Surgery

• Outpatient surgery


  Not admitted to a ward facility
• Day-care or same-day surgery


  Admitted and discharged within 12 hours
• Overnight stay


  23 hour admission with early morning discharge
• Selection criteria for day care surgery

  • Medical: ASA status over 2 requires careful review
  • Social: Carer must be present for the first 24 hours
  • Surgical: Operations up to 2 hours
• Eligible for day care surgery

  • ASA 1 & II in a stand alone day care unit
  • ASA III in an integrated day care surgery centre (attached to hospital)
• Other criteria for day care surgery

  • BP < 180/100
  • In a diabetic, HbA1c <8.5 (should omit morning dose of oral hypoglycemic drugs/ OHA)
  • BMI < 40 kg/m2 for surface procedures
  • BMI < 38 kg/m2 for laparoscopic procedures
  • Well controlled case of epilepsy are eligible
• Total intravenous anaesthesia (TIVA)


  Propofol leads to reduced post operative nausea & vomiting
• Analgesia infiltration post surgery

  Bupivacaine (long acting local anaesthetic with side effect of cardiotoxicity)
• Post operative complications of day care surgery

  • Post op nausea & vomiting (PONV)
  • Hemorrhage (Reactionary Hemorrhage)
  • Pain
• APFEL score


  Used to predict risk for post operative nausea and vomiting (PONV)
• Discharge criteria for day care surgery

  • Vital signs stable for at least 1 hour
  • Oriented to time place and person
  • Adequate pain control with a supply of oral analgesia
  • Understands how to use oral analgesia supplied
  • Ability to dress and walk where appropriate
  • Minimal nausea, vomiting or dizziness
  • Has taken oral fluids
  • Minimal bleeding or wound drainage
  • Has passed urine (if appropriate)
  • Has a responsible adult to take them home
  • Written and verbal instructions given about post operative care
  • Knows when to come back for follow up
  • Emergency contact number supplied
• ERAS protocol (Enhanced Recovery After Surgery Protocol)


  • Preoperative: Avoid mechanical bowel preparation, Solids up to 6 hours prior to surgery, Clear fluids up to 2 hours prior to surgery (carbohydrate loading can be done)
  • Intraoperative: Minimally invasive surgical approach, Local anaesthetic or long acting local (liposomal bupivacaine), Prophylaxis for nausea and vomiting (at least 2 classes of medications), Opioids only for breakthrough pain
  • Post operative: Regular diet within 24 hours, Discontinue IV fluids within 24 hours, Ambulate within 24 hours
• Adverse event


  An incident that results in harm to the patient
• Near miss


  An incident that could have resulted in unwanted consequences but did not, either by chance or through a timely intervention preventing the event from reaching the patient
• No-harm event


  An incident that occurs and reaches the patient but results in no injury to the patient. Harm is avoided by chance or due to mitigating circumstances
• IV Cannula sizes


  • Yellow 24G (max flow 13 mL/min)
  • Blue 22G (max flow 30 mL/min)
  • Pink 20G (max flow 60 mL/min)
  • Green 18G (max flow 96 mL/min)
  • Gray 16G (max flow 240 mL/min)
  • Orange 14G (max flow 270 mL/min)
• Superficial thrombophlebitis


  Most common complication of cannula insertion, Cord like structure formed, can persist for 3-4 months, Associated with pain, fever
• Surgical safety checklist


  • Sign in: Before induction of anaesthesia
  • Time out: From ward to OT table, Before skin incision
  • Sign out: Before patient leaves operating room, at skin closure
• Items checked in surgical safety checklist

  • Written consent
  • Confirm identity of patient
  • Confirm site marking
  • Inquire about allergies
  • Re confirm identity of patient
  • Name of procedure
  • Estimated blood loss
  • Antibiotic prophylaxis given
  • Gauze and instrument count
  • Actual blood loss
  • Specimen labeling
• OT zones


  • Protective Zone
  • Clean Zone (Connects protective zone to aseptic zone): Change rooms, Transfer bay, Pre & post op rooms, ICU/ PACU, Equipment store room, Maintenance workshop
  • Aseptic zone: OT
  • Disposal zone: Waste disposal
• Surgical positions


