You are on page 1of 42

Surgical Procedure

WOUND SUTURE ABDOMINAL PROCEDURE AIRWAY PROCEDURE THORACIC PROCEDURE VASCULAR PROCEDURE URINARY PROCEDURE

WOUND SUTURE

Basic Principle
Hemostasis should be meticulous to prevent wound hematoma All foreign material and devitalized tissue should be removed to prevent contamination Potential space (dead space) in the wound should be closed using absorbable suture. Not to tied too thigh to prevent from tissue ischemia, leading to delayed healing or non-healing and increased risk of infection. Not too loose which may result in failure to appose the wound edges or inadequate hemostasis.

Suturing the skin


Non-absorbable interupted sutures
Advantage:
the removal of one or two apprpriately sited stiches may allow adequate drainage if the wound become infected. Simple and easy to place Greater tensile strenght

Disadvantage:
need subsequent removal Will left cross-hatching scar if sutures are tied too thightly of left in too long.

Subcuticular continuous suture


Advantages:
Good cosmetic result No need for subsequent removal

Disadvantage:
Less tensile strength Need deep suture/ subcutaneous suture to increase tensile strength Need more skill

Times recommended for removal of sutures


Face and neck 4 days

Scalp Abdomen and chest Limbs Feet

7 days 7 10 days 7 days 10 14 days

Cosmetic result as good as those archived by subcuticular suturing can be obtained by removing sutures in the half the time listed and replacng them with adhesive strips

Suture materials
Non-absorbable
1. Natural braided sutures (eg. Silk)
Have good handling qualities and knot easily and securely. Disadvantage:
increased tissue reaction and suture line sepsis, caused by the capilary action of the braided metarial drawing microorganisms into the suture track. Lose tensile strength quickly with time or when wet.

2. Synthetic braided materials (eg. Nurolon, Ethibond, Mersilene)


Less tissue reaction Good handling qualities and knot easily and securely

3. Synthetic monofilament metarials (eg. Nylon, propylene)


Have less drag through tissues and cause little tissue reaction Less suture track sepsis Disadvantage:
handle less well because of increase memory (i.e. they retain the configuration in which they are packaged) Knots are less secure

Absorbable sutures (eg. Vicryl)


Generally made from synthetic material Little tissue fraction Retain their tensile strength and are absorbed slowly Commonly used for subcuticular wound closure.

Suggested gauge of suture material


Around the eyes: 6/0 sutures Elsewhere on the face: 5/0 sutures Neck, hand and digits: 4/0 sutures Other sites: 3/0 or even 2/0 sutures Subcuticular wound closure: 4/0 sutures

Nasogastric tube Gastric lavage Esophageal tamponade Abdominal Paracentesis Diagnostic peritoneal lavage

ABDOMINAL PROCEDURES

Nasogastric tube insertion


Function
To drain stomach contents Administer enteral nutrition

Procedure
1. Inspect nose for any deformity 2. Patient is placed in the sitting position 3. Local anaesthetic spray to anaesthetize the nasal passage 4. The tube is well lubricated with gel and passed backward along floor of nasal passage 5. A slight resistance may be felt as the tube passes from nasopharynx to the oropharynx and patient should be warned that a retching sensation maybe experienced at this point 6. Asked patient to swallow, and with each swallow the tube is advanced down the oesophagus

7. Not to push rapidly, rather slow and steady. 8. Ideally 10-15 cm of tubee should be placed into the stomach 9. Usually esophagogastric junction is about 40cm from incisor teeth 10.Confirm the placement by:
Free aspiration of gastric content Auscultation in the epigastrium while 20ml of air is insulfflated.

