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Principles of Surgery

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Principles of Surgery 2

Principles of Surgery 3

Preoperative Respiratory Assessment

How would you assess a patient with severe respiratory disease or surgery?
Previous admissions or Exercise tolerance Cough
Home oxygen Spooking.
Dyspnoea at rest
Chest auscultation and percussion for active disease.

What investigations would you perform?
Peak expiratory flow rate
o FEV1.
o FVC.
o FEV1/FVC ratio.
Arterial blood gases.
Low-volume loops.
Chest X-ray.
CT thorax (if indicated).

How would you identify a high-risk respiratory patient?
FEV1< 1000ml.
FEV1/FVC< 50%.
Paco2> 6 kpa.
Body mass index (BMI)> 27 kg/m2.
Peak flow < 200 liters/minute.
Age > 60 years.

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Diabetic Surgical Patient

What is diabetes mellitus?
It is a condition characterized by an absolute or relative insulin deficiency. It is
classified according to the need for insulin replacement therapy, and untreated gives
rise to a host of complications, most of which are due to small vessel disease.

How do you classify diabetes mellitus?
Primary: genetic, infective, immunological.
Secondary: pancreatic disease, insulin antagonism (steroids), drugs.
Type 1 diabetes: insulin.-dpendent.
Type 2 diabetes: non-insulin-dependent; diet-controlled or requires oral
hypoglycemic drugs.

How would you diagnose?
The diagnosis may be suspected from the presentation with polyuria, polydepsia and
tiredness. Alternatiely, random blood or urine analysis may reveal an excess of
glucose, but the definitie diagnosis is made by glucose tolerance testing.

Diabetes is defined as:
Fasting venous glucose 7.8mmol/L. or
Fasting venous glucose > 11 mml/L 2 hours after a standard glucose load.
(A standard glucose load is 75 g of glucose, usually represented by 353 ml of
Impaired glucose tolerance is defined as:
Fasting venous glucose between 5.5 and 7.8mmolL. or
Fasting venous glucose between 7.8 and 11 mmol/L 2 hours after a standard
glucose load.

How do you assess diabetic control and how does diabetes affect the body?
Diabetic control:
History, e.g. of hypoglycaemic episodes, fatigue, weight loss, thirst, excessive
Glycosylated haemoglobin (HbA1,) levels (normal levels are 3.8%-6.4%; >9%
indicates poor control).

Systems affected by diabetes mellitus:
Peripheral nervous-system - autonomic and peripheral neuropathy, e.g.
hypotension, sexual dysfunction, bladder dysfunction, faecal incontinence,
constipation, gastroparesis.
Cardiovascular system- ischaemic heart disease, cerebrovascular disease,
Peripheral vascular system - leg ulceration, claudication
Rend system - diabetic nephropathy, end-stage renal disease
Eye disease - retinopathy, cataract, glaucoma.

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What are the potential operative complications in the diabetic patient?
Infections: diabetics are prone to infection at the surgical site and elsewhere.
Wound healing: this is impaired in diabetics due to micro-vascular disease.
Cardiovascular complications: due to macro-vascular disease, (myocardial
infarction may be painless due to autonomic neuropathy).
Renal damage: they are more at risk of postoperative renal failure and extreme
care must be taken fluid balance.
Neuropathy: leads to specific problems, such as pressure sores, especially on
the heels.

What special problems does the surgeon face when investigating a diabetic
patient taking metformin?
Radiological investigations involving the use of contrast are contraindicated in
patients on metformin because of the risk of renal impairment and precipitation of
severe metabolic acidosis. To investigate them safely, renal function should be
checked to ensure normality, and metformin withheld for 24 hours before
investigation, and not recommenced until 48 hours afterwards.

Why is tight control of glucose so important?
Hyperglycemia causes:
Osmotic diuresis.
Hyperviscosity of blood and predisposition to thrombosis.
Cerebral edema.
Increased-risk of wound infection.
All these lead to increased complication rates and prolonged hospital stay.

How do you manage the diabetic patient once they are on the ward?
1. Patients with diabetes often have gastroparesis, and they should fast at least 12
hours before elective surgery.
2. Always try to put the patient first on the list.
3. Patients with diet-controlled diabetes usually just require glucose monitoring.
4. Patients on oral hypoglycemic agents should have those agents discontinued
on the day of surgery. Sulphonyl-urea drugs should be withheld at least 1 day
before surgery, because of their long half-life.
5. For those on insulin prescribe 5% dextrose with potassium and start sliding
scale insulin infusion Continue the insulin and dextrose infusion until the
patient has had a second meal with their normal dose of subcutaneous insulin

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How should these different types of diabetics managed preoperatively?
Pre-operative starvation poses a problem for diabetics as their blood glucose
concentrations can become seriously disordered, thus various regimes have been
devised to ensure the safety of diabetic patients undergoing surgery.
NIDDM patients:
Undergoing minor to intermediate surgery:
They should omit their morning dose of diabetic tablets and be starved as
They should be operated on first on the list.
They allowed to eat on return to the ward and recommence their diabetic
regime as normal.
Undergoing major surgery:
They should be started on a sliding scale.
The patient fasted but commenced on intravenous (IV) fluids and a variable IV
insulin regime.
Regular monitoring of blood sugar by finger-prick testing allows the rate of
insulin infusion to be varied to alter the glucose concentration as appropriate.
This can be continued until the patient is able to take a reasonable diet
postoperatively, at which point normal diabetic therapy can be reinstituted.

A typical sliding scale would be as follows.
The patient is infused 1 L of 5 percent dextrose with 20 mmol/L KCI at the
rate of 100 ml per hour, and
50 units of human actrapid insulin are added to 50ml of normal saline in a
syringe on a syringe driver.
The rate of insulin infusion is varied according to BM thus:
o BM < 4 - 0.5 ml per hour.
o BM = 4-15 - 2 m per hour
o BM = 16-20 - -4 ml per hour
o BM = 20 - review.

Why are diabetic patients high-risk surgical candidates?
Diabetic patients are high-risk surgical candidates because the often have:
Co-existing cardio vascular disease (hypertension, angina, previous C A and
Increased risk of metabolic disturbance (hyperglycemia and ketoacidosis)
Co-existing renal disease
Poor wound healing
An increased probability of infection

How might these surgical risks be minimized?
These risks may be minimized by:
Pre-operative correction of any cardiovascular and metabolic problems and
optimization of their current clinical status.
Throughout the peri-operative period the blood glucose level must be kept
stable. This will decrease the risk of metabolic disturbance and reduce the
probability of infection.
The precise method of controlling blood glucose levels depends on the severity of the
diabetes and whether the surgery being undertaken is major or minor.
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How are diabetic patients managed in the peri-operative period?
Diabetes can be classified as:
IDDM: Insulin controlled
N1DDM: Oral hypoglycemic controlled
Diet controlled

For diet controlled patients undergoing minor surgery no additional precautions to
the normal daily routine of blood glucose monitoring need to be taken. However,
when undergoing major surgery these patients require hourly blood glucose
monitoring. An insulin sliding scale is started and the glucose is maintained between 7
and 10 mmol/l.
For oral hypoglycemic controlled patients who are undergoing surgery, the morning
dose of oral hypoglycemic agent should be omitted. & blood glucose is monitored 4
hourly and the oral hypoglycemic drug is recommenced only when the patient is
eating & drinking normally. When these patients are undergoing major surgery, an
insulin sliding scale is used to control the blood glucose. This regimen is commenced
when the patient is starved for surgery and stopped when the patient is eating and
drinking normally and has no electrolyte disturbance.

For insulin controlled patients undergoing only very minor surgery the insulin dose
is omitted whilst nil by mouth. Otherwise, these patients are managed with an insulin
sliding scale and dextrose infusion until normal dietary fluid and intake are resumed.

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Explain the ways in which the obese patient causes problems to the surgeon?
The problems of the obese surgical patient are plentiful. Aside from the technical and
anesthetic problems of operating on the obese, they are at high risk of certain
complications and are prone to many coexistent diseases. There are many technical
problems encountered when operating on the obese:
Exposure is limited and the view often obscured by adipose tissue.
Instruments, particularly laparoscopic ones, need to be logger to provide
High pressures are needed for a pneumoperitoneum in laparoscopic work to
support the weight of the abdominal wall.
Vessels are less well supporter a more likely to retract causing hematoma.
Wounds have increased dead space collections and infections are
The tissues of the abdominal wall are of poor quality and wound
dehiscence is commoner.

The anesthetic problems of obesity are often of even greater importance when
considering surgery.
Intubation can be extremely difficult in these patients.
Higher ventilation pressures are needed.
The volume of distribution of drugs is variable owing to variation in distri-
bution in adipose tissue.
Respiratory failure owing to hypoventilation consequent on the weight of
the thoracic cage. Atelectasis and chest infections are more common
Cardiac failure is more common due to increased cardiovascular demands.

The conditions associated with obesity not only increase the frequency with which
surgical conditions become apparent but increase the complications associated with
subsequent surgery.

Diabetes mellitus more common in the obese, increasing wound healing
problems and increasing the incidence of vascular disease.
Hypertension is more common in obesity and contributes to vascular
Obesity is independently associated with increased risk of atherosclerosis,
.heart disease and peripheral vascular disease.
DVT & PE in the peri-operative period are greater owing to the increased
pressure on the calf veins during surgery. This is exacerbated by patient inertia
in the postoperative period.
Gallstones, gout and osteoarthritis are all more common in the obese. Such
patients are poor candidates for surgery for all the above reasons. They are
particularly poor candidates for joint arthroplasty because of the excessive
wear on the prosthesis.

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What is BMI and define the gradations?
BMI stands for body mass index. It is calculated thus:
)] [
) (
m Height
kg Mass

A variety of graduations of BMI have been published and the specifics of them vary
slightly. One accepted classification is shown in Table
BMI Description
<20 Underweight
20-25 Normal
26-30 Grade I obesity overweight
31-40 Grade II obesity obese
41-45 Grade III obesity extremely obese
>46 Morbidly obese

How is obesity associated with excess mortality?
Obesity is associated with excess mortality from diabetes mellitus, heart disease,
stroke, pneumonia and accidents.

What are the respiratory complications of obesity?
Obesity increases the work of ventilation and impairs the function of the chest
Post-operative Atelectasis is more common in obese patients.
Obese patients may suffer from obstructive sleep apnoea.

What surgical options are there for the treatment of obesity?
Gastric restriction surgery for the severest forms of obesity is an option if other
methods have failed.

What surgical procedures for treating obesity are in current use? Do they work?
The common surgical procedures are intra-gastric balloon placement, gastric
partitioning and gastric bypass procedures. Jaw wiring is rarely practiced these days
as it seldom works.
There is evidence that surgery for obesity works but it is heavily dependent on patient
The intra-gastric balloon:
It offers a simple way of assessing whether patients will be able to tolerate and
succeed after gastric reduction surgery.
A balloon is inserted endoscopically into the stomach and filled with 500 ml
of fluid. This limits the gastric capacity.
After 3-6 months, however, the stomach adapts, so it is not a permanent
solution but, if the patient has maintained some weight loss during this period,
then surgery is more likely to have a better outcome.
Gastric partitioning:
It do by vertical banded gastroplasty, or more recently by the Swedish
laparoscopically placed "Lap-band", partitions a small reservoir of stomach
30-50ml in volume in the proximal stomach.
The small reservoir prevents large meals being eaten.

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Gastric bypass procedures:
It involves joining a distal portion of bowel to the stomach, bypassing a
portion of proximal bowel.
The commonest bypass procedure currently is an anastomosis of the distal
small bowel to the proximal stomach as a roux-en-Y procedure, thereby
limiting the amount of small bowel absorption that can occur.
Given the huge potential for psychological and physical morbidity from these
procedures, each patient should be assessed, and treatment options considered
on an individual basis.
Patients can obtain excellent weight loss after these procedures, often to within 30
percent of ideal weight, but close follow-up is needed to maintain this benefit in most

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How would you classify hypertension?
I would classify hypertension into primary (or essential) and secondary causes.

How common is secondary hypertension?
Secondary hypertension is very much less common than essential hypertension and
accounts for about (5%) of all cases.

What are the causes of secondary hypertension?
The causes can be broadly divided into:
Reno-vascular diseases.
Chronic renal failure
Conn's syndrome.
Cushing's syndrome.
Renin-secreting tumors.

What is the commonest renovascular condition that causes hypertension?
Renal artery stenosis

What is the nature of this stenosis?
The stenosis is usually due fibro-muscular dysplasia or atheroma.

What is the mechanism of this hypertension?
According to Goldblatt, constriction of the renal artery leads to a transient rise in
renin levels, lasting up to a few weeks. After this period, Renin levels return to
normal. However, continued hypertension is seen. The precise mechanism is
unknown but may involve another renal pressor agent or decreased secretion of
another renal vasodilator substance. An alternative hypothesis is that patients become
abnormally sensitive to angiotensin II.

A patient in your pre-admission clinic has a blood pressure of 160100 mmHg.
What do you do?
The blood pressure measurement and enquire about previous readings to find out if it
is just one-off reading.
If it seems likely that the reading is not just a one-off reading looks for evidence of
end-organ damage:
Left ventricular hypertrophy.
Peripheral vascular disease.
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Renal failure.
Retinal changes (cotton wool spots, macular edema and hemorrhages).
Enquire about a past medical history of myocardial infarction, angina or stroke.
The BP should be measured again at least three times with each measurement a week
24 hours ambulatory BP monitoring can be considered, if hypertension is confirmed
then liaison is required with the patient's general practitioner (GP) prior to re-
scheduling surgery.

What is hypertension is a risk factor for?
Stroke and myocardial infarction. Diastolic blood pressure (DPB) 110
A risk factor for peri-operative cardiac complications.

How does Conn's syndrome cause hypertension?
In Conn's syndrome, there are raised, levels, of the mineralocorticoids, Aldosterone.
Aldosterone stimulates sodium and water retention, so leading to elevated blood

What is the cause of Conn's syndrome?
In 80% cases it is due to an adrenal adenoma. In rare instances it is due to a
carcinoma, and occasionally it is the result of bilateral hyperplasia of the zona

What biochemical abnormalities does Conn's syndrome produce?
Conn's syndrome produces high plasma Aldosterone and low Renin levels. This
results in a hypokalemia and metabolic alkalosis.

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What are the adverse effects of alcohol?
Alcohol adversely affects numerous systems within the body
Nervous system:
Psychological disturbances leading to depression, anxiety, memory
disturbances (including Wernicke-Korsakoff syndrome).
Cerebral atrophy.
Cerebellar degeneration.
Thalamine deficiencies.
Cardiac: dilated cardiomyopathy.
Liver: alcoholic liver disease (fatty change hepatitis, cirrhosis)
Pancreas: pancreatitis
Stomach and Duodenum: ulceration

What effects does alcohol have on the liver?
Alcohol can lead to a wide spectrum of liver problems, including fatty change,
hepatitis and cirrhosis. Fatty change is due to malnutrition and the direct metabolic

What histological changes are seen in the liver?
In alcoholic hepatitis, there is cellular necrosis and infiltration with
polymorphonuclear leucocytes. The hepatocytes occasionally contain eosinophilic
structures called Malory bodies which consist of a meshwork of fibrils in an area
where the rough endoplasmic reticulum has broken up. In alcoholic cirrhosis, there is
destruction and fibrosis seen in regenerating nodules. In addition, there is also
bridging between the portal tracts and terminal hepatic veins.

Are Mallory bodies' pathognomonic of alcoholic cirrhosis?
No, Mallory bodies are suggestive of alcoholic liver damage but they are seen in other
conditions such as primary biliary cirrhosis.

