Surgery

Surgical briefing

• Before induction of anesthesia
• Confirm:
  • 1. Patient ID
  • 2. Procedure / site
  • 3. Consent
  • 4. Clinical info / labs / imaging displayed / results
  • 5. ASA
• Review
  • 1. Risk of blood loss
  • 2. Allergies
  • 3. Airway management
  • 4. Monitoring / equpiment
  • 5. Medications – VTE / antibiotics / other
  • 6. Nursing / MD / anesthesia concerns
  • 7. Any special precautions
  • 8. Expected time
• ** anesthesia
• ** nursing
• Surgeon not required but is suggested

Time Out

• Before skin incision
  
• 1. Team members introduce themselves
  
• 2. Final confirmation of:
  
  • – patient
    
  • – procedure
    
  • – antibiotics
    
  • – VTE prophylaxis
    
  • – positioning
    
• 3. Review any final questions

Debriefing

• As soon as the operation is over before patient leaves OR
• 1. Operation that was completed
• 2. Sponge / instrument counts
• 3. Labelling of surgical specimens
• 4. Equipment problems
• 5. Plans for post-operative management
• 6. Review anesthesia / surgery / nursing any intra-operative concerns or could anything be improved

Cardiac conditions associated with the highest risk of endocarditis

• 1. Prosthetic cardiac valve
• 2. Previous infective endocarditis
• 3. Congenital heart disease
  • – unrepaired cyanotic
  • – completely repaired with prosthetic material < 6 months
  • – repaired with residual defect at site of prosthetic material
• 4. Cardiac transplant with valvulopathy
• GU surgeries to not cause endocarditis – prophylaxis not recommend BUT
  • 1. If established gyne / GU infection – cover enterococcus (ampicillin, piperacillin)
  • 2. If established enterococcal UTI – antibiotics prior to urinary tract manipulation
• Endocarditis prophylaxis for GU procedures:
  • No!
    
  • Unless
    
    • 1. known enterococcal UTI and urinary tract manipulation
      
  • ** if do give antibiotics needs to cover enterococcus
    
    • – ampicillin
      
    • – piperacillin
      
    • – vancomycin

Classification of surgical site infections

• Occur within 30 days of surgery or within 1 year of implant
• 1. Superficial
  • – skin / subcutaneous tissue
  • – purulent drainage or symptoms (red, warm, edema + opened)
• 2. Deep
  • – fascia/muscle
  • – dehiscence, signs/symptoms of infection, access
  • – does NOT involve deeper organ space
• 3. Organ space
  • – involves anatomy OTHER than the incision

Cutting vs. Coagulation electrocautery

• Cutting:
  
  • continuous sinusoidal wave
    
  • low voltage
    
  • high frequency
    
  • rapid tissue heating
    
  • lower thermal spread
    
  • cellular water is vaporized
    
  • minimal coagulation
• Coagulation:
  
  • non-continuous wave
    
  • high voltage
    
  • low frequency
    
  • slower tissue heating
    
  • higher thermal spread
    
  • cells are not vaporized

Benefits of PDS / maxon over vicryl for fascial closure

• 1. Tensile strength maintained for longer
  
• 2. Delayed absorption
  
• 3. Lack of interstices that can be nidus for infection (monofilament)
  
• 4. Less inflammatory response

Benefits of LMWH over UFH for VTE prophylaxis prior to surgery

• o Longer half-life
  
• o Less bleeding risk
  
• o More bio predictable
  
• o Equivalent risk reduction
  
• o Lower risk of HIT

Benefits / limitations of Pfannenstiel incision

• Benefits:
  • 1. Cosmetics -> Follow Langer’s lines
  • 2. Postoperative pain
  • 3. Less fascial wound dehiscence
  • 4. Less incisional hernia
  • 5. Less adhesions
  • 6. Less atelectasis post-op
• Limitations:
  • 1. Limited exposure to upper abdomen
  • 2. Limited Lateral uterine / adnexal exposure
  • 3. Difficult to extend if more room required
  • 4. Poor visibility in obese patients

Advantages of direct trocar entry compared to Veress

• 1. Avoid complications of Veress
  
  • -failed pneumo
    
  • -preperitoneal insufflation
    
  • -intestinal insufflation
    
  • -CO2 embolism
    
• 2. 1 blind step as opposed to 3 (Veress, insufflation, trocar)
  
• 3. Faster

• ** no increased complication rates – is a safe alternative but is the least performed entry modality

Types of bladder injuries

• 1. Thermal
  
• 2. Laceration
  
• 3. Suturing

Types of bowel injuries

• 1. Monopolar cautery (injury 4-5cm beyond apparent site)
  
• 2. Bipolar cautery (visual injury reflects the extent of damage)
  
• 3. Puncture
  
• 4. Laceration
  
• 5. Crush
  
• 6. Devascularization/ischemic

Types of electrothermal injury

• 1. Direct application
  • -unintended activation of the electrosurgical probe
• 2. Insulation failure
  • -self-explanatory
• 3. Direct coupling
  • -electrosurgical unit is activated in close proximity to another metal instrument -> Current from active electrode flows through the adjacent instrument and damages adjacent structures not within the visual field that are in direct contact with the secondary instrument
• 4. Capacitive coupling
  • -electric current is transferred from one conductor (the active electrode) through intact insulation and into adjacent conductive materials without direct contact

