gypsum then crushing it into powder. in the limbs. In the upper limbs they include; Then rolls of moslin bandages are stiffened above elbow cast, fore arm cast, wrist cock up with the POP powder and cut into 3 sizes 10, splint. 15 and 20cm. Lower limb: long leg cast, long leg cylinder, above knee cast, below knee cast, booth POP. APPLICATION OF POP CAST ii. Slabs:- Incomplete POP support for limbs  Materials: e.g. above elbow slabs. (slabs are temporal and o Rolls of POP used when there is severe pain or infection o Rolls of cotton wool/Velband around the fracture. Can be complete or made o Bucket/bowel of clean water into a cast when pain has reduced or infection o Plaster shear – Manual, Electric has been taken care of.) Procedure iii. Jackets:- Complete POP casts for trunks  Pad the area concerned with the Velband e.g. Thoracolumbar jacket; lumbar jacket,  Soak a plaster bandage in a cold-to-warm Minerva Jacket (a plaster of Paris body cast clean water and allow the air bobbles to incorporating the head and trunk, usually for escape. fracture of the cervical spine.)  Roll the bandage smoothly over the padding. iv. Spicas:- Casts which branch from the main Smoothen further with the palm not the body of the casts: shoulder spicas, hip spicas fingers. and thumb spicas.  Complete your manipulation quickly before the v. Cast bracing:- Sarmiento – allows movement plaster sets. of the joint, after callus has formed.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

COMPLICATIONS OF PLASTER SPLINT DISADVANTAGES 1. Pain  It is very expensive 2. Pressure Sores  It cannot be easily manipulated 3. Compartmental Syndrome (remember the 6Ps of compartment syndrome). Other Orthopaedic Splints Include Tractions 4. Peripheral nerve injury (neuropraxia) 1. Skin traction 5. Joint stiffness 2. Skeletal traction 6. Plaster Blister and Sores Parts of skeletal traction 7. Breakage  Steinmann’s pin (which is non- threaded) or 8. Allergic dermatitis Denhan’s pin (threaded) The principle of pop application in fracture mgt is  Stirrup that the plaster should start proximal to the  in-extensible cord or traction cord proximal joint and stop distal to the distal joint i.e it  Pulley system must cross 2 joints.  Weights ADVANTAGES OF POP  The Steinman’s pin is inserted into the bone i. It is cheap below the fracture and attached to a weight ii. Easy to fashion through a cord which pulls the bone to correct iii. Easily available the deformity. For fractures of the femur, the iv. Quick setting pin is inserted under the tibia tubercle. v. Permeable to x-ray i.e transparent to x-rays  The foot of the bed is usually elevated to vi. Non-inflamable balance the weight at the pulley and the patient’s DISADVANTAGES weight and ensure a resultant weight of zero at i. Slow to dry the pulley (just like Newton’s 3rd law of motion). ii. Very heavy when wet  In skeletal traction, the weight used is usually iii. Not very durable about 10% of the patient’s weight.

Indications of skeletal traction i. To reduce fractures SCOTCH CAST ii. To immobilize fractures Made of fibre glass COMPLICATIONS

ADVANTAGES a. Pin tract infection

 It is lighter b. Injury to underlying nerves and vessels

 It is durable c. DVT

 It is stronger d. PTE

 Water resistant e. Orthostatic pneumonia

 Non-allergic f. Chest infections

 Permeable to x-rays g. Pressure sores

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

SKIN TRACTION AMPUTATION Parts of skin traction Surgical amputation is removal of a limb or part of it  Adhesive tapes or any other appendage from the body  Spreader (or foam) INDICATIONS  In-extensible cord or rope • Congenital conditions like  Pulley system • polydactyly,  Weight (not more than 5% of patient’s • digital or gross limb giangantism, weight) • phocomelia, etc Indications of skin traction Acquired conditions like: i. To reduce and immobilize fractures in 1. Severe trauma resulting in dead or dying limb children e.g ii. To rest the limbs e.g in acute osteomyelitis i. traumatic amputation, iii. In pelvic fractures ii. mangled or severely crushed limb, iv. To achieve bed rest in adults iii. type 3C open fracture presenting v. Used to immobilize fractures in adults with late- after 6 hrs very low weight 2. Limb neoplasms e.g advanced osteosarcoma

3. Peripheral vascular disease leading to EXTERNAL FIXATORS severe limb ischaemia or gangrene. TYPES 4. Deadly infections e.g gas gangrene and  Uniplanar chronic resistant damaging and deforming  Multiplannar bone or soft tissue limb or digit infection.  Modular 5. Metabolic conditions - grade 4/5 diabetic

foot INDICATIONS 6. Neuro conditions – insensate, deformed or  To reduce fractures flail functionless limb e.g in late leprosy.  To immobilize fractures TYPES OF AMPUTATION PARTS 1. Provisional or open amputation  Pin 2. Definitive or closed amputation  Clamp OPEN AMPUTAIONS  Bar/frame Indications; CARE OF FIXATORS - when primary healing is unlikely b/c infection  Clean pin site daily or ischemia,  Daily dressing of wound - when clinical condition of pt does not allow COMPLICATIONS ( As in skeletal traction) for long op eg very ill patient.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Types of open amputation include; 4. Flap necrosis.  Guillotine 5. Gangrene of stump.  Flap technique 6. Oedema of stump. DEFINITIVE OR CLOSED AMPUTAION 7. Infection. Indicated in ideal clinical and clean surgical condition. 8. Phantom limb. Phantom pain (painful phant Types of closed amputation; limb). i. End-bearing 9. Neuroma formation. ii. Non end-bearing amputation 10. Joint contracture. e.g of end-bearing amputation include; 11. Instability of stump. a) Syme’s amputation near the ankle 12. Stump ulceration. b) Gritti Stoke’s amputation near the knee 13. Psychological disturbance b/c of stigma of e.g of non-end bearing amputation include; amp. i. All amputations in the upper limb ii. Ray’s amputation iii. Transmetatarsal (Gilles) iv. Tarsometatarsal (Lisfranc) v. Mid-tarsal (Choparts) vi. Below knee vii. Above knee TALIPES EQUINOVARUS Non-end bearing are the commonest amputations. Diagnosis is made from the triad of;  Equinus deformity of the ankle  Adduction of the forefoot (varus deformity) SITES OF ELECTION FOR AMPUTATION  Inversion of the midfoot. • In the upper limb: • B/E: 18 cm from tip of olecranon process Goals of treatment • A/E: 20 cm from tip of acromium  To correct deformity early • In the lower limb:  To correct fully • B/K: 14 cm from knee joint line  To maintain correction until growth stops • For A/K, 12 cm from knee joint line must be TREATMENT MODALITIES removed proximally to allow good knee 1. Conservative by serial manipulation and function application of POP • From greater tronchanter, 25 cm is best level  Treatment starts 2 – 3 days after COMPLICATIONS birth 1. Primary hemorrhage.  Maternal stretching for 15mins about 2. Reactionary hemorrhage. 6x daily 3. Secondary hemorrhage & Hematoma  Manipulation/ POP application formation.  Reverse shoe wear