What types of anemia are associated with chronic alcohol ingestion?
o Megaloblastic anemia:
The most common anemia seen with alcohol abuse.
This is usually due to folate deficiency.
This is usually due to inadequate dietary intake, but may also be due to
disorders of metabolism by the liver.
o Anemia of chronic disease and sideroblastic anemia:
It may be seen.
(Sideroblastic anemia is a condition of hypochromic anemia with the presence
of abnormal sideroblasts in the marrow).

What happens to vitamin B12 levels in alcoholic cirrhosis?
Vitamin B2 levels remain normal or are increased.

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What types of cancer are associated with alcohol?
There is evidence that alcohol interacts with tobacco smoke and other agents to cause
cancer of the mouth, pharynx, larynx and esophagus
Pure alcohol per se is not carcinogenic, but alcohol may render other agents soluble or
it may be that the carcinogenic agent is another component of alcoholic drinks.
Cancer of the liver is the other major tumor associated, over 80% of hepatocellular
carcinomas arise in cirrhotic livers.

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How would you try to optimize the following patients?

A 78-year-old man with longstanding COPD and a BMI of 31 who has smoked 25
cigarettes/day for half a century who needs a right hemicolectomy for cancer?
The main worries are his weight and His poor respiratory function. He should he
encouraged in the strongest possible terms to stop smoking. Pre-operative
physiotherapy and bronchodilators may help pre-operative spirometry, including low-
loop analysis, and reversibility studies are arranged. A pre-operative blood gas would
be useful to act as a baseline for postoperative samples, when respiratory assessment
may be required. Attending to his weight is trickier, as a reduced calorie intake before
a cancer resection is not optimal, nor is significant weight loss possible before urgent
surgery, thus his weight is not addressed in this instance; if he were undergoing
surgery for a non-malignant condition, dietetic advice should be arranged to try and
reduce his BMI.

A 62-year-old man, who had his second myocardial infarction 6 weeks ago, who
requires a partial gastrectomyor carcinoma?
This patient is at huge risk of cardiovascular morbidity and he should be warned of
the substantial mortality risk of undergoing what is essential surgery so soon after a
myocardial infarction. The mortality risk of undergoing general anesthesia for major
surgery within 3 months of a myocardial infarct is around 50 %. Discussion with the
patient and anesthetist is arranged, and the surgical risks explained, and also the risks
of waiting another 6 weeks to reduce the anesthetic risks. When surgery is an
acceptable risk to all concerned, he should be admitted pre-operatively to HDU or
ITU and a pu1monary artery flotation catheter considered so that cardiac output and
oxygen delivery can be optimized. Pre-operative echocardiography should be
performed to assess ventricular function and advice obtained from a cardiologist
regarding the need to arrange a cardiac thallium scan to further assess function.

A cachectic 56-year-old with dysphagia about to undergo an oesophago-
gastrectorny for a lower third tumor?
Dietician review arranged, and his oral intake maximized prior to surgery. This may
be possible using nutritionally balanced high-protein drink but may not be possible
because of his dysphagia. This is one of the occasions where pre-operative parenteral
nutrition may be appropriate. He is in a poor nutritional state already and, during
surgery and for several days thereafter, he is going to be hugely catabolic. At surgery,
feeding jejunostomy can be placed but, prior to surgery, TPN may help steady the
decline in his nutritional status. Surgery should not be delayed because, although TPN
can help prevent further decline, there is no evidence that it is beneficial in restoring
nutritional parameters to normality when given pre-operatively.

A 45-year-old smoker of 20 cigarettes/day about to have a small bowel resection
for Crohn's disease?
His nutritional status is assessed, since a poor nutritional state is not uncommon in
Crohn's disease, and this may affect the surgical options. If nutrition is poor, oral
supplements or TPN feeding pre-operatively and postoperatively may be required.
The patient must be advised to stop smoking since not only are general complications
higher in smokers, but Crohn's disease-specific complications, including recurrence,
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are higher. He should, of course, have an ECG and chest x-ray. He should also be
counseled, consented and marked for a stoma in preparation for this possibility.

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Chronic Obstructive Pulmonary Disease

When would you suspect that a patient has chronic obstructive pulmonary
disease (COPD)?
If the patient has a cough, producing sputum on most days for 3 months of the year
for two consecutive years.

What steps should you take in the preparation of a patient with COPD for
Emphasise the importance of stopping smoking.
Speak to the anesthetist beforehand and organize a respiratory consultant
opinion. Discuss the need for post-operative ventilation.
These patients often need preoperative lung function tests and optimization of
current therapy.
Book the procedure in the summer months if possible.
Consent issues- important to mention all pertinent risks.

How the patient is managed postoperatively?
Multidisciplinary approach (e.g. anesthetist, respiratory physician,
May require postoperative ventilation in an ITU or HDD.
Early intensive physiotherapy.
Sitting the patient upright.
Discharge planning as soon as possible to prevent postoperative infections.

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Valvular heart disease

Which patients are at risk of endocarditis and what precautions should be taken
in these patients?
Patients at risk of endocarditis are those with:
Heart valve lesions.
Septal defects.
Patent ductus arteriosus.
Prosthetic heart valves.
Previous history of endocarditis.
Invasive procedures have the potential to cause transient bacteraemia, including
dental procedures, genitourinary procedures, gastrointestinal procedures, upper
respiratory tract procedures and obstetric and gynecological procedures. Prophylactic
antibiotics should be administered pre- and post-procedure.

What are the important points in the peri-operative management of patients
with aortic stenosis?
Aortic stenosis causes left ventricular outflow
Obstruction and eventually a fixed low-output state which is associated with
high mortality. These patients are at high risk of major perioperative cardiac
events, including myocardial infarction, arrhythmias and sudden cardiac death.
Perioperative management should include a careful assessment of cardiac and
valvular function. Most easily achieved by echocardiography.
In the event of severe valvular, the patient should be considered for valve
surgery prior to other procedure.
Other disturbances which compromise cardiac function, such as atrial
fibrillation, should e corrected or optimized.
At induction, antibiotics should be given for endocarditis prophylaxis.
The anesthetic is selected in order to maintain hemodynamic stability and in
particular, any manoeuvres which lower systemic vascular resistance must be
Postoperatively, the patient should be monitored closely, watching for the
development of complications such as cardiac failure and infarction.

What are the complications of prosthetic cardiac valves?
Early complications:
Structural damage during valve insertion - damage to the coronary circulation,
conduction system or cardiac rupture.
Complications arising from the use of cardiopulmonary bypass, including
bleeding and anemia.
Late complications:
Valve failure: can result from degeneration of the valve from calcification,
ingrowth of pannus, mechanical failure (such as strut fractures in the old
Embolisation of valve fragments
Valve dehiscence and paravalvular leaks related to the surgical technique or
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Heart failure

What are the symptoms and signs of heart failure?
Shortness of breath at rest or on minimum exertion.
Paroxysmal nocturnal dyspnoea.
Third heart sound.
Raised Jugular venous pressure (JVP).
Peripheral edema.
Displaced apex beat.
Basal crepitations.
Pulsus alternans.

What can be done pre-operatively to assess fitness for surgery in someone with
heart failure?
History and physical examination are always the first part of the assessment. An
electrocardiography (EGG) and chest X-ray are easily arranged first-line
investigations. Echocardiopranh is extremely useful as a left ventricular ejection
fraction of 35% is associated with high risk of peri-operative myocardial infarction
(MI). Liaison with a cardiologist may be necessary.

What cardiovascular effects can general anesthetics have?
Changes in the arterial and central venous pressure (CVP).
Reduce systemic vascular resistance (SVR).
Reduce myocardial contractility and hence reduce stroke volume).
Increase myocardial irritability.
Note: Fentanyl causes less cardiac depression than many other general anesthetic
agents but it still has an effect on vanodilatation which reduces preload and hence
cardiac output. Patients with congestive heart failure are very sensitive to this effect.

What other anesthetic options are there for patients with congestive heart
Epidural and spinal anesthesia can be used. However, both these methods still cause
venodilatation by blocking sympathetic outflow, decreasing preload and therefore
reducing CO. It is possible to increase preload by administering fluids pre-operatively
but this increases the post-operative risk of heart failure. Recent studies comparing
general and regional anesthesia found that there may be no difference in cardiac
complications or mortality.

How would you classify the risks for surgical procedures with respect
to the likelihood of cardiac complications?
High risk >5% risk of peri-operative death or MI: aortic surgery; peripheral vascular
surgery; or prolonged procedures of the abdomen, head or thorax.
Intermediate risk l-5% risk of peri-operative mortality or MI: orthopedic or urological
Low risk < l% risk of peri-operative mortality or MI: endoscopy and cataract surgery.

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Preparation of Patients for Theatre

What needs to be checked before a patient goes to theatre for elective surgery?
The patient should be interview and re-examined to ensure that the pathology for
which surgery is indicated is still present.
It is also imperative to confirm that the patient still wants surgery and to find out if
they have any further concerns of queries before going to the theatre. (Blood. X-rays,
etc.) to ensure that they are up to date and that the results are satisfactory.
Consent must be obtained from the patient and documented in the notes. Clear
instructions should be given to nursing staff regarding administration of medications
and fluids pre-operatively.
All notes and relevant investigations should accompany the patient to theatre.
It is essential to review the medication chart to ensure that there are no medications
that are contra indicated with surgery and that any premedications have been
The surgical team should liase to ensure that they have made the own assessment of
the patient and have discussed the anesthetic with them.

When are antibiotics prophylactic with surgery?
Patients with valvular heart disease.
With implantation of a foreign body.
Vascular surgery and transplant surgery.
Amputation of an ischemic limb.
Penetrating wounds and open fractures.
Where there is a high risk of bacterial contamination.

If a patient is already taking on anticoagulants, such as warfarin, what
precautions should be taken peri-operatively?
Epidural, spinal and regional blocks are contraindicated.
Depending on the indication for anticoagulation, the patient might have to be
converted to intravenous heparin (e.g. patients with prosthetic heart valves) or surgery
delayed until the course is finished (e.g. first episode of venous thrornboembolism).

What precautions should be taken if a patient is on oral contraceptives?
It is recommended that patients stop the OCP 6 weeks before surgery and use an
alternative means of contraception.

How do you prepare the bowel prior to elective colorectal surgery?
Put the patient on a low residue diet for 3 days pie-operatively.
24 hours prior to surgery only free fluids are allowed.
One sachet of Picolax may be given in the morning before surgery and a 2
during the afternoon before surgery.

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What precautions can be taken to avoid infections in theatres?
Precaustions against infection intheatres can be considered under the
following headings:
Design of theatre suites:
Theatres sited away from main hospital traffic.
Clearly designated areas of asepsis (the operating theatre
itself), clean areas dirty areas (sluice) each with separate
Vent's kept open and doors kept closed.
Appropriate ventilation:
Positive-pressure (plenum) ventilation directing bacteria from
clean areas with a minimum of 20 air changes per hour.
Ultra-clean laminar airflow system (used in orthopaedic
surgery) to reduce levels of circulating mocro-organisms, with
a minimum of 300 air changes perhour. This result in a
fourfold reduction in joint implant infection.
Theatre staff:
Minimum number of individuals necessary in theatre.
Avoidance of excess traffic through clean areas.
Operating personnel:
Growns-cotton gowns reduce bacterial count by 30%.
Caps and masks.
Initially with chloroxidine or proviadance iodine.
Effective antisepsis between cases with alcohol gel hand-
Patient prepration:
Minimal practical preoperative stay.
Preoperative showering (shown to reduce infection rates in
Shaving only if required and immediately prior to surgery.
Skin prepration:
1%iodine or 0.5% chlorokhexidine in 70% alcohol.
Aquoeas providone iodine (can be used on open wounds).
Sterile wound drapes-reduce wound contamination but not
wound infection rates.
Use of sterile equipment.

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Theater design

What is the ideal location for a hospital operating theatre suite?
Away from the main entrance.
Away from any traffic (i.e. not on the ground floor)
Next to the Intensive therapy unit (ITU).
All theatre next to each other therefore less movement of staff and equipment)
Close to the surgical wards.
Next to Sterile Supply Unit.
Easy route from the emergence surgery (and also near the Radiology

What are the features of an operating theatre that promote a sterile
Zoning of the theatre i.e.
1. Outer zone: patient reception area.
2. Clean zone: between reception and theatre; no outside clothing.
3. Aseptic zone: within the theatre itself.
4. Dirty zone: disposable areas and dirty corridors.
Laminar air flow - air is pumped into theatre through vents in the walls (20-40
air changes per hour)
Wearing disposable operating garments - bacteria pass more easily through
wet, re-usable garments than they do through disposable ones.
Skin preparation using non-spirit-based solutions (e.g. Betadine).
Shaving as close to the time of surgery as possible.
Proper scrubbing technique.
Operating suit.

What are the principles behind an operating tent?
Particularly relevant for orthopedic surgery.
High vertical laminar flow in a marked area within the theatre.
Clean air from above the table is pumped out through a funnel shape below
the table
Up to 600 changes of air per hour (normal is 20-40 hour).

How would you attempt to minimize infection risk in an operating theatre suite
The theatre area can be divided into zones:
o An outer zone containing the theatre reception, which is general access.
o A limited access zone between the reception and theatres, which includes the
corridors and staff rest area.
o A restricted zone, Where only appropriately clothed staff are allowed, such as
the anesthetic room and scrub areas, and aseptic zone, incorporating the
operating theatre itself.

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Apart from the operating table, what other services tend to be provided for your
operating theatre?
An emergency electricity supply.
Sufficient power points.
Wall suction.
Viewing boxes.
Anesthetic gas scavenging system.
Efficient air filtration system with a laminar airflow system.

Accessory facilities would you provide?
Recovery area.
Toilets areas.
Seminar rooms.

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Positioning of the surgical patients

What cardio-respiratory changes occur when a patient is placed in the supine
When placed in the supine position:
Stroke volume and cardiac output increase as a result of increase in central
venous pressure.
Bradycardia may be seen as baroreceptors sense the increase in arterial
pressure so leading to a fall in heart rate and systemic vascular resistance.
Respiratory changes may also be seen and include:
changes in the ventilation and perfusion ratio, which becomes more
uniform. Hence, the dependent portions of the lungs are better perfused
as a result of gravity.

How may nerves be injured intraoperatively?
1. Direct surgical injury.
2. Compression by tourniquets, limb supports or operating staff.
3. Traction.
4. Poor positioning and inadequate padding resulting in direct

What nerves may be injured as a result of direct pressure during anesthesia?
Peripheral nerves may be damaged via local ischemia caused by compression or
stretching. It is most likely to occur in extreme positions and prolonged surgery.
1. The ulnar nerve may be injured and this is the most common nerve injury
occurring during anesthesia. Compression occurs between the medial
epicondyle, the humerus and the edge of the operating table.
2. The radial nerve too may be injured due to compression between the edge of
the operating table or arm board and the shaft of the humerus.
3. The brachial plexus may also be injured during stretching, especially when the
arm is abducted to more than 90.
4. The facial nerve may be injured through compression by the anesthetist's
fingers against the ramus of the mandible or by face mask.
5. The supra-orbital nerve may also be damaged by compression for example by
tracheal tube connectors. Other nerve injuries include damage to the sciatic by
direct compression if the patient is undergoing prolonged surgery.
6. The common peroneal nerve may be injured particularly in the Lioyd Davis or
lithotomy positions.

When might you use the Trendelenburg (head down) position?
The Trendelenburg position might be used when performing pelvic surgery or during
insertion of central venous lines.

Principles of Surgery 26

What are the physiological effects of the Trendelenburg position?
The physiological effects include:
A rise in the central venous pressure with a concomitant increase in cardiac
Prolonged head down position might cause venous congestion and edema in
the head and neck.
Greater reduction in the functional residual capacity as a result of pressure of
the abdominal contents on the diaphragm.

