General Surgery

General surgery • • • • Urethral catheterisation Wound Drains Wounds and Wound healing Breast 2 4 5 10 Surgical Sieve Vascular Inflamatory Trauma Autoimmune Metabolic Infective Neoplastic DON’T FORGET Iatrogenic & Physiological Congenital Degenerative Endocrine Surgery 1 Urethral catheterisation • List the indications and contraindications for the passage of a urethral catheter Indwelling catheter Indications Treatment for acute or chronic retention of urine Instillation of drugs Monitoring urine output Before certain operations After certain operations Bladder washout Performing certain urological investigations Maintaining patency of the urethra Relieving incontinence if all else fails Spinal cord compression Contraindications for use include :Immunosuppression Cytopoenia Urethral stricture / prostatic obstruction (use suprapubic) Trauma Common hazards include… Infection (introduced retrogradely with the catheter) Trauma (including creating a false passage & stricture formation) Haematuria (due to trauma or infection) No drainage (kinked tube, full bag / above bladder / severe constipation / blockage) Leakage Encrustation Biofilm formation Intermittent catheters Indications Treatment of retention of residual urine Post operative retention/acute retention Maintaining patency of the urethra Determining residual urine volumes Common hazards include… Infection and trauma but at a reduced rate compared to indwelling urinary catheters Urethral bleeding Formation of false urethral passages Suprapubic catheters Indications Long term disability Patients experiencing problems related to urethral catheters (regular blockage – e.g. haemorrhagic cystitis caused by chemotherapy) Females when urethra is surgically closed Sexually active clients who require catheterisation Trial of voiding Common hazards include… Infection Trauma Leakage Surgery 2 • By performing the requisite tasks and outlining them in written orders, demonstrate knowledge of the daily catheter care and maintenance necessary for preventing stricture formation and retrograde infection. Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve The connection between the catheter and the urinary drainage system should only be broken when changing the bags Normal hygiene of daily bath or shower should be sufficient to remove dried secretions from around the meatal opening. Too frequent washing may upset patient normal meatal flora which acts as a defence mechanism Advise the drinking of cranberry juice if the urine is infected / as prophylaxis Aim for a fluid intake of 1500 -2000mls over 24 hours, providing there are no medical/surgical contra-indications as this helps to prevent infection Maintaining a closed drainage system A link system should be used to facilitate overnight drainage, to keep the original system intact. Healthcare personnel should ensure that for good clinical reasons (for example changing the drainage bag in line with the manufacturer’s recommendations) Drainage bag position The drainage bag should be above floor level but below bladder level, to prevent reflux or contamination. • Demonstrate proper technique for sampling urine (for routine urinalysis and culture) through a catheter or spontaneously voided specimen. Urine samples must be obtained from a sampling port, using an aseptic technique. Surgery 3 Wound Drains • Discuss the differences between closed suction and open drains. Open drains drain by capillary / gravity, sepsis is more common & these are only used if the fluid is expected to resolve quickly Include corrugated rubber or plastic sheets Drain fluid collects in gauze pad or stoma bag They increase the risk of infection Closed drains remain closed even during emptying & reactivation. Suction removed fluid from the wound Consist of tubes draining into a bag or bottle They include chest and abdominal drains The risk of infection is reduced Active drains Active drains are maintained under suction, They can be under low or high pressure Passive drains Passive drains have no suction, Function by the differential pressure between body cavities and the exterior • Describe the indications for drain placement, advancement and removal. Drains are inserted to: Evacuate establish collections of pus, blood or other fluids (e.g. lymph) Drain potential collections (haematoma, bile leaks or pus) Arguments for their use include: Drainage of fluid removes potential sources of infection Drains guard against further fluid collections May allow the early detection of anastomotic leaks or haemorrhage Leave a tract for potential collections to drain following removal Arguments against their use include: Presence of a drain increases the risk of infection Damage may be caused by mechanical pressure or suction Drains may induce an anastomotic leak Most drains abdominal drains infective within 24 hours Surgery 4 Wounds And Wound Healing • Recognise the various phases of wound healing by evaluating the surgical and