11.The tube is fixed using adhesive tape

Contraindication
Head injury
risk of introducing infection NG tube can go into the central nervous system through an open fracture of the base of skull

Post oesophagectomy
May disrupt the anastomosis

Gastric lavage
Indication
Removal of indigested poison or drugs Lower or raise the core body temperature (less common)

Procedure
1. Assess the airway, presence of gag reflex and ability to cough. KIV for ET intubation of any doubt about pts ability to maintain airway. 2. Placed pt on the left side in the recovery position with a 15 head-down tilt of the trolley 3. A large-bore gastric tube is introduced into the mouth. 4. A mouth gag is useful to prevent the patient biting the tube.

5. The tube is advance into the stomach and its correct position is confirmed by the free flow of gastric contents. Auscultate to reconfirm. 6. About 100-200cc of warm water is passed down the tube into the stomach. 7. The end of the tube is then lowered below the level of the stomach into a collecting bucket, and gastric contents allowed to syphon out. 8. Repeat until the returned water become clear 9. Avoid overdistension of the stomach 10. Activated charcoal can be instilled into the stomach as an absorbent if needed. 11. Removed the tube on completion.

Esophageal tamponade
Sengstaken-Blakemore or Minnesota tube Indication: Emergency treatment of bleeding esophageal varices

Procedure
1. The esophageal and gastric balloons are checked for leaks and completely deflated. 2. The tube is inserted in the same way as normal NG tube. 3. The tube is advanced approximately 60 cm and the gastric balloon inflated with 150-200cc of air or water. 4. The tube is then drawn back until the lower balloon impacts at the cardia 5. An assistant maintain the tube in this position, and the esophageal balloon is inflated with air to a pressure approximately 40mmHg (checked by attaching a sphygmomanometer) 6. The tube is secured in this position with tape.

7. The stomach is aspirated regularly through the main lumen of the tube to check for further bleeding. Can also be used for administration of medication. 8. A fourth lumen allows aspiration of the upper esophagus and pharynx and reduces the risk of bronchial aspiration. 9. Sengstaken-Blakemore tube is a temporary measure to control hemorrhage prior to definitive treatment. 10. It is advisable to deflate the esophageal balloon for 5 min every 6 hours to avoid risk of ischemic necrosis and ulceration of esophageal mucosa. 11. The tube is not normally kept in place for more than 24 hours.

Abdominal paracentesis
Indication:
To relieve the discomfort caused by distension with ascites fluid To obtain fluid for cytological examination.

Procedure
1. Bladder must be emptied, if necessary put CBD 2. LA is infiltrated through all layers of abdominal wall 3. 3 landmark:
Midline 1/3 umbilicus to symphysis pubis Left or Right illiac fossa (at the junct of outer and middle 1/3 ASIS to umbilicus)

4. The depth at which the peritoneum is entered is determined by aspiration with the syringe 5. 3 mm stab incision is made to the skin with scalpel. 6. The trocar is introduced into the catheter and the shaft of the catheter is held firmly between left thumb and the index finger some 4-5cm higher than estimated depth of the peritoneum. 7. This prevent overshoot as the right hand thrusts the trocar and catheter trough the abd wall into peritoneum.

8. The catheter is now advance further with the left hand while the trocar is withdrawn with the right. 9. If any resistance is noted the catheter is withdrawn 2 3 cm, rotated 180 and then advanceed again. 10. The minimum final length of catheter within the peritoneal cavity must be 10 cm. 11. The one-way metal disc is slid down the catheter to make contact with the skin and secured to it with adhesive tape. 12. The catheter is divided some 4 cm above the disc and attached via a connection tube with a flow control clamp to a sterile drainage bag

13.Drainage of a large volume ascitic fluid must be accompanied with IV infusion of albumin in order to avoid precipitating a marked shift fluid from intravascular compartment into peritoneal cavity.

Diagnostic peritoneal lavage


Indication:
Test for intra-abdominal injury to look the presence of blood or intestinal contents.