  • Supine position
  • Trendelenburg position: Foot end is raised, head end is low
  • Reverse trendelenburg position: Head end is raised, foot end is low
  • Lithotomy position
  • Lateral or kidney position
  • Prone position
  • Sitting/Fowler's position
• Lithotomy position


  Common peroneal nerve injured if legs are not supported properly
• Lateral or kidney position

  Brachial plexus injury if arms are hyperextended
• Sitting/Fowler's position


  Advantage: Relatively bloodless field, Good exposure

  Disadvantage: Air embolism if veins are nicked
• Air embolism


  50-100 cc of air, Typical clinical presentation: During thyroid/head & neck surgery or CNS surgery, Vein gets nicked → Sudden desaturation, Can occur in Sitting position, Treatment: Durant position (recovery position)/ Left lateral legs up position, Air can be aspirated through a central line or direct aspiration under image guidance
• Jack knife position


  Earlier used for hemorrhoid and fissure surgeries, Not preferred these days due to positional asphyxia
• Surgical blades


  • Number 11 (Pointed/tab blade): For incision & drainage
  • Number 12 (Curved): For suture removal
  • Number 10, 15, 20, 21, 22, 23: For making incisions
• Factors while planning an incision

  • Skin tension lines (Langer's lines): Represent orientation of dermal collagen fibres and incisions should be placed parallel to them
  • Incision not to be made directly over vital Anatomical structures
  • Cosmetic factors: Try to make incisions over skin creases so that they remain hidden
  • Incision must give adequate access for surgery
• Monopolar cautery


  Current flow: Current from machine to tip, surgeon uses tip to cut or coagulate, Current leaves body through cautery pad, Cautery pad should be placed over a well vascularized area & should have a wide area of contact, Can injure nerves and end arteries and nearby vital structures (Current traveling throughout the body)
• Bipolar cautery


  Current enters through one channel and exits from another channel, Circuit is getting locally completed, Can be used near vital structures, end arteries, Avoid near nerves, end arteries (Eg: ear lobule, penis) and in patients with cardiac pacemakers
• Surgeries using monopolar and bipolar cautery

  • Monopolar: Thyroid, Parotid, Penile

  Bipolar: Can cut and coagulate
• Cutting current


  Low voltage continuous current and sufficient heat to cause cell water to explode into steam
• Coagulation


  High voltage Alternating current, Cell death by dehydration and protein denaturation
• Ligasure


  Heat plus pressure, Uses collagen & elastin to seal & divide, Can coagulate vessels up to 7mm in diameter
• Harmonic Scalpel


  Works on the ultrasonic principle: Coagulation without heat production, Oscillatory blade: Oscillates between 20,000–50,000 Hz, Advantages: Precise cut, Can cut through scar tissue, Can be used close to vital structures, Can coagulate vessels up to 7 mm in diameter
• Radiofrequency ablation (RFA)


  High frequency Alternating current, In between infra red & radiowaves, Similar to electrocautery, Grounding/cautery pad needed, Till 3 cm tumors
• Microwave ablation


  Oscillation & frictional heat, No grounding pad, Less time than RFA, Larger, more homogenous zone of ablation
• Argon photocoagulation

  Rapid activity, Shallow penetration, Faster heat dissipation, Less eschar, Ineffective for large vessels → avoided close to larger veins → can give rise to gas embolism, Used in Barrett's esophagus, Gastric Vascular Antral Ectasia (GAVE)
• Types of drains

  • Corrugated rubber drain: Open drain for abscesses
  • Romovac suction drain: Closed drain with negative pressure, Can be used after mastectomy, thyroidectomy, neck dissection
  • Abdominal drain: Connected to abdominal drainage bag
  • Underwater seal bag: Connected to intercostal chest tubes
  • Minivac drain: Negative pressure drain (smaller version of romovac drain), Used in sentinel lymph node biopsy
  • Jackson Pratt drain: Closed suction negative pressure drain, Flat tubing and bulb instead of bag in the end, Mainly used for abdominal surgery
• Knots

  • Square/reef knot: Secure knot, doesn't open up
  • Surgeon's knot: Two throws followed by one throw, Secure knot
  • Granny knot/Slip knot: Insecure knot