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8/13/2019 ERN Surgery UG
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Essential Revision Notes inSurgery for Medical Students
8/13/2019 ERN Surgery UG
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Contents
v
Contributors vii
Editors Preface ix
About this book xi
1Principles of Surgery 1
Irfan Halim, Amir Halim, Akash Sharma
2Surgical Pathology 11
Shahzad Raja
3Peri-operative Care and Anaesthetics 65
Saima Saeed
4Abdominal Surgery 77
Irfan Halim, Rajib Das, Nirooshun Rajendran,
Seyed MM Ameli Renani, Ibraheim El-Daly
5Orthopaedics and Trauma Surgery 145
Naveed Shaikh, Ibraheim El-Daly
6Head, Neck and Neurosurgery 167
Ibraheim El-Daly
7Breast Surgery 207
Irfan Halim
8Endocrine Surgery 219
Rajib Das
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Contents
vi
9Plastic Surgery 235
Shelain Patel
10Cardiac Surgery 247
Shahzad Raja, Giles D Dreyfus
11Thoracic Surgery 265
Shahzad Raja, Giles D Dreyfus
12Vascular Surgery 275
Ahmed Farhan Haq
13Urology 295
Barnaby Garner Chappell, Karim Jamal
Revision Index 313
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CONTENTS
Principles of surgery Chapter 1
1.1 Introduction to surgery 2
1.1.1 Learning surgery
1.1.2 Diagnosing surgical patients
1.1.3 Surgical examinations
1.2 Surgical methodology 3
1.2.1 Incisions
1.2.2 Sutures
1.2.3 Drains
1.2.4 Attending operations
1.3 Peri-operative surgical care 6
1.3.1 Preparing for surgery
1.3.2 Informed consent
1.3.3 Communication
1.3.4 Post-operative review
1.3.5 Post-operative complications
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Principles of surgery
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1.1 INTRODUCTION TO SURGERY
1.1.1 Learning surgeryYour first exposure to surgery and to seeing patients being cutopen on the operating table will usually occur in your first
clinical year. Your experiences of surgery may be varied,
depending on your surgical firm, and the teaching quality can
range anywhere from excellent to an unacceptable waste of
time. Often this diversity in teaching can motivate or dishearten
you about a genuinely exciting subject. This section aims to
provide advice on how you can maximise your clinical learning
experience in surgery.
My personal advice on learning surgery is to start early, even
before joining a surgical firm. Some points that you should
follow routinely include:
Speak to students already on the firm before joining
Establish a rapport with the surgical team you are joining
Get a good surgical textbook for theory and one for
examinations. Read them at least once properly and then
as needed. My personal recommendations are:
Theory Lecture Notes in General Surgeryby Ellis et al
Examination Introduction to Symptoms and Signs of
Surgical Diseaseby Browse et al
Attend all the teaching offered regularly
Use free time to explore clinical experience (theatres,
clinics, clerking)
Stick to good teachers and spend time with them regularly
Try to clerk and present as many patients as possibleHave doctors demonstrate clinical signs and examination
techniques to you
Have doctors observe the way you examine and present
patients
Scrub in to as many cases as possible
Try to observe patients and cases from other surgical firms
with permission
Learn relevant procedures and skills from day 1
Do not be put off if doctors are too busy to teach you. Use
self-directed learning here
Read further about clinical cases encountered during the
day
Never be disheartened by doctors who treat you in anunacceptable manner. This is common in surgery and
actually means nothing to you in the long run. Do not let
them take you off your path to learning surgery. Be good
and proper as a student
It is not difficult to follow the above points if these are built
into a routine. They will not always apply, but their aim is to
make your surgical experience fulfilling and your exams much
easier. For those of you pursuing surgery in the future, you will
be building upon these skills. For those of you pursuing other
specialties, this may be the last opportunity for you to explore
and learn surgery and become comfortable with assessingsurgical patients.
Surgery is fun. Surgery is challenging. Surgery requires an
engaged mind with a skilled hand. Learn it, apply it, teach it!
1.1.2 Diagnosing surgical patientsDiagnosing patients involves:
History
Examination
Investigation
Every patient being seen for the first time should have a history
taken and an examination performed as the minimum in
diagnosing conditions. The only exception to this rule not being
followed is in the acute state where a critically ill patient may
require resuscitation and stabilisation first before reverting to
the thorough clinical history and detailed examination when
appropriate.
