Tutorial

بسم الله الرحمن الرحيم

Pre-operative care

Preoperative Care

Diagnostic Work Up (Investigations). Preoperative Assessment (evaluation). Preoperative Preparations Counseling. On going to theater.

Diagnostic Workup

Investigations Determine the cause and extent of the illness

Investigations

General: Done to all patients depending on other factors than the surgery scaduled. (cardiac, renal…….).Specific: Related to the scaduled surgical procedure. (partial laryngectomy need pulmonary function).

Pre-operative Investigations

General: 1- CBC all patients. 2- Clotting screen all patients and those on anticoagulants. 3- Hepatitis & HIV viruses secreening. 4- ECG all patients > 40Ys. 5- Echocardiogram Abnormal ECG, ischemic heart…. 6- Chest x-ray All patients >30Ys. 7- Blood sugar level.


Pre-operative Evaluation
General Specific

Pre-operative Evaluation

General This include the following: 1-General condition of the patient. 2-Psychological condition. ( Specially in major operations).Overall assessment of patient’s health Identify significant abnormalities that may increase operative riskShould begin with a complete history and physical evaluation

Specific This include the following: 1-Related to anaesthesia. Air way. Evaluation by the anesthesiologist 2-Related to the surgery. Class and grade of surgery.

Risk

Anaesthesia: 1- Airway. 2- ASA grading. Surgical: 1- Grade & type of surgery. 2- Site of surgery.

Specific Factors Affecting the Surgery

History of angina or infarction History of anemia, lung disease, kidney disease, bleeding problems Nutritional status

Pre-operative counselling

Ensure that indication for operation is still valid. Identify any other medical condition. Discuss options with patient / relatives. Consent. Prophylactic antibiotic Prophylactic against DVT. Pain control. Nutrition. Discussed with patient & his relatives.

Routine Preoperative care for the Adult Patient

Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless approved by physician 2. Discontinue nonsteroidal anti-inflammatory medications 48 to 72 hours before surgery 3. Bring a list or container of current medications 4. Sedation and pre-op anesthetic medications


5. Prophylactic antibiotics 6. Instruct the patient to bathe/shower the evening before or morning of surgery. Men should be cleanly shaved. 7. Nothing by mouth at least 8 hours before surgery Prepare blood (if necessary) Hydration and IV access Consent for surgery

On going to the operating room

He/she will have to remove: 1. Dentures 2. Glasses/contact lenses 3. prosthesis 4. Makeup/nail polish

Factors Affecting Wound Healing

Steroids Malnutrition Radiation Diabetes

Factors Leading to Postop Infection

Diabetes Renal failure Steroid medications Immunosuppressive agents Smoking Preoperative infection

Classification of Operations

Clean Surgery. Clean-Contaminated. Contaminated. Dirty.

Grades of Surgery

Grade I (Minor) Excision of a skin lesion or drainage of abscess. Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy…….Grade III (Major) Thyroidectomy, total abdominal hysterectomy….Grade IV (Major+) Radical neck dissection, joint replacement, lung operations…

Grades of surgery

This can help in estimating: 1- Expected time. 2- Morbidity & risk. 3- Need for blood transfusion.


Postoperative Care &postoperative complications

The aim of postoperative care is: To provide the patient with as quick, painless and safe a recovery from surgery as possible.

Postoperative Care

Pain management Postoperative fever Recognize postoperative complications

Immediate Postoperative Period: Anesthesiologist in charge of cardiopulmonary functions

Immediate Postoperative Phase Recovery Room, ICU
ABCs of Immediate Recovery period airway breathing Consciousness Circulation system review

Discharge from the recovery room, ICU

Vital signs Controlled pain Awake Gag reflex returned Respirations and circulatory function normal

Surgeon responsible for all the rest

Surgeon’s ResponsibilitiesPost Operative Checks Note time of return, note level of consciousness, monitor vital sign• Check dressings, location• Check incision, report drainage, redness, edema• Check IV site• Report kinked tubing


• Check pulses distal to op. site.• Measure and record 1st. Void, report flatulence.• Learn type, purpose, location of all tubes, and how to empty.• Report change in character of drainage, notify nurse of need for dressing change.• Report changes in skin color.• Equipment- report if disconnected or malfunctioning.

Position in bed Mobilization Medications Diet

Fluid balance, electrolytes Respiratory care

Postoperative Phase

Level of consciousness, movement, sensation Skin color, temperature, nailbeds, oxygen saturation Lungs sounds, pulses, heart rate. Inspect abdomen for distention, monitor return of bowel sounds, ask about flatus

Pain control. Comfort measures: reposition, oral care, hygiene. Monitor dressing. Empty drainage tubes.


Turn, cough & deep breathing; incentive spirometry every hour.early ambulation. Monitor output – minimum of 30cc/hr; should void within 8 hours of surgery

NPO until ordered, start with clear liquids – full liquids – soft dietMonitor closely for signs of infectionAdminister medications as ordered-antibiotics.

