SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

SURGICAL INSTRUMENTS
SURGERY POSTING
8th BATCH 1st ROTATION

2013/2014

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

INSTRUMENTS
Topic discussion 1. Proctoscope 2. Nephrostomy tube 3. Incentive spirometry 4. Central venous line 5. Nasogastric tube 6. Chest tube 7. Foleys catheter (CBD) 8. Stoma 9. Surgical drain 10. Total parenteral nutrition (TPN) 11. Tracheostomy Page 3 4 5 7 8 12 16 20 24 26 28

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

PROCTOSCOPY
What the HELL is proctoscopy???
An examination of the rectum using a special metal or plastic scope called a proctoscope

Proctoscope
Two parts: proctoscope tube & obturator

What is it for???
1. Determine abnormalities of the anus or the lower part of the rectum such as haemorrhoids, a tear of the skin (fissure), inflammation or stricture 2. Evaluate abnormal results of a barium enema 3. Look for causes of rectal bleeding 4. Monitor growth of polyps (benign growths on the lining of the intestine) 5. Recurrent rectal cancer

How do I do it??
Ask the patient to remove clothing below the waist and lie on lateral side on a table Wear gloves on both sides of hands Clean the area around anus (eg. normal saline) Lubricate a gloved finger Gently insert a gloved finger into your anus to check for tenderness or blockage Lubricate the proctoscope then carefully insert it into the rectum Remove the obturator After finished the examination, remove the proctoscope without re-inserting the obturator Clean the area around the anus once again

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

NEPHROSTOMY TUBE

What is it??
A hollow plastic tube which is used to drain the kidney when there is an obstruction (stone/infection) or urine cannot pass freely down the ureters

Risks developing:
Hemorrhage Infection Pain Leakage of urine into abdomen

Be aware if:
Develop fever Urine draining from tube contains blood or becomes cloudy Severe pain Tube falls out Not draining urine

Bladder Irrigation
Help prevent urinary tract obstruction by flushing out small clots that form after prostate or bladder surgery Continuous flow of irrigating solution through the bladder also creates a mild tamponade that may help prevent venous haemorrhage Continuous irrigation can also be used to treat an irritated, inflamed or infected bladder lining.

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

INCENTIVE SPIROMETRY

Indication
Therapeutic Improve lung function eg. Thoracic/ upper abdominal surgery (prevent atelactasis), prolong bed rest, restrictive lung defect Optimize cough mechanism (help clear airway with mucus) eg. Pulmonary atelactasis Exercise lung muscle effective inspiration Diagnostic Baseline for early detection of acute pulmonary disease (postoperative evaluation)

Complications
Procedure related Poor technique hyperventilation, barotrauma Device related Infection

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

How to use??
Sit up straight Keep head & neck centrered over body Hold spirometer upright in both hands

Exhale

Place mouth on the mouthpiece (seal lips around it)

Inhale slowly, deeply

Try to raise the indicator to target measurement

Inhale as long as you can, then exhale normally

Record the highest level you can reach

Relax following each prolonged deep breath, take a moment to rest, and breathe normally. Then, repeat the exercise as directed by your physician. Be sure to clean the mouthpiece with water and shake it dry after each use.

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

CENTRAL VENOUS LINE

Indication
Therapeutic Placement Trans venous pacemaker Long term antibiotic/ parenteral nutrition/ pain medication administration Deliver high flow fluid/ blood product Performance haemodialysis/ plasmapheresis/ chemotherapy Diagnostic Central venous pressure measurement Repettitive venous cannulation Peripheral blood stem collection Frequent blood draw

Complications
Procedure related Hemo/ pneumothorax Hemorrhage Thrombosis Arrythmias Device related Displacement Infection

Approach
Internal jugular Subclavian

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

NASOGASTRIC TUBE

Same applied to adults

Defintion
Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, past the throat, and down into the stomach.