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

2. Surgical CATHETERIZATION Timing  Done within 2 – 3 months after birth Parts of a catheter: in developed countries  Tip  9 – 12 months before the child walks  Eye in our environment  Stem (tube)  If child presents >5years, osteotomy  Flange ( Y-junction) – it determines the type is done of catheter whether2way or 3way. Surgical procedure include; o 2way has a balloon port and a drainage A. Below 5years port. 1. posteromedial release and elongation o 3way (balloon port, drainage port and of tendo-Achillis (ETA). For children irrigation port). below 4years of age. Classification B. ABOVE 5 YEARS. 1. Self-retaining catheters e.g 2. Calcaneo-cuboid joint wedge excision a. Foley’s catheter, and fusion (Dillwyn Evans operation) b. Malicot catheter 3. Medial open-wedge osteotomy of the c. T-man’s catheter calcaneus with a wedge bone graft 2. Non-self retaining catheter e.g Jacki’s (Dwyers operation) catheter. C. ABOVE 10YEARS Other classification based on material used; 4. Triple arthrodesis-fusion of the 1. Latex catheter subtalar, calcaneo-cuboid and talo- 2. Rubber catheter navicular joints. This is indicated in 3. Silicon catheter older children above 10years usually 4. Metal catheter. to correct neglected or relapsed  Silicon catheter is the best, it can stay up to clubfoot. 6 months and has less complications when 5. Tendon transfers: used.  Metal catheters are used to catheterize INDICATIONS FOR SURGERY women in labour.  Rigid type of TEV; SIZING OF CATHETERS  Failed conservative treatment;  They are sized in French in ‘charireie’ (CH).  Recurrent TEV  The sizing is in even numbers only.  Late presentation.  The larger the number, the larger the catheter.  The size of the drainage channel is a function of the size of the catheter e.g size 24CH 24/3 = 8mm.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

The drainage channel is 1/3 the size of the catheter.  Inflate the balloon with 15 – 20ml of water Urethral catheterization for injection. Materials  Pull out the catheter a little so that the 1. Foley’s urinary catheter size balloon rest at the bladder neck. 2. Urine bag  Clean up the patient. 3. Surgical gloves For a woman: 4. Water for injection  Flex the legs at knee and the thighs at the 5. 20ml syringe hip. 6. Sterile drape  Clean the vulva and labia from anterior to 7. Anaesthetic lubricant e.g xylocaine gel (or posterior. improvise with KY jelly)  Use your fingers to part (push aside) the labia Procedure and instill the catheter.  It is an aseptic procedure  In this case a xylocaine or KY jelly may not be  Explain the procedure to Px and obtain used because of the shortness of the female consent urethra (4cm). Thus there is no discomfort.  Wash your hands with soap and detergent. INDICATIONS FOR CATHETERIZATION  Put on an apron and sterile gloves. 1. To relieve Urinary retention  Lie the patient in a supine position. 2. For monitoring urine for surgery  Clean the Px from the umbilicus to the mid- 3. Pelvic surgeries thigh and clean the ext genitalia thoroughly 4. For cystourethrogram using povidone iodine or chlorehxidine. 5. After prostatectomy  N/B: do not use iodine or spirit b/c it 6. After urethral surgery irritates the mucosa. 7. Following trauma to the bladder  Drape the patient to expose the ext genitalia. 8. To irrigate the bladder following haematuria  Instill the xylocaine gel into urethra via the with clot formation. meatus by holding up the penis and milking CONTRAINDICATIONS down the content of the tube into the 1. Urethral damage following pelvic fractures urethra. 2. Very large prostate which causes the urethra  The Px is allowed to sit for about 5mins so to kink that the xylocaine can take effect. 3. Urethral strictures  While holding the penis with the left hand at 4. Urethral tumours an angle of 450 to the horizontal, the catheter is inserted with the right hand and COMPLICATIONS advanced right down to the flange so that the 1. Cystitis because of inflammation balloon will be in the bladder and/or urine 2. Formation of stones starts flowing out. 3. Urethral damage 4. Retained catheters