Pain Management

Essential part of postoperative management Pain can increase risk of complications Pain relief- Multimodal E.g. PCA, IM pethidine, oral analgesics

Postop Fevers

An important sign of postoperative complications. History Examination Investigations (to confirm the diagnosis) Many possible DDX. Time of onset may guide the management.


First 48hrs Atelectasis Transfusion rx Pre-existing infection 3-7 days: infections like: UTI, wound infection, Catheter related phlebitis , pneumonia, anastomotic leakage

About 7 days onwards Abscess formation Allergy to drug Transfusion related fever DVT/PE

Postop Complications
General Specific Complications do occur, but many are preventable!

General Important examples: MI pneumonia DVT/Pulmonary embolism CVA

Specific Examples: anastomotic leakage abscess formation wound infection ileus bleeding

Wound complications Postoperative urinary retention Respiratory complications Postoperative parotitis GIT complications

Wound complication

Wound infection Wound hematoma Wound seroma Wound dehiscence

Wound infection

Operative wound classification : I clean 3.3-4 % II clean-contaminated 8-10 % III contaminated & IV dirty (infected) 28 %

Wound infection

Clinical manifestation : pain swollen & edematous redness & cellulitis warm to touch

Wound infection

Wound infections are classified as : Minor ( purlent material around skin suture sites) Major ( discrete collection of pus within the wound )

Wound infection

Wound infections are classified as : Superficial infection ( limited to skin & subcutanous tissue ) Deep infection ( involve area of the wound below the fascia )

Wound infection

Prevention : Skin preparation Bowel preparation Prophylactic antibiotic Meticulous technique Appropriate drainage

Wound infection

Management : Incision should be opened for drainage Debridement if there is necrosis Antibiotic if there is cellulitis


Wound Hematoma
Caused by inadequate hemostasis Good media for bacteria Manifested by pain & swelling Drain should be used Must be evacuated in certain location The wound should be opened in OR

Wound Seromas

Are lymph collections Operation in which large areas of lymph-bearing tissues are transected Closed-suction drain with pressure dressing Repeated aspiration is indicated Fertile ground for bacteria

Wound Dehiscence

Dehiscence ( is separation within the fascial layer , usually of abdomen )Evisceration (extrusion of peritoneal contents through the fascial separation) Incidence : 0.5 – 3.0 % in all abdominal procedures .

Wound Dehiscence

Related factors : Imperfect technical closure Increased intra-abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining Hematoma with or without infection Infection Metabolic diseases such as diabetes mellitus, uremia, Malignant disease, Radiation

Wound Dehiscence

Detected by the classical appearance of salmon colored fluid draining from wound occurs in about 85 % of cases about fourth or fifth postoperative days Present late as an incisional hernia

Wound Dehiscence

Complete repair , the skin and subcutaneous tissue, facial layers closed.



Urinary retention
Incidence : major abd. Surgery : 4 – 5 % Anorectal surgery : > 50 %

Urinary retention

Stress ,pain ,spinal anesthesia & anorectal reflexes lead to increased Alpha-adrenergic stimulation , which prevent release of musculature around the bladder neck Urgency ,discomfort , fullness ,enlarged bladder Catheterization to relive retention

Respiratory complication

5 – 35 % of postop. Deaths Predisposing factors : smoking , age , obesity , COPD , cardiac disease

Respiratory complication

Atelectasis Aspiration Pulmonary edema Pulmonary embolism

1) Atelectasis :

Collapse of alveoli Anesthesia , postop. Incisional pain Lung inflation in postop. period

2) Aspiration :

During induction of anesthesia CXR show progression of local damage & infiltration Prevention is only effective treatment

3) Pulmonary edema :

Most common causes are fluid over load or myocardial insufficiency Occur during : * resuscitation * postop. Period


3) Pulmonary edema :
Simple therapy including O2 , digitalization & upright position

4) Pulmonary embolism :

100’000 patients died in US per year90 % originate from DVT of iliofemoral ves.

4) Pulmonary embolism :

Mild tachypnea to sudden cardiopulmonary arrest Diagnosis require combination of : - ABG - CXR - ECG - Doppler studies for lower extremities - Radionucleotide ventilation – perfusion scan

4) Pulmonary embolism :

Management options : * intensive supportive measures & resuscitation. * direct or systematic thrombolysis. * surgical pulmonary ebolectomy. * IVC filter. Prevention of PE by using mechanical devices or pharmacologic inhibition of coagulation

Postoperative Parotitis

Serious complicationHigh mortality rate Rt. & Lt. equally involved Bilaterally 10 – 15 % of cases 75 % of patients are 70 year or older Poor oral hygiene , dehydration , use of anticholinergic drugs