There is no good substitute for taking a thorough history when
seeing patients for the first time. Regardless of your own level
of surgical expertise, it is best to start taking full histories to
obtain as much information as possible. Later on, as the student
or junior doctor becomes more experienced, a focused and
targeted history can be a more efficient means of assessment.
This is required during busy times such as in the outpatient
clinics and emergency departments.
Although this book is intended as purely a revision guide to
surgery, no apology is made for recapping the very important
history-taking section below, which is vital in any patient being
assessed.
History taking follows a standard approach anywhere in the
world and comprises the following:
Introduction
Presenting complaint
History of the presenting complaint
Past medical/surgical history
Medications and allergiesFamily history
Social history
Systems review
Relevant sections such as immunisations, obstetric history and
developmental milestones may be added as required, depending
on the patient.
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Surgical methodology
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One of the commonest presenting symptoms in surgery as well
as medicine is that of pain. In general surgery, abdominal pain
is part of most disease processes in combination with other
symptoms. The SOCRATES approach to ascertaining a historyin patients presenting with abdominal pain allows for an easy
and thorough assessment. This method is covered further in
Chapter 4 and can also be applied to other common presenting
complaints.
If you find it difficult to take histories, it is probably best to
learn it via a combination of books, videos and personal
observations of more senior doctors. Most importantly, though,
is the self-directed practice of history taking with patients
one-on-one. There is no substitute for this and it should be
done with as many patients as possible. Once the full history is
mastered, you should aim to make this more efficient by taking
it in less time, or taking a more focused approach. Presenting
histories is also equally important as this often alerts you towhat you are doing right and what you are missing out. Many
medical students of mine have taken a near-perfect history
and presented it to me, often forgetting a single key question
in the presenting complaint (eg forgetting to ask about dysuria
or last menstrual period in a young woman with abdominal
pain). Another great thing about taking and presenting
histories is that it can be done before having learnt any
examinations.
1.1.3 Surgical examinationsSurgical examinations are slightly different from the standard
medical examinations applied in a general clerking, although
the same principles apply, such as inspect, palpate, percuss
and auscultate. Different conditions are focused upon in
examination settings. Also, different examination algorithms
exist for assessing particular surgical conditions and these
must be learnt in order to complete any patients surgical
assessment.
Examples of surgical examinations include:
Abdominal examination
Vascular arterial examination (usually lower limbs and
systemic)
Vascular venous examination (lower limbs)
Lump examination
Ulcer examination
Breast examination
Neck/thyroid examination
Hernia/groin-lump examination
Scrotal examination
Joint examination
Genuine effort should be made to learn these examinations as
they are easy to learn and perform as well as appearing in
every surgical exam! These are best learnt from surgical
outpatient clinic settings as well as from emergency patients
admitted on-take and elective surgical patients awaiting a
surgical procedure (eg a patient awaiting a thyroidectomywith a palpable goitre).
Some chapters of this book cover an outline of the relevant
surgical examinations as a revision tool, but this is not the
books main focus. There are many excellent textbooks to read
in conjunction with practising and performing examinations
under supervision. It is the supervision by and feedback from
different doctors that will enhance your diagnostic skills, by
learning how to pick up signs and combine the clinical
assessment with a history. Demonstration of normal signs in
addition to key signs is needed to learn them properly. How
can you be expected to recognise an abnormal breath or heart
sound if you dont yet know what a normal one sounds like?
1.2 SURGICAL METHODOLOGY
1.2.1 IncisionsRecognition and identification of surgical incisions is a key
element of inspection in a clinical examination. The organ
being operated on dictates the incision choice, in addition to
other factors listed below:
Site depends on which organ is being operated on
Size access to the organ dictates size of incision
Orientation follow Langers line to allow for better
healing and cosmesisSurrounding tissues healthy and non-infected tissues
Anatomy of site underlying structures that may need
avoiding (eg nerves and arteries)
Cosmesis hidden scar (eg inframammary scar for breast
implants)
With the advent of laparoscopic surgery, large incisions are
now disappearing and nowadays scars as small as 512 mm
are located in various sites around the abdomen. The
combination of sites of these incisions can give a clue to the
laparoscopic operation performed, although it is beyond the
scope of undergraduate and early postgraduate teaching to
learn these.
The most common incisions are shown and listed below, along
with potential organs that may have been operated on through
them (Figure 1.1, Table 1.1).