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

5. Long term catheters can cause Small bladder  After the examination, a diagnosis is made syndrome. with the following description; 6. Long term catheters can also cause urethral 1) On which side is it? strictures. 2) Is it indirect or direct? N/B 3) Is it complete or incomplete?  Catheters should be changed every 2-3 weeks 4) Is it reducible?  Silicon and small sized catheters are usually • Thus it is reported as such; e.g Right, indirect, the best. complete, reducible inguino-scrotal hernia.  The average male catheter is size 18CH and 16CH for females. DIFFERENTIALS OF INGUINAL HERNIA: In Males: • Femoral hernia EXAMINING AN • Vaginal hydrocele • Encysted hydrocele of the cord INGUINOSCROTAL SWELLING • Ectopic or undescended testis 1. Tell Px to stand • Cyst of the epididymis 2. Inspect the genitalia thoroughly • Inguinal lymphadenopathy 3. Do a visible cough impulse • Saphena varix 4. Then do a tactile cough impulse • Sebaceous cyst 5. Try to get above the mass • Lipoma 6. If you get above the mass, then it is an In Females: intrascrotal mass. If you can’t get above it, • Femoral hernia as above then it is inguinosrotal. • Cyst of the canal of Nuck – it is in the groin 7. Tell the Px to lie down and try to reduce it. and is soft or tense and fluctuant. There is no 8. While he is lying down locate the pubic cough impulse. It is the female equivalent of tubercle to distinguish an inguinoscrotal encyted hydrocele of the cord in males. hernia from a femoral hernia. • Lipoma, sebaceous cyst, inguinal  If the hernia enters the scrotum or labium lymphadenopathy, saphena varix as in males. majus, then it is complete, if not, it is incomplete. TREATMENT • Mid inguinal point is midway b/w the ASIS and Operative repair is the treatment as there is always the pubic symphysis. the risk of strangulation. • Mid pt of the inguinal ligament is midway b/w Indirect Inguinal hernia: the ASIS and the pubic tubercle. There are 3 essential requirements: • Finger breath (1.25cm) above the mid pt of the 1. Excision of the hernia sac at the neck inguinal ligament is the deep ring. (herniotomy)

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

2. Tightening of the internal inguinal ring around the foot and the sacrum and on bony areas in the spermatic cord. a bed ridden patient i.e bed sores. 3. Repair of the weak posterior inguinal wall in  Ischeamic or arterial ulcers are common on those aged over 15yrs (Herniorraphy). the dorsum of the foot and the toes  Diabetic ulcers common on the planter area of the foot, the leg, upper limb, back, scrotum, perineum etc. 5. Margin & edge of the ulcer: the margin is ULCERS the ‘border’ or “transitional zone” of skin An ulcer is a breech in continuity of epithelial surface around the ulcer i.e the line demarcating the with stigmata of chronicity ulcer from the intact skin. There are three  Marginal fibrosis/scarring types of margins;  Pigmentary changes a. Healing margin: is a typical bluish line  Lichenification of squamous epithelium with outer  microscopic chronic inflammatory cell cornification hence looks bluish. infiltrates Outsite the bluish line is a white line INSPECTION of newly cornified epithelium. Inside Look out for the bluish line, is a red/pink line of 1. Size: measure the size using a tape in granulation tissue. Thus the margin of centimetres in two dimensions. a healing ulcer shows 3 lines 2. Shape i. Outer white line 3. Site: anatomical position using any land mark. ii. Central blue line 4. Number: note the number whether it is a iii. Inner red/pink line single ulcer or there are many others in other b. Inflamed margin: typical of a parts of the body. spreading ulcer with inflamed N/B: surrounding skin Many ulcers have a characteristic site where they c. Fibrosed (callous) margin: typical of a occur e.g chronic, non-healing ulcer with marked  Varicose ulcers (venous ulcers) are located on fibrosis and thickened white skin the medial aspect of the lower 1/3 of the leg margins without the blue line of (gaiter area). growing epithelium.  Rodent ulcers on the face EDGE OF AN ULCER:  Tuberculous ulcers are common in the neck Is the mode of union b/w the floor and the area of TB lymphadenopathy margin of the ulcer. There are 5 types of  Trophic or neuropathic ulcers are common on edges weight bearing areas e.g over the heels of 1) Slopping edge 2) Punched-out edge

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

3) Undermined edge FOCAL EXAMINATION 4) Everted edge . Regional lymph notes 5) Raised and rolled edge o Hard, discrete, non-tender notes = 6. Floor & Base of the ulcer: Floor is the malignant ulcers exposed surface of the ulcer that u can see o Soft, tender = infective ulcer Note: o Non-tender, matted together = TB i. The kind of granulation tissue. (Proud ulcers flesh is hypertrophic granulation . Examine state of the arteries by checking tissue.) the pulses around that area, venous ii. Amount of slough present circulation & nerves. iii. Nature of discharge which could be . Mov’t of neighbouring joints serous, sanguinous, serosanguinous or . For ulcers of the lower limb, ask Px to stand purulent. and examine the long and short saphenous Base: is the tissue on which the ulcer rest. It veins and varicose veins. could be bone, muscle or fascia. . Also check for DVT if venous ulcer is 7. Surrounding skin: suspected by checking for calf tenderness . Shiny red skin due to cellulitis and Homan’s sign. . Pigmentation e.g in varicose ulcers . Check for the pulses on the lower limb i.e . Multiple scars and puckering of skin posterior tibialis artery pulsation and anterior as in TB ulcers tibia artery pulsation. . Hypopigmentation of skin common in . Test for sensations with a pin prick around non-healing ulcers the ulcer especially in neuropathic ulcers. . Ulcers within a large scar – marjolin’s . Test mov’t across the joint: mov’t restriction ulcer. signifies muscle involvement, pain or tendon PALPATION involvement. a. Surrounding skin for temperature & . Ask patient to walk and check the gait. tenderness SYSTEMIC EXAMINATION b. Wear gloves and palpate the edge, floor and A. CVS – for evidence of CCF which delays ulcer base. Soft edge (healing ulcer), firm edge healing. (non-healing ulcer), hard edge (malignant B. Resp system – TB and secondaries ulcer). Palpate the floor to note the C. Abd system – for evidence of splenomegaly in consistency of the base and to note the heamolytic anaemia in leg ulcers. underlying structure whether bone or muscle. c. Test the fixity of the ulcer to the structures in the base. Move the ulcer from side to side in 2 dimensions to find out if it is attached to the underlying structures.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

