Surgery Management Quick Review

Surgery Management Quick Review

Skin Infections

Seborrheic keratosis

• no txt
  
• cryotherapy with pt wants it removed

Actinic Keratosis

• observation
  
• excision, cryotherapy (most often)
  
• if multiple 5-fu, or imiquimod

Lipoma

• excision with local

BCC

• electrical desiccation/curettage tx of choice
  
• excision
  
• Mohs for difficult cases (around eye)
  
• can also do 5-fluro and imiquimod

SCC

• Excision txt of choice
  
• or 5-fluro and imiquimod

Malignant melanoma

• Excision (surgery) with lymph node bx is definitive treatment

Abscesses

• I & D + abx (skin mostly staph aureus-can use clinda)
  
• (local anesthetic, 11 blade, pack wound)

Ganglion cyst

• 1/3 resolve spontaneously
  
• cyst aspiration, steroid injection, surgical excision

Sebaceous cysts

• local anesthetic + removal with I & D

Pilonidal cyst

• I and D (incision lateal to avoid slow healing)

Dehiscence

• prompt elective reclosure of incision
  
• abx from previous wound infection must be given at time of repair

Decubitus ulcer

• 1st relieve pressure
  
• I and II = Topical abx + NaCl + wet-to-dry, hyrdogels
  
• III + IV = debridement of necrotic tissue, flap reconstruction; reposition and correct nutritional def.

Burns

• referral if:
  
  • >10%
    
  • hands, feet, genitalia, perineum major joints
    
  • third degree
    
  • electrical or chemical inhalation
    
• Skin grafting:
  
  • if don’t heal within 3 wks
    
  • full-thickness burns

Neurological Disorders

Epidural hematoma

• ABC’s first with any head trauma (airway, breathing, fluids-crystalloids)
• evacuation

Subdural hematoma

• ABC, fluids
• evacuation

Subarachnoid hemorrhage

• IV BB when MAP >130
  
• Mannitol, loop diuretics to dec. ICP

Intracranial hemorrhage

• steroids for edema
  
• phenytoin for seizures
  
• evacuation if mass effect

Cerebral aneurysm

• unruptured =supportive–> ABGs, IV crystalloids, neuro consult, BP control
  
• Ruptured= surgical clipping; coiling procedure

Hydrocephalus

• sx ventriculoperitoneal shunting (catheter placed into the lateral ventricle under general anesthesia)
  
• diuretics
  
• control of BP

Eye Disorders

Orbital cellulitis

• IV abx (clinda, vanco, cefotaxime)
  
• op: lateral canthotomy, cantholysis (release of pressure)

Ear Disorders

Cholesteatoma

• surgical marsupialization/removal (mastoid bowl),can cause otitis externa

Otitis media

• amoxicillin 10-14 days
  
• augmentin 2ed line
  
• if recurrent pressure equalization tube surgery (myringotomy)

Otitis externa

• drying agents if wet
  
• Cipro/dexamethasone
  
• otic drops (aminoglycoside abx + anti-inflammatory)
  
• Remove debris

• Avoid additional moisture in ear
  
• Neomycin sulfate, polymyxin B sulfate, hydrocortisone

Eustachian tube dysfunction

• if viral= decongestants, pseudoephedrine, phenylephrine
  
• Myringotomy with tube placement

Nose, Sinus and Mouth Disorders

Epistaxis

• anterior pressure
  
• if persistent: topical vasoconstriction or topical anesthetic (lidocaine)
  
• silver nitrate cautery
  
• double-balloon catheter
  
• endoscopically guided electrocautery

Sinusitis

• non-op: Amox. 10-14 days, Bactrium, quinolones
  
• op: Endoscopic sx may be relieved w/needle

Tonsillitis

• Tonsillectomy + adenoidectomy if:
  
  • recurrent strep infections
    
  • recurrent peritonsillar infections
    
  • chronic tonsillitis
    
  • sleep apnea
    
• non-op:
  • drainage and abx (PCN or erythromycin)

Ludwigs angina

• PCN + metro + clinda + ampicillin/sulbactam
  
• external drainage- b/l submental incisions
  
• emergency airway I and D

Respiratory Disorders

Pneumothorax

• chest tube insertion (5th ICS midaxillary) if large PTX
  
• needle for tension 2 ICS midclavicular above the affected side if tension followed by chest tube placement.

Hemothorax

• chest tube 5ics
  
• VATS for non-traumatic

Empyema

• Thoracentesis 7ths and 9th ribs spaces btw posterior axillary line and the midlines
  
• zyson or vanco.

Pleural effusion

• treat underlying condition
  
• thoracentesis gold standard

Lung Carcinoma

Thymomas

• limited thoracotomy

Cardiac Disorders

Thoracic aortic aneurysm

• surgery if:
  
  • >6cm, symptomatic, recent inc. in diameter, or rupture.
    