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Figure 1.1: Common abdominal incisions
ASIS
Lateral
border of
abdominus
rectus
muscle
(1) Mid-line incision through linea alba
(2) Sub-umbilical incision(3) Para-median incision
(4) Para-rectal Battles incision
(5) Kochers incision(6) Double Kochers (rooftop) incision
(7) Transverse muscle-cutting incision(8) McBurneys/Gridiron incision
(8a) Rutherford Morrison incision(9) Lanz incision
(10) Pfannenstiel incision(11) Transverse incision
(12) Thoraco-abdominal incision
1
2
34
5 6
7
8
8a
910
11
12
Table 1.1 Common incisions
Organ Approach Organ Approach
Oesophagus
Upper thoracic
Mid thoracic
Lower thoracic
Abdominal
Stomach
Liver
Biliary tree
Pancreas
Duodenum
Small
intestine
Cervical
Right 4/5 postero-lateral thoracotomy
Right 5/6/7 postero-lateral thoracotomy
Right 5/6/7 postero-lateral thoracotomyLeft 6/7 postero-lateral thoracotomyLeft thoracoabdominal
Left thoracoabdominalRooftop
Upper midline
Left thoracoabdominalRooftopUpper midline
Right thoracoabdominal
RooftopUpper midlineRight paramedianKocherTransverse
Rooftop
Upper midlineRight paramedianKocherTransverse
MidlineParamedianTransverse
Colon
Appendix
Rectum
Uterus, ovaries
Aorta
Iliac vessels
Bladder
Kidney
Adrenal
glands
MidlineRight paramedianRight transverseRutherfordMorrisonGridiron
GridironLanz
MidlineLeft paramedianLeft transverse
MidlineLeft paramedianLeft transversePerineal
MidlinePfannenstiel
MidlineTransverse
MidlineTransverse
RutherfordMorrisonLower midlinePfannenstiel
Midline
Kocher12th rib incision
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1.2.2 SuturesSutures are used in surgery to appose tissue edges that have
been cut, as well as to tie off structures and provide secure
ligation. Sutures may be found attached to needles or on theirown as ties.
Many different materials can be used to suture and there is
much commercial competition between differing suture
brands. At the undergraduate level, a basic understanding and
classification of sutures is provided here with examples.
Sutures may be absorbable or non-absorbable
Sutures may be synthetic or natural
Sutures may be monofilament or braided
Absorbable suturesare used for tissues that heal quickly, such
as bowel anastomosis, skin suturing, ligation of vessels and
mesentery and stoma creation. These sutures are understood
to provide initial strength to achieve their purpose and then todegrade and dissolve over time by natural processes within the
human body. Examples include Vicryl, Monocryl, Dexon, PDS
and catgut (no longer used).
Non-absorbable suturesare used for tissues that heal slowly.
They retain strength for a longer period of time to allow greater
healing to occur (eg abdominal wall closure). They also cause
less tissue reaction compared with absorbable sutures so they
have some cosmetic advantage (exception is silk, which causes
an inflammatory reaction). Examples include steel wire
(sternotomy closure), nylon, silk, Prolene and PTFE. Although it
is often assumed that non-absorbable sutures do not absorb
within the body as their title suggests, this is not often thecase and almost all suture materials (except steel) lose their
strength and absorb over time. The main difference is the
length of time which may elapse before a non-absorbable
suture is dissolved (months to many years) as compared to an
absorbable suture (weeks to months).
Synthetic suturesinclude Dexon, Vicryl, PDS, nylon, Prolene
and PTFE.
Natural suturesinclude catgut and silk.
Monofilament sutureshave a single filament and are easier
to pass through tissues. They do not have braids in them in
which infection can reside so they are less of an infection
source. Disadvantages include the fact that they are slipperyand difficult to knot due to the stiffness. Knots may not hold
as securely because of this and lead to inadequate closures.
Braided sutures have multiple filaments running through
them. Examples include Dexon, Vicryl, silk and nylon. They have
the advantage of providing a more secure closure. They can
cause more of a tissue reaction than monofilaments and also
harbour bacteria between the braids, leading to infections.
