General Surgery Part-I

DAY CARE SURGERY

Personal Notes
| Day care surgery: Admission to discharge < 12 hours
| Overnight stay: Admission to discharge < 23 hours
| Short stay: Admission to discharge < 72 hours
| Most common complication post day care surgery: Nausea and vomiting
| Most common complication requiring readmission: Hemorrhage after a
day care surgery

Discharge Criteria in Day Care Surgery

| Vitals must be stable at least for 1 hour + oriented (Time, place, person).
| Adequate analgesia: Pain control from oral medication
| Has taken orally and tolerated.
| Must have passed urine.
| No bleeding/minimal discharge/soakage from wound site.
| Able to dress/able to walk/responsible person available to take home.

ERAS

| Enhanced recovery after surgery

Preoperative
| Counselling
| Avoid mechanical bowel preparation
| Oral intake prior to surgery:
™ Solids are allowed till 6 hours before surgery.
™ Liquids are allowed till 2 hours before surgery (Clear carbohydrates
rich liquid).

Intraoperative
| Minimally invasive surgery
| Bupivacaine infiltration
| Keep the patient warm
| Nausea and vomiting prophylaxis:
™ At least 2 class of the drug
Postoperative
Personal Notes
| Use NSAIDs > opioids
| Discontinue within 24 hours:
™ Discontinue IVF
™ Start liquid followed by solid
™ Early ambulation
| Avoid drains:
™ Plan for early removal

POSITION FOR SURGERY

Supine Position

| Most common for general surgery procedure.

| Breast surgery
| Abdominal surgery
| Inguinal surgery
| Sternotomy

Prone Position

| Keep patients in supine position then after intubation with log roll
technique prone position.

2 Surgery
Lateral Position
Personal Notes

| Kidney position
| Lateral decubitus
| Thoracotomy
| Urological position
| Retroperitoneal surgery
| Renal surgery

Lithotomy Position

| Hip flexion: 90°

| Perineal surgery
| Endo urological procedure
| Gynecological procedure

General Surgery Part-I 3

VARIATIONS IN SURGICAL POSITION
Personal Notes
Jack Knife Position

| Variation of prone position

| Hemorrhoids surgery
| Fissure surgery

Lloyd-Davis Position

| Variation of lithotomy position

| Hip flexion: Obtuse angle : 15°
| 30°: Head down with tilt

Trendelenburg Position

| Laparoscopic surgery
| Cholecystectomy

4 Surgery
Reverse Trendelenburg Position
Personal Notes

| Upper GI surgery
| HBP surgery
| Transverse colon surgery

Fowler’s Position

| Cranial surgery
| Reduce ICP but increase risk for air embolism.

Rose Position

| Barking dog position

| Thyroidectomy
| Submandibular gland surgery
| Neck dissection

General Surgery Part-I 5

Sims Position
Personal Notes

| Digital rectal examination

| Midway between prone and lateral position.

PREPARATION OF THE SURGICAL SITE

Removal of Metals and other Foreign Bodies

| Pre-operative

| Acts as nidus for infection.

| Thermal injury due to diathermy.
| Postoperative edema: Digit constriction

Hair Removal from Surgical Sites

| Better for surgical site exposure.

| Application and removal of bandage: Early

| Ideal time: On the OT table after giving prophylactic antibody: Hair
removal

Skin Antisepsis
| Alcohol base: Chlorhexidine

| Concentric method : horizontal = vertical (Clean surgery : incision site

avoid, contaminated wound : peripheral to central)

Draping
| 1st periphery

| Maintain 1 arm distance from table

| Blunt tip clips to fix drops.
| Avoid crossing over table

VARIOUS TYPES OF INCISIONS

Scalpel Versus Diathermy

| Surgical site infection

| Blood loss
| Operating time
| All are the same for scalpel and diathermy.
| Diathermy: Postoperative analgesia requirement is less.

6 Surgery
Transverse Versus Longitudinal
Personal Notes

Transverse
| Pain less compared to longitudinal incision.
| Better pulmonary function
| Lower risk for incisional hernia.