  • graft or endovascular stent

Aortic dissection

• surgical in acute proximal (type A/debakel I and II) or acute distal (type III) with complications (vital organ involvement or impending rupture)
  
• Medical management done in descending
  
• BB

Aortic stenosis

• valve replacement with tissue
  
• percutaneous balloon aortic valvuloplasty

Aortic valve replacement

• sx if:
  
  • pt. symptomatic
    
  • LV dilation
    
  • dec. in LV function
    
  • dec. EF

Pericardial effusion/tamponade

• emergency pericardiocentesis (5-6th ICS at left sternal border)

CAD

• sx if:
  
  • left-main dz
    
  • >3 vessels dx
    
  • chronic unstable angina unresponsive to PTCA
    
• post-op: asa + BB

Gastrointestinal Disorders

Cholecystitis

• cholecystectomy is definitive (emergent)
  
• if severe: cholecystostomy (drain) with delayed removal. open chole if perf.

Small bowel obstruction

• NPO bowel rest, IV fluids, bowel decompression (via NG tube)
  
• if strangulated the surgical intervention:
  
  • lyse adhesions

Large bowel obstruction

• malignant= resection
  
• diverticular- resection
  
• volvulus resection

Appendicitis

• non-perf: prompt lap-appy, 24 hours abx post-op, home on POD #1.
  
• Perf: IV fluid, appendectomy, post-op abx 3-7 days. would left open after the closing of fascia.

Ischemic bowel dz

• Non-op= anticoagulation
  
• revascularization stenting +/- bypass
  
• resection if not managable

Diverticulitis

• losis= high fiber diet
  
• itis= clear diet and cipro + metro

• sx if:
  
  • perf, abscess, fistula
    
  • resection of entire sigmoid to prevent reoccurance
    
  • mobilize splenic
    
  • circular stapler for anastamosis

Volvulus

• Sigmoid= detorsion counterclockwise if no ischemia
  
• with sigmoidoscope, colonoscope; gangrene= exploratory and resection

• cecal= cant be detorsed endoscopically
  
• needs surgical exploration= R hemicolectomy with primary ileocolic anastomosis

Crohn’s dz

• 5-ASA (sulfasalazine mesalamine)
  
• corticosteroids (acute flares only)
  
• immunomodulators: methotrexate, c-mercaptopurine
  
• anti-TNF drugs: infliximab

• sx:
  
  • obstruction, massive bleeding, fistula, perf. abscess or stricture

Ulcerative Colitis

• same med as Crohn’s

• sx if:
  
• Toxic megacolon
  
• cancer prophylaxis
  
• total proctocolectomy with end ileostomy is the gold bc complete cure with no worries about cancer.

Peritonitis

• removal of indwelling catheter
  
• BSA (broad spectrum abx)-ceftriaxone, metro

• sx; drainage of abscesses, exploration/resection/repair

Incarcerated hernia

• reduction should be attempted if fail then sx

Incisional hernia

• if reducible: hernia belts, trusses, bindings, watchful waiting.
  
• non-reducible: abx laparoscopic sx

Inguinal hernia

• asx= watchful waiting (controversy over this. some say if hernia must get it repaired) wear belts until sx
  
• strangulation- emergent herniorrhaphy
  
• elective herniorrhaphy to prevent strangulation (bassini or coopers repair) with mesh

Femoral hernia

• Mcvays (coopers) with mesh plug repair

Anal fissures

• 80% resolve spontaneously
  
• lidocaine for pain
  
• ischemia= nitroglycerin (open up)
  
• sphincterotomy- fissures that failed therapy
  
• fistulotomy- inside openings are joined and allowed to heal from the inside out.
  
• flaps, plugs, glue

Hemorrhoids

• high fiber diet, stool softener, inc. fluid
  
• Rubber band ligation if 1st to 3rd degree
  
• excision of necrotic tissue, broad-spectrum abx
  
• sclerotherapy for 1-3 degree (injection of sclerosing agent)
  
• operative hemorrhoidectomy if 4th degree (cant be reduced)

Lower Extremity Disorders

Acute arterial occlusion

• preop: anticoag with IV heparin for embolism (thrombolytics for thrombus)
  
• surgical embolectomy via cutdown and Fogarty balloon
  
• bypass if embolectomy fails

DVT

• stable: anticoag (heparin LMWH–> warfarin)
  
• unstable thrombolytic therapy or embolectomy
  
• IVC filter if pt has C/I or failed anticoag.

Compartment syndrome

• open compartments
  
• B/L calf incisions with fasciotomies of all 4 compartments of the calf.