When would you use the lithotomy position?
The lithotomy position may be used for operations on the perineum, anus, rectum and
or urological procedures.

Why is it important to carefully position a patient in lithotomy?
1. Hip dislocation can occur if there is slippage of the lithotomy poles.
2. Compartment syndrome has been described and is thought to be caused by
pressure on the calf muscles by the stirrup poles.
3. Back-ache is common and the sacrum must be supported and not hang over
the end of the table.
4. Marked flexion of the hips and knees may also cause sacro-iliac strain.

What nerves may be injured when a patient is placed in lithotomy position?
Nerve injuries can occur in the lithotomy position and these include injuries to the
tibial, femoral, obturator, common peroneal, sciatic and saphenous nerves.

Do all these nerve injuries lead to permanent disability?
Neuropraxia is the most common form of nerve injury and complete clinical recovery
usually occurs within 6-8 weeks. However, it may take several months. Severe
damage may be associated with permanent injury.

Principles of Surgery 27

Light Sources in Theatre

What is the main source of light in operating theatres?
The light source is primarily artificial. This can be divided into operative illumination
and background illumination.

Why is natural light not used as the main light source?
Natural light is too unpredictable to be used as a main light source, although there is
evidence to show that there is a reduction in staff fatigue with natural light.

What factors should be taken into consideration with artificial lights?
Artificial light needs to be of sufficient intensity.
This light needs to focused and should be under the direct control of the surgeon.
The lights also need to be reliable and a backup generator needs to be available if the
main lights fail.

Do you know what the light intensity should be approximately?
At the operation site, the light intensity should be about 40.000 lux.

Can you think of any problems associated with artificial lights?
They can create obstacles and affect the characteristics of airflow. They supply heat
which increases the temperature in the operating theatre. They are also a source of
bacteria so need to be carefully cleaned.

Principles of Surgery 28


What characteristics would the ideal surgical suture ha e?
All purpose i.e. can be used for all types of surgery.
Easy to handle.
No memory.
Minima reactive with tissue, with no predisposition to bacterial growth.
Capable of holding tissue layers throughout the critical wound-healing period.
Holds securely when knotted without fraying or cutting.
Resistance to shrinking in tissues.
Absorbed completely with minimal tissue reaction after serving its purpose.

By what mechanisms are sutures absorbed?
Proteolytic digestion.

How do the characteristics of a suture material affect their behavior?
Braided suture materials are easier to handle and knot tying is easier.
However, the braided surface creates friction and therefore less easy passage
through the tissues than monofilament materials.
Monofilament sutures glide more smoothly through the tissues and incite less
tissue reaction, but they are difficult to knot than braided materials.

How can you classify sutures?
Sutures can be classified according to their source, filament type and absorbability.
Sutures can be:
1) Natural or synthetic.
2) Monofilament or multifilament.
3) Absorbable or non-absorbable.

What are the features of natural suture materials?
These sutures handle well and are relatively inexpensive. However, they have
unpredictable absorption and can cause tissue reaction and fibrosis. They are absorbed
Possible viva questions related to this topic:
What criteria would the ideal suture fulfil?
How do the charactristics of a suture material affect its behaviour?
What are the charactristics of natural verus sunthetic suture materials?
What are the differences between monofilament and multifilament sutures?
How would you classify sutures? Give examples of commonly used sutures?
Name some examples of absorbable and non-absorbable suture. Describe some features
of each?
What suture-related factors may lead to wound dehiscnce?
When might you use clips instead of sutures?
Describe the type of needles in common surgical use and their characteristics?
What are the various parts of a needle called?

Principles of Surgery 29

by enzymatic action. Localized infection can occur as they are not monofilament so
more likely to trap bacteria. This can lead to wound sinus formation.

What are the features of synthetic suture materials?
Compared to biological sutures, these sutures are inert and absorbed by hydrolysis.
They have predictable absorption and strength. However they are more difficult to

Can you tell me the difference between: monofilament and multifilament
Multifilament sutures are strong and handle well. However, they can increase tissue
trauma and tend to trap bacteria. Monofilament sutures have smooth surfaces. They
do not trap bacteria like multifilament, but handling and knotting is more difficult.

Can you give me any examples of absorbable sutures and tell me the
characteristics of one of them?
Polydixanone (PDS).
Polyglactin (Vicryl).
Vicryl is an absorbable suture that has predictable strength. It has less tissue reaction
and handles well. It may not last long enough for healing when used in some tissues.

Can you do the same with non-absorbable sutures?
Prolene is a non-absorbable suture. It is inert and very good for subcuticular sutures.
However it is difficult to handle and knot.

What factors involving the suture may lead to wound dehiscence?
Weak suture material.
Damage to the suture by a surgical instrument.
Damage to the suture by diathermy.
Poor technique in knotting the suture.
Wound under high rension that lead to necrosis.

When might you use clips instead of sutures?
Staples confer only one advantage in wound closure over sutures: speed of
application. Staples are useful when rapid wound closure is desirable or where the
wound is large and suture closure would be laborious, e.g. in laparoscopic work.

Principles of Surgery 30

Suture Type Description
Catgut Natural

Rapidly hydrolyzed. Gives wound support for 7-
10 days only. This may be increased by chromic
coating. Rarely used nowadays


Elicits little tissue reaction; absorbed by
hydrolysis between 56 and 70 days, but gives
wound support for only 30 days. Vicryl
Rapide is similar but more rapidly degraded
with wound support for only 10 days.
Only slowly hydrolysed (180 days) with good
tensile strength for up to 56 days, it is often used
as an alternative to nylon for abdominal closure.

Natural Braided

The original non-absorbable suture, it is used
less commonly now as it evokes a marked tissue
reaction. It gives active wound support for 1
year but cannot be found in the wound after
about 2 years.


Slides excellently making it the suture of choice
for vascular anastomosis, but can be difficult to
knot and has a significant memory, making it
difficult to handle. Inadvertent crushing will
lose 90 per cent of the sutures tensile strength.

Similar handling characteristics to Prolene but
less memory. It loses approximately 15-20 per
cent of its tensile strength per year.

Describe the needles in common surgical use?
Modern needles are virtually all ready-swatched to the suture, i.e. the scrub nurse no
longer has to thread the needle each time. One exception to this is the aneurysm
needle, which is still threaded by hand.
Needles may be straight, curved or j-shaped.
Straight needles are used for suturing skin wounds, which are easily accessible and
are used by hand.
Curved needles vary according to the extent of the circle they describe, ranging from
0.25 0.75 the circumference. They are generally manipulated with a needle holder,
although there are large hand needles a available for abdominal closure, but holding
needles by hand is now being actively discouraged to minimize needle stick injuries.
The J needled is used to approximate two tissues that are typically difficult to access
deep within a surgical wound. The J needle commonly used to close the umbilical
port site after laparoscopy.

Principles of Surgery 31

Describe some suture-needle types and their characteristics?
Round bodied needle: separates but does not cut tissue, minimal tissue trauma
therefore suitable for fragile or delicate tissue.
Conventional cutting needle: triangular Cross section with the cutting edge on
the concave side of the needle. Size 3/0 is adequate for most indications, but
for wound closure on the face 4/0 or smaller may be indicated.
Reverse cutting needle: for tough tissue, triangular cross section, with the
cutting edge on the convex side of the needle, this strengthens the needle.
Atraumatic or blunt needle: used for friable tissue types minimizing tissue
trauma. Reduced risk of operative needle-stick injury.
Taper cut needle: pro ides effective initial tissue penetration, but subsequent
protection as the remainder of the needle is round bodied.

What are the various parts of a needle called?
Swage (attachment to the suture).

What are the important characteristics of suture needles in surgery?
The type of needle is determined by the procedure, the tissue, access, gauge of
the suture and surgeon preference.
Needles are mostly swaged/eyeless (pre-threaded and less traumatic), except
Mayo needles.
Some needles have a flat, grasping section in the body with ribs to prevent
Cutting needles have a sharp triangular cross-section with an apex on the
inside for tough tissue {skin).
The body of the needle can be:
Circular, with variable factions of circumference, e.g. 3/8 circle, 1/2 circle.
Rounded, to separate tissues and create a watertight suture line
(gastrointestinal or cardiac).

What types of specialized needles do you know of?
Increased circumference -or more restricted areas (5/8 circle)
Reverse cutting - with the sharp edge on the outside of the curvature to protect
tissue inside.
Blunt taper point - to reduce the risk of needle stick injuries.
Blunt point - for suturing friable vascular tissue (e.g. liver, spleen, and kidney)
Heavy body -or tough tissue
J-shaped or compound -or specific uses (laparoscopy wound closure or
femoral hernia repair).

Principles of Surgery 32


What are the surgical indications for the use of a pneumatic tourniquet?
To produce an effectively bloodless surgical field to facilitate anatomy
identification and surgical procedure.
To provide temporary haemostasis in the face of catastrophic uncontrollable
blood loss.
To allow effective regional anaesthesia. For example, Biers block anaesthesia
which requires a double tourniquet.
They are used in the tourniquet test for identifying the presence of lower limb
venous incompetence.

Are there any contraindications to the use of tourniquets?
Crush injury. Infection. Peripheral vascular disease.
Sickly cell disease. Sickle cell trait.
Are all relative contraindications to the use of a tourniquet.

What size of tourniquet should be used?
The wider the tourniquet the lower the effective pressure required to occlude the
arterial circulation. The size of tourniquet can estimated by the cuff width
approximating the diameter of the limb plus 20%.

To what pressure should the tourniquet be inflated?
No consensus opinion exists.
The correct answer is as low a pressure as will provide arterial and venous occlusion.
One common recommendation is as follows:
Upper limb use a pressure equal to the systolic blood pressure + 50 mmHg.
Lower limb use a pressure twice the systolic blood pressure.

What are the safe tourniquet ischemic times?
Again, there is no consensus opinion.
The correct answer is as short a time as possible.
It should be remembered that such a long ischemic time will not be safe-for all
patients particularly in the presence of known relative ischemia or injury.
When using a tourniquet around upper arm or thigh, the surgeon should be informed
every half an hour of ischemic time. Ideally 1.5 hours should not be exceeded. The
duration of 2 hours without a reperfusion time 20 minutes.
Possible viva questions related to this topic:
When would you use a touniquet in surgery?
What are the contraindications for using a tourniquet?
What are the potential problems associated with tourniquet use? How would you
avoid them?
What are the complications of tourniquet use?
What size of touniquet should you use and to what pressure should the tourniquet
be inflated?
For how long should you leave a tourniquet on?
Describe the procedure for application and removal of a tourniquet. Will you
ignore your anaesthetists when romving the tourniquet?

Principles of Surgery 33

What precautions should you take when using a tourniquet?
Tourniquets should not be used in patients with peripheral vascular disease
and should be avoided in patients who have risk factors for thrombosis.
Applying a tourniquet, a well-covered area of the limb should be chosen
(avoid joints).
The limb should be well padded with wool, and the tourniquet should have a
width of at least half the limb circumference.
Pneumatic pressure should be applied up to twice the systolic blood pressure
in lower limb or up to the systolic pressure plus 80 mmHg in the upper.
The maximum time allowed is 2 hour.
Exanguinate the limb by elevation for 2 minutes or expression blood using an
exsanguinating tube. Avoid expressive exsanguinations in the presence of
tumour, infection or known D T.

Describe the procedure for application of a tourniquet?
Timely inflation of the tourniquet to predetermined level, to optimize
effective operating time.
Record inflation pressure and time of inflation.
L ring surgery monitor the inflation pressure and ensure the surgeon is
regularly informed of the ischemic time.

Describe the procedure for removal of a tourniquet.
Request anesthetist's permission to deflate and remove the tourniquet.
Record time of deflation.
Check the neurovascular status of the limb after removal.

Why is it important to request the anesthetist's permission to remove the
During prolonged ischemia the products of anaerobic metabolism concentrate in the
limb, which is effectively excluded from the general circulation. Upon release of a
tourniquet the cardiovascular afterload drops suddenly and a bolus of acidotic.
Hypercapnic blood is released into the circulation. In a patient with limited cardiac
reserve cardiac dysrhythmias and reduced cardiac perfusion may ensue.

Why is it necessary to continuously monitor tourniquet pressure?
Tourniquet pressure drop may allow arterial bleeding obliterating surgical field.

What are the complications of tourniquet use?
Immediate complications:
Deflation causing a bleeding field.
Pain if applied for longer than 5 minutes.
Cardiovascular collapse when deflated (volume diversion).
Muscle damage.
Arterial damage (rare).
Early complications:
Inadequate pressure leading to venous congestion.
skin blistering (especially if there are ridges in the cuff to The skin)
Nerve damage (due to pressure effect, not ischemia).
Pulmonary embolism (reported).
Principles of Surgery 34

Late complications:
Post-tourniquet palsy
Nerve damage (due to pressure effect, not ischemia).

Why may post-operative bleeding be an issue following tourniquet use?
Missed unligated vessels may bleed significantly following tourniquet deflation.
Tourniquet deflation and haemostasis prior to wound closure is one way of reducing
this risk.

Principles of Surgery 35


Why would you use retractors in surgery?
Refractors are used in all forms of surgery. They are used to improve the field of
vision of the surgeon and protect structures from damage in the surgical field.

What methods of retraction do you know about?
Retraction can be instrumental or non-instrumental. With non-instrumental retraction,
the surgical assistant would provide retraction by holding back structures with a swab.
This method can be used if the structures are at risk of being damaged by
instrumentation. Instrumental retraction may involve self retaining retractors or hand
held retractors. Instrumental retractors can also be divided into sharp or blunt

What hazards of retraction can you think of?
The use of inappropriate retractors or over retraction can lead to organ damage,
damage of blood vessels and Subsequent ischemia to the structure it supplies.

Can you tell me about any retractors that you ha e used in your experience?
A commonly used retractor is the Langenbeck retractor. It is a medium sized retractor
that is blunt to avoid damage to the structures it is retracting. Devers retractors are
commonly used in abdominal surgery to provide deep retraction.

When would you use sharp surgical retractors?
These are typically used to retract skin or soft tissues not containing vital structures.

Principles of Surgery 36


Why is surgical haemostasis important?
To prevent blood loss.
To ensure a adequate visibility: bleeding obscures the operative field affecting
operative technique.
To prevent formation of hematomas: hematomas may become infected or
compress vital structures.
To reduce the risk of wound breakdown.

What patient factors would affect haemostasis?
Co-existing medical conditions: bleeding diathesis, chronic liver disease.
Anticoagulant therapy: heparin, warfarin and aspirin.

What preventative measures can you take prior to surgery?
Appropriately manage any abnormalities.
Stop any anti-coagulation therapy in sufficient time before the procedure.

How would you ensure adequate haemostasis in theatre?
Good surgical technique: dissection along tissue planes, control bleeding as operation
progresses, minimizes the area of raw tissue exposed.
Use of instruments to control haemostasis: ligation, clips, electrocautery, haemostatic
agents (e.g. Surgical), swabs, tourniquets and hypotensive anaesthesia.

Are there any other agents you may use if bleeding cannot be controlled?
Pharmacological agents (e.g. tranexamic acid).
Fresh frozen plasma.

Principles of Surgery 37


What is diathermy and how does it work?
Diathermy is the passage of high-frequency: alternating current (AC) through the
body to produce a localized heating effect.
Cell water is instantly vaporized, causing tissue disruption with coagulation of blood
vessels. It is also known as electrocautery.
Low -frequency current up to 50 Hz causes neuromuscular stimulation at amperages
of up to 100mA, but this effect disappears above the 50 kHz threshold.
Surgical diathermy operates in the frequency range of 400 kHz to 10 MHz with
amperages of approximately 500mA, which generates a locally concentrated heating
effect of up to 1000C without widespread neuromuscular stimulation.