GENERAL INFORMATION ON ULCERS 4. Peripheral neuropathy CLASSIFICATION OF ULCERS Ulcers associated with metabolic or systemic disease Chemical classification; - Diabetic ulcers i. Spreading ulcers - Haemoglobinopathic ulcers ii. Healing ulcers - Ulcers of ulcerative colitis iii. Callous ulcers Neoplastic ulcers Pathological classification (most important); i. Squamous cell carcinoma i. Specific ulcers ii. Basal cell carcinoma (rodent ulcers) ii. Non-specific ulcers iii. Malignant melanoma ulcers iii. Neoplastic/malignant ulcers iv. Kaposi’s sarcoma Spreading ulcer: v. Penetrating malignant tumour - Edge is inflamed and oedematous vi. Marjolin’s ulcer Healing ulcer Parts of an ulcer: - Edge is sloping into pink/red granulation - margin tissue with serous discharge - Edge Callous ulcer - Floor - Floor contains pale unhealthy granulation - base tissue characteristics of an ulcer - Has indurated edge and base - site - Does not show any tendency to heal. - shape Specific ulcers: - size a. Tropical ulcers - surrounding skin b. TB ulcers - edge c. Buruli ulcers - floor d. Syphilitic ulcers - base e. Yaws ulcers EDGE: Non-specific ulcers: 1. sloping edge – healing/ non-specific ulcers i. Traumatic ulcers 2. undermined edge – Tb ulcers, pressure ulcers ii. Pyogenic ulcers on buttocks iii. Ulcers of vascular origin (arterial ulcers and 3. punched-out edge – syphilitic and trophic venous ulcers) ulcers (due to end arteries), leprosy, iv. Decubitus ulcers peripheral arterial ischemic ulcers. v. Pressure sores 4. raised and rolled out – BCC ulcers, rodent Neurotropic/neuropathic (trophic) ulcers: ulcers. 1. Leprosy 5. Everted edge – SCC, malignant melanoma 2. Diabetic neuropathic ulcers ulcers. 3. Cord lesions

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Phases of an ulcer Daily dressing - Extension phase - This is done using solutions and type of - Transition phase solution depends on type of wound - Repair (healing) phase - For dirty wounds/ulcers in the extension Extension phase phase, wash with hydrogen peroxide and pack  Lots of exudate and slough with EUSOL (A & B) – a desloughing agent.  Wound is dirty - EUSOL: Edinburg University Solution of Lime.  Could contain devitalized tissues and debris - For dirty wounds, you can also use sterile Transition phase horney. It is a powerful agent for dressing  Granulation tissue formation wounds because of the following properties  Decrease in slough and exudate quantity o It is bactericidal Repair phase o It helps to regress the wound and  Granulation tissue is mature prevent edema via osmosis due to its  Wound is red/pink sugar content  Absence of slough or exudate o It contains inhibin that prevents or inhibits bacterial growth SPECIFIC INVESTIGATIONS FOR ULCERS o It is able to eat up necrotic and  Wound swab for mcs devitalized tissue.  Wound biopsy for histology o Reduces the tendency for  FBS hypertrophic scars formation.  Mantoux test - For dirty wounds, you can also use mashed  Chest Xray pawpaw or maggots. Mashed pawpaw contains  Xray of limb where ulcer is located to r/o sugar that helps to draw water from the bone involvement wound and prevent edema.  Sputum AFB if px has cough - N/B: EUSOL is not used in wounds that are  Hb electrophoresis to r/o sickle cell disease granulating because it eats up the granulation  Serology tissue. EUSOL A contains hypochlorite while  ESR EUSOL B contains boric acid.  FBC - For wounds that are granulating (Transition or  Urinalysis Repair phase), use savlon, chlorhexidine, TREATMENT OF ULCERS hibitane or normal saline. - Daily dressing to allow for granulation tissue formation & Limb elevation Layers of wound dressing (NTAR) - Treatment of underlying cause 1) Non-Adherent layer: made up of sufra- - Patient education of not using that part of tulle gauze (Vaseline gauze). It is the body without control or foot care in case impregnated with an antibiotic- framycetin of diabetic patients. sulphate and a clean jelly so that it can be

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

pealed-off without pains and bleeding. The PTERYGIUM Vaseline in it also prevents entrance of bacteria into the wound. Parts: 2) Transmissive or conductive layer: made up . Head of gauze. it is like a capillary layer i.e it . Neck conducts discharge from the wound by . Body capillary action into the 3rd layer. . Base 3) Absorbent layer: made up of a layer of Stages: thick cotton wool to absorb the discharge I. Incipient stage: the apex is at the limbus that has passed through the 2nd layer. (corneo-scleral junction) 4) Restrictive or Occlusive layer: made up of II. Established stage: apex is between the limbus plaster or creppe bandage. and the pupillary margin. Treat underlying cause based on laboratory III. Critical stage: the apex is at the pupillary findings from investigations carried out e.g strict margin. glyceamic control in diabetics, venous ligation and IV. Blinding stage.: the apex is beyond the sripping in varicose veins. pupillary margin and encroaches on the visual Use of occlusive/elastic stockings in case of axis. venous ulcers. Provide wound cover when the wound is clean and CLINICAL FEATURES sufficient granulation tissue has formed. Split skin . Foreign body sensation graft or a flap as may be appropriate. . Redness of the eye Complications of ulcers . Visual impairment  Bleeding . Triangular conjunctival growth  Osteomyelitis if the base is a bone . Astigmatism  Malignant transformation TREATMENT  Keloids and hypertrophic scars Surgical excision N/B: the absolute indication for removal of pterygium is stages III and IV. Indications for removal of stages I & II is cosmesis TECHNIQUES FOR REMOVAL . Bare sclera removal . Pterygium excision with sliding graft . Pterygium excision with conjunctival autograft.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