Longitudinal
| Pain is more compared to the transverse incision.
| Decrease pulmonary function
| Increase risk for incisional hernia.

Reentry Incision

| Incisions should always include previous scars.

General Surgery Part-I 7

NAMED INCISIONS
Personal Notes
Lazy s Incision/Blairs Incision

| Parotid surgery

Kocher’s Incision

| Thyroid surgery

8 Surgery
 Personal Notes

| 15 : Precise incision
| 11 : Incision and drainage, to make stab incision, arteriotomy.
| 12 : Suture removal
| 10 : Precise incision
| 22 : Thoracotomy, laparotomy

DRAINS

2 Types
| Open: Drain outside the body (Absent collecting system)

| Closed: Gets collected in bags. To observe color, consistency, quantity,

quality and analysis.

Open Drain
| Passive drainage

| Gravity dependent drainage

Closed Drain
| Passive: Drainage is due to capillary gradient force or against gravity.

| Active: Drains due to negative pressure.

Corrugated Drain : Subcutaneous Drains (Open Drain)

Orange - latex (Biologically inflammatory)

General Surgery Part-I 9

Silicon Corrugated Drain : Silicon, Green Line (Radio Opaque)
Personal Notes

Romovac Drain : Closed Drain, Negative Pressure.

Foley’s Cath : Closed Drain, Passive Drain.

Mnemonic : White GORY Very Beautiful

| White : 12F

| Green : 14F
| Orange : 16F
| Red : 18F
| Yellow : 20F
| Violet : 22F
| Blue : 24F

10 Surgery
French: Outer Diameter
| Distilled water used for balloon inflation.
Personal Notes
| Unable to deflate foley’s balloon: USG guided puncture of balloon

3 way’s foley’s: Used for bladder irrigation (Surgery on bladder)

| Color code tip: Balloon inflating channel

| Big channel is for urine collection.
| Irrigating channel

Penrose Drain : Open Passive Drain

General Surgery Part-I 11

Romovac Drain : Closed Active Drain, Negative Pressure
Personal Notes

T-Tube : Bile Drainage

| CBD exploration

Pigtail Catheter

| Drain from the solid organ.

NGT : Nasogastric Tube (Ryles Tube)

12 Surgery
| Length : 100 cm
Personal Notes
| Adequate length of insertion : NEX - rule

Nex - rule: Measure from the nose to earlobe, and earlobe to xiphisternum,
insert the ryles tube according to that length.

Jackson Pratt Drain : Closed Active Drain, Negative Pressure.

SBT Tube : Sengstaken Blakemore Tube

| Used to control bleeding from esophageal varices.

| Esophageal balloon: 40 mm Hg air
| Gastric balloon: 300 ml air

Linton Blakemore Minnesota

Gastric + + +
Esophageal - + +
balloon
Channel 3 3 4

Fenestrations Esophageal and Gastric Esophageal and

gastric gastric

General Surgery Part-I 13

CANNULA
Personal Notes

Flow Rate
| Orange: 240 ml/minute

| Gray: 180 ml/minute

| Green: 90 ml/minute
| Pink: 60-65 ml/minute
| Blue: 35 ml/minute
| Yellow: 20 ml/minute
| Violet: 12 ml/minute

Maximum flow: Wide bore and shorter length

Ideal size for resuscitation in trauma: 16 G
Minimum size for resuscitation in trauma: 18 G

14 Surgery
LAPAROSCOPIC INSTRUMENT
Personal Notes

Port and trocar

| Port : Hollow
| Trocar : Solid
| 10 mm : Optical port
| 5 mm : Instrument port

Blunt trocar
| Blunt trocar : Hanson’s port
| Atraumatic port

SILS (Single Incision Laparoscopic Port)

Laparoscopic lens

General Surgery Part-I 15

| 30° lens used (Wide viewing angle)
Personal Notes

Veress needle
| Inserted to create pneumoperitoneum.
| Most common gas : Co2
| Initial flow rate : 1-4 l/min
| Maximum flow rate : 20 l/min
| Intra abdominal pressure during laparoscopic surgery : 12-15 mmHg
| Angle between needle and skin : 90°
| Angle between needle and body : 45°
| Insert towards the pelvis.
| Usual site: Umbilical region
| Previous laparotomy: Palmer’s point (Left subcostal region)
| While inserting needle accidental injury: Keep needle in situ and take the
patient for exploratory.