What is the difference between bipolar and monopolar diathermy?
Monopolar diathermy:
Uses a high power unit (400 W).
The current passes from the active electrode (high current density), which is
held by the surgeon.
The current passes through the body via a patient plate electrode (low current
The plate electrode should have a contact area of 7o cm
, good contact with
skin, and should be away bony prominences.

Bipolar diathermy:
Uses a lower power unit (50 w).
The current passes down one limb of the forceps, through the tissue and up
the other limb.
There is no need for a patient plate electrode.
Inherently safer.
No cutting or "buzzing modes".

What advantage does bipolar diathermy have over with unipolar diathermy?
Bipolar diathermy has greater accuracy and safety compared with unipolar diathermy.
This results in reduced tissue damage.

Possible viva questions related to this topic:
What are the possible complications with using diathermy in theatre?
What different sorts of diathermy do you know?
How does diathermy work?
What different settings do you know for diathermy and how do they work?
Why does diathermy induce very little neuromuscular stimulation?
What is the difference between monopolar and bipolar diathermy?
What are the problems with using diathermy in patients with pacemakers?

Principles of Surgery 38

What is the difference between the cutting and "coag" settings?
In cutting mode a continuous output is generated, resulting in arcing between the
active electrode and the tissue. Cell water is instantly vaporized leading to tissue
destruction, and some coagulation of vessels.
In Coagulation mode pulsed output is generated, resulting in tissue desiccation and
sealing of blood vessels with minimal tissue destruction. Some machines have a
"blend" function, which is a mixture of the two mechanisms and allows cutting of
tissue with enhanced coagulation.
In spray coagulation (fulguration): a very high voltage is used to coagulate over a
wide area.

Why is no return plate/diathermy pad applied to the patient's body when using
bipolar diathermy?
With bipolar diathermy the patient's whole body is not a part of the electrical circuit.
There is no need for a return plate/diathermy pad as current is applied to and returns
from the body via the forceps only. The local heating and hence coagulative effect is
exerted upon the held tissues only.

Why does the patient not get a heating effect at the return plate/diathermy pad?
There is a measurable increase in local temperature at the pad, but as the pad is of a
relatively high surface area the current density and consequent heating effect is low.
Heat generated is conducted away through the tissues and through the circulation.

Why is it a bad idea to use monopolar diathermy on a low diameter extremity
such as finger or penis?
Local current density will be high enough to produce a potential heating effect high
enough to cause coagulation within the extremity, causing infarction, severe injury or
extremity loss.

Why is it important to avoid placing the return plate/diathermy pad over bony
prominences or over operation sites containing metal work when using
monopolar diathermy?
These sites are likely to concentrate current and produce local heating and possibly
tissue burns. The safest policy is to avoid having internal metal work in most direct
pathway along which current returns to the diathermy pad.

What are the complications of diathermy?
Complications include an explosion if there are any flammable or volatile anesthetic
agents being used (for example ether or cyclopropane).
Explosion: Gas explosion in obstructed hollow viscera.
Electrocution: Electrocution of the patient or the surgeon, if there faulty
Burns: Superficial burns if an inflammable spirit is used, for example if there
is pooling in the umbilicus.
Diathermy burns due to improper application of the indifferent electrode or if
there is a break in the connection to the diathermy unit or if there is accidental
activation of the foot pedal or contact with electrode active retractors.
Inadvertent diathermy burns are also a particular hazard of laparoscopic
Principles of Surgery 39

Channeling: Channeling effects may occur whereby heat is produced where
the current tends to be at its greatest, leading to thrombosis of a vessel with a
narrow pedicle, so causing ischemic damage of that organ, for example in
operations of the penis or testis.
Coupling: The phenomenon of direct coupling whereby instrument contact
occurs whilst the diathermy is activated.
Capacitor coupling and retained heat in the diathermy tip are other
complications unique to laparoscopic surgery.
Diathermy can also interfere with cardiac pacemakers by inducing either complete
pacing block or reversion to fixed rate pacing. Modern devices tend to be less
susceptible to these effects. Discussion with a cardiologist beforehand will allow
prediction of any likely interactions and monopolar diathermy is best avoided, if
possible. If monopolar is essential, then the plate should be sited so that the current
does not cross the heart and the anesthetist should have a magnet available to reset the
pacemaker, if necessary.

If a patient suffers a diathermy plate burn on the thigh, who is responsible for it?
Although it is usually the Operating Department Practitioner (OOP) who applies the
diathermy plate - and is usually the only one who understands the intricacies of the
machine - it remains the operating surgeon's responsibility to ensure that the system is
safe to use and that the plate is safely attached to the patient.

What are the dangers of using diathermy in patients with cardiac pacemakers
and what can you do to avoid these?
The high-frequency diathermy current may interact with the logic circuits in the
pacemaker which can inhibit the pacemaker itself, increase pacing, or even cause
Diathermy close to the pacemaker box may result in current travelling down the
pacing wire, causing a myocardial burn. The resultant effects range from affecting the
threshold potential to cardiac arrest.
Safety considerations when using diathermy:
Contact the cardiologist: the patient may need re-programming of their
pacemaker pre- and postoperatively.
Use bipolar diathermy if possible.
If monopolar diathermy is needed, use shod bursts at the lowest possible. The
patient pad should be placed as far away from the active electrode as possible
and in a way that directs current away from the pacemaker.

How would you ensure diathermy safety?
1. Before commencing the operation, ensure that the generator is in good
working order and that the theater staff are familiar with its use.
2. The patient should have no possible contraindications for the use of the
3. The patient should be positioned approptiately on the table away fro any metal
4. The patient plate should be of adequate size and appropriately sited:
5. Size no less than 70 cm2.
6. Fully adherent to dry skun which shaved only if hirsute.
7. No skin preparation solution beneath the pad.
8. Sited close to the site of diathermy use.
Principles of Surgery 40

9. Sited over well vascularized muscle.
10. Sited away from bony prominence, scar tissue or metal protheses.
11. With the diathermy current moving towards the pad and away from any ECG
or monitoring electrodes.

What are the causes of diathermy burns?
1. Older earth-referenced machines:
These are from ECG electrodes, metal drip stands or metal components of the
operating table in contacts with the patient's skin. They provide other earths
for the diathermy machine and, as their surface area is relatively small, current
denisty may be high and sever burns will result. Modern isolated, as opposed
to earth-refenced machines get around this problems by not needing an earth
and using a tight frequency range for the AC current, resulting in less earth
current leakage.
2. Inncorrect placement of patient palte (most common cause):
Needs good contact with dry, shaved skin (no kinking because it reduces
Contact surface must be at least 70 cm2 (minimal heating).
Plate must be away from bony prominences and tissue with poor blood
supply (e.g. scar tissue).
3. Carless technique:
Failure to replace electrode in insulated quiver after use of spirit-based skin
preparation (use of diathermy without aloowing sufficient time for the prep to
4. Use of diathermy on large bowel:
Methane and hydrogen in large bowel can be explosive.
Use of monopolar on appendages (e.g. penis, digits or tissue pedicles):
Current is concentrated along the line of tissue pedicles and can cause
tissue damage far distance to the site of the electrode. In circumstances
such as these where coagulation is needed, bipolar should be used.
5. Used close to metallic implants (e.g. hip protheses):
Current can be induced locally around metal implants, causing local heating
and tissue damage.
6. Active electrode not in view in laparoscopy.
7. Metal laparoscopic ports used with platic insulator cuff

Why does diathermy induce very little neurimuscular stimulation?
To produce profound neurostimulation, alternating current needs to be below 50 kHz.
The mains electricity in UK works at 50 kHz and:
A current of only 5-10 Ma will cause painful muscle stimulation.
80-100 mA across the heart will result in ventricular fibrillation.
Surgical diathermy involves a current at 400 kHz-10 MHz and with these frequencies,
current of up to 500 mA may be safely through the tissues.

Principles of Surgery 41

LASER in surgery

What does laser stand for? How do lasers work?
Laser is an acronym that has entered -common English usage and represents light
amplification of stimulated emission of radiation. It is a device for producing a beam
of high energy electromagnetic radiation. Energy is passed into a lasing medium,
usually a gas or crystal, and its constituent electrons release photons of energy as they
fall back from an excited to ground state. Amplification occurs by multiple reflections
of photons between a pair of mirrors at either end of the lasing cavity until the laser
energy beam eventually escapes the lasing cavity. The laser energy is then channeled
into a delivery system, allowing the beam to he produced at the desired site. It is the
lasing medium that determines the wavelength of energy emitted.

Which lasers are in common surgical uses?
: an infrared laser that is invisible to the human eye and, therefore,
requires a guiding beam. It uses a mirror delivery system. It has very little
penetration and is useful in vaporizing surface tissue. Treatment is relatively
painless. Healing is rapid, with minimal scarring. It is commonly used in ear,
nose and throat surgery for haemostasis and lesion ablation, and in gynecology
for treatment of cervical and vulval pre-cancerous lesions.
NdYAG (neodymium, yttrium, aluminium, and garnet): This is another
invisible infrared laser, with penetration of 3-5 mm in tissue; it coagulates
larger tissue volumes than CO
laser and leaves an eschar of damaged tissues.
It can be used for debulking esophageal tumours as well as ampullary and
rectal cancers. Other indications include control of upper gastrointestinal
hemorrhage and ablation of transitional cell carcinomas of the bladder.
Argon: blue-green visible laser with little penetration. It is used in
ophalmology for traculoplasty and photocoagulation of diabetic retinopathy,
and in dermatology for treatment of port wine stains. Both Argon and NdYAG
lasers are delivered via fibreoptic cabling.
Ruby: a visible red laser with superficial effects only. It is used for tattoo

What precautions need to be taken when using lasers?
Each hospital should have a Laser Protection Advisor, and each department a Laser
Safety Officer. All persons using the laser should have received adequate training and
be named on a designated user list. When in use, a "laser controlled area" should b e
established with controlled access and appropriate warning markers. Eye protection
is mandatory and should be appropriate to the type and class of laser. The class (1 -4)
of laser refers to a system reflecting the degree of hazard and power output. Most
medical lasers are Class 4. Simple precautions, such as cut-out devices and shrouded
foot pedals, should be designed into the machine. The lasing area should be non-

Principles of Surgery 42

Is argon beam photo coagulation the same as argon laser? Explain
No, they are different. The argon laser is described above but the argon beam
coagulator is a modification of standard electrocautery circuit. The tip of the electrode
emits a stream of inert argon gas that acts as a conducting agent for the current, which
can be sprayed on to the tissue without direct contact. It tends to generate only a thin
layer of necrotic charred tissue compared to conventional cautary and the additional
advantage that the flow of argon das will clear away blood from the target site,
allowing accurate application of the energy.

Principles of Surgery 43


How may a patient who is strictly "nil by mouth" maintain nutritional input?
There are several methods, depending on the circumstances and anticipated duration
of restriction of oral input.
Enteral routs:
The ideal is to provide nutrition.
It helps to maintain gut mucosal function integrity and decreases bacterial
If the patient is nil by mouth (NBM) to protect an esophageal anastomosis or
following radical maxillofacial surgery, then the enteral route may be used by
ensuring the food enters the gastrointestinal tract distal to any problem areas.
This might be achieved by passage of a nasogastrc or nasojejunal tube
although the latter are considerably more difficult to pass.
If longer-term enteral nutrition is required, then consideration should be given
to the placement of either a gastrostomy or jejunostomy.
A gastrostomy can be fashioned operatively at laparotomy or as a
percutaneous endoscopic procedure in instances such as long-term feeding in
stroke patients. Feeding jejunostomy tubes may also be placed at operation.
Nill by mouth routs:
If the patient is NBM to rest the gut, then the enteral route is prohibited and
feeding will have to be parenteral.
In the short term, specially formulated intravenous feeds such as "Vitrimix"
may be used through a standard peripheral cannula, although the high
osmolality of the feeds often means a short life f tor these lines.
Peripherally inserted central lines (PIC lines) are a reasonable compromise
allowing peripheral access with central delivery of nutritional mix.
Finally, fully-fledged total parenteral nutrition can be given via a central line.

What is the preferred route and why?
If available, the enteral route should be used, as it maintains the integrity of the gut
mucosal barrier and reduces bacterial translocation, a primary factor implicated in the
pathogenesis of multi-organ dysfunction syndrome and related septic complications.
Using this route also obviates the problems of complications associated with central
venous access.

What are the complications of TPN?
The complications can broadly be divided into those associated with delivering the
TPN and those associated with the metabolism of it.
All those factors that are complications of sitting a central line are also the
complications of TPN, such as infection, pneumothorax, haemothorax, TPN-thorax,
arterial puncture, etc.
TPN gives rise to a wide variety of metabolic disturbances, including hyper- and
hypoglycemia, hyper- and hypokalemia, hypo- and hypernatremia, and deranged
liver function. This hepatic dysfunction is characterized by intrahepatic cholestasis
and fatty infiltration; it is usually self-limiting and resolves after cessation of theTPN.

Principles of Surgery 44

How many calories and grams of nitrogen should be provided daily?
The requirement for energy and nitrogen in the form of protein varies according to
the degree of metabolic stress the patient is under.
An adult patient should receive 105-170 kJ/kg per day and 1.3-3.0 g/kg per
day of protein.
In situations of:
Mild metabolic stress:
1 g of nitrogen should be provided for each 625 kJ of energy provided.
But, as metabolic stress increases:
This ratio falls to 1 g of nitrogen per 420 kJ of energy.
A total of 6.25 g of protein provides 1 g of nitrogen.

Principles of Surgery 45


What are the features of an ideal dressing?
An ideal dressing:
Helps remove excess exudates from the wound.
Allows for granulation of the wound.
Keeps the wound warm.
Protects against secondary infection.
Free from particulate or toxic matter.
Will not traumatise the wound when removed.

Why is excessive exudate a problem in wound healing?
Excessive exudate leads to maceration of both the granulation tissue and the tissue
surrounding the wound edge. Exudate is also a site for potential infection. Absorptive
dressings remove exudate optimizing wound hydration.

What is the purpose of a wound dressing?
To absorb excess moisture.
To control skin temperature.
To prevent bacteria entering a wound.

Can you describe some types of wound dressing and their properties?
Dressings may be permeable or impermeable:
1. Permeable dressings:
Alginates (e.g. Kaltostat

): forms a highly absorbent gel coating with

Foam dressings (Allevyn): variable absorbency; good secondary covering.
Hydrogel (e.g. lntrasite

gel): hydrates wound; facilitates autolytic

debridement (some absorption) requires secondary covering.
2. Impermeable dressings:
Hydrocolloid (e.g. Granuflex

): impermeable absorbent layer on vapour-

permeable film; facilitate rehydration and autolytic debridement; promotes
3. Vapour-permeable dressings:
Allow the passage of oxygen, but not water or bacteria.
Suitable for moderate exudates only (not leg ulcers).
Good as secondary dressings and to protect frail skin.
4. Low-adherence dressing:
Paraffin gauze (Jelonet

) or silicone (Mepitil

5. Odour absorbent dressings:
Activated charcoal (Lyofoam).

Principles of Surgery 46

Do living organisms have any role in wound care?
Leeches (Hirudo medicinalis):
Synthesis an anticoagulant, a local vasodilator and local anesthetic allowing
continued bleeding (normally up to 10 hours after the leech has detached).
Venous circulation usually re-established after 3-4 days.
Used in plastic and micro-vascular surgery for the re-establishment of blood
flow to poorly functioning grafts.
Secrete a Proteolytic enzyme which digests slough and necrotic tissue into
semi-liquid form (hat can be ingested along with bacteria.
Eggs of the greenbottle (Lucilia sercata) are collected from pig's livers and
chemically sterilized.
Bottles of 300 larvae are applied onto wounds such as leg ulcers, pressure
sores, diabetic ulcers, burns and necrotizing fasciitis wounds.