1.2.3 DrainsDrains are used in various parts of the body to drain and collect
air or fluids that can accumulate in compartments around the
body. Some indications for usage of drains include but are notlimited to:
Wound drain (eg post-thyroidectomy or mastectomy)
Abscess cavity drainage (eg corrugated drain)
Abdominal drainage for ascites or post-operatively to
check for blood, bile, urine, or anastomotic leakage
Chest drain for air, effusion, blood, or rarely chyle
Ventricular drains (eg external ventricular drains following
subarachnoid haemorrhage)
Drains come in many forms and varieties. Drains are best
classified into:
Open or closed drains
Open drainsallow drainage into dressings or a stomabag through gravity or natural flow. Often, just making
an incision into a superficial collection creates an open
drain which can then be dressed appropriately. This is
more often used in heavily infected cases or where a
natural fistula has already formed. A corrugated drain is
an example of an open drain.
Closed drainsallow drainage of substances into a bag
or bottle. As this is a closed system, infections are less
likely to develop. A Robinsons drain is an example of a
closed drain.
Suction or non-suction drains
Suction drainshelp to collapse down wound cavities
and drain them. If vacuum is applied, this can also helpwound healing. Examples include Redivac drains, sump
drains with suction and Vac dressings. Never apply a
suction drain in a brain ventricle.
Non-suction drainsare usually used in the brain
ventricles or abdominal cavities post-operatively or for
chest drains generally. They allow for natural collection
of fluids, air, or other content as necessary within the
body cavity.
1.2.4 Attending operationsIt is a privilege as a student to be allowed to scrub in and assist
a surgical procedure. This allows you to appreciate the anatomy
and pathology of the surgical procedure and to feel part of theteam involved in caring for a surgical patient.
Scrubbing-inAlways ask permission of the most senior surgeon if you can
scrub up in the procedure to observe. If allowed to, make sure
you learn the appropriate technique for scrubbing up from the
theatre sister or surgeon. Once this has been learned properly
and practised a few times, it should become a natural act
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provided it has been practised regularly as well. Try to wear a
mask at all times with visor protection. This is to ensure that no
bodily fluids get splashed onto your eyes and into your mouth.
This is extremely common in surgery and following thesesimple measures can save a lot of unnecessary distress. The
standard rule for hand washing is to scrub up for 5 minutes for
the first scrub of the day and for 3 minutes between subsequent
cases. The closed gloving technique is preferred over the open
one, although it is best to learn both for comparison and
personal choice.
Scrub brushes should not be used as they promote bacteria on
the skin and also irritate the skins surface. They can be used if
necessary on the fingertips and nails, but they should not be
used on skin. An appropriate glove size should also be checked
prior to scrubbing up to allow for smooth assisting. Try to
double-glove as much as possible to ensure universal
precautions are carried out in every patient regardless of whothey are and the nature of their operation. The human
immunodeficiency virus (HIV) and hepatitis status of most
surgical patients is not known and there is no point risking
your life and career over something that could have been
avoided. This advice is no different from asking all drivers to
wear seatbelts whilst driving regardless of where and when
they drive. If the law didnt insist on it, would all drivers neglect
the seatbelt?
AssistingAssisting in an operation can be exciting as it allows you access
to view the operation upfront. It can also be boring, tiring and
may not give you the view and angle you wanted to see theoperation from. In certain cases, it is not always ideal to scrub
up to get the best view and remaining unscrubbed also allows
you freedom of movement within the case. Always follow the
lead of the senior surgeon and do not ever risk the life and
well-being of the patient by interfering or not following orders.
You may often have to provide retraction for long periods of
time in a particular stance and this can get painful for anyone.
If there is a particular discomfort, it is best to ask politely for a
break to readjust at the right moment in a surgical case. This
allows you to carry on doing your job well and does not put the
patient at any risk.
The operating roomWhen you are in the operating room you should notice that
there are many things in this new environment that you
havent encountered before. Firstly, the people around the
operating room have particular, defined job roles and you
should introduce yourself to them so that they know how to
help you and how you may be able to help them. Always try to
assist them in any way possible, including the transferring of
patients. They will, in return, teach you how to scrub and assist
in cases, and teach you about the operating room environment.