COMPLICATIONS OF THE SURGERY AQUIRED CAUSES – . Recurrence 1. Senility, . Corneal perforations 2. Trauma, . Rectus muscle dis-insertion (esp medial 3. Uveitis, rectus) 4. Drugs (Steroids) . Infection e.g conjunctivitis, iritis TYPES OF CATARACT: . Granuloma formation • Hypermature- wrinkled capsule PREVENTION OF RECURRENCE • Intumescent – swollen lens Use of; • Morgagnian- liquified cortex, nucleus sunken . 5-flurouracil inferiorly. . Mitomycin C TREATMENT TECHNIQUES . β- irradiation . Intracapsular cataract extraction + anterior . thiotepa chamber intraocular lens. DIFFERENTIAL DIAGNOSIS . Extracapsular cataract extraction + i. penguiculum intraocular lens implant. ii. phlyctenular keratoconjunctivitis . Small incision cataract surgery. iii. episcleritis (nodular) . Phaecoemulsification iv. marginal keratitis . Lensectomy v. glaucoma filtering bleb . Lens washout vi. pseudopterygium vii. conjunctival cyst COMPLICATIONS OF THE SURGERY viii. conjunctival papilloma i. Post-operative endophthalmitis ix. conjunctival telangiectasia ii. Corneal edema iii. Retinal detachment iv. Suprachoroidal haemorrhage CATARACT v. Rupture of posterior capsule vi. Posterior dislocation of intraocular lens Possible causes vii. Posterior capsule opacification i. young: congenital viii. Iris prolapse ii. young Aldults: Trauma ix. Cystoid macular edema iii. Elderly: senile How will you visually rehabilitate a patient after CONGENITAL CAUSES - (DIGIMOS) cataract surgery? a. Drugs, . Give spectacles b. Infection, . Put intraocular lens c. Genetic, . Use of contact lenses d. Idiopathic,

e. Metabolic Syndromes,

f. Ocular /Systemic Syndromes. © Besong on behalf of MEDIX FRONTIERS

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

DIFFERENTIALS OF CATARACT xix. Allergy. a. Retinoblastoma SYMPTOMS b. Coat’s disease (exudative retinitis) i. Blurred vision c. Toxocariasis ii. Coloured haloes . Cataract is said to be mature when there is a iii. Discharge complete cortical opacity and the fundus iv. Itching cannot be seen even after dilatation of the TREATMENT pupil.  Admit Px if very serious . Fundoscopy is done to make a diagnosis of  Assess VA cataract.  Assess the IOP  Place px on drugs that can reduce IOP e.g mannitol or IV Diamox RED EYE  Maintain IOP with drugs such as 2 or 4% pilocarpine or use timolol to reduce secretion CAUSES of acqueous humour. i. Acute angle closure glaucoma  Reduce pain by giving analgesics. ii. Acute conjunctivitis  Treat underlying cause iii. Iritis or iridocyclitis  If any need, prepare for surgery (peripheral iv. Herpes simplex keratitis iridectomy or laser iridectomy) v. Episcleritis

vi. Scleritis vii. Subconjunctival haemorrhage viii. Pterygium PROPTOSIS ix. Keratoconjunctivitis x. Corneal abraision CAUSES OF PROPTOSIS xi. Foreign body 1. Hyperthyroidism xii. Trauma 2. Intra-orbital tumour (retinoblastoma) xiii. Sinusitis 3. Ethmoidal sinusis mucocele xiv. Anterior uveitis 4. Lacrimal gland tumour xv. Panuveitis 5. Metastatis from extra-occular tumours e.gh xvi. Tumours e.g retinoblastoma burkitt’s xvii. Systemic diseases e.g hypertension & DM 6. Lymphangioma xviii. Adnexal diseases 7. Retrobulbar heamangioma a. Blephoritis 8. Cavernous angioma b. Thyroid eye disease 9. Dermoid cyst c. Dacryocystitis 10. Orbital cellulitis d. Hordeolum 11. Panophthalmitis e. chalazion 12. Carvenous sinus thromboembolis © Besong on behalf of MEDIX FRONTIERS

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

 Exophthalmometer is the instrument used to TRACHEOSTOMY measure proptosis (exophthalmos)  If the measurement is >20mm from the Tracheostomy – This is an opening created in orbital margin, then there is proptosis the anterior wall of the trachea to establish  If the difference in the values between the an airway. two eyes is >2mm, it is significant. Tracheotomy – It is a slit made on the anterior wall of the trachea.

DIFFERENCES B/W PROPTOSIS & TYPES OF TRACHEOSTOMY EXOPHTHALMOS Type depends on;

i. Proptosis is the protrusion of any organ from - Duration: Permanent / Temporary its original location while exophthalmos is as a - Site: High, Intermediate, Low result of an endocrine cause. - Indication:- Elective or Emergency

ii. There is lid retraction in exophthalmos but no Normal tracheostomy is done between C3 & C4 lid retraction in proptosis High is done between C1 & C2

iii. Lid lag is present in exophthalmos but absent Low type is done below C4. in proptosis iv. There is a stearing appearance in exophthalmos but absent in proptosis 4 MAIN INDICATIONS OF TRACHEOSTOMY

v. Infrequent blinking in exophthalmos but 1. Relief of upper airway obstruction

normal blinking in proptosis. 2. Protection of tracheobronchial tree

vi. Both have lid edema 3. In Conditions leading to respiratory vii. Both have conjunctival congestion. insufficiency 4. Elective procedure in the head and neck

surgery PTOSIS Relief of Upper Airway Obstruction CAUSES OF PTOSIS Congenital i. 3rd CN nerve palsy - Bilateral Choanal atresia ii. Horner’s syndrome - Laryngeal web/cysts iii. Congenital - Upper tracheal stenosis iv. Inra-cranial aneurysm - Laryngeal web/cysts v. Myasthenia gravis - Trachea-Oesophageal fistula vi. Lid tumour - Treacher-collins syndrome vii. Myotonia dystrophica Acquired viii. Abnormal 3rd nerve innervation ( Marcus Gunn - Foreign body in the larynx syndrome) - Gunshot - Inhalational burns - Iatrogenic-Thyroid surgery