Indications
Diagnostic Evaluation of upper gastrointestinal (GI) bleed (ie, presence, volume) Aspiration of gastric fluid content Identification of the esophagus and stomach on a chest radiograph Administration of radiographic contrast to the GI tract Therapeutic Gastric decompression, including maintenance of a decompressed state afterendotracheal intubation, often via the oropharynx Relief of symptoms and bowel rest in the setting of small-bowel obstruction Aspiration of gastric content from recent ingestion of toxic material Administration of medication Feeding Bowel irrigation

Contraindications
Absolute contraindications Severe midface trauma Recent nasal surgery Relative contraindications Coagulation abnormality Esophageal varices or stricture Recent banding or cautery of esophageal varices Alkaline ingestion 8

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

Equipment
Nasogastric tube Adult - 16-18F Pediatric - In pediatric patients, the correct tube size varies with the patient's age. To find the correct size, add 16 to the patient's age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F) Viscous lidocaine 2% Oral analgesic spray (Benzocaine spray or other) Syringe, 10 mL Glass of water with a straw Water-based lubricant Toomey syringe, 60 mL Tape Emesis basin or plastic bag Wall suction, set to low intermittent suction Suction tubing and container

Techniques
Explain procedure, benefits, risks, complications, and alternatives (patient or relative) Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards, and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect

Measurement: measure the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube.
Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the nasogastric tube Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow. Continue to advance the nasogastric tube until the distance of the previously estimated length is reached. Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences respiratory distress, is unable to speak, has significant nasal hemorrhage, or if the tube meets significant resistance. Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL Toomey syringe or by aspirating gastric content. The authors recommend always obtaining a chest radiograph (as shown below) in order to verify correct placement, especially if the nasogastric tube is to be used for medication or food administration.

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014 Apply Benzoin or another skin preparation solution to the nose bridge. Tape the nasogastric tube to the nose to secure it in place as shown. If clinically indicated, attach the nasogastric tube to wall suction after verification of correct placement.

Pharyngeal discomfort Erosion of nares Sinusitis

General cx

Nasotracheal intubation
Gastritis Epistaxis Knotting & impaction Tube beyond pylorus Double backing & kinking Breakage

Complications

Tube enteral cx

Tracheobronchopleural cx Intravascular penetration NG tube syndrome

General complications: Pharyngeal discomfort: Nasopharyngeal discomfort is one of the major factors of NG tube rejection among patients. It is, therefore, necessary to explain the procedure, the likely discomfort and the rationale of the procedure to the patient. Usually, patient is reassured following this counseling. Erosion of nares: Erosion of the nares has been noted to be a serious hazard of NG tube insertion particularly when it is not properly lubricated. Sinusitis: Cases of sinusitis have been reported following passage of an NG tube. This may happen when the procedure is not aseptic. Nasotracheal intubation: Malpositioning of the NG tube into the trachea is a common complication of NG tube passage even among experienced medical practitioners.Therefore, it is necessary to verify its position before any medication or fluid is administered into the tube. Gastritis: Gastritis is a frequent complication of NG tube insertion. In this case, continue pressure and irritation of the stomach by the tip of the NG tube has been implicated. Frequent changing and alteration of the NG tube and the set up should be reduced so as to minimize incidence of gastritis in patients with NG tube in situ. Epistaxis: Epistaxis resulting from minor bruises during insertion is a common complication particularly in hypertensive and in patients with coagulopathy. Therefore, it is necessary to be gently and be more cautious in patients suspected to hypertensive or have abnormal coagulation. Tube enteral complications: 10

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014 -Tube knotting and impaction in the posterior nasopharynx: The NG tube could occasionally coil and get knotted within the esophagus. It may also accumulate in the posterior nasopharynx thereby causing obstruction to both airway and the esophagus. -Tube beyond the pylorus: The tube could be pushed beyond the pylorus in which case itbecomes counterproductive particularly if it was meant for gastric drainage. -Tube double backing and kinking: When this happens, the tube becomes block and stops functioning. -Tube rupture: There are reported cases of tube rupturing particularly during feeding when the pressure of the feeding syringe is high or is forcefully pushed. -Tube breakage: This may happen when an expired tube is wrongly inserted into a patient.