In other moments when you are not assisting or learning, it is
advisable to introduce yourself to the anaesthetist as well, who
can teach you a lot. Many skills such as cannulation, intubation,central venous pressure (CVP) and arterial line insertion, lumbar
puncture (LP)/spinal and ventilation can be learnt in a short
time. Topics such as physiology and pharmacology can also be
applied really well during the anaesthetic course and it is an
asset to learn from these doctors as well. Rules include:
Do not touch anything unless you know what you are
doing
Stay off the green sterile field unless you are scrubbed and
sterile
Always wear a mask as a student, even if not assisting
Be polite to everyone and introduce yourself to make your
own life easier
Help out at all timesUse every free moment to learn in the operating room, ask
questions appropriately, take a surgical textbook to read
on the side, read through patient notes and learn from
anaesthetists
Thank everyone for taking the time to accommodate you
and for teaching you
Post-operative careAs a junior doctor, it is good practice to see the patient in the
recovery room as they wake up. Many vital signs can be
monitored here and on occasion a patient who may have to go
back to the operating theatre can be recognised by following
good clinical judgement (eg excess bleeding from a drain sitein the recovery room, or blood-soaked dressings). After
recovery, it is also advisable to see the patient on the ward at
the end of an operating list or between cases if possible. This
allows you to see the patient recovering and to speak to them
about what happened during surgery. This helps in building
rapport through communication and often allows you to speak
to any family members at the same time so that any concerns
are alleviated. If you get into this practice as a student, it
becomes part of your good clinical practice and routine and
makes you feel part of the surgical team. Students often spend
more time with patients talking to them than the doctors
looking after them. If a rapport has been established pre-
operatively, the patient may expect to see the student aftersurgery as a friendly face who cares about their well-being.
1.3 PERI-OPERATIVE SURGICAL CARE
1.3.1 Preparing for surgeryWhen preparing for surgery, many things need to be considered
in advance. It is surprising to see how often most of these
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things can go wrong. The following need consideration and
addressing well before undertaking surgery on any patient:
Ensuring appropriate indication for surgery
Ensuring that the patient wishes to go ahead with surgeryEnsuring appropriate setting and facilities (eg ITU,
laparoscopic unit, anaesthetists with special skills)
Full clerking of patient and identification of any special
needs, medications or investigations
Liaising with anaesthetists, theatre staff and the
consultant/registrar about the cases
Ordering and submitting the theatre list with appropriate
case load and mix
Ordering any special equipment well in advance of surgery
Ensuring all investigations are adequate and results acted
upon in the week before surgery
Ensuring all patients have a bed on the wards or are
admitted pre-operativelyEnsuring that all patients have been consented and
marked appropriately (if necessary)
Ensuring that all the patients notes and scans are
available well in advance (few days) of the operation
Ensuring that any special adjuncts have been addressed on
the day (ITU bed, surgical equipment, blood products, etc)
Making sure that an appropriate time has elapsed since
the patient last ate or drank
Ensuring that the anaesthetist and theatres are aware of
the patients location (ward)
Although these points seem like a long list of chores, they
often become second nature to the junior doctor once they areestablished on a surgical firm. For those who are still finding
their way, there is never any harm in reverting back to the
above checklist.
1.3.2 Informed consentInformed consent should be sought before undertaking any
investigation, treatment, screening, or research on a patient.
All patients have a right to information about their condition
and any options for further investigation and management
plans. They also have the right to refuse any investigation or
treatment offered to them at any time, even after a consent
form has been signed. Acting against a patients wishes can be
regarded as assault. Most informed consent applies tocompetent patients who can:
Understand the information given to them
Retain the information
Contemplate the information
It is good practice to ask if patients have understood the
information and if they have any further questions of their
own before proceeding.
Different laws apply for patients deemed incompetent and for
children:
For children under 16 years parents should consent to
treatment. If a child is deemed competent and understandsthe risks and benefits of treatment, they can consent to
treatment even if their parents refuse. The converse is also
true if a competent child refuses treatment, but the
parents wish for it, then treatment may be given. A court
order can be obtained in life-threatening cases where both
child and parent refuse treatment.
For incompetent adults (including temporary and transient
incompetence) the doctrine of necessity applies, where a
physician can act in the patients best interests.
Informed consent can be implied or acquired. Informed consent
is implied in situations where there are no major complications
resulting from it. A good example is when a doctor cannulatesa patient or takes blood from them; no consent form is signed
for the procedure or investigation. Any situation in which a
major complication can arise should ideally have a signed
consent form. This happens to be a grey area in most hospitals
for intermediate ward procedures such as CVP line insertions,
chest drains and LPs, which all have well-defined major
complications listed. They are often treated as no different
from any other ward procedure provided the appropriate
precautions are taken and the procedure is discussed with the
patient in the usual manner.