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Infective Elective Procedures in Head And Neck Surgery - Acute Epiglottitis - To facilitate anaesthesia in - pharyngeal abscesses - laryngectomy and maxillofacial - Laryngeal diphtheria - surgeries eg TMJ ankylosis release - Acute laryngotracheobronchitis (croup) PROCEDURE - Ludwig’s angina  hyperextend the Px’s neck by placing sand Tumour bags under the shoulder. Benign and malignant diseases of the;  Infiltrate the muscles and skin with 2% - tongue lidocain - Pharynx  Make a skin incision at a level 2 finger breath -Larynx and above the suprasternal notch ( the incision -upper trachea in advanced stage could be vertical or transverse). Neurological  Maintain the midline to avoid injury to the - Bulbar palsies oesophagus, vessels and nerves. - Laryngeal nerve paralysis e.g. post  Retract the strap muscles laterally to reveal thyroidectomy the pretracheal fascia. - Pharyngeal & Laryngeal paralysis as in  Division/lifting of the thyroid isthmus motor neurone disease.  Palpate until you get to the trachea – feel the tracheal rings Protection of Tracheo-Bronchial Tree  Use a syringe to aspirate air – to be sure you In conditions leading to aspiration of (gastric are at the trachea. cont) and stagnation of bronchial secretions :-  Vertical incision of tracheal ring 2nd – 4th.  Myasthenia gravis  Use local anaesthesia to reduce coughing.  Tetanus  Use of tracheal dilator/insertion of T. T.  Polyneurutis  Tie the tube around the neck  Bulbar poliomyelitis  Aspirate the secretions that are coming out.  Facial burns  Wound closure and dressing  Multiple facial fractures The following are kept beside a patient with  Coma in head injury, drug overdose tracheostomy tube in situ; Conditions Leading To Respiratory Insufficiency 1. A bell Pulmonary diseases – chronic bronchitis & 2. Pen and paper emphysema 3. 2 tracheostomy tube (one bigger and one Severe chest injury e.g flial chest smaller than the one in situ) Neuromuscular incoordination needing IPPR. 4. Tracheal dilator 5. Functional suction 6. Normal saline or NaHCO3

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

POST-OP CARE TRACHEOSTOMY TUBES (1) Nursing Care:- 2 main types in UNTH - Trained Nurse 1. Silver Jackson tube - Communication Materials 2. Portex tube - Counselling on speech defect (2) Removal of Secretion: - Adequate suction - Inflation vs deflation of cuff (3) Humidification: CLEFT LIP & PALATE. - Room humidifiers, kettle & wet gauze CAUSES (4) Care of tube: 1. Genetic - Cleaning, changing of T.T (48-72HRS) 2. Environmental (5) Wound Care: a. Maternal Dx e.g - Dressing i. DM +/_emoval of stitches. ii. Rubella b. Drugs e.g COMPLICATIONS i. Steroids Immediate: ii. Cytotoxic drugs

Haemorrhage iii. Thalidomide

Surgical trauma to oesophagus, lung apices, iv. phenytoin recurrent laryngeal nerve v. Hypervitaminosis A

Pneumothorax vi. Hypervitaminosis B

Temporary apnoea c. Oligohydramnios Intermediate: d. X-irradiation  Tracheobronchitis  Tracheal erosion and haemorhag EMBRYOLOGY  Tube displacement  Lip formation = 4-6 weeks  Tube obstruction  Palate = 6- 10th week  Subcutaneous Emphysema  Structures that form the face include; the  Aspiration and lung abscess frontonasal process (medial & lateral), Late maxillary and mandibular prominences.  Persistent Tracheocutaneous fistulae  CL results from failure of fusion of medial  Laryngeal & tracheal stenosis nasal prominences (from the frontonasal  Tracheomalacia process) with the maxillary prominences.  Tracheo-oesophageal fistulae  CP results from failure of fusion of the  Difficult decanulation especially in children maxillary prominences from both sides of the  Tracheostomy scar face.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Epidemiology  Cleft lip & palate - Commonest among Asians >Whites > Africans = first repair lip @ 3- 6months - Whites (Caucasians) = CLP>CP>CL = then palate @10 – 15 months - Nigeria in the 1980s = CL> CP> CLP - Nigeria now = CLP> CL > CP REPAIR - CL & CLP are more common on the left side Conditions that must be met (Millard’s criteria) – Rule and in males. of 10. - Isolated CP is more common in females and on  Weight of 10 pounds (4.5kg) the left side. The 20 palate takes 1week  Hb of 10g/dl longer to fuse in females.  Age of 10weeks (3 months) - Associated anomalies and syndromes are GOALS OF TREATMENT commoner with CP.  Cosmesis PRESENTATION  Correct speech defect Upper Lip  Correct feeding difficulties  Unilateral TYPE OF ANAESTHESIA USED  Incomplete – Left or Right  For palate repair = GA in all ages  Complete - Left or Right  For cleft lip = LA in adults  Bilateral = GA in children.  Incomplete REPAIR TECHNIQUES  Complete  Lip repair = flap advancement and rotation Palate (Millard’s procedure)  Unilateral (Complete or Incomplete)  Palate repair = midline flap shift (Veau  Bilateral (Complete or incomplete) Langenberg’s procedure)  Sub mucous POST-OP CARE 10 & 20 palate a) Feeding the child using Spoon/bottle  Cleft anterior to incisive foramen is cleft of b) In-patients hospital stay; 5-7 days CL 10 palate and 10 days for CP.  Cleft posterior to incisive foramen is cleft of c) Suture removal 7days 20 palate. PROBLEMS OF CL & P Clinically,  LIP Cleft lip = anterior  Cosmetic (parents feel bad Cleft palate = posterior. psychologically)  Suckling problem/feeding ( hence Px TIME OF REPAIR looks malnourished)  Cleft lip = 3 – 6 months  Alveolar arch deformity  Cleft palate = 10 – 15 months  Some speech deficiency