-Intracranial entry Following repair of choanal atresia and transnasal transphenoidal surgery Following maxillofacial trauma. -Tracheobronchopleural complications Bronchial placement: Bronchial placement may cause airway obstruction which may lead to atelectasis, pneumonia and lung abscess. -Bronchial perforation is often a deadly complication in this patient. -Pleural cavity penetration-Its quite rare but very serious complication of NG tube insertion. It may cause severe pneumothorax. -Isocalothorax (enteral feed hydrothorax) particularly when it was meant for feeding and the feeding was commenced without prior verification of its placement. -Empyema and sepsis is also a known fatal complication -Intravascular penetration Erosion into retroesophageal aberrant right subclavian artery has been reported in the past. -Nasogastric tube syndrome (NTS) is a rarely reported complication of NGT use that can cause lifethreatening laryngeal obstruction. The syndrome results from post-cricoid ulceration, which affects the posterior cricoarytenoid muscles, thus causing vocal cord abduction paralysis and upper airway obstruction.

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SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

CHEST TUBE Indications

General indication Absolute Indications Relative Indications Drainage of hemothorax, or large Pneumothorax (tension, open Rib fractures & Positive pressure pleural effusion of any cause or simple) ventilation Drainage of large pneumothorax Haemothorax Profound hypoxia / hypotension (greater than 25%) Traumatic Arrest (bilateral) & penetrating chest injury Prophylactic placement of chest Profound hypoxia / hypotension tubes in a patient with suspected and unilateral signs to a chest trauma before transport to hemithorax specialized trauma center Flail chest segment requiring ventilator support, severe pulmonary contusion with effusion NOTES: Chest tube placement may be diagnostic as well as therapeutic. After entering the pleural cavity a finger is inserted, and depending on the position of the tract one may feel the texture of the lung surface (for contusion), the surface of the diaphragm (for lacerations) and the heart (for the presence of tamponade). The nature of the material draining from the tube is also important. If it is blood, the chances of requiring a thoracotomy are much higher if the blood is bright red and arterial rather than the dark red of venous blood. Drainage of intestinal contents implies either an oesophageal injury or stomach / bowel injury with diaphragmatic tear. A persistent air leak implies an underlying lung laceration, and large leaks may indicate bronchial disruption.

Contraindications
1. Infection over insertion site 2. Uncontrolled bleeding diathesis

Materials
Chest tube with or without trocar; OR Fuhrman catheter Chest tube suction unit (PleurevacR or SaharaR), tubing, wall suction hookup Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver, scissors Packet of 0 or 1.0 silk suture on a curved needle Tape, gauze 2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration Sterile prep solution; mask, gown and gloves

Size of Chest Tube

Adult or Teen Male Adult or Teen Female Child Newborn 28-32 Fr 28 Fr 18 Fr 12-14 Fr 12

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

Preprocedure patient education

1. Obtain informed consent 2. Inform the patient of the possibility of major complications and their treatment 3. Explain the major steps of the procedure, and necessity for repeated chest radiographs

Procedure
NOTE: Conscious sedation during this procedure is an option for those patients who are clinically stable. Site The chest tube is placed (on the correct side) in the mid- or anterior- axillary line, behind pectoralis major (to avoidhaving to dissect through this thick muscle). On expiration, the diaphragm rises to the 5th rib at the level of the nipple, and thus chest drains should be placed above this level. Rib spaces are counted down from the 2nd rib at the sternomanubrial joint. Practically, the highest rib space that can be easily felt in the axilla (usually the 4th or 5th) is the most appropriate. Anaesthesia / Analgesia Chest tube insertion is a painful procedure, especially in muscular individuals. A combination of intravenous analgesia and local anaesthesia is used for the procedure. An intravenous opioids such as morphine is standard analgesia for trauma patients. It is best given in small aliquots titrated to effect, to avoid subsequent respiratory depression from overdose. An analgesic dose of ketamine (20mg adult) is a good alternative to opioids for chest tube insertion. For local anaesthesia, 10-20mls of local anaesthetic is required. This is infiltrated under the skin along the line of the incision. The needle is then directed perpendicular to the skin and local anaesthetic infiltrated through the layers of the chest wall down onto the rib below the actual intercostal space. Here local is injected around the periosteum of the rib. The needle is then angled above the rib and advanced slowly until air is aspirated. The last 5 mls or so of local anaesthetic is then injected into the pleural space. Procedure The steps in insertion of a chest drain are as follows: 1. The area is prepped and draped appropriately 2. An incision is made along the upper border of the rib below the intercostal space to be used. The drain track will be directed over the top of the lower rib to avoid the intercostal vessels lying below each rib. The incision should easily accommodate the operator's finger. 3. Using a curved clamp the track is developed by blunt dissection only. The clamp is inserted into muscle tissue and spread to split the fibres. The track is developed with the operator's finger. 4. Once the track comes onto the rib, the clamp is angled just over the rib anddissection continued until the pleural is entered. 5. A finger is inserted into the pleural cavity and the area explored for pleural adhesions. At this time the lung, diaphragm and heart may be felt, depending on position of the track. 6. A large-bore (32 or 36F) chest tube is mounted on the clamp and passed along the track into the pleural cavity. 7. The tube is connected to an underwater seal and sutured / secured in place. 8. If desired, a U-stitch is placed for subsequent drain removal (see below). 9. The chest is re-examined to confirm effect. 10. A chest X-ray is taken to confirm placement & position. 13