What sort of dressing would you use for a necrotic wound?
A moisture donating dressing e.g. hydrocolloid containing dressing, which by
donating moisture to the wound would help breakdown of necrotic tissue.

What sort of dressing would you use for a granulating wound?
A non-adhesive dressing to preserve granulation tissue. Moisture donating dressings
would also be useful.

What sort of bandaging is often used for venous leg ulcers?
Charing cross four-layer compression bandaging.

What are the four layers of the Charing Cross bandaging system?
Bandage class 3a and 3b with a class 2 support bandage and orthopedic wool.

What are the potential problems of compression bandages?
They may cause ischemia due to a tourniquet effect, particularly is used in the
presence of peripheral arterial disease.

Principles of Surgery 47


What are the uses of drains in surgical practice?
Nasogastric tube to drain stomach air and fluid contents (to prevent aspiration).
Chest drains (with an underwater seal to prevent backflow resulting from
negative intra-thoracic pressures) - to drain pleura space.
Operative wound drains (anticipated fluid collection in a closed space) - to
prevent seroma formation, e.g. following incisional hernia repair or in the
Pericardial drain post-coronary artery bypass surgery.
Infected abscess cavity drain (intra-abdominal).

What are the types of drains?
Open: these should be non-suction in nature, e.g. corrugated or Penrose drain.
Closed: suction verus non-suction (under the influence of gravity only).

Suction: examples include sump, Radivac, firm mutli-holed PVC, for skin flaps.
Non-suction (closed) examples include Robinson drain, T-tube, urinary (Foley)
catheter, chest drain, Blake drain.

Closed drain systems: advantage of reducing the risk of introducing infection.
Suction drains provide the advantages of better drainage, but may damage adjacent
structures, e.g. bowel, which could precipitate a leak.

How does the underwater seal work in chest drains?
The underwater sea drainage system requires an airtight system to maintain a sub-
atmospheric intra-pleural pressure in a collection chamber. The tube is submerged 1-2
cm under the water to minimize resistance to drainage of air/fluid. Inspiration causes
fluid to be drawn up the tube until the water pressure matches the intra-thoracic
pressure. The chamber should be 100 cm below the chest as sub-atmospheric
pressures up to -80 cmH
O may be produced during obstructed inspiration.

What complications can occur with drains?
Immediate complications:
Trauma at insertion.
Air leak ariund a chest drain.
Early complications:
Failure to drain adequately (incorrect placement, too small, blocked lumen)
Disconnection or removal postoperatively.
Fracture of drain.
Late complications:
Introduction of infection.
Erosion of adjacent tissues.
Possible viva questions related to this topic:
What is the purpose of a surgical drain?
What are the complications associated with the use of drains in surgery?
What type of drains have you seen or head about? Give examples.

Principles of Surgery 48

Retain foreign body during difficult removal.
Herniation e.g. bowel at drain site.
Fistula formation.
Anastomotic leakage: by direct trauma to the anastomosis.

What dains used in surgical practice?
Nasogastric tube: used to drain stomach air and fluid contents and to prevent
Chest drain: used to drain the pleural spaces, this is attached to an underwater
seal to prevent backflow from negative intrathoracic pressures.
Operative wound drain: used for an anticipated fluid collection in a closed
space; this prevents seroma formation, e.g. after an incisional hernia repair.
Pericardial drain: used after coronary artery bypass surgery.
Infected abscess: cavity drain (intraabdominal).

Principles of Surgery 49

Anatomosis and Anastomotic leak

What is the definition of an anastomosis?
Joining 2 hollow organs or structures in order to re-establish a lumen through which
flow can continue.
Aim of anastomosis:
To restore the continuity of a hollow organ, e.g. artery or bowel after removal of a
diseased section of that organ.
To bypass an obstructed segment of an organ and divert flow through the lumen
To remove inflow and outflow between a donor organ and the recipient body, e.g.
renal and liver transplantation.

What are the principles of performing an ideal anastomosis?
Any anastomosis requires:
1. No tension.
2. A good blood supply.
3. Acuurate position.
4. Good size approximation: avoid mismatch between the 2 ends.
5. Accurate suture technique, i.e. no holes or leaks.
6. Good surgical technique:
o Don't perform anatomosis in watershed areas.
o Perform adequate mobilization of the ends to be joined: avoid tension.
o Invert edges (bowel) to discourage leakage or everet edges to avoid risk of
lumen narrowing and intimal disruption (vascular).
o Consider use of preoperative bowel preparation to prevent mechanical
damage to join in bowel anastomosis.
o Prophylactic antibiotics: to vcover approptiate organisms and minimize
o Consider the type of suture material: staples verus suture, absorbalble
verus non-absorbable or continous verus interuppted.
o Avoid strangulating the tissue in tying the knots: hand ties advisable.
o Single layer verus 2 layer in bowel anastomosis: ischemic verus leak rate.
Perform technique with which you are familiar.

Possible viva questions related to this topic:
What is the definition of an anastomosis?
How do bowel and vascular anastomosis differ?
What are the reasons for performing an anastomosis?
What are the principles of performing an ideal anastomosis?
What are the main risk factors for developing an anastomotic leak?
What are the signs of an anastomotic leak? How do they typically occur?
If an anastomotic bowel leak was found intraoperatively, what are the different
options available to the surgeon?
What would you do if the patient developed signs of an anastomotic leak a few
days after surgery and began to deterioate?
What are the different anastomoses performed in a Whipple's operations?

Principles of Surgery 50

Bowel anastomosis:
o Bowel anastomosis is performed usually using a 3/0 dissolvable
monofilament suture e.g. PDS with atraumatic round-bodies needle.
o This should inverting technique advised, discourage faecal or bile leakage.
o Bowel can be joined together with either a continous or an interuppted
suture technique.
o Surgical royal colleges teach a single-layer interuppted seomuscular
technique of sutures.
Vascular anastomosis:
o Between arteries, veins, prosthetic, material or combination of these.
o Invariablly performed with a non-absorbable monofilament suture, which
moves smoothly through the vessel wall e.g. Prolene.
o It is perforemd with a continous suture technique to ensure equal
distribution of tension around the sutrue line.
o Use small needle and suture strong enough to hold anastomosis.
o Prphylactic antibiotics: to include staph. Cover.
o Requires gentle handling\: never g=hold between foreceps.
o Inside-to outside technique: prevent displacement and lifting up of
atherosclerotic plaques.
o A vascular anastomosis aims to achieve eversion of the intima.

Anastomotic leak:
Occurs when there is ischemia of the two ends of the anastomosis especially in
oesophageal and rectal surgery.
Predisposing factors:
A. Patient factors:
Malnutriion. Old age. Malignancy.
Immunosuppression. Steroids. Radiotherapy.
B. Presentation factors:
Peritonitis. Abscess. Ileus.
Fistula. Signs of sepsis.
C. Intraoperative factors:
Poor surgical technique. Suture failure.
Stapler malfunction. Disease malfunction.
Disease process at the level of the anatomosis.
D. Postoperative factors:
Haematoma formation at the anatomosis line. Infection.

What are the signs of an anastomotic leak? How do they typically occur?
Typically occurs around 7-10 days after surgery:
1. Low grade pyrexia usually first sign.
2. Unexplained new onset tachycardia or arrrhythmia (usually AF).
3. Other signs of sepsis, inckuding rise in inflammatory markers.
4. Renal impairment.
5. Cardiac and repiratory problems.
6. Increasing abdominal pain and peritonism.

Principles of Surgery 51

If an anastomotic bowel leak was found intraoperatively, what are the different options
available to the surgeon?

Checking for an anastomotic bowel leak (intraoperatively):
Typically performed after a low rectal anastomosis (low anterior resection):
Examine the anastomotic doughnuts within the circular surgical stapler carefully,
making sure that they are complete and of good size.
Air or fluid test: using a syringe or a rigid sigmoidoscope judiciouly per rectally.
Request a water soluble contrast enema if worried postoperatively. This swould
demonstrate the site and extent of any leak.

If a leak is found intraoperatively:
Options include:
Repair leak with further sutures.
Place a pelvic drain near the anastomosis
Carry out a defunctioning stoma to pevent faecal leakage and peritonitis and hence
pelvic sepsis. Defunctioning shouldn't be deemed a failure by a surgein.
Not performing one can put the patient at significant risk postoperatively if he or she
develops an anastomotic leak.
The current trend is to perform a defunctioning loop ileostomy because it has the least
morbidity associated with it and is the easier stoma to close at a later date. Patients
also find it easier to manage a loop ileostomy compaed with a loop colocstomy.
Never perform an anastomosis in contaminated surroundings, e.g. perforated
diverticular disease leading to faecal peritonitis. This join is likely to breakdown.

If a leak develops postoperatively and the patient begins to deterioate and has not been
defunctioned, he or she should be taken back promptly to theatre and emergency laparotomy
performed. The surgeon should:
Drain the resulting collection.
Perform the safe option. Which is to take down the anastomosis and bring out both
ends as stoma, i.e. defunction the anastomosis.
Perform a full peritoneal lavage.
Place drains as approptiate.
Consider taking the patient to intensice care after discussion with anaesthetic
colleagues for ventillation or multisystem support, because the patient is likely to be

Whipple's operation:
Roux-en-Y anastomosis performed involves:
1. Proximal loop of jejunum divided.
2. Distal end of divided loop anastomosed to stomach (gastrojejunostomy).
3. Proximal end of divided loop anastomosed as an end-to-side anastomosis to the
jejunum further downstream (entero-enterostomy).

Other anastomosis performed are:
1. Choledochojejunostomy.
2. Pancreaticojejunostomy.
As part of the operation, a cholecystectomy and artial duodenectomy are also performed.

Principles of Surgery 52

Principles of Surgery 53

Post-operative Complications

How do you classify post-operative complications?
Complications may be local (at the operation site) or general (affecting any other
system of the body). They may be classified according to how soon they occur after
surgery: immediate - within the first 24 hours, early - within the first 4 weeks and late
> 4 weeks post-operatively.

If a patient has a fever post-operatively how would you proceed?
Most patients will develop a transient fever approximately 24-48 hours post-
operatively. This is usually attributed to basal Atelectasis of the lungs. However, the
patient should be fully examined for a source of infection. Particular attention is given
to inspecting the wound and examining the respiratory system. Sputum and urine
samples can be sent for microscopy and culture. If the temperature is very high, or
persistent, then the patient should be examined for further signs of sepsis and blood
cultures should be sent to the laboratory.

What are the possible reasons for a patient being hypoxic post-operatively?
Reduced alveolar ventilation: hypoventilation (airway obstruction, excess
opiods), Atelectasis, bronchospasm and pneumothorax.
Decreased diffusion across the alveolar membrane: pneumonia, pulmonary
edema and acute respiratory distress syndrome (ARDS).
Lack of alveolar perfusion: pulmonary embolus, tension pneumothorax and
cardiac failure.

What are the possible reasons for a patient being hypotensive post-operatively?
Cardiac failure.
Effects of medication.
Spinal or epidural anaesthesia.

Principles of Surgery 54

Post-operative Hypoxia

Can you describe the respiratory mechanisms that lead to post-operative
Basal dependent Atelectasis leads to impaired gas exchange.
Drugs such as opiods suppress ventilatory drive.
Inadequate pain relief can impair ability to cough leading to retained
secretions and respiratory infections.

What are the post-operative strategies used to prevent respiratory complications
such as bronchopneumonia?
Adequate analgesia including epidurals and intercostal blocks.
Encourage deep breathing and coughing.
Physiotherapy: chest percussion and postural drainage.
Early use of antibiotics if there is strong suspicion of infection.

Apart from infection, can you name a few other respiratory causes of post-
operative hypoxia?
Chronic obstructive airways disease.
Pleural effusions.
Pulmonary embolism.
Adult respiratory distress syndrome (ARDS).

What investigations would you consider for the hypoxic patient?
Pulse oximetry.
Peak-expiratory flow rate.
Arterial blood gases.
Full blood count.
Chest radiograph.
Sputum microscopy and culture.

What methods are available to provide oxygen for the hypoxic patient?
Oxygen by face mask or nasal prongs.
Continuous positive airway pressure
Non-invasive positive pressure ventilation (NIPPV).
Intubation and ventilation.

What is the analgesic ladder?
When the type of pain has been established (bone, visceral, tissue and neuropathic),
treatment should follow the World Health Organization analgesic ladder, with co-
analgesics according to the other features contributing to the pain. All patients should
start on step 1 of the ladder and should climb up until the pain is controlled. Changing
drugs within a step will not achieve an improvement in analgesia. At any step, co-
analgesics can be added (e.g. non-steroidal anti-inflammatory drugs (NSAIDs),
Principles of Surgery 55

corticosteroids, antidepressants, anticonvulsants and anxiolytics). It is important to
remember to add laxatives and anti-emetics as necessary.
Step 1: Non-opioids: Paracetamol.
Step 2: Weak opioids: Codeine, Dihydrocodeine and Tramadol.
Step 3: Strong opioids: morphine, Fentanyl, Diamorphine and Hydromorphone.

Principles of Surgery 56

Wound Healing

What types of wound healing are you aware of?
Healing by primary intension (1ry healing).
Healing by second healing (granulation).
Delayed primary closure (third intention).

Can you describe the phases of wound healing by primary intension?
The phases of wound healing are:
1. Haemostatic phase (Platelets predominant):
Initial hematoma formation
2. Inflammatory phase 1 (Neutrophil predominant):
2-3 hours later an acute inflammatory reaction occurs with subsequent
epidermal cell migration from the skin edges.
At 12 hours, epidermal cell proliferate from the basal layer of the
3. Inflammatory phase 2 (Macrophages predominant):
At 48 hours, macrophages migration into the inflammatory infiltrate in the
dermis serves to co-ordinate further healing.
4. Granulation tissue phase (fibroblast predominant and neovascularization):
By day 3-4 fibroblast infiltration occurs. Collagen and other tissue proteins
are synthesized.
By day 6 collagen bundles cross the wound.
Further macrophages and fibroblast infiltration occurs accompanied by
5. Epithelial phase.
6. Remodeling phase
By 6 months, 70% of the tensile strength of the wound has been achieved.
At 1 year the scar is mature and appears pale.

Are the phases of wound healing discrete?
No. There is considerable overlap in the types and degree of cellular recruitment
throughout wound healing. It is convenient to divide the phases up to commit to
memory, but the cytokine cascade that conducts wound healing continually changes to
involve the necessary players, as required.

Possible viva questions related to this topic:
How do wounds heals?
What factors influence the quality of a scar?
What are hypertrophc scars?
What is the difference between a hypertrophic and a keloid scar?
What is the reconstructive ladder?
How woould you determine which reconstructive technique to consider?

Principles of Surgery 57

What is the role of the macrophage in wound healing?
Macrophages ha e three principal roles:
1. Phagocytosis: clearing the debris of the initial inflammatory exudate and
participating in extracellular matrix and collagen remodeling.
2. Bactericidal: killing of bacteria.
3. Production of various inflammatory mediators: cytokines, transforming
growth factor B, monocyte chemotactic protein-1, fibroblast growth factor and
vascular endothelial growth factor.

What is difference between healing by Primary intention and healing by
secondary intention?
Primary intention: There is no tissue loss and the wound is often closed by means of
sutures. This may be by:
Primary closure (closed at time of trauma or surgery), or
Decayed primary closure (3-4 days later when the wound is free of
potentially infecting organisms).
Secondary intention: This occurs in wounds with tissue loss. Healing is via the
formation of granulation tissue that fills the area of tissue loss.