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

 PALATE WOUND DRESSING o Regurgitation of feeds SOLUTIONS USED FOR DRESSING WOUNDS o Respiratory distress (Pierre Robin A. inorganic syndrome) i. Lugol’s Iodine: (25% Iodine + 25% KI o Speech deficiency + 90% Ethanol) . In overt type ii. Povidone Iodine . In sub mucous iii. Hydrogen peroxide o Middle ear infection & deafness iv. Potassium permanganate o Airway/breathing problems. B. Organic ASSOCIATED ANOMALIES i. Ethanol 1. Pierre Robins syndrome (features include; (MUG) ii. Chloroxylenol (Dettol) i. Micrognathia iii. Chlorhexidine (Hibitane) ii. U-shaped cleft palate iv. Savlon = Chlorhexidine + cetrimide iii. Glossoptosis solution 2. Trachea Collins syndrome (find out features) v. Hexachlorophane (phisolex) COMPLICATIONS OF REPAIR vi. Formalin (40% formaldehyde gas in 1. Anaesthetic complications water). 2. Bleeding Classification of wounds 3. Trauma to the tongue and surrounding tissues. 1. Clean wounds 4. Aspiration pneumonitis a. 1-2% infective rate 5. Infections e.g tonsillitis, laryngitis, pneumonia b. GIT, UGS, RESP system not entered etc. c. e.g hernioraphy, excisions, herniotomy 6. Repair Breakdown. 2. Clean contaminated 7. Fistula formation a. 5 – 10%b infective rate CLEFT REPAIR TEAM. b. GIT, Resp system entered and no  Plastic surgeon spillage  ENT surgeon c. e.g appendicectomy, bowel surgeries  Orthodontist 3. Contaminated  Paediatrician a. 15 – 20% infective rate  Speech therapist b. Acute inflammation, no pus, gross  Radiologist spillage, frsh trauma.  Paediatric nurses c. E.g open fresh accidental wounds.  Anaesthetist 4. Dirty Wounds Differential of cleft palate = cancrum oris. a. 50% infective

b. Pus, perforated viscus, trauma wounds.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

c. E.g abscess drainage, pyocele, faecal N/B: the best cleansing agent for healthy granulation peritonitis tissue is normal saline. LAYERS OF WOUND DRESSING (NTAR) 1) Non-Adherent layer: made up of SCRUBBING AND WASHING IN SURGERY sufra-tulle gauze (Vaseline gauze). It  This is done religiously for at least 10mins is impregnated with an antibiotic-  Thoroughly scrub and wash hands well above framycetin sulphate and a clean jelly the elbows in running water. so that it can be pealed-off without  Brush the nails and hands. pains and bleeding. The Vaseline in it  Raise the hands and flex at the elbow to avoid also prevents entrance of bacteria water running down on the hands. into the wound.  Dry hands on sterile towel 2) Transmissive or conductive layer:  Put on the sterile gown without touching the made up of gauze. it is like a capillary outside. layer i.e it conducts discharge from  Waist belt of the gown is tied on the back by the wound by capillary action into the a nurse. 3rd layer. GLOVING (wearing gloves) 3) Absorbent layer: made up of a layer  Powder the hands of thick cotton wool to absorb the  Turn up cuff of the left hand glove is held in discharge that has passed through right hand and the glove is slipped on to the the 2nd layer. left hand. 4) Restrictive or Occlusive layer: made  Fingers of the gloved left hand are slipped up of plaster or creppe bandage. into the turned down cuff of the right glove. Slutions used in dressing clean wounds  The glove is slipped on to the right hand i. EUSOL A & B  Sleeves of the gown are tucked into the ii. Honey gloves. iii. Sugar  The cuff is slipped over the tucked in sleeves Solutions used in dressing contaminated wounds without allowing the gloved hand to come in i. EUSOL A & B contact with the bare skin. ii. Honey iii. Maggots SURGICAL SITE PREPARATION (SKIN PREP) Solutions used in dressing dirty wounds STEPS: i. EUSOL A & B  Clean the site with cetrimide ii. Hydrogen peroxide  Clean again using cetrimide iii. Hibitane in water  Dry the site iv. Cetrimide – chlorhexidine  Apply iodine v. Iodine in spirit or iodine.  Drape

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

3 Day prep: BOWEL PREP. Day 1: It is prep done in large gut esp the left colon to - Give low residue diet e.g pap, rice, agidi etc reduce faecal or bacteria load and make GIT - Give oral carthetics e.g 3tabs of ducolax bd. surgeries safe. - Neomycine: 1g tds (for gram –ve) TYPES: - Metronidazole 400mg tds (for anaerobes)  Mechanical Day 2:  Chemical - Repeat all in day 1  3 day bowel prep; done in gen surgery. Day 3: (morning of surgery)  5 day bowel prep; done in CTU. - Do saline washout + NPO INDICATIONS FOR BOWEL PREP. Mechanical : 1. Investigative procedures:  Used to clear feaces from the gut. - Sigmoidoscopy  It involves the use of; - Colonoscopy • Low residue diet - IVU. • Oral Cathartics: such as; 2. Surgeries: - Ducolax (3tabs 2x daily) - Haemorrhoidectomy - Oesophageal replacement with colon following - MgSo4 (Epson salt -1 satchet 3x daily) - ethylene glycol, stricture ( corrosive). - bisacodyl, etc 3. Total gut irrigation: - irrigating the gut with - Suppositaries??? normal saline through an NG TUBE until what  Other ways of mechanical bowel prep is coming out from the gut is as clear as • Soap & water Enema normal saline. It may require up to 11 – 13 • Rectal wash out?? litres of saline. You can also use polyethylene • Total gut irrigation: saline enema, sodium glycol for the procedure. sulphate, ethylene glycol N/B: • On-table lavage. Prostate biopsy may not require any bowel prep, Chemical (MEN) however antibiotics cover may be given.  Metronidazole, Erythromycine & Neomycine.  Anti anaerobes: Erythromycin, metronidazole  Anti aerobes: neomycin, ampiclox, etc

In 3 day bowel prep, both chemical + mechanical are done from day 1 to day 3. While in 5 day prep, mechanical alone is done for day 1 & 2, then both chem. & mechanical done from day 3 – 5.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