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014 Position For blunt trauma patients lying supine, drains should be placed anteriorly in the chest. These can prevent tension pneumothorax to develop if the chest tube is blocked by a dependent lung tissue. Normal movement of the lungs will allow drainage of a basal haemothorax through an anterior chest tube. For penetrating trauma where patients are not restricted to the supine position, haemothoraces may be more efficiently drained with a posterior, basally directed drain. The final resting place of the tube is determined in part by the direction of the track it follows through the chest wall. If a drain is to lie anteriorly in the chest, the track should be developed in a slightly anterior direction. If the track is directed posteriorly, the drain may fall back to lie in the oblique fissure, where it may become blocked with lung tissue. Chest tubes should be inserted so that the last hole of the drain is inside the thoracic cavity. However if passed too far into the chest, drains can cause severe intractable pain as Underwater Seal An underwater seal is used to allow air to escape through the drain but not to re-enter the thoracic cavity. The drainage bottle should always be kept below the level of the patient, otherwise its contents will siphon back into the chest cavity. Persistent bubbling of air through the water indicates an air leak from the lung. Chest tubes should NEVER be clamped for any reason, to avoid the development of a tension pneumothorax. The air outlet of the underwater seal may be connected to moderate suction (-20cm water) to assist in lung reexpansion. This is more important in the presence of an air leak. Removal Chest drains may be removed when they are no longer draining any fluid and any air leak has resolved. Removal is ideally performed with two people - one to remove the tube and one to occlude the drain site. The tube should be removed either at the end of expiration or at peak inspiration, to avoid further air being entrained into the pleural cavity. The area is cleaned and sterilised. An occlusive dressing is prepared and held ready. Any stay sutures are removed. With the patient holding his breath (out or in), the tube removed rapidly and the occlusive dressing applied. Some surgeons prefer to use a purse-string or U-suture to close the wound. This may be placed at the time of drain insertion. While there is no detriment in using a closing suture, they probably serve little purpose and the purse-string especially may produce an ugly scar.

Acute complications (technique)

Haemothorax, usually from laceration of intercostal vessel (may require thoracotomy) Lung laceration (pleural adhesions not broken down) Diaphragm / Abdominal cavity penetration (placed too low) Stomach / colon injury (diaphragmatic hernia not recognised) Tube placed subcutaneously (not in thoracic cavity) Tube placed too far (pain) Tube falls out (not secured)

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Late complications
Blocked tube (clot, lung) Retained haemothorax Empyema Pneumothorax after removal (poor technique)

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SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