Postoperative Parotitis

Majority of infections are from staphylocociLack of oral intake to stimulate parotid secretions predisposes to bacterial invasion of Stensen’s ductInterval between operation & the onset varies from hours to many weeks

Postoperative Parotitis

Present with : pain in the parotid region swelling & tenderness cellulitis on face & neck temperature & leukocyte high Prophylaxis includes adequate hydration & good oral hygiene


Postoperative Parotitis
Antibiotic should be started against staphylococi Surgical drainage ( by incision made ant. to ear extending to mandible angle ) In 80 % of patient treated with incision & drainage the parotitis was palliated or cured

GIT complications

Ileus Anastomotic leaks Fistulas Stomal complication

1) Ileus :

Non-mechanical obstruction that prevents normal postop. Bowel function Arise from neural inhibition of bowel motor activity & effective peristalsis Increased with manipulation ,inflammation , peritonitis & blood left in peritoneal cavity

1) Ileus :

Blood in retroperitoneum often produces ileus Hypokalemia , hypocalcemia , hyponatremia & hypomagnesemia prolong postop. Ileus Treatment is purely supportive

2) Anastomotic leaks :

The etiology factors : 1) poor surgical tech. 2) distal obstruction

Risk increase with S.Albumin < 3.0 mg/dl

2) Anastomotic leaks :
Three technical factors play roles in a proper anastomosis : 1- both end of bowel should have adequate blood supply 2- anastomosis should lie in tension-free manner 3- adequate hemostasis


3) Fistulas :
Abnormal communication between two epithelial surfaces Common problem of GIT surgery Can occur between : ( enterocutanous fistula ) , ( enteroenteric fistula ) ( enterovesical fistula ) , ( enterovaginal fistula )

3) Fistulas :

Most common cause is anastomotic leakage Persistence secondary to ( FRIEND ) ( F.B. , Radiation , Infection , Epithiallization , Neoplasm , Distal obstruction ) Spontaneous closure usually occurs within 5 weeks with adequate nutrition If persist >5 weeks operation is indicated

4) Stomal complications :

Stomal necrosis & retraction ( inadequate blood supply lead to ischemia ) Stomal stricture ( late complication , caused by development of serositis ) Peristomal hernia & prolapse ( resecting the stomal prolapse & fixing it again in place ) Skin complication

“ Surgical Drains”

Why use Drains ?
Haematoma Other Fluids (serous, chyle, pus, etc)

Drain…. Indications : Life saving measure : Tension pneumothorax . Therapeutic benefit : Chest drainage : haem\ pneumothorax , empyema . Thoracotomy , cardiothoracic procedure , oesophegeal resection and perforation . Drainage of abscess and infected cyst . Drainage gastrointestinal , biliary and pancreatic fistula . Drainage after extensive dissection and elevation of skin flaps . After operation for injury to solid organs and partial excision of these organs . After pancreatic necrosectomy .

DRAINS

What kind of drain you need and which size ?The drain should be :Soft to avoid tissue injury .Non-irritating . Firm….incompressible .Resistant to decomposition .Smooth for easy removal .

The Perfect Product

Greater tissue contact Inert material. Slides smoothly past any tissue Promotes ease of movement and deep breathing Minimal pain on removal Comes in various sizes


Drain material
Latex rubber ( red rubber)…soft , but excites a profound inflammatory reaction within 24 H. .Polyvinyl chloride (PVC) …less reactive and incompressible , however , tend to harden and splite with prolonged use, especially when in contact with bile .Silicon ( best drain material ) least reactive and the most pliable, and show no tendency to harden with prolonged use .

Drainage systems

Open ( static) drainage ;Penrose , multitubular ,corrugateClosed siphon drainage :Closed suction drainage :Low negative-pressure ( -100 to –150 mmHg ) e,g, Portovac , Reliavac .High negative-pressure ( -300 to –500 mmHg )e,g. Redivac , .Sump suction drainage : for irritant discharge .Underwater seal drainage .

Type of Drains

Suction Non - Suction Via wound Separate site

Principles of Drain Placement

Maximum area Minimal trauma (nerves, vessel repair ) Gravitational Patient comfort Ease of removal

Packs

Abscess cavity Infected wound Must contain an anti septic must be replaced frequently.

wicks

Fistulae. Discharging sinuses. Same principles of packs.

Corrugated rubber drain

Sheet drainage Simple insertion, care and removal . Not expensive. Tissue irritant.

Tube drain

Most effective method of drainage. Closed drainage.

Suction machines can be connected intermittently.

Problems with Drains
Obstruction Suction system Diameter vs Fluid Patient mobility Removal

Wound principles

Skin Placement



Suction Channels

Drain Length

Placement

Trochar removal

Fixation

Suction “Tip”

Suction adaption

Skin Closure

Drain “Organiser”

Patient issues Post Op

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