What are the main histological differences between healing by primary and
secondary intention?
In contrast to healing by primary intention, healing by secondary intention occurs in
open wounds (e.g. following a burn, necrosis or infection). Similar cellular processes
occur in both these types of healing. However, there are some important differences.
Formation of neovascularised collagen producing tissue (granulation tissue) is
much greater in wounds healing by secondary intention, because the size of
the defect is much larger
Within the first week, myofiboblasts appear at the edge of a wound healing by
secondary intention. The defect is thus reduced both by wound contracture as
well as epidermal cell migration and proliferation.
Wounds healing by secondary intension frequently have a thick collagenous
scar in the dermis due to the non-apposed epidermal layer.

When would you empoly delayed primary closure?
This is suitable for wounds that have a significant risk of intention if closed
promarily, including the following:
Wounds that present late more than 6-8 hours after trauma, although wounds
in highly vascular areas such as the face or scalp can be closed up to 24 hours
after trauma.
Grossly contaminated wounds.
Animal bites.
Penetrating trauma.

Principles of Surgery 58

List the factors associated with poor wound healing.
Local factors:
Poor blood supply (arterial deficiency, microvascular pathology or venous
Local foreign material prejudicing healing, e.g. granulation tissue will not
cover exposed subcutaneous metalwork.
Local malignant metaplasia in chronic wounds.
Exclude fistula or sinus formation.
Systemic factors:
Vitamin and trace element deficiency (vitamin C, zinc).
Drugs: immunosuppressant, cytotoxic agents, steroids and anticoagulants.
Co-existent systemic disease, diabetes mellitus, anemia, uraemia,
jaundice/liver disease and malignancy.

What are factors influence scarring?
Patietnt factors:
Age: infants and elderly people scar well.
Skin type: Celtic skin types are more likely to form hypertrophic scars, dark
skinned patients are more likely to form keloid scars.
Anatomical region: anterior midline, chest and shoulders scar poorly.
Concurrent morbidity: nutritional state, diabetes, wound infection.
Local tissue: oedema, previous radiothrapy,vascular insufficiency.

Surgical factors:
Atraumatic skin handling.
Eversion of wound edges: inversion places keratinized epidermis (dead
Tension-free skin closure.
Clean, healthy wound edges.
Scar orientation: parallel to lines of relaxed skin tension.
Suture tension: over-tightening leads to pressure necrosis, under-tensioning
can lead to wound gaping and wideing of scar.
Scar length: skin ellipse length should be at least four times the width to
minimize tension and avoid dog-ears.
Suture type: non-absorbable synthetic sutures cause least inflammation.
Timing of suture removal:
7 days or less leaves no stitch marks.
14 days or more leaves stitch marks.
Between these times depends on skin type and wound location.

Principles of Surgery 59

Can you describe some technical measures that may help optimize tissue healing
in a patient undergoing operation?
These measures can be classified into operative and non-operative.
The non-operative measures include reducing infection by using prophylactic
antibiotics, laminar air flow, and reducing the number of non-essential personnel in
Operative measures include gentle banding of tissue, short operation time and in
irrigation/lavage of dirty wounds.

What is the difference between hypertrophic and keloid scars?
Hypertrophic scar Keloid scar
Appearance Scar confined to wound
Scar extends beyond wound
Site Across flexor surfaces
and skin creases
Ear lobes, chin, neck, shoulder,
Age group Any age (commonly
8-20 years)
Puberty to 30 years
Gender F = M F > M
Racial groups affected All races Black and Hispanic races
Biochemical features Normal rate of collagen
synthesis, but increased
breakdown of collagen by
collagenase activity.
Increased rate of collagen
synthesis (increased proline
increased collagenase activity.
Genetic links Not proven Significant
predisposition in Black and
Hispanic races
Oxygen levels Relative hypoxia, possibly
due to wound tension.
No link

Immunology May be important but no
specific association
Increased IgG, IgM, and C3
levels; antinuclear antibodies
to keloid fibroblasts.

What are the reconstructive ladder?
1. Allow to heal.
2. Primary closure.
3. Delayed primary closure.
4. Tissue expansion.
5. Split-thickness skin graft.
6. Full-thickness skin graft.
7. Local flap (a flap raised immediately next to the defect).
8. Distant flap (a flap raised some distance from the defect, maintaining a
vascular supply through a pedicle).
9. Free flap (a flap completely detached from the body and re-anastomosed to
vessels close to the defect).

Principles of Surgery 60

Organisation and Granulation

What does the term organization refers to?
A fibrinous inflammatory exudate can form following tissue injury. If this can't be
removed by the body, it stimulated growth of fibroblasts and blood vessels
(granulation tissue) with eventual conversion of the exudate into scar tissue. This
process is known as organization.

Which cells responsible for removal of necrotic tissue during this process?
Phagocytic cells such as Neutrophil polymorphs and macrophages.

Can you name a cytokine that stimulates ingress of these cells?
Transforming growth factors B.

What processes are involved in clearance of venous thrombus by organisation?
This is a form of "intravascular" wound healing where the thrombus is organized into
a scar within the vein. Initial stages involve an infiltration of macrophages which
remove some of the thrombus. They may also orchestrate formation of small
endothelial cell-lined channels within the thrombus which eventually coalesce and
restore patency of the vein lumen. With time, a localized thickening of the vein wall
may be the only remaining sign of thrombosis.

Describe the classical staged in the healing of a long bone fracture?
Fracture of a long bone results in haemorrhage from the torn ends of periosteum and
from the disrupted marrow as well as the surrounding soft tissue. This fills the bone
defect with a clot rich in plasma proteins the stage of haematoma formation. It is
the site of the subsequent inflammatory response with Neutrophil and later
macrophage invasion. The macrophages are particularly important for resorption of
the necrotic bone and marrow, which occurs at the fracture site and for a little distance
back from it. Subsequent resorption of the haematoma leads to formation of
granulation tissue. Following this, there is formation of callus around the outside of
fracture site mediated by osteoprogenitor cells from the torn periosteal ends. Initially,
this provisional callus traverses the outside of the bony defect and only later does
medullary callus actually fill the gap. Conversion to woven bone occurs in most cases
by gradual endochondral ossification of the provisional callus. By this stage, the
fracture is immobile and healed, although it will take many months to regain full
strength, as this woven bone is gradually resorbed and replaced by true lamellar bone.

Describe the complication of a bony fracture and its healing
The systemic complications of fractures are thankfully not common but are important
Hypovolaemic shock may occur after long bone fracture; a femoral fracture may lose
2 L of blood into the surrounding soft tissues. Disruption of the marrow releases fat
globules into the circulation, giving rise to fat embolism, a cause of ARDS in these
patients. ARDS may occur in the absence of fat emboli as a result of a systemic
inflammatory response to the injury and conversely fat emboli may be identified in
the absence of bony fracture. The fracture may also be a portal for infection and
subsequent septicemias.
The local complications may be broadly divided into early or late complications.
Early local complications include infection of the bone or overlying soft tissues and
neurovascular injury, especially at particular sites, such as a supracondylar humeral
Principles of Surgery 61

fracture, causing brachial artery injury. There may be associated joint injury or the
fracture may cause additional soft tissue injuries, such as a pneumothorax associated
with rib fracture. All long bone fractures must be carefully assessed to exclude the
presence of compartment syndrome, which may cause disability far in excess of the
fracture itself.
Late local complications: are generally complications of bone healing rather than the
injury itself. .
Delayed union or non-union may occur. These are separated only temporally.
The dividing line between delayed healing and no healing is vague.
Although a fracture may heal, its position may be such as to be described as
Elbow injuries are particularly prone to myositis ossificans, which is depos-
ition of calcific material in the muscles and soft tissue around the joint. It
occurs more severely after passive movement, so active mobilization is the
key in rehabilitating elbow fractures.
All bone fractures may predispose to osteoarthritis, either by direct disruption
of the joint or by imperfect healing causing altered patterns of wear on joints.
Bone injuries in children impinging on the growth plates may cause permanent
disruption of growth leading to short limbs.
Certain bones are at particular risk of a vascular necrosis following fracture
owing to peculiarities of their vascular supply. Good examples are the necrosis
of the proximal pole of the scaphoid after a waist fracture as the arterial supply
is from distal to proximal and that of the femoral head after intra-capsular
femur neck fractures interfering with the retinacular supply.
Less common but potentially disabling complications include Volkmann's
ischemic contracture after a missed vascular injury or dystrophy, which may
occur after a trivial injury.

What are the immediate events that take place at the site of a bony fracture?
Haemorrhage within and around the bone results in formation of haematoma which
will later provide a lattice for ingress and proliferation of cells. The devitalized
fragments of soft tissue and bone are removed by Neutrophil and macrophages.

What is the name given to new bone laid down following a fracture?

Which cell is responsible for laying down callus and what is the pattern of
Callus is a mass of new bone laid down in an irregular, woven pattern by the

What is the fate of this callus?
It is eventually resorbed and replaced by lamellar bone which is laid in a more orderly

Principles of Surgery 62

What are the factors that can delay fracture healing?
Poor circulation.
Systemic disease (e.g. malignancy).
Drugs (Corticosteroids, Alcohol, Smoking).
Movement of bone.
Soft tissue interposition.
Misalignment/distraction of bones.

Principles of Surgery 63


What is the Gustilo and Anderson classification?
The Gustilo and Anderson classification is a classification of open fractures. It is
based on the size of the wound and the amount of soft tissue injury. There are three
classes in this system:
I. Open fracture + wound < 1 cm.
II. Open fracture + wound > 1 cm.
III. Open fracture + wound with extensive soft tissue, nerve and blood vessel
Class III is subdivided into IIIa. IIIb and IIIc depending on the extent of soft tissue
injury and neurovascular compromise.

How can operative ways surgical wounds be classified?
Operative surgical wounds can also be classified according to the degree of
contamination by foreign material.
Clean: no areas infection encountered during surgery; the alimentary, urinary,
biliary and respiratory tracts are not entered; sterile technique maintained
throughout the operation.
Clean-contaminated: dean operation but endogenous flora are encountered;
alimentary, urinary, biliary or respiratory tracts are entered under controlled
conditions; a minor break in sterile technique may ha e occurred.
Contaminated: inflammation seen but without frank pus, alimentary tract
entered with spillage of contents, infected biliary or urinary tracts entered,
major break in sterile technique.
Dirty: frank pus around at surgery due to presence of pre-existing infection or
prior perforation of a viscus, faecal contamination and retained foreign
material in wound.

Can you give some examples of the types of operation that would fit with the
classification described in the above question?
Clean: mastectomy and splenectomy,
Clean-contaminated: bowel resection with no spillage of contents and
transurethral resection of prostate.
Contaminated: acute appendicitis.
Dirty: incision and drainage of an abscess and ruptured appendix.

What technical surgical factors increase postoperative infection rates?
Increased duration of surgery.
Rough or careless handling of tissue.
Ligating large tissue pedicles.
Over-thick ligature.
Necrotic or ischemic tissue.
Insertion of a drain through the wound.

What are the key issues in managing an acute traumatic wound on a limb?
The limb needs to be assessed for fractures and neurovascular damage as these
injuries may need to be dealt with formally in theatre. In the absence of any associated
Principles of Surgery 64

injuries to the limb the wound needs to assess for the need for formal debridement. If
the wound is not badly contaminated with foreign material it may simply be washed
out thoroughly with saline and closed or dressed. However, if there is obvious
contamination then the wound will need to be formally debrided in theatre. An
assessment of the patient's tetanus status is also necessary and appropriate cover

What are the general principles of managing chronic wounds?
The main aim is to turn the chronic wound into an acute wound, thereby promoting
the formation of granulation tissue and healing. Necrotic material is removed from the
wound bed and the wound subjected to regular cleansing and debridement. This will
help reduce bacterial load and promote vascular of the wound bed.

What is the theory behind the use of vacuum dressings in the management of
chronic wounds?
The vacuum results in localized hypoxia of the wound bed which stimulates
angiogenesis, promotes the formation of granulation tissue and reduces bacteria load.

When should prophylactic antibiotics be used?
Prophylactic antibiotics should be used:
When there is an increased risk of infection.
When a graft or implant is used.
In patients with vulvar heart disease (infective endocarditis prophylaxis).
"Administer antibiotics at the time of induction of anaesthesia -and repeat dose at 4-6
hours if the operation is prolonged".

Can you list some local causes of delayed wound healing?
Tissue hypoxia.
Poor blood supply.
Foreign body.

Do you know any systemic causes of delayed wound healing?
Poor nutrition.
Vitamin A and C deficiency.
Zinc deficiency.
Glucocorticoid treatment.
Cytotoxic treatment.

Principles of Surgery 65

Wound Dehiscence

What is abdominal wound dehiscence?
It occurs when the fascial layer of the abdomen is not intact. In the majority of cases it
represents a technical surgical error. It is important to exclude an intra-abdominal
problem as the cause of the dehiscence. Abdominal lavage, wound irrigation and re-
suturing forms the mainstay of treatment.

What are the signs that would inicate impending wound dehisence?
Low-grade pyrexia.
Bloodstained fluid from the wound (pink fluid sign).
Abdominal distension.
Abdominal pain.

What may be the result failure of a wound to heal?
Superficial wound disruption.
Wound dehiscence.
Incisional hernia.

What are the risk factors for wound dehiscence?
The main risk factor is technical surgical error. There are, however, other factors that
play a role.
Preoperative factors:
Chronic obstructive pulmonary disease.
Protein deficiency.
Malignant disease.
Intra-operative (i.e. surgical) factors:
Inadequate evacuation of pus, haematoma, slough and any foreign body
Tissues sutured under high tension
Incorrectly placed sutures.
Postoperative factors:
Persistent cough.

How is an abdominal wound dehiscence managed?
Resuscitation of the patient.
Application of a sterile Betadine

gauze pack over the wound (and bowel if
Urgent re-exploration of abdomen
Copious peritoneal la age
Resuture of the wound with non-absorbable suture material.

Principles of Surgery 66

Gunshot Wounds

How would you classify gunshot wounds?
The injury inflicted by a projectile is dependent mainly on its velocity:
Kinetic energy = mv

Gunshot wounds can be broadly divided into those caused by low- velocity (energy)
and high- velocity (energy) projectiles. High- velocity projectiles induce temporary
cavities up to 30 times the size of the projectile. This causes extensive tissue damage
well away from the track, sucking in debris and bacteria on collapsing.
Some bullets flatten on impact, increasing their cross-sectional area, leading to more
rapid deceleration and greater transfer kinetic energy. Other bullets are designed to
fragment on impact, extending the tissue damage,

How can you tell the difference between an entry wound and an exit wound?
Entry wounds usually lie against the underlying tissue due to the direction of the
shock wave on impact. The exit wound is not supported by subcutaneous tissue.
Entry wounds are usually well-defined and round or oval-shaped, with a surrounding
1 to 2 blackened area of burn or abrasion at the periphery of the wound.
Exit wounds are usually ragged as result of tissue tearing, having an irregular or
stellate appearance.

How would you treat an isolated gunshot wound to the thigh?
Resuscitate the patient according to ATLS (acute trauma life support)
Apply direct pressure to any bleeding point.
Cross match-4 units of blood.
Administer intravenous antibiotics.
Tetanus prophylaxis.
Assess neurovascular status of the limb.
Photograph and keep wound covered with dressing soaked in Betadine

Further management would involve treatment of the vascular system, bone and soft
tissues. This would include:
Debridement and excision of necrotic tissue.
Delayed closure: may need plastic surgery if a large defect.
May need vascular grafting, nerve grafting.
Stabilization of fractures.

The Mangled Extremity Severity Score provides a guide to the viability of the limb.