Risk factors for fascial dehiscence

• 1. Surgical technique
  • – most important factor in preventing dehiscence
  • – MC cause – intact sutures pulling through the fascia
  • – bites 1cm lateral / 1.5cm apart
• 2. Suture
  • – delayed absorbable best (Maxon (polyglyconate), PDS (polydioxanone)
• 3. Type of incision
  • (midline > transverse)
• 4. Mechanical stress
  • – obesity
  • – ascites
  • – cough
  • – vomiting
• 5. impaired wound healing
  • – malnutrition
  • – steroids
  • – chemo / rads
  • – diabetes
  • – age
  • – malignancy
• 6. Local factors
  • – infection
  • – hematoma
  • – seroma

Fascial incision strength

• – 1 week – 10%
  
• – 2 weeks – 25%
  
• – 3 weeks – 30%
  
• – 4 weeks – 40%
• fascial dehiscences usually happen:
  • 2-12 days post-operatively

• ** suggests by 2 weeks fascia has gained enough strength to resist daily activities

Evisceration

• 1. inc. serosanguineous discharge from wound
  • patient describes tearing / popping
• 2.- open wound
  • – probe fascia
  • – IV antibotics – broad spectrum
  • – cover w/ moist sterile dressing
  • – OR – GA
• IN OR
  • – determine extent of dehiscence
  • – cultures
  • – irrigate
  • – run bowel
  • – close fascia
• How to close fascia
  • – retention sutures
  • – Smead-Jones mass closure technique (far-near, far, near)

Stages of wound healing

• 1. Hemostasis
  
• 2. Inflammation
  
  • – vascular
    
  • – cellular – PMN
    
• 3. Epithelialization
  
  • – complete ~24 hrs
    
• 4. Fibroplasia
  
  • – fibroblast migration
    
  • – collagen production
    
• 5. Contracture
  
  • – myofibroblasts
    
• 6. Remodelling
  
  • – replacement of disordered collagen fibrils w/ mature ordered fibrils

Types of wound healing

• 1. primary intention
  
• 2. secondary intention
  
• 3. tertiary intention (delayed primary closure)

Contraindications to Laparoscopy and Hysteroscopy

• 1. laparoscopy:
  
  • – hemodynamically unstable
    
  • – bowel obstruction / dilated loops
    
  • – severe cardiac/respiratory disease
    
  • – increased intra-cranial pressure
    
  • – uncorrected coagulopathy
    
  • – suspected abdominal compartment syndrome

• 2. Hysteroscopy:
  
  • – advanced cervical/endometrial cancer
    
  • – pregnancy
    
  • – active PID

Virchow’s triad

• Def:
  • – hypercoagulable state
  • – vascular injury / endothelial injury
  • – venous stasis
     

Levels of VTE risk in surgical patients

• Low risk (2% calf DVT/0.2% PE without prophylaxis):
  • -minor sx <40yo, no RFs
• Moderate risk (10-20%/1-2%):
  • -minor sx with RFs
  • -non-major sx 40-60yo, no RFs
  • -major sx <40yo, no RFs
• High risk (20-40%/2-4%):
  • -non-major sx >60yo with RF
  • -major sx >40 with RFs
  • -major sx with RFs
• Highest risk (40-80%/4-10%):
  • -major sx >40 with prior VTE/ca/hypercoag/trauma/SCI
• RFs:
  • -age
  • -obesity
  • -immobility
  • -trauma
  • -malignancy
  • -radical pelvic sx
  • -medical disease
  • -cardiac disease
  • -previous VTE
  • -severe varicose veins

Risk factors for post-operative wound infection

• 1. Patient
  • – obesity
  • – immunocompromised
  • – steroids use
  • – diabetes
  • – poor nutrition
  • – prolonged hospitalization
  • – BV
  • – systemic illness
  • – low SES
  • – smoking
• 2. Surgical
  • – wound class – gross infection, devitalized tissue, foreign body
  • – entry into GI/GU/Gyne tract esp. w/ spillage of GI contents
  • – long OR
  • – significant blood loss / poor hemostasis w/ hematoma
  • – seroma
  • – inadequate antibiotic prophylaxis
  • – radical surgery
  • – excessive cautery use
  • – pre-operative shaving

Warfarin reversal pre-op

• 1. Elective
  
  • – hold x 5 days

     

• 2. Semi-urgent (1-2d)
  
  • – hold
    
  • – low-dose Vitamin K
    
  • – INR 5-9 = 1-2mg PO
    
  • – INR > 9 = 5-10mg PO

     

• 3. Emergent (< 24hrs)
  
  • – hold
    
  • – high-dose vitamin K 2-10 mg IV
    
  • – Prothrombin complex concentrate OR fresh frozen plasma

Opioid conversion

• Codeine – 7x more than morphine
  
• Oxycodone – 0.7x more than morphine
  
• Hydromorphone – 0.2x more than morphine

• To convert:
  
• oral to IV/SC for narcotics = 0.5
  
• (i.e. 4mg PO morphine is 2mg IV morphine)