traumatic wound. A wound is a disruption of tissues normally associated with a loss of substance. Wound healing is the bodily mechanism of regeneration and repair which serves to restore/match the original function of the damaged tissue. Primary intention Skin edges are directly opposed Healing is normal with minimal scar formation Secondary intention The wound is left open Healing occurs by a combination of contraction and epithelialisation There is increased inflammation/proliferation compared to healing by primary intention Tertiary intention This occurs in wounds that are initially left open and then closed by secondary procedure (e.g. suturing) Phases of wound healing Haemostasis – vasoconstriction, plateet plugging & platelet degranulation, propagation of thrombus Inflammation – Occurs 2-3 days post in jury, stimulated via injury, infection, growth factors from endothelial cells. PMNs & mononuclearcyte cells enter surrounding tissues Proliferation – begins on day 2-3, lasts for 4 weeks. Macrophages release growth factors. Fibroblasts migrate into wound secreting GAGs. Collagen & elastin are produced Remodelling – 2-4 weeks after injury. Collagen haemostasis. Involution of capillary network. Collagen fibres become more organised Healthy healing surgical wound A wound closed by surgical intervention. There is disruption to the integrity of the skin and underlying tissues that progress through the normal healing process in a timely and uneventful manner Surgery 5 • Recognise the appearance of a wound that has healed by epithelialisation. Wound pink in appearance with fragile tissue Aim to protect and promote new tissue growth by maintaining a moist environment. Apply a thin hydrocolloid Always consider a low or non-adherent dressing for patients with fragile skin If necessary, irrigate the wound with warmed sodium chloride 0.9% at dressing change to remove debris • Identify normal granulation tissue in a wound and describe its significance in terms of epithelialisation and defence against contamination. Granular appearance, glossy red and bleeds easily Aim to promote and protect angiogenesis by maintaining a warm moist environment Irrigate if necessary with warmed sodium chloride 0.9% For low/moderate exudating wounds use a hydrocolloid dressing For highly exudating wounds use a foam dressing Always consider a low/non-adherent dressing for patients with fragile skin • Recognise and differentiate wounds that have resulted in loss of tissue and those that have not. Cavity wound They may be present with a wound bed of differing tissue type ie clean, infected, sloughy, granulating, or a combination. The tissue type and amount of exudate will affect treatment Aims Management of exudate Protection of surrounding skin Removal of devitalized tissue Promotion of granulation from the wound bed Prevention of infection Manage pain Maintain adequate nutritional and fluid intake Manage the underlying cause, not just the wound Surgery 6 • Recognise and differentiate traumatic wounds that can be safely closed primarily and those that cannot. Wounds that cannot be closed without further intervention include: Infected Potential for foreign body Bites Burns Too big to close Deep penetrating wounds Wounds covering a large area Pretibial area Crush injury Patients on long term steroid therapy • Understand the important components of abdominal wound closure to avoid dehiscence and herniation. A premature bursting open or splitting along natural or surgical suture lines. Due to failure of wound closure technique Broken sutures or slipped knots Inadequate muscle bites & usually secondary to poor wound healing. Risk factors include diabetes, advanced age, obesity and trauma during the post-surgical period. Affects about 2% of mid-line laparotomy wounds Serious complication with a mortality of up to 30% Usually occurs between 7 and 10 days post operatively Often heralded by serosanguinous discharge from wound Should be assumed that the defect involves the whole of the wound Management Opiate analgesia Sterile dressing to wound Fluid resuscitation Early return to theatre to resuture • Identify the development of inflammatory changes in a wound and around a suture. Allergy to wound / sutures The area may show a combination of the following signs: Inflammation, blistering, pain, irritation Remove the cause Apply a low/non-adherent dressing Avoid adhesives if at all possible Make patient aware of the cause of the allergy and ensure it is documented in their notes Surgery 7 • Assess a wound for signs of infection, attending to local heat, erythema and excessive pain; outline the management of an infected surgical wound. Painful wound characterised by the presence of pus, odour and excessive exudate which is often green in colour. The Patient may have a pyrexia. If there is granulation present, it may be a dull dark red in colour Aims: To identify and resolve the infection To contain the exudate and reduce odour To address