Principles of Surgery 67

Ethical & Medicolegal

Principles of Surgery 68


What is informed consent?
Making a considered choice about a treatment or procedure after sufficient
appreciation of the patient facts that is in the individual patient's best interests,
balancing the views of the doctor with their own opinions, values and beliefs.
The doctor's role is to:
Describe the procedure itself, including the prognosis
Discuss risks and complications.
Offer alternatives where available.

What should be included in the discussion when obtaining informed consent?
The diagnosis and prognsis of the disease with or without treatment.
Management options, including the possibility of no treatment.
A detailed explanation of the procedure for which consent is being obtained.
The expected side effects of treatment.
The optional complications, and the consequences of these complications.

What are the principles of informed consent?
There are three guiding principles for obtaining informed consent: the must be
competent to give consent, consent must be given voluntarily and it must be an
informed decision.
Competent person: The patient must have the mental power to deal with the
matter, based on understanding rather than status. The surgeon must make a
judgment as to whether the patient is sufficiently mentally competent to make
such a decision. Patients less than 16 years may consent, as many patients
detained under the Mental Health Act, provided they are competent to do so.
Voluntary consent: The patient must not feel under constraint or duress, and
should be allowed to make their decision freely without coercion.
Informed consent: The patient must be given sufficient information to allow
them to retain, deliberate and make an informed choice about their treatment.
Information must give in a form and manner that the individual can
understand. They must be told about the proposed treatment, and its potential
benefits and commonly occurring risks - usually those occurring in more than
1 in 100 cases. They must be told about any alternative, treatments or the risks
associated with no treatment. They must also be told about any serious hazards
that any prudent person would wish to know of irrespective of how uncommon
those hazards might be.
The Department of Health has recently issued new guidelines on the process of
informed consent. Those guidelines notwithstanding, the law on consent remains
unaltered. As outlined in the DoH guidelines, consent should now be a two-stage
procedure. The proposed treatment and anesthetic should be discussed with the patient
and ideally written information provided. At this stage, the patient may sign the
consent form. At some later stage before surgery, another health professional should
re-discuss the procedure with the patient and ensure that they still wish to go ahead
with the procedure as previously outlined. This is then affirmed on the consent form.

Principles of Surgery 69

What are the main objectives in obtaining informed consent?
Informed consent pre-supposes a joint decision and agreement between the doctor and
the patient. It should now be considered a discussion between the doctor and patient,
and include:
A description of the procedure, including a prognosis.
The likelihood of specific and general complications of the procedure.
Information about alternative options and risks incurred by doing nothing.
Patients should participate and share in decisions and give active, not passive
Who should obtain consent?
The consultant is responsible for obtaining consent. This task may be delegated, but
only to a trained and qualified junior colleague who has sufficient knowledge and
understanding of the procedure to ensure that the patient can make an informed

Who can give valid written consent?
All competent patients over the age of 16 years may sign the consent form. The
clinician obtaining consent must also countersign the form.

What are the principles of good consenting practice?
A suitable environment should be used, i.e. private and free from possible
Simple language which is understood by patients and their relatives.
Confirmation that the patient has understood the procedure, by asking
him/her to re-explain the procedure and whether any questions remain
Find out patients individual needs and priorities when providing
information about treatment options.

Who is not competent to give consent?
Under the age of 16, children may consent to procedures, but may not withhold their
consent. In such cases, consent is required from a parent or guardian. The Mental
Health Act (1983) allows for the compulsory treatment of any physical disability or
one arising from a mental health disorder, in the case of the mentally incompetent.

Do these precepts always apply?
Emergencies do not alter the patients' rights or the principles of informed consent.
However, if it is not possible to obtain consent, e.g. in the case of say a child or an
unconscious patient, a clinician may proceed without consent to save life or prevent

Why does one obtain consent from a patient for a general anesthetic but not for
Implied verbal consent is adequate for simple procedures for routine physical
Note that a signed consent form does not give legal proof the patient having
consented, but implies that some degree of discussion has taken place.

Principles of Surgery 70

How should you obtain consent for children?
Consent should be obtained from a person - usually the parent or designated legal
guardian - deemed competent to make informed choices about the child's best
interests. In some circumstances consent may be obtained from a child below 16 years
old if they are mature enough to understand the nature, purpose and possible
consequences of the proposed treatment, as well as the consequences of non-treatment
(i.e. Glick competent). However, they should be encouraged to communicate with
their parent/legal guardian.

What is Gillick competence?
This relates to an anomaly in the consenting of children in that they can only agree to
treatment after the age of 18 years but can refuse it from the age f 16 years. The
Gillick competence is a legal term which means that if the child (under 16 years) can
understand the significance of the treatment, they can consent to treatment without
their parents or legal guardian consenting on their behalf. In practice, it is a situation
that should be avoided if at all possible.

Can a child of 15 give valid consent?
Yes, provided he or her able to understand the procedure, and also the risks associated
with not undergoing the procedure. However a child cannot refuse life-saving
treatment for example, if a parent signs a consent form for a procedure on their 15-
year-old child, then that consent is valid in law and the child cannot revoke it.
Obviously, the practicalities of operating on an unwilling patient raise other medical
and ethical issues that would most likely preclude the operation proceeding, but in
terms of law, the consent form is valid.

What is the accepted practice for consenting an unconscious adult patient for an
emergency operation?
It is the surgeons responsibility to act in the patients best interests surgery without
consent is permitted if deemed life saving. Relatives cannot legally consent to surgery
because no adult can legally consent on behalf of another.

What is the accepted practice for consenting a mentally ill or handicapped
person for an emergency operation?
In emergency situation, if the patient is believed to be incompetent and unable and
give informed consent, the surgeon should proceed with treatment in the patient's best

In the case of a demented 85-year-old man who requires elective surgery, who
should sign his consent form - the wife, the daughter or someone else?
No one other than the patient himself can sign a valid consent form. In the event that
informed consent is not possible, as in this case, then it is reasonable under common
law to act in the patient's best interests, In most cases, it is usual practice for two
doctors to document agreement that the procedure is in the patients best interests and
it is usual to gain the assent of the patients next of kin. This procedure has been
formalized in the Department of Health's recent consent guidelines.

A man is brought in collapsed with a diagnosis of leaking AAA. He has no relatives
with him. Who should give consent and should the operation wait until the form has
been signed appropriately?
Principles of Surgery 71

No. Again it is reasonable under common law to act in the patients best interests. This
would be to operate immediately, rather than to wait for relatives or for forms to be
filled in. In this case, the surgeon should act of necessity and a second opinion is not

A paranoid schizophrenic is refusing to sign the consent form for a laparotomy
to repair her perforated duodenal ulcer. Your house officer suggests sectioning
her under the Mental Health Act to force her to have the operation. What is your
Under the Mental Health Act, a patient may be sectioned for psychiatric treatment,
but may not be forcibly treated for any other medical condition. As such, sectioning
this patient would not allow further treatment of her perforated ulcer. Even in life-
threatening Illness, the patient's right to self-determination supersedes the principle of
the sanctity of life. A sensible way to proceed would be to have the patient urgently
assessed by a psychiatrist with a view to deciding her mental state and competence. If
deemed competent to make decisions regarding her treatment, then the patient's view
must be respected and best therapy instituted in the circumstances.

Principles of Surgery 72

Death and Dying

What common symptoms are often seen in a dying patient?
Urinary incontinence or retention.
Noisy breathing.
Restlessness or confusion.
Loss of appetite.
Nausea or vomiting.

How is death diagnosed?
Death is characterized by apnoea, no pulse and no heart sounds, and fixed pupils. If
the patient is on a ventilator, death may be diagnosed by using the UK brain death
criteria: deep coma with absent respirations; the absence of drug intoxication and
hypothermia; the absence of hypoglycemia, acidosis and urea and electrolyte (U&E)
imbalance. Diagnosing brainstem death requires the tests to be performed 24 hours
apart by two doctors, one of whom should be a consultant.

Which deaths are referred the coroner In England and Wales?
Unknown cause of death.
The patient was not seen by a certifying doctor within l4 days of death.
Death was caused by medical treatment.
Death was suspicious.
Death occurred within 24 hours of admission to hospital.
Death was caused by a road traffic accident, an industrial disease or accident,
a domestic accident violence, neglect, abortion, suicide or poisoning.
Death occurred during legal custody.
Where there is any claim of negligence against medical or nursing staff.
Death of a foster child, patient under the Mental Health Act (1983), rnental
defectives or service pensioners.

When would you refer a patient to the coroner?
The role of the coroner is to investigate deaths to ensure that no suspicious
circumstances are attached to them. There are certain circumstances, listed below, in
which referral to the coroner is mandatory. There are other cases in which one should
voluntarily seek guidance from the coroner or his officer. Incidentally, the coroner is
also the proper officer to investigate the finding of treasure troves. Coroners in the
UK are either medically or legally trained and often both, but a background in
medicine is not obligatory.
The circumstances requiring mandatory referral to the coroner are as follows:
When the cause of death is unknown.
Where a doctor has not attended the deceased in the terminal illness or when
the patients normal medical practitioner did not attend within 14 days of the
When the death is associated with any medical treatment. This includes any
death within 24 hours of an operation or anesthetic.
Sudden death - including all deaths within 24 hours of admission to hospital.
Principles of Surgery 73

When death may be due to industrial accident or disease, road traffic accident,
domestic accident or violence. Deaths from poisoning which include alcohol,
abortion, suicide or neglect must also be reported,
Deaths in which there may or will be claims of negligence against medical or
nursing staff
Deaths in custody.
If there is any doubt as to the cause of death or the circumstances surrounding death,
or simply to check whether a cause of death is acceptable on the certificate, it is
advisable to discuss the matter with the coroner or, more commonly, his officer.

What is NCEPOD?
NCEPOD is the National Confidential Enquiry in to Perioperative Deaths.
This is a national body that considers the factors involved in perioperative deaths in
order to try to identify areas in which practice could be improved.
It looks for potentially remedial factors in anaesthesia, surgery and other invasive
medical procedures.
The data collected are not research, and do not compare units or clinicians.
The data are subject to "crown privilege", which means the data cannot be sub-
poenaed. All data are shredded after use.
NCEPOD reports annually with recommendations for practice.
Each year, the report focuses on a particular facet of surgical practice, such as out-of-
hours operating, care of the elderly surgical patient or cancer surgery.
Recent recommendations include that surgeons and anesthetists should be involved in
multidisciplinary audit, patients with aortic stenosis should have pre-operative
echocardiography and every effort should be made to refer emergency cancer
presentations to a muhidisciphnary oncological team.

In 2003, the name changed to National Confidential Enquiry into Patient Outcome
and Deaths (still NCEPOD) to reflect its expansion.
Additionally, in 2003, NCEPOD became separate from the Association of Surgeons,
and became an independent body.
In 2002-3, the survey included patients under the care of physicians, general
practitioners and "near-miss" occurrences.
In 2003-4, there will be a 3-month survey of all endoscopic procedures by surgeons
and physicians.
Future reports will focus on intensive care of medical patients in 2004, ruptured
abdominal aortic aneurysm in 2005 and emergency medical admissions in 2006.

In 1987, regional CEPOD was performed in 3 health regions run by an association of
surgeons and anesthetists following the first report, it was immediately expanded to a
national survey and became NCEPOD.
The first NCEPOD report was published in 1989 and looked at deaths in children
under 10 years old. In 1990, NCEPOD surveyed 10 % of all deaths within 30 days of
surgery and this standard remains today.

Principles of Surgery 74

What are the specific exclusion collections?
So far, the report does not consider deaths related to obstetric care, of either the baby
or mother. Hospital dental surgery is included but community practice is excluded.
It is interesting to note that several private hospital groups also participate fully in
NCEPOD reporting and funding, as do the hospitals on the Channel Islands and the
Isle of Man.

Principles of Surgery 75

Outcomes of Surgery

What do you understand by the term outcomes, respect to surgery?
Defined as the result of clinical intervention and may represent success of or failure of
a procedure. It can be measured in terms of:
Surgical mortality.
Complication rates.
Patient satisfaction.
Length of hospital stay.
Quality of life.

How can the benefits of surgical treatment be measured economically?
Economic measurements are quite difficult to make, but cost effectiveness can be
assessed in terms of:
Cost savings or avoidance of unnecessary costs (e.g. reducing smoking).
Effective improvement in patient care.
Benefits can therefore be measured by;
Increased life expectancy
Increased quality of life.

What is a "quality-adjusted life year" (QALY) and how is it defined?
One QALY is the value of a healthy life measured in years that is one full-quality year
of life is one QALY. Two 6-month periods over 2 years in full health is also defined
as one QALY.

Management of local anesthetic toxicity:
Airway support with oxygen administration.
Establish intravenous access
Anticonvulsant agents (diazepam, thiopentone) and cardiopulmonary
resuscitation (adrenaline).

Principles of Surgery 76

Surgical Audit

What is audit?
Audit is defined as "the systemic, critical analysis of the quality of medical care,
including the procedures used for diagnosis and treatment, the use of resources and
the resulting outcome and quality of life for the patient.

What is the audit cycle?
The audit cycle commences with the selection of a suitable topic appropriate
to the experience and the time constraints of the lead person conducting the
Standards to be compared should be agreed and the audit planned.
The next phase is initial data collection and analysis.
Areas for exchange are highlighted, changes implemented, and then data re-
collected, so completing the audit cycle.
This cycle can be repeated continuously, to improve standards of care.
Repeats data collections can be also made several years later, to confirm that
high standards have been maintained.

Why is clinical audit used in the National Health Service?
Clinical audit is used to monitor the care received by patients and the use of
interventions within NHS.
By comparing service position against either local or nationally agreed
guidelines, deviation from "best practice" can be highlighted and clinical
standards maintained and improved.
This allows for improvements to be made within a system, in a non-
threatening or judgmental environment.
The audit cycle allows for continued assessment of that system, once
improvements have been implemented. Health care managers can be informed
of areas which require organizational change and additional investment.
Both patients and the general public gain confidence in the service provided,
knowing that best practice has been ensured.

Who takes part and how often?
All doctors are required to take part. All the people who are involved in delivering the
health care of the particular process being audited should attend the relevant audit
meeting. This includes nursing and ancillary staff as well as clinicians.
The Government and Medical Royal Colleges state that audit should be held
regularly, and this arises from unit to unit. In some centers, a short weekly meeting is
held, whereas in others it is held every 3 months with a session set aside for the

Is it voluntary?
No. Since 1989, the Department of Health has made it a requirement of every hospital
doctor to participate in audit.

Principles of Surgery 77

What types of audit are there?
The all-encompassing title of audit may be subdivided in several ways. It may be an
overall process examining all admissions, investigations, procedures, finances,
operations, and morbidity and mortality, or may be topic-based, concentrating on a
specific area, such as results of temporal artery biopsy over a 5-year period.
Audit may also be described by the three main elements of health care it looks at,
namely; structure, process and outcome.
1. Audit of structure analyses the infrastructure and resources available to
provide care, and is not often clinically relevant.
2. Audit of process examines the way in which a patient is treated from start to
finish of a clinics and might include such things as waiting times,
drug prescribing or operative technique.
3. Outcome audit is the sort most familiar to clinicians, and is based on the
traditional mortality and morbidity meeting, although other factors may be
assessed, such as length of hospital stay and patient satisfaction.