16 Surgery
 Personal Notes

| Elevating angle: Between port and body : 60°

| Azimuth angle: Between working port and optical port : 30°
| Manipulating angle: Angle between 2 working port : 60°

ENERGY DEVICES
| Monopolar (Works on electrical energy)
| Bipolar (Works on electrical energy)
| Harmonic (Works on ultrasonic waves : 20000-50000 Hz) : vibrating
energy converts into heat and results in protein denaturation.
| Thunder beat (Works on electrical energy)

Monopolar
| Worked on electrical energy.

Bipolar

General Surgery Part-I 17

| Worked on electrical energy.
Personal Notes

Harmonic
| Worked on vibration energy.

Thunder beat
| Combined energy source
| Both electrical and vibrating energy.

Ligasure
| Worked on heat and pressure.
| Upto 7 mm diameter.
| Vessels can be sealed.

18 Surgery
 Personal Notes

| Cut: Low voltage, high frequency

| Coagulate: High voltage, low frequency
| Bland: Moderate voltage, moderate frequency
| Safest electrical source patient with pacemaker: Harmonic

SUTURE MATERIAL

Absorbable
| Enzymatic digestion +

1. Natural:
™ Catgut : 7 - 10 days : Submucosa of sheep intestine (High tissue
reaction), yellow colour
™ Chromic catgut: 90 days, brown colour, monofilament

2. Synthetic:
™ Vicryl (Polyfilament, polyglactin: 60 - 90 days (Used to suture bowel,
bile duct, bladder), violet colour
™ Polyglyconate: 180 days
™ PDS: 180 days, monofilament (Used to suture bowel bile duct, bladder)
™ Dexon (Polyglycolic acid): 60 - 90 days
™ Monocryl (Polyglycoprone): 90 - 120 days

Non-Absorbable
1. Natural:
™ Silk (Fix drains, outer layer anastomosis of bowel), 3.0 material used.
™ Cotton
™ Lenin
™ All are polyfilament

General Surgery Part-I 19

 2. Synthetic:
Personal Notes
™ Proline (Polypropylene)
‘ Monofilament
‘ Purple colour
‘ Used for vascular anastomosis:
Š Anastomosis of aorta (2.0)
Š Anastomosis of femoral vessels (3.0)
Š Anastomosis of popliteal vessels (4.0)
™ Used for rectus closure
| Nylon
| Polyester
| Stainless steel
| Etilon (Monofilament)
™ Used for skin suture

SUTURING RULE

1. The length of the suture material should be 4 times the length of the
wound.

2. The depth of the wound should be equal to the distance between the
edge of the wound and the bite size.

3. The angle between the needle and the skin should be 90 degrees.

4. The distance between 2 sutures should be twice the depth of the wound.

5. The length of the suture should be 1-2 mm.

Suturing Techniques

Simple continuous running suture

20 Surgery
 Personal Notes

Simple interrupted suture

Vertical mattress suture

Horizontal mattress suture

Subcuticular suture
| Best for cosmetic outcomes.

General Surgery Part-I 21

KNOTTING
Personal Notes

| Half hitch knot: Single loop, unstable

| Granny knot: Unstable
| Square or reef knot: Stable
| Surgeon’s knot: Most stable

SUTURE REMOVAL PERIOD

| Face : 3-5 days
| Scalp : 7-10 days
| Arms : 7-10 days
| Trunk : 10-14 days
| Legs : 10-14 days
| Hands/feet : 10-14 days
| Palms/soles : 14-21 days

22 Surgery