pain issues If the wound is clinically infected appropriate systemic antibiotics should be given If the wound is sloughy with a heavy exudate, consider an alginate or hydrofibre dressing, these are thought to retain micro-organisms within the dressing Dressings should be changed daily whilst infection is present Sloughy wound Slough is the formation of a viscous, predominantly yellow layer of tissue Aim to remove all debris and promote autolysis Irrigate with warmed sodium chloride 0.9% if required to remove dressing debris If the wound shows no evidence of improvement, consider alternative options, ie surgical debridement or larval therapy Necrotising wound Dead dehydrated tissue, easily recognisable by a black or brownish appearance. Necrotic areas may completely cover a wound, forming a dry eschar or, alternatively, may present as small patches in the base or margins of a wound bed Aim to identify the cause of the necrotic wound ie pressure or vascular disease Debridement of the necrotic area to allow treatment to the underlying tissue by gentle rehydration promoting natural debridement through autolysis Aim to remove/control of the cause, for good DM control, & stop smoking Surgery 8 • Factors affecting wound healing Systemic factors: Congenital Pseudoxanthoma elasticum Ehlers-Danlos Cutis Laxa Progeria Werner syndrome Epidermolysis bullosa Systemic factors: Acquired Nutrition Pharmacological Endocrine abnormalities ↑Age Smoking Local Factors Infection Radiation Blood supply Trauma Neural supply AR. Increased collagen degradation Collagen tissue disorder Abnormally lax skin (neonatal presentation) Premature ageing AR. Mimics premature ageing. Heterogeneous collection of conditions Vitamins A, C and E. Zinc and albumin. Steroids ↓ inflammation, NSAIDS ↓collagen synthesis. Diabetes. ↓cell multiplication, ↓tensile strength, ↑ healing time, (Tissue healing in the first 3mnths of fetal life occurs via regeneration. This is characterised by the absence of scarring.) Nicotine causes vasoconstriction which ↓tissue perfusion, CO2 in cigarette smoke ↓tissue oxygenation Endothelial cell, capillary and arteriole damage. Evidence that wounds in denervated tissues heal slow Surgery 9 The Breast Anatomy The breasts are modified sudoriferous (sweat) glands The areola is colored from pink to dark brown and has several sebaceous glands. The mammary glands within the breast produce the milk. They are distributed throughout the breast. These are drained to the nipple by between 4 and 18 lactiferous ducts, where each duct has its own opening. Remainder is composed of connective tissue (collagen and elastin), adipose tissue, and Cooper's ligaments (connect breast to dermis). The ratio of glands to adipose tissues rises from 1:1 in nonlactating women to 2:1 in lactating women. Gross anatomy The breasts sit over pectoralis major and usually extend from the level of the 2nd rib to the level of the 6th rib anteriorly. The superior lateral quadrant of the breast extends diagonally upwards towards the axillae and is known as the tail of Spense. The arterial supply to the breasts is derived from the internal thoracic artery (internal mammary artery), lateral thoracic artery, thoracoacromial artery, and posterior intercostal arteries. The venous drainage is mainly to the axillary vein, but there is some drainage to the internal thoracic vein and the intercostal veins. The breast is innervated by the anterior and lateral cutaneous branches of the fourth through sixth intercostal nerves. The nipple is supplied by the T4 dermatome Surgery 10 Lymphatic drainage 75% of lymph from the breast travels to the ipsilateral axillary nodes (pectoral, subscapular, and humeral à central axillary lymph nodes à apical axillary lymph nodes). The rest travels to parasternal nodes, to the other breast, or abdominal lymph nodes. Development Triggered mainly by oestrogen (also causes gyneacomastia in men) During the menstrual cycle oestrogen (1st ½ of cycle) à growth of milk ducts and progesterone (2nd ½ of cycle) à formation of milk glands Tanner I -- no glandular tissue; areola follows the skin contours of the chest (prepubertal) Tanner II -- breast bud forms, with small area of surrounding glandular tissue; areola begins to widen Tanner III -- breast begins to become more elevated, and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast Tanner IV -- increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast Tanner V -- breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. • Describe the diagnosis of a breast lump, including cytology, mammography and biopsy (trucut and open). Triple assessment clinics Clinical examination Inspect with arms by side, arms in air / behind head and on hips Palpate the normal breast first – split the breast into 4 quadrants. Remember to palpate the tail in the axillae & the supraclavicular LNs Imaging <35yrs à US >35yrs à Mammogram + MRI if no confident finding / for staging NB: US only looks at