What does closing the loop mean?
Audit is a circular process that runs as follows: an area of concern is identified and a
set of ideal standard laid down. This is the level that should be achieved. The relevant
data pertaining to that area are collected, examined and a comparison made to the
ideal standard.
If deficiencies against the standard are identified, corrective measures are instituted
into that specific area of practice. After a suitable time, further data are collected and
re-examined hopefully to demonstrate an improvement in performance and the
attainment of the standard. It is this re-examination after change that is referred to as
"closing the loop".
It is important that audit is a tool for change and improvement rather than merely
collection of data and closing the loop is the means of demonstrating that the audit has
been effective. However, it should be noted that audit is an ongoing process and does
not end with closing the loop, but is more akin to a spiral, as the new changes are

What characteristics make a surgical audit successful?
A complete. Honest and accurate. Educational.
Confidential. Objective. Reproducible.

What is clinical governance?
It is defined as a "system through which the NHS organizations are accountable for
continuously improving the quality of their services and safeguarding high standards
of care, by creating an environment in which clinical excellence will flourish".
It has been introduced in an attempt to improve the performance the NHS and is a
requirement for all trusts and staff.
All NHS trusts must institute effective means of identifying and managing risk,
introduce lines of responsibility and have a widespread policy for quality
It is different from audit, although audit is one tool that might be used to demonstrate
those improvements that clinical governance requires.
It is overseen by Commission for Health Improvement (CHT), who regularly inspect
hospitals to ensure that the relevant standards are being met.
Principles of Surgery 78

For the clinician it involves standard setting, often centrally by the National Institute
for Clinical Excellence (NICE), as part of the National Service frameworks.
Professional self-regulation that is transparent should ensure that clinical standards are
met, and clinicians should be updated continuously by involvement in continuing
professional development (CPD) and lifelong learning. All of this is overviewed by

What do you understand by the term "randomised clinical trial"?
The randomised clinical trail is the most powerful method for the accurate assessment
of and comparison between treatment options. The treatment options will usually
include the standard treatment options will usually include the standard treatment or
placebo and the new treatment options. Randomised ensures that each patient has an
equal chance of receiving either arm(s) of treatment.

What is the definition of clinical governance?
It is a framework through which NHS organisations are accountable for continually
improving thhe quality of their services and safeguarding high stanards of care by
creating an envirnment in which wxcellence in clinical care will flourish.

Its aims to ensure that:
There are systems in place to monitpr quality of clinical practice and that they
are functioning well.
Clinical practice is reviewed and improved as a result.
Surgeons continue to meet the national standards as issued by the professional

The areas covered by clinical governance are divided into 7 pillars:
1. Clinical effectiveness (the degree to which the organisation ensures that best
practice is used):
Evidence-based medicine.
NICE (National Institue for Health and Clinical Excellence): this
organisation appraises the evidence for and against funding new treatment
and produces guidelines for best practice based on the available evidence.
2. Risk management (having systems to monitor and minimize risk to staff,
patients and visitors):
Incident and near-miss reporting.
Health and safety.
3. Clinical audit.
4. Education and staff management.
5. Staffing and staff management.
6. Information use (systems in place to collect and analyse information on
service quality).
7. Patient experience and public involvement.

Principles of Surgery 79

What is the diffence between between audit and research?
Clinical audit is not research, but it does make use of research methodology in order
to assess practice.
Althiugh research and clinical audit are 2 distinct activities with different purposes,
they are interrelated in several ways:
Research provides a basis for defining good-quality care for clinical audit purposes.
Clinical audit can provide high-quality data for non-experimental evaluation research.
Research into the effictiveness and cost-effictiveness of clinical audit is needed.
Research need to be audited to ensure that high-quality work is performed.

Rearch Clinical audit
The process of trying to find the truth. The process used by clinicians to improve
care by assessing clinical practice,
comparing againsst accepted standards
and making changes if necessary..
Aims to establish best practice. Aim to see how close current practice is
to best practice and identify ways to bring
the 2 closer together.
Designed to be replicated and validated
by other groups.
Specific to one particular patient group-
the results are not transferable to other
Aims to generate new evidence /
Aim to improve services.
Usually initiated by researchrs. Usually initiated by service providers.
Is theory driven. Is practice baaed.
Is often a single one-off study. Is an ongoing process.
May involve randomization. Never involves randomization.
May involve a placebo. Never involves a placebo.
May involve a novel treatment. Never involves a completely novel

Principles of Surgery 80

Principles of Surgery 81


How does ultrasound scanning work, and what are its advantages and
Ultrasound is a medical imaging technique that uses high-frequency sound waves and
their echoes to produce an image. The ultrasound machine generates a high-frequency
(1-5 MHz) sound wave, which is transmitted to the body via a probe. When the pulse
waves reach a boundary between tissues of different characteristics, such as soft tissue
and air, some of the energy is reflected and detected by the probe. The remainder of
the energy travels further through the body, until it reaches another tissue boundary,
where further reflection occurs. The machine analyses the reflected waves in terms of
distance to the reflecting boundary, the speed of sound in tissue (l540m/s) and the
time for reflected waves to return to the probe. The machine displays the distances
and intensities of the echoes on the screen as a two-dimensional image.
Ultrasonography is safe, quick, cheap and non-invasive. It does not involve ionizing
radiation and can be used intra-operatively and endoscopically. Unfortunately, it is
highly operator dependent and poor-quality scans make it less useful in obese
patients. It gives poorer tissue definition than other modalities and is confounded by
overlying gas-filled structures such as dilated bowel.

How does Doppler ultrasound work and what extra information does it provide?
This is simply ultrasound that employs the Doppler principle. The Doppler Effect
states that frequency of sound waves reflected from a moving object. The frequency
of the reflected waves is higher if the object is moving towards the probe, and lowers
if it is moving away from the probe. The magnitude of frequency shift is dependent on
the speed of the target object.
Doppler ultrasound uses this principle to assess the speed of a moving target, most
commonly intravascular blood, reflecting the ultrasound waves. The information can
be represented by an audible signal or by colour-coded flow on the ultrasound
machines screen (duplex scanning), Doppler ultrasound is used mostly to measure the
rate of blood flow through the heart and vessels, and it can be used to assess arterial
supply or venous flow in the investigation of thrombotic disease.

What is a Hounsfield number?
It is a standardized method of representing tissue density on computed tomo-graphic
scans; the system of units represents tissue density, reflecting x-ray attenuation, on a
scale ranging from -1000 to +1000. Airs, by convention, is assigned the value -1000,
and water a value of zero. A change of one Hounsfield unit (HIT) corresponds to 0.1
per cent of the difference in the attenuation coefficient between water and air.
The use of this standardized scale facilitates the comparison of scans obtained from
different CT scanners, and can be used to identify different types of tissue or fluid on
a scan; fresh blood has a value of 55HU, for example, whereas a haematoma has a
Hounsfield value of 80.

Principles of Surgery 82

What are the benefits of magnetic resonance imaging over conventional
Magnetic resonance imaging, previously called nuclear magnetic resonance imaging,
generates a three-dimensional image from the energy emitted by hydrogen, ions as
they; realign themselves after being resonated by an array of powerful external
magnets. It has many benefits and some disadvantages. MRI does involve an ionizing
radiation dose, which makes it safer than conventional radiology. The data from MRI
scanning can be reconstructed in any plane, allowing excellent visualization
abnormalities, with high tissue resolution. It is better at delineating between scar
tissue, inflammatory tissue and tumour than CT scanning. The MRI can be set to
image certain substances selectively, such as certain intravenous contrast agents,
allowing MRI angiography. It is the investigation of choice in the assessment of
central nervous system tumours and spinal disorders. Although capital outlay costs are
high, once established, MRI scanning is relatively cheap. Unfortunately, this cost
means that MRI scanning is not as widely available as is desirable. Patients who have
metallic implants or fragments may not be suitable for MRI scanning, as it involves
lying within an extremely powerful magnetic coil. Many patients find the enclosed
tube of the scanner claustrophobic.

List some surgical applications of radio-nucleotide scanning
Sestamibi scanning: used to identify parathyroid adenomas. Thallium scanning
will outline both thyroid and parathyroid tissue, whereas technetium is only
taken up by the thyroid. Subtraction of one from the other images the
parathyroid glands.
Red cell scanning: patients own red cells are technetium-labelled, reinjected
and the patient scanned. It is a method of localizing occult gastrointestinal
White cell scanning: labelled white cells are injected into the patient in an
attempt to localize foci of sepsis,
Bone scans: demonstrate metastatic lesions in the skeleton by virtue of their
increased vascularity.
PTPA (diethylenetriamine penta-acetic acid) and DMSA (dimercapto-succinic
acid) scans: show the renal pelvis/ureters and the renal cortex function

Principles of Surgery 83

Epidemiology of disease

What is the difference between Incidence and prevalence?
Incidence is the number of new cases in a defined time period within a defined
Prevalence is the total number of cases within a defined population.

What do you understand about the term cancer registries in the UK?
Population-based cancer registries try to assemble a complete count of all incident
cancers from notifications of cancer diagnoses by doctors and health service
providers, although there is no absolute requirement to do so.
In the UK, the cancer registry is based in Southport and is voluntary.
The system is cross-checked by the use of death certificates. The Office of
Population, Censuses and Surveys publish all resulting data.

What epidemiological factors need to be considered before a relationship
between cause and effect can be established?
The Bradford Hill criteria (1965):
1. Temporal sequence.
2. Strength of association.
3. Consistency of association.
4. Biological gradient (dose response).
5. Specificity of association.
6. Plausibility of association.
7. Coherence of association (does not conflict with current evidence).
8. Reversibility.
9. Analogy.
10. Predictive performance.

Principles of Surgery 84


What is a P value and why is a value of 0.05 most frequently used?
The strength of the difference recorded in hypothesis testing is called the P
When a value of 0.05 is used, it implies that one is 95% confident (in 19 out of
20 cases) that any observed difference in the results is real.
A false conclusion may still occur in 1 in 20 cases.
There is no scientific basis as to why this figure of P < 0.05 is used.
In general, the smaller the P value, the greater the statistical significance.
A P value of 0.01 means that one is even more confident that the findings are
real; a false conclusion will only occur in 1 in 100 cases (99% confidence).

When is a chi-squared test used?
The chi-squared test is another form significance testing for categorical data. It is used
to test for an association between two variables (contingency table).

What is the null hypothesis?
When using statistical tests it is usual to have a position of truth which is constantly
being refuted.
The null hypothesis is the position of truth; the null hypothesis states that there is no
difference between two results,
If a statistical test rejects the null hypothesis, on the basis of the P value which is
generated, we can conclude that there is indeed a difference.

Clinical trial types:
Clinical trials can be prospective or retrospective with the latter having a higher
statistical power than the former.
1. Observational conhort study:
Usually retrospective but can be propective.
Observational investigation where a group of individuals with a
specific diseaseor characteristic are followed over a period of time to
detect complications or new events.
Comparisons may be made with a control group.
No intervenous are normally applied to the participants.
2. Case control study:
Usually retrospective but can be prospective.
Observational investigation in which characteristics of people with a
condition (cases) are compared with a selection of population without
the disease (control).
3. Case-sectional study:
Usually retrospective.
A survey of the frequency of a disease or risk factor in a defined
population at a given time.
Used to assess prevalence.
Cannot evaluate statistical hypothese but can suggest statistical
and generate hypotheses.
Principles of Surgery 85

4. Controlled trial:
Intervention under investigation is applied to one set of individuals.
Outcome compared with a similar group (the control group) not
receiving that particular treatment.
In drug trials the control group usually has a placebo , eliminating
placebo effect in the intervention group.
5. Randomized trial:
Participates are placed in a particular arm of the investigation in a
random way , rather than via the conscious choice of the investigator
or participant.
Eliminates selection bias.
Ensures that confounding factors are spread evently yjroughout the
trial groups.
6. Binded (or masked ) trial:
Either investigations or patient is unware of treatment group to which
the participant has been assigned.
Eliminates assessment bias.

7. Double-binded (double masked) trial:
Both investigators and patient are unware of treatment group to which
the patient has been assigned.
Eliminates both assessor and patient bias.

Which type of clinical trial has the most statistical power and why ?
A double-blind randomized placebo-controlled trial has the most statistical power by
eliminating as much as possible ans spreading confounding factors evenly between
the different trial arms . It ensures that statistical samples come from truly random
dataset , allowing the use of more powerful statistics that make assumptions about
randomization and population distributions.

Sstatistics power and Pvalues:
Statistical power is defined as the ability of a study to demonstrate an association or
causal relationship between two variables ,given that an association actually exists .
For example : 90 % power in a clinical trial means that the study has a 90 % chance
of ending up with a value < 0.05 in a statistical test if there really is an important
difference (e.g. 30 % versus 15 % mortality rate ) between treatment groups.
The values
The probability (ranging from 0 to 1) that the results obsereved in a study (or more
extreme results) could have occurred by chance.
Convention dictates that we take a value < 0.05 to indicate statistical significance .
It is worth bearing in mind that this could still mean that there is a 1 in20 chance that
a ' statistically significant ' result could have occurred by chance.
The meta-analysis
Although not strictly a clinical trial , this is a study that attemps systematically to
merge the results from many clinical trials that are trying to answer the same clinical
Principles of Surgery 86

question , in an attempt to increase the statistical power through an increase in the
overall number of cases.

Statistical error:
Broadly statistical error can be divided into two : type 1 and type II errors.
Type 1 error:
A true null hypothesis is incorrectly rejected (i.e. although there is no dofference
between two groups , chance has shown there to be a statistical difference and the
null hypothesis is incorrectly rejected ).
Type II error:
Rejection of the alternative hypothesis when it is true (i.e. although there is a
difference between two groups , it is determined that there is no difference).
The 95 % confidence intervals:
This quantifies the uncentainty in measurement of a value .
A 95 % confidence interval (CT) gives a range in which there is a 95 % confidence
that the unknown value will lie within that range.
Usually expressed as 95 % CI in clinical journals now insist on the quotation of 95 %

What is meant by the sensitivity and specificity of a clinical test?
Sensitivity: the sensitivity of a test is the proportion of people with the disease who
have a positive test result ( the higher the sensitivity, the greater the detection rate the
lower the false-negative rate).
Specificity: the specificity of the test is the proportion of people without the disease
who have a negative test ( the higher the specificity , the lower will be the false-
positive rate)

Predictive value
The positive predictive value of a test is the probability of a patient with a
positive test actually having a disease.
The negative predictive value is the probability of a patient with a negative
test not having the disease.
A confidence interval that include 0 implies that the treatment effect is not statistically

Odds ratios in clinical trials:
The ration of the odds of having the target disorder in the control group.
An odds ration is calculated by dividing the odds in the treated or exposed group by
the odds in the control group.

Parametric and non-parametric statistics
For parametric statistics to be valid , they make an assumption that the groups being
compared are randomly sampled and confirm to a normal distribution.
Typical examples of parametric statistics are Student t-tests and
(chi-squared) tests.
For non-parametric statistics to be valid, they make an assumption that the groups
being compared are randomly sampled, but they make no assumptions about the
distributions that they follow. N
on-parametric statistics are not as statistically powerful parametric statistics but are
useful in circumstances where populations do not conform to the normal distribution.
Principles of Surgery 87

Deposition and Stones

What types of renal tract calculi do you know?
Calcium oxalate.
Calcium phosphate.
Magnesium ammonium phosphate.

What proportion of renal tract stones show up on plain radiographs?
The proportion is 90% (compared to only 10% of gallstones).

In what conditions do magnesium ammonium sulphate stones develop?
Alkaline urine, especially in the presence of Proteus infection, which can split urea
molecules into ammonium. These stones are smooth and can enlarge rapidly hence
they can fill the whole renal calyx, as is the case in stag-horn calculus.

What other factors can predispose to calculus formation?
Urinary stasis.
Inherited metabolic abnormalities.

By what mechanism does a stone blocking the ureter lead to pain?
Backpressure of urine on the kidney stretches the renal capsule causing the classical
severe constant pain. Spasm of the ureter is not thought to be the major cause of
ureteric colic.