FOLEYS CATHETER (CBD) Introduction

A Foley catheter is an indwelling urinary catheter use for continuous bladder drainage (CBD) Definition: A hollow, Flexible tubes (latex) that are passed thru the urethra during urinary catheterization & into the bladder to drain urine They are retained by means of a balloon at the tip which is inflated with sterile water Balloon has different sizes: 5cc 30 cc The foleys catheter size : using French units (F) Range: 10 F 28 F (tp dr syaz ckp pling kecil: 6F ; pling besar: 24F) 1F = 0.33mm in diameter (internal) Types of Foleys catheter 2 way catherter 3 way catheter used primarily after bladder, prostate cancer or prostate surgery Has 2 or 3 openings 1st opening: urine output 2nd opening: ballon dilatation(use water for injection to inflate the balloon, dont use NS as it can pass thru the latex. Has small plastic valve that allow the water goes in or out thru small channel to inflate or deflate the retaining balloon. 3rd opening(if present): Drip They have 3rd arm or bell: Allows irrigant to pass to the tip of catheter thru a small separate channel into bladder. Serves to wash away blood and small clots thru the Primary arm that drain into collection devices. Prevent the larger clot which might plug the catherter from forming.

Indication

Diagnostic or therapeutic drainage!!! Perioperative monitoring of urinary output Acute and chronic urinary retention - urinary hesitancy, straining to urinate, decrease in size and force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying Obstruction of the urethra by an anatomical condition that makes it difficult for one to urinate: prostate hypertrophy, prostate cancer, or narrowing of the urethra Aid to abdominal or pelvic surgery Incontinence Nerve-related bladder dysfunction, such as after spinal trauma (A catheter can be inserted regularly to assist with urination. Surgical intervention involving the the bladder and prostate. To ripen the cervix to allow induction of labour Can be used in cholecystectomy it can be left in side Gall bladder and inflate the balloon to drain the GB.

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Contraindication
Urethral injury Urethral stricture or obstruction Acute cystitis, urethritis, pyelonephritis, and epididiymitis, unless obstruction is the predisposing cause of infection

Complication
Early complication Urinary tract or kidney infection Urethral injury Hematuria Urethral or bladder spasm Paraphimosis Late complication Blood infection (sepsis) Urethral stricture Bladder stone Skin breakdown Bladder cancer (many years)

Equipment & Supplies Required Foley catheter of the appropriate size, material, and contour (different catheters are discussed below) Urinary drainage bag and connecting tube Sterile lubricant (Xylocaine Jelly) Antiseptic solution (Betadine Solution) and sterile cotton balls to sterilize the male urethral meatus and the female perineum Sterile disposable syringe, 10-mL, filled with enough sterile water to inflate the balloon on the catheter The size of the balloon is usually printed on the catheter (10 mL) Sterile gloves and drapes

Types of catheters used in the emergency

- retaining catheters, most commonly used is the Foleys catheter. -way Foleys -way Foleys (for bladder irrigation) indwelling

Size of the catheter

Adult: 16F Children: 8F or 10F 1 French (F) indicates the circumference of the catheter being 1 mm.

Selecting a Catheter
1. The Foley catheter is used in almost all cases when an indwelling urinary catheter is required. It consists of a double-lumen rubber tube with a terminal retaining balloon. The larger channel is for drainage of urine, and the smaller is for inflation of the balloon. Some indwelling catheters have a third lumen, for constant bladder irrigation. Foley catheters are of standard length (46 cm [18 in]) but come in varying diameters that are numerically graded (French system), with the larger number indicating a larger diameter. 10-mL balloons for routine catheterizations and 30-mL balloons for special situations. Most Foley catheters are made of rubber. Teflon or Silastic is sometimes used for long-term, indwelling catheters. 2. For routine, short-term catheterization in males or females, a 14F or 18F rubber catheter with a 10-mL balloon is satisfactory. Smaller sizes are required for children. 3. Men with prostatic hypertrophy may require larger catheters (eg, 20-22F). 17

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Positioning of the Patient

Females
The patient should be in the lithotomy position. If she is comatose or under anesthesia, flex her knees and hips, and allow the legs to abduct. If the soles of the feet are pressed together, this position can easily be held by the patient without assistance.

Males
The patient should be supine.