symptomatic area! Surgery 11 Mammography Above = Mediolateral oblique (MLO) view (shows pec major) Below in craniocaudal (CC) view Right Mammogram has 3 density patterns Very dense = low detection rate Mixed = medium detection rate Low density = high detection rate A young breast has a high fibroglandular makeup = very dense so low detection rate As the breast ages the fat content increases making mammography more reliable Features to look for include: Masses Distortion Asymmetry Calcification Left MLO view Sup Inf CC view Lat Med With any mass try to describe the shape, margins, associated findings and the axillary nodes SMOOTH LOBULATED Smooth – is almost always benign Lobulated - vary in nature Ill defined – CA is likely Spiculate – almost always CA Macrocalcification is almost always benign Microcalcification can vary ILL-DEFINED SPICULATE Distorted architecture (left) with signs of pulling is usually associated with a speculated mass (which may not show up on the mammogram) Surgery 12 Ultrasound Cyst Benign Mass Black / anechoic Lobulated / smooth Very sharp margin Very good through transmission (“acoustic enhancement”) Multiple Malignant Mass Irregular outline Fuzzy margin / halo Acoustic shadowing Crosses tissue planes “Tall” in breast Smooth outline Ovoid / lobulated Flat in breast Good sound transmission No halo Doesn't cross tissue planes Intermediate mass Some features of both Neither ovoid nor tall Lobulated or angular margins Variable through transmission Some fuzziness of margins Biopsy FNA = Fine needle aspiration cytology Uses a needle to remove cystic or solid samples. Better for cystic. Fluid should be checked for cells if bloodstained Can be performed under US guidance Core biopsy (trucut) Several cores are removed using a cutting needle on a mechanical gun Performed under US guidance Open biopsy Only if other sampling techniques have failed Can à scarring & pain at removal site Hooked wire inserted under imaging to show surgeon the site The specimen should be x-rayed after to confirm the correct area removed • Identify and describe the major types of breast lump (fibroadenoma, fibroadenosis, cyst, carcinoma) & describe their treatment 95% of cases will be carcinoma, fibroadenoma, fibroadenosis or cyst Malignant tumours – see below Fibroadenoma 13% of all palpable breast lumps (60% in women < 20yrs) Mobile lump in young women (25-30) Hormone dependent benign, local proliferation Contains stromal and epithelial components as an entire lobule evolves As the woman ages the fibroadenoma calcifies à 1-4cm in diameter, discrete, firm, mobile breast lump = “breast mice” Surgery 13 NO malignancy risk, most will self resolve Diagnosis – based on cytology if patient is < 30 & lesion < 3cm. If not then à core biopsy Management – large / symptomatic lesions are excised Fibroadenosis (Fibrocystic change) Hyperplastic overgrowth of components Occurs in 10% of all women, 40% are asymptomatic Increasingly common towards the menopause but decreases after Unequal growth à Firm, rubbery replacement & cystic nodules Palpable thickening & nodularity. Can be a single lump Cysts – upto 1-2cm. Lined by lobular duct epithelium & filled with watery fluid Sclerosing adenosis – solitary palpable lesion in young women Management – Aspiration of cyst (should disappear/no palpable mass), Send fluid for histology. Surgery - Excision often not required but can help if localised pain. Medical (pain) - Mild – evening primose oil, Severe – danazol, bromocriptine Cysts Common in perimenopausal women / those on HRT Uncommon post menopausal Painful, tender swelling, May be tense but usually fluctuant Can be multiple and bilateral Diagnosis – on XR show as round, well defined opacity. Confirm as fluid with US Management – aspirate to dry under US. If blood stained aspirate à send for cytology. If palpable mass remains à biopsy Other causes include Mastitis – painful tender enlargement (usually staph aureus / streps) Abscess – if mastitis goes untreated Fat necrosis - à local inflammation à fibrous repair Can resemble Ca if skin tethering occurs Duct ectasia – dilatation of the ducts (periductal mastitis) Usually in perimenopausal, parous women Firm lump +/- nipple discharge Ducts filled with inspissated creamy material Features macrophages, fibrosis & inflammation Gynaecomastia Can be caused by chronic liver disease, drugs (cimetidine, spironolactone, digoxin, cannabis, prostate Ca treatments), adrenal tumours (secreting oestrogen), lung cancer (secreting ectopic hormone), occupational exposure to oestrogens or chromosomal abnormalities (Kleinfelters) • Outline a diagnosis and therapy plan for nipple discharge Most cases are benign Requires investigation in clear, single-duct or blood stained Blood stained Duct papilloma – blood from a single duct Intraductal Ca Paget’s disease Invasive carcinoma (rare) If mammography normal & single duct à microdochectomy, if multiple à total duct clearance Clear Surgery 14 Intraduct