Informed consent in all other situations should include:
Details of the clinical condition, including prognosisManagement options
Explanation of any proposed procedures
Risks, benefits, side-effects and complications which may
arise from it
Common (>1%) and serious complications and risks
should be discussed
The doctor responsible for their treatment
An opportunity for the patient and family members to ask
any questions
Normally, the consent forms provided these days in most
hospitals have sections laid out which comply with the above
points (except the last one) and can easily be gone through in
a stepwise approach. Remember that patients may changetheir minds at any stage, even after signing the consent form.
Consent should ideally be obtained by the doctor performing
the procedure although it can be delegated to an appropriate
team member of sufficient seniority and knowledge.
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1.3.3 CommunicationCommunication is regarded as the most important part of any
aspect of patient care. It is extensively taught and examined
nowadays in the medical school curriculum. It is very brieflyrecapped in this section and the following skills should be
learnt well as part of learning in surgery. They are only included
here to remind you of the skills necessary and are not expanded
upon any further in this book.
Informed consent
Explaining common procedures for a lay person to
understand (eg gastroscopy, hernia repair, magnetic
resonance imaging (MRI) scan)
Breaking bad news (eg post- or peri-operative death)
Dealing with angry patients (eg cancelling their operation
due to lack of beds or overbooked lists)
Communicating with foreign-language-speaking patients
(eg use of translators, family, etc)
1.3.4 Post-operative reviewThe first post-operative review of a patient should ideally be
done in the recovery area of theatres as the patient is waking
up from anaesthesia. In reality, time pressures and other cases
may prevent a surgeon from seeing a patient in recovery for
review. It is good clinical practice to see all post-operative
patients after the operating list has finished on the same
evening. A quick ward round can be done to assess the patients
for any potential problems as well as communicate with the
patient as to the progress made by the surgical procedure.
Analgesics and antibiotics can be given as well as permission toeat and drink as appropriate. Blood tests can also be ordered
for the next morning during this round.
During the subsequent daily ward rounds it is important to
monitor the surgical patient carefully to ensure that they are
on the path to recovery from their surgical procedure. The aims
of the ward round are to:
Identify and address any problems reported by the patient
or nursing staff
Check routine observations:
Temperature
Heart rate
Blood pressureRespiratory rate
O2saturations
Blood glucose (diabetics)
Fluid balance
Input
Output
Nutritional status ladder
Sips of water
30 ml/60 ml/90 ml per hour of water
Clear free fluids
Free fluids (anything liquid)
Soft light dietLight diet
Full diet
Check analgesic control
Examine the patient
Cardiorespiratory
Abdomen
Wound
Calves for deep vein thrombosis (DVT)
Inspect the wound and drains
Note future date for suture removal
Drains (eg nasogastric tube, catheter, cavity drains,
lines)
Check blood and imaging results and compare withprevious results
Communicate findings
To patient (and relatives)
To own team
To nurses and other allied health professionals (eg
physiotherapist, dietitian)
Document findings
Clear legible and accurate notes
1.3.5 Post-operative complicationsPost-operative complications occur frequently. They may be
easily categorised by timing or by cause:
Timing
Immediate (within 24 hours of surgery)
Early (occur up to 30 days for outpatients or during the
inpatient stay)
Late (post-discharge or more than 30 days post-op)
Cause
General complications of surgery (haemorrhage,
infection, DVT)
Specific operative complication (eg anastomotic leak)
Complications as a result of patient co-morbidities (eg
cardiac failure)
The commonest causes of post-operative complications in
general are found in Section 3.3. I would highly recommendreading that section to familiarise yourself with a description
of the commonest post-operative complications.
Complications should also be learnt which are specific to the
procedure being performed (eg common bile duct injury during
laparoscopic cholecystectomy). Although this is a post-
graduate topic, some knowledge is tested in the written exams
as well as in OSCEs.
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The goal of a junior doctor in the post-operative period is to
recognise complications early and prevent their progress by
initiating appropriate management.
REFERENCES
Burnand K, Thomas W, Black J, Browse N. 2005. Browses
Introduction to the Symptoms and Signs of Surgical Disease.London: Hodder Arnold.
Ellis H, Calne R Y. 2002. Lecture Notes on General Surgery, 10th
revised edition. Oxford: Blackwell Science.
Recommended