Procedure
1. Can be performed using closed or open technique, open technique to minimize the risk of intraabdominal injury 2. Under sterile condition and following LA, a 5 cm vertical subumbilical incision is made. 3. Dissection continued through the subcutaneous tissue and linea alba. 4. The peritoneum is opened and cannula inserted into the peritoneal cavity and advanced into the pelvis. 5. A syringe is connected to dialysis catheter, and if frank blood is immediately aspirated, this is a +ve DPL result

6. If gross blood is not obtained, 1 L of warm sterile isotonic saline is infused and allowed to distribute evenly throughout peritoneal cavity 7. The fluid is then retrieved by placing infusion bag on the floor and allowing the effluent to drain from the abdomen by gravity 8. An equivocal test will reveal gross evidence of blood, bile or faeces. 9. Fluid can be send to lab for analysis. 10.+ve result if the RBC > 100 000/mm3 , WCC > 55 mm3 or amylase >175 U/mL

Endotracheal intubation Cricithyroidotomy

AIRWAY PROCEDURE

Endotracheal tube
Indication:
Life-saving to maintain a patent airway Facilitate oxygenation Prevent aspiration

Procedure
Patients neck is flexed and the head extended at the atlanto-occipital joint Retaining a pillow under the head but free from beneath the shoulder will usually help to attain this position

The laryngoscope is held in the left hand and its blade is inserted into the right side of patients mouth and passed backwards along side of the tonge into the oropharynx. The laryngoscope is pulled upwards and forwards, not used as a lever, to lift the tongue and jaw and reveal epiglottis. The blade is then advanced to the base of epiglottis.

Failure to visualize the epiglottis usually reflect the fact that the blade has not been inserted far enough (only the base of the tongue will be seen) If it has been inserted too far, upper esophagus will be seen. For women an 8 mm cuffed tube is usually appropriate and for men a 9 mm tube. For children tube size is (age/4)+4.5 mm. Normally uncuffed tube is used in children.

The ET tube is passed through the vocal cords into the trachea and advanced until its cuff is about 1 cm through (usually have a mark to indicate this position) The blade is then withdrawn and cuff inflated to provide an airtight seal in the trachea

Complication
Failure to recognized misplacement of the tube, particularly in the esophagus or to a lesser degree, in the right main broncus
avoid by direct visualization Inspection of chest wall for equal movement Auscultation for breath sounds billaterally in the mid axillary line.

If any doubt about positioning the tube, it should be removed and ventilation instituted by mask.

Cricothyroidotomy
Indication:
Inability to intubate the trachea, eg:
patient with severe facial trauma or pharyngeal Pharyngeal oedema secondary to burns

Surgical cricothyroidotomy is not recommended for children under 12 years of age.


To avoid damage to the cricoid cartilage which the only circumferential support to the upper trachea.

Needle cricothyroidotomy
Insertion of a large-caliber plastic cannula through the cricothyroid membrane below the level of the obstruction Intermittent jet insufflation of oxygen at 15L/min (1s inspiration and 4 s to allow expiration)
3-mL syringe barrel to a 7.5-mm inner diameter endotracheal tube adapter Connect the endotracheal tube adapter to a bag-valve-mask device

Can provide oxygenation for a limited period (30-45 min) until definitive procedure can be undertaken.

Surgical Cricothyroidotomy
1. With the patient in the supine position and the neck in a natural position, the thyroid cartilage (Adams apple) and cricoid cartilage are palpated.

The skin is cleansed with antiseptic solution and LA infiltrated into the skin if patient is conscious. The thyroid cartilage is stabilized with the left hand and small transverse skin incision made over cricothyroid membrane. The blade of the scalpel is inserted through the membrane and then rotated through 90 to open airway. An artery clip of tracheal spreader may be inserted to enlarged the opening enough to admit a cuffed endotracheal or tracheostomy tube.

The central trocar of the tube is removed and the tube connected to a bag-vavle or ventilator circuit. The cuff is then inflated and air entry to each side of the chest is checked The tube is secured to prevent dislodgement.

You might also like