carcinoma If mammography is normal then likely to be intraduct papilloma à excision of duct (microdochectomy) is required Multicoloured (often multiduct) Duct ectasia (commonly yellow, brown or green) If examination & mammorgram normal then no further treatment is required Milky Galactorrhoea – may be lactation, be drug induced or sign of hyperprolactinaemia Purulent Breast abscess • Describe the aetiology, morphology and pathological consequences of carcinoma of the breast. Benign tumours Less common than malignant breast tumours Hamartoma – similar to fibroadenoma. Seen on mammogram screening Duct papilloma – common in middle age à blood stained discharge (if multiple higher risk of à malignancy True adenoma – very uncommon. Tend to occur in young women. Adenoma of the nipple (à ulcerated & red). Can be confused with Paget’s disease of the nipple. Phyllodes – epithelial & stromal components. Occur at any age post puberty (but usually over 40). 10% recur locally after excision. Malignant tumours 1 in 12 UK women Incidence increases with age 4 Main presentations Lump Mammogram screening detection Incidental in tissue / scans for other purposes Effects of distant mets Types Intraductal = carcinoma in situ 5% of those presenting with a lump 20% of mammogram detections Peak 40-60yrs If left 30% will become invasive Excellent prognosis if removed as still in situ Lobular in situ 6% of all breast cancer Usually found incidentally High risk of being invasive (20% within 20 yrs) and bilateral Invasive ductal ( > 80%) Most common Invasive lobular (10%) 2nd most common Often multifocal with high % bilateral Tubular (2%) Rare Good survival Mucoid (2%) Rare Post menopausal Good survival Surgery 15 Medullary (2%) Rare Post menopausal Reasonable survival Paget’s disease of the nipple Spread of ductal carcinoma to epidermis à reddening & thickening of skin of nipple & areolar region Consequences Local spread à tethering & deep fixation Lymphatic spread à pea’d’orange à axillary & internal mammary chain affected Vascular spread à bone, lung, pleura & ovary mets • List the risk factors for carcinoma of the breast. Family history (BRCA1, BRCA2) Proliferative disease (hyperplasia) x 11 if assoc FH Early menarche (10 rather than 15yrs à x3 risk) Late menopause (55 rather than 45yrs à x3 risk) Late 1st child (35 rather than 20 à x3 risk) Nulliparous Exogenous hormones (mainly HRT) Diet (obesity, high alcohol) • Describe the clinical staging of breast carcinoma. Poor prognostic factors Young age Pre-menopausal Tumour size High grade tumour Oestrogen & progesterone receptor negative Positive nodes Survival & operability depends on the stage, grade & type of the tumour Stage – is the most powerful prognostic index Large 1o (>2cm) OR fixation = poor prognosis Spread to nodes reduces 5yr survival from 80 to 60% Vascular spread is assoc with poor prognosis & 5yr survival of approx 10% Grade Looks at degree of gland formation, pleomorphism & no of mitoses Grade I = 85% 10 yr survival Grade II = 60% 10 yr survival Grade III = 45% 10yr survival Type Some of the specialised types (tubular, mucoid) have better prognosis Hormone receptor status Tumours which express oestrogen & progesterone receptors have a longer disease free survival as they are more likely to respond to anti-hormone therapy • List and discuss the treatment options for breast cancer. Early breast cancer Local treatment Wide local excision & breast conservation OR mastectomy (+/reconstruction & axillary dissection) Surgery 16 Radiotherapy if wide local excision (or tissue margins in doubt at mastectomy) to reduce recurrence by 25% Adjuvant systemic treatment Tamoxifen if oestrogen / progesterone receptor +ve disease à reduces risk of death by 25% Ovarian ablation has similar effects Advanced breast cancer If cancer has spread Endocrine therapies treatment cannot be curative Premenopausal Endocrine therapy Suppress ovarian function (oophorectomy / Those with high GnRH analogue e.g. Goserelin) levels of oestrogen & Anti-oestrogen – tamoxifen progesterone recptors Progesterone have best response Postmenopausal rates Tamoxifen Chemotherapy Progesterone If unlikely / have Aromatase inhibitors (e.g. anastrozole) failed to respond to endocrine treatments / require rapid response (e.g. on verge of liver failure) Agents used include: CMF (cyclophosphamide, methotrexate & 5FU) MM (mitoxantrone & methotrexate) – one of the least toxic Doxorubicin & cyclophosphamide • List the current results (survival and recurrence rates) of treated breast cancer according to clinical stage. Survival rates are scored by the Nottingham Prognostic Index NPI = (0.2 x size in cm) + score on LN staging + score of grade Node scores – 1 if no nodes, 2 if 1-3 nodes, 3 if 4 or more nodes Grade scores – Grade I = 1, Grade II = 2, Grade III = 3 NPI value <2.4 2.4-3.4 3.4-4.4 4.4-5.4 > 5.4 Prognositic group Excellent Good Moderate I Moderate II Poor Surgery 17 10 yr survival (%) 94 83 70 51 19