Surgery 2012 v2 Alasdair Scott BSc (Hons) MBBS MRCS PhD 2018 [email protected] www.scottsnotes.co.uk © Alasdair Scott, 2018 © Alasdair Scott, 2018 Table of Contents 1. Perioperative Management ..................................................................................... 1 2. Fluids and Nutrition ............................................................................................... 11 3. Trauma .................................................................................................................. 17 4. Upper GI Surgery .................................................................................................. 25 5. Hepatobiliary Surgery ............................................................................................ 35 6. Lower GI Surgery .................................................................................................. 43 7. Perianal Surgery .................................................................................................... 59 8. Hernias .................................................................................................................. 65 9. Superficial Lesions ................................................................................................ 70 10. Breast Surgery .................................................................................................... 81 11. Vascular Surgery ................................................................................................. 86 12. Urology ................................................................................................................ 95 13. Orthopaedics ..................................................................................................... 110 14. Ear, Nose and Throat ........................................................................................ 132 15. Ophthalmology .................................................................................................. 145 i © Alasdair Scott, 2018 © Alasdair Scott, 2018 Perioperative Management Contents Pre-Operative Assessment and Planning .............................................................................................................. 2 Specific Pre-operative Complications .................................................................................................................... 3 Anaesthesia ........................................................................................................................................................... 4 Analgesia ............................................................................................................................................................... 4 Enhanced Recovery After Surgery ........................................................................................................................ 5 Surgical Complications .......................................................................................................................................... 5 Post-op Complications: General ............................................................................................................................ 6 Post-op Complications: Specific ............................................................................................................................ 7 Post-op Pyrexia ...................................................................................................................................................... 8 Deep Venous Thrombosis ..................................................................................................................................... 9 Other Common Post-Operative Presentations .................................................................................................... 10 1 © Alasdair Scott, 2018 Pre-Operative Assessment and Planning Aims Preparation • Informed consent • Assess risk vs. benefits NBM • Optimise fitness of patient • ≥2h for clear fluids, ≥6h for solids • Check anaesthesia / analgesia type ¯c anaesthetist Bowel Prep Pre-op Checks: OP CHECS • May be needed in left-sided ops • Operative fitness: cardiorespiratory comorbidities § Picolax: picosulfate and Mg citrate • Pills § Klean-Prep: macrogol • Consent • Not usually needed in right-sided procedures • History • Necessity is controversial as benefit of minimising § MI, asthma, HTN, jaundice post-op infection might not outweigh risks § Complications of anaesthesia: DVT, § Liquid bowel contents spilled during surgery anaphylaxis § Electrolyte disturbance • Ease of intubation: neck arthritis, dentures, loose § Dehydration teeth § ↑ rate of post-op anastomotic leak • Clexane: DVT prophylaxis • Site: correct and marked Prophylactic Abx • Use § GI surgery (20% post-op infection if elective) Drugs § Joint replacement • Give 15-60min before surgery Anti-coagulants • Regimens: (see local guidelines) • Balance risk of haemorrhage ¯c risk of thrombosis § Biliary: Cef 1.5g + Met 500mg IV • Avoid epidural, spinal and regional blocks § CR or appendicetomy: Cef+Met TDS § Vascular: co-amoxiclav 1.2g IV TDS AED § MRSA+ve: vancomycin • Give as usual • Post-op give IV or via NGT if unable to tolerate orally DVT Prophylaxis OCP / HRT • Stratify pts according to patient factors and type of • Stop 4wks before major / leg surgery surgery. • Restart 2wks post-op if mobile • Low risk: early mobilisation • Med: early mobilisation + TEDS + 20mg enoxaparin β-Blockers • High: early mobilisation + TEDS + 40mg enoxaparin + • Continue as usual intermittent compression boots perioperatively. • Prophylaxis started @ 1800 post-op • May continue medical prophylaxis at home (up to 1mo) Pre-op Investigations Bloods ASA Grades • Routine: FBC, U+E, G+S, clotting, glucose • Normally healthy • Specific • Mild systemic disease § LFTs: liver disease, EtOH, jaundice • Severe systemic disease that limits activity § TFT: thyroid disease • Systemic disease which is a constant threat to life § Se electrophoresis: Africa, West Indies, Med • Moribund: not expected to survive 24h even ¯c op • Cross-match § Gastrectomy: 4u § AAA: 6u Cardiopulmonary Function • CXR: cardiorespiratory disease/symptoms, >65yrs • Echo: poor LV function, Ix murmurs • ECG: HTN, Hx of cardiac disease, >55yrs • Cardiopulmonary Exercise Testing • PFT: known pulmonary disease or obesity Other • Lat C-spine flexion and extension views: RA, AS • MRSA swabs 2 © Alasdair Scott, 2018 Specific Pre-operative Complications Diabetes Jaundice • Best to avoid operating in jaundiced pts. ↑ Risk of post-operative complications • Use ERCP instead • Surgery → stress hormones → antagonise insulin • Pts. are NBM Risks • ↑ risk of infection • Pts. ¯c obstructive jaundice have ↑ risk of post-op renal • IHD and PVD failure \ need to maintain good UO. • Coagulopathy Pre-op • ↑ infection risk: may → cholangitis • Dipstick: proteinuria • Venous glucose Pre-op • U+E: K+ • Avoid morphine in pre-med • Check clotting and consider pre-op vitamin K IDDM • Give 1L NS pre-op (unless CCF) → moderate diuresis • Urinary catheter to monitor UPO Practical Points • Abx prophylaxis: e.g. cef+met • Put pt. first on list and inform surgeon and anaesthetist Intra-op • Some centres prefer to use GKI infusions • Hrly UO monitoring • Sliding scale may not be necessary for minor ops • NS titrated to output § If in doubt, liaise ¯c diabetes specialist nurse Post-op Insulin • Intensive monitoring of fluid status • ± stop long-acting insulin the night before • Consider CVP + frusemide if poor output despite NS • Omit AM insulin if surgery is in the morning • Start sliding scale § 5% Dex ¯c 20mmol KCl 125ml/hr Anticoagulated Patients § Infusion pump ¯c 50u actrapid • Balance risk of haemorrhage ¯c risk of thrombosis § Check CPG hrly and adjust insulin rate • Consult surgeon, anaesthetist and haematologist • Check glucose hrly: aim for 7-11mM • Very minor surgery may be undertaken w/o stopping • Post-op warfarin if INR <3.5. § Continue sliding-scale until tolerating food • Avoid epidural, spinal and regional blocks if § Switch to SC regimen around a meal anticoagulated, • In general, continue aspirin/clopidogrel unless risk of NIDDM bleeding is high – then stop 7d before surgery • If glucose control poor (fasting >10mM): treat as IDDM Low thromboembolic risk: e.g. AF • Omit oral hypoglycaemics on the AM of surgery • Stop warfarin 5d pre-op: need INR <1.5 • Eating post-op: resume oral hypoglycaemics ¯c meal • Restart next day • No eating post-op § Check fasting glucose on AM of surgery High thromboembolic risk: valves, recurrent VTE § Start insulin sliding scale • Need bridging ¯c LMWH § Consult specialist team ore. restarting PO Rx § Stop warfarin 5d pre-op and start LMWH § Stop LMWH 12-18h pre-op Diet Controlled § Restart LMWH 6h post-op • Usually no problem § Restart warfarin next day • Pt. may be briefly insulin-dependent post-op § Stop LMWH when INR >2 § Monitor CPG Emergency Surgery • Discontinue warfarin Steroids • Vit K .5mg slow IV • Request FFP or PCC to cover surgery Risks • Poor wound healing COPD and Smoking • Infection • Adrenal crisis Risks • Basal atelectasis Mx • Aspiration • Need to ↑ steroid to cope ¯c stress • Chest infection • Consider cover if high-dose steroids w/i last yr • Major surgery: hydrocortisone 50-100mg IV ¯c pre- Pre-op med then 6-8hrly for 3d. • CXR • Minor: as for major but hydrocortisone only for 24h • PFTs • Physio for breathing exercises • Quit smoking (at least 4wks prior to surgery) 3 © Alasdair Scott, 2018 Anaesthesia Analgesia