Procedure
Catheterization of Females 1. Assemble all necessary equipment 2. Open the catheter/dressing tray and selected catheter, and position them on a sterile field placed on a bedside table or stand so that all required materials are readily accessible. 3. Place a generous amount of lubricant on the sterile field. 4. Put on sterile gloves, and drape the perineal area. 5. Make sure that the catheter is open and the lubricating jelly is accessible. 6. Pour the antiseptic solution in provided tray, and moisten the cotton swabs with antiseptic solution. 7. Be sure that the syringe is filled with enough sterile water to inflate the balloon being used. 8. Using the left hand (standing on the patients right side), spread the labia and identify the superior fornix with the clitoris at the apex. Thoroughly cleanse the entire area with 4-5 swabs soaked in antiseptic. Clean the labia with front to back strokes with 2 successive swabs; then cleanse the urethral meatus with another 2 successive swabs. 9. The left hand continues to hold the labia spread apart from the rest of the procedure. 10. Make a loop in the Foley catheter for easier handling. Grasp the catheter with the right hand, coat the tip and proximal portion with lubricating jelly, and insert the catheter into the urethral meatus, which lies just below the clitoris. Advance the catheter until urine returns. Then advance it 4-5 cm (15/8-2 in) farther to make sure that the balloon is well within the bladder (Female urethra is 3.8 cm long). 11. Inflate the balloon with the appropriate amount of sterile water (usually10 mL; the balloon volume is usually printed on the catheter), and withdraw the catheter gently until the balloon is pulled snugly against the trigone. 12. Collect a small amount of urine in a sterile container for appropriate studies (urinalysis should be obtained routinely), and then connect the catheter to the urinary drainage bag. 13. Tape the Foley catheter and the urinary drainage tube to the upper thigh, leaving enough slack so that abduction of the legs will not put tension on the catheter. Note: The most common mistake in catheterization of the female bladder is to miss the urethral meatus and inadvertently slip the catheter into the vagina. No urine will return. Leave the catheter in place in the vagina as a marker. Obtain a new, sterile catheter, and try again. Remove the other catheter.

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SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014 Catheterization of Males 1. Steps 1-7 are the same as those described under Catheterization of Females, above. 2. Using the left hand (standing on the patients right side), grasp the penis so that the shaft lies in the palm and the glans of the penis is free but secure. The penis should be held at a right angle to the abdomen. The left hand should remain in this position for the remainder of the procedure; it is no longer sterile. 3. Sterilize the glans and urethral meatus with 34 swabs dipped in antiseptic solution. 4. Put a single loop in the Foley catheter for easier handling, grasp the catheter in the right hand, and coat the tip of the catheter with lubricating jelly. It is often helpful to place some on the meatus as well. You can do it with the appropriated nozzle fitted in the tube of the jelly. Put the sterile tip of the nozzle inside the meatus and squeeze the tube, so the jelly enters into the urethra. 5. Insert the catheter into the urethral meatus, and advance it down the penile urethra to the base of the penis with successive, steady movements. 6. Advance the catheter through the membranous and prostatic urethra into the bladder. 7. Advance the catheter to the hilt (even if urine is obtained earlier) to ensure that the balloon is not inflated in the urethra. As soon as the catheter has been advanced to the hilt, release the penis to free both hands for inflation of the balloon. 8. Inflate the balloon with the proper amount of sterile water for its size (usually 10 mL), and withdraw the catheter until the balloon is pulled snugly against the trigone. 9. Obtain a specimen for appropriate tests (at a minimum, routine urinalysis should be performed). Connect the urinary drainage system bag to the catheter, and tape the catheter to the upper thigh, leaving sufficient slack so that movement of the leg will not pull on the catheter.

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STOMA
Examination & how to comment 1) Site (Which quadrant the stoma located) 2) Type of stoma - End stoma - Loop - Double barrel stoma 3) Surrounding skin - Excoriation - Fungal infection - Redness 4) Covering of surrounding skin (paint, lotion, cream) 5) Loop - Retracted - Parastomal hernia (conceal vs. reveal) - Stenosis 6) Stoma functioning or not, then comment on the discharge 7) Stoma discharge Color (bilious, red, clear) Type (mucous, blood, pus, feces) Amount (copious, moderate, no amount) 8) Open up the stoma bag and examine Comment

1. 2. 3. 4. 5. 6.