THE BREAST MANCHESTER CLASSIFICATION TNM STAGING (summarized) Stage 1- The tumour is confined to the breast and is not attached to the underlying muscle. T-Primary Tumour  Skin attachment or ulceration if present Tx = Tumour not accessible must be in continuity with the tumour and not extend beyond it. Tis = Carcinoma insitu  There is no axillary node involvement. T0 = No evidence of tumour Stage 2 -As in Stage 1, but axillary lymph nodes are T1 = tumour ≤ 2cm in diameter, no fixation or involved but mobile. tethering T2 = tumour >2cm but <5cm ( i.e 2 – 5 cm) in Stage 3 - (i) Skin involvement is beyond the diameter with tethering or nipple retraction. periphery of the tumour, T3 = tumour 5 – 10 cm in diameter with infiltration, Or (ii) The tumour is attached to the underlying ulceration or peau d’orange muscle, T4-tumour of any size with direct extension to (a) Or (iii) Axillary lymph nodes are mobile or fixed. chest wall or (b) skin only as follows:  There are no distant metastases.  T4a—extension to chest wall Stage 4-  T4b—oedema (including peau d’orange),or (i) Lymphatic spread is beyond the ipsilateral axilla ulceration of skin of the breast or satellite skin or (ii) Distant blood-borne metastases are present. nodules confined to the same breast.

 T4c—both T4a & T4b. TREATMENT OF BREAST CA  T4d— inflammatory carcinoma.  Determined by the stage of the tumor. N = Nodes (Regional Lymph Nodes)

 N0—No palpable regional lymph nodes  The modality for local regional control involves surgery & irradiation.  N1—Mobile palpable ipsilateral axillary lymph nodes. 1. Surgical treatment are;

 N2—Ipsilateral axillary nodes fixed to one . conservative i.e wide local excision another or to other structures. . modified radical = Patey’s mastectomy  N3 spread to ipsilateral internal mammary lymph node(s), palpable supraclavicular nodes, 2. Role of Radiotherapy. oedema of the arm. . Used in combination with simple M = Distant Metastases mastectomy & conservative excision.  MO - No evidence of distant metastases. N/B: Post op irradiation reduces local recurrence, it  M1 - Distant metastases present including skin does not improve survival. involvement beyond the breast area.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

3. Adjuvant chemotherapy  Neoadjuvant chemotherapy potentially downstages local tumours and treats metastatic . Started immediately after completion of disease. surgical treatment because of occult metastasis.  This is followed by mastectomy or wide excision and radiotherapy. . Given for 6 cycles—CMF,CA,CAF N/B: . Patients above 50yrs or have positive hormone receptor status benefit from The locally advanced disease is actually tamoxifen therapy—duration 5yrs. metastatic in most pxts.

. Dangers of Tamoxifen are dev of endometrial TREATMENT OF METASTATIC DISEASE ca., venous thrombosis, ophthalmologic  Recurrence of breast ca is thought to be complications. incurable with median life expectancy of 18— SURGICAL TREATMENT OF A SMALL STAGE I, 24 months. OR II (T1 OR T2) BREAST TUMOUR  Despite aggressive approaches like high dose  Usually requires only wide local excision chemotherapy, distant metastatic disease is rather than mastectomy. not curable.

 But mastectomy may have to be performed if  However, breast ca is sensitive to both the breast is very small, the tumour central chemotherapy & hormone therapy or multifocal, or for patient’s preference.  The hormonal agents,

. tamoxifen being the first choice.

TREATMENT OF LOCALLY ADVANCED AND . Newer aromatase inhibitors INFLAMMATORY CA. (anastrozole,letrozole,exemstane) are 2nd  Locally advanced breast ca. refers to Stage line drugs followed by megestrol acetate. IIIA and IIIB  Chemotherapy agents;

 The disease is advanced on the chest wall (any . Cyclophosphamide and doxorubicin—1st T3 or T4 tumour) and /or in regional lymph line agents. nodes (NI or N2) but not distant metastasis. . Taxanes—2nd line agents(active as single Rx agent)

 Neoadjuvant chemotherapy is used to reduce the size of the primary tumour to reduce local relapse rate.

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COMMON SHORT CASES IN SURGERY: THE UNTH EXPERIENCE – BY DR. BESONG.

Good prognostic factors DIFFERENTIALS • Patient’s age: older than 50 years  Macrocephally • Axillary nodes: not involved  Rickets • Size of tumor: small (< 1 cm)  Hydrancephaly • Local extension of tumor: Absent  Sickle cell (frontal & parietal bossing) • Histologic examination: Well-differentiated  Familial big head tumor (gr I)  Osteogenesis imperfecta. • Cytologic study: little atypia of nuclei (grade I) TREATMENT • Positive Estrogen /Progesterone receptors. (ER + a) shunting; and PR +) i. Ventriculo-peritoneal (V-P) shunt • Oncogene amplification: Absent. ii. Ventriculo-atrial (V-A) shunt iii. Ventriculo – pleural (V- P) shunt Poor prognostic factors iv. Lumbo –peritoneal (L-P) shunt • Patient’s age: 35–40 years v. Endoscopic 3rd ventriculostomy • Axillary nodes: involved b) External ventricular drain • Size of tumor: large (>5 cm) COMPLICATIONS: • Local extension of tumor: Present 1. Shunt sepsis e.g meningitis • Histologic examination: Anaplastic tumor (grade 2. Shunt nephritis III) 3. Shunt migration • Cytologic study: Severe nuclei atypia (grade III) 4. Shunt kinking • Negative Estrogen/Progesterone receptors (ER – 5. Shunt obstruction & PR –) 6. Shunt breakage • Oncogene amplification: Present (HER-2/neu. c- 7. Hypotention erb b-) 8. Intestinal obstruction.

X- ray findings: HYDROCEPHALUS – Copper beating appearance of the cranium – Erosion of the posterior cliniod process Clinical features – Sutural diasthesis 1. An Abnormally large head (measure the head

circumference b4 reporting) Which other part of the body will you want to 2. Cranio-facial disproportion examine? 3. Dilated scalp veins 1. Back/spine (to r/o spina bifida) 4. Sunsetting appearance of the eyes. 2. The limbs (to r/o talipes equinovarus) 5. Sutural diasthesis. 3. Also check if Px can see or can hear.

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