I think this is end/ double barrel / loop stoma Located at right iliac fossa/ left iliac fossa/ epigastric region. It is most likely Ileostomy/ colostomy/ gastrostomy. It is well/ not functioning. There are feces/ bilious/ clear fluid discharge with copious/ moderate/ no amount. The surrounding skin is excoriated/ inflamed/ suggestive of fungal infection / not inflamed. 7. The loop is retracted/ with presence of Parastomal hernia/ stenosed.
Common questions 1) What is stoma 2) What are the functions of the stoma? 3) How to know whether stoma is functioning or not? 4) When to remove the stoma 5) Complication of stoma 6) Ileostomy vs. colostomy. How to differentiate?

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Answer
Stoma definition (1)
Literally means mouth or opening Being described as artificial external opening in lumenated organ

Indication/Function (2)
Feeding purposes (gastrostomy or jejunostomy) Bypass the surgical site like distal end of bowel (ileostomy to bypass large bowel, colostomy to bypass anus,urostomy bypass the bladder)

How to know whether stoma is functioning or not? (3)

By looking at whether there is a discharge or not and the amount of discharge.

When to remove the stoma??(4)

Stoma may be removed after the distal end (site of surgery) healed. It could be as early as 2 months.

Colostomy diarrhea, constipation Superficial infection

Skin irritation
Prolapse

Retraction

Complications
Electrolyte imbalance

(5)

Necrosis

Fistulation Bleeding Para-stomal hernia

Stenosis

Apart from that, patient may be affected psychologically with the appearance of the stoma and phantom rectum (urge to defecate)

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Ileostomy vs colostomy (6)

Site Spout Discharge Surrounding Color Ileostomy Right sided (RIF) Present Watery Excoriation, inflamed Dark pink/ red Colostomy Anywhere but more common in left side Flush Solid (feces) Nil Light pink

Stoma care (7)

Referral to stoma nurse and support group Avoid fizzy drink before and during air travel and use stoma with gas filter as change in pressure in the aircraft can cause lot of wind to be passed. Take extra fluid and salt intake for patient with ileostomy Explain regarding various types of stoma bag and seals. Care for the surrounding skin. Wipe with warm water to prevent inflammation, excoriation.

Colostomy

Ileostomy

Loop ileostomy

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Ileostomy with stoma bag at right lower quadrant region. Notice the fluid discharge.

Mix stoma (Vesicostomy and colostomy)

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SURGICAL DRAIN Definiton : conduit which facilitate movement from one compartment to another Indication
To help eliminae dead space To evacuate existing accumulation of fluid or gas ( to remove pus, blood, serous exudates, chyle, bile) To prevent potential acculumulation of fluid/gas To form a controlled fistula, eg: after common bile duct exploration

Drains
Interno-external

Interno-internal from internal compartment to internal compartment

from internal copartment to external compartment

Open system
-Drain fluid collects in gauze pad or stoma bag -They increase the risk of infection

Closed system
-Consist of tubes draining into a bag or bottle -The risk of infection is reduced

Example : -VP shunt -Double J stent, pigtail (ureteric stent)

Example : -Saucerization (carbuncle) -Corrugated drain (perianal abcess) -Penrose drain

Passive
-No suction -Drain by means of pressure differentials, overflow, and gravity between body cavities and the exterior Active -Maintained under suction

Example : -Foleys catheter -Peritoneal drainage -T-tube (drain common bile duct -Nephrostomy tube -NG tube -Chest tube -EVD ?

Example : -J-vac , Redivac drain (post mastectomy, thyroidectomy) -Jackson-Pratt Drain/Bulb drain

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Material

Silastic or rubber Silastic drains are relatively inert and induce minimal tissue reaction Red rubber drains can induce an intense tissue reaction, sometimes allowing a tract to form (this may be considered useful - for example, with biliary T-tubes)

Complication (actually it depends on the types of the drains, this is just in general)
Early ection

Late

Accumulation of fluid is) REMEMBER, all these points must be included during short case presentation of any surgical drain: System (open/closed) Active/passive Compartment (int-ext/int-int) What it drains (hemoserous/blood/ purulent/bile) Volume of drainage What is likely material Others : dressing, any suture to the skin for anchoring

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SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

TOTAL PARENTERAL NUTRITION Definition

TPN refers to the IV administration of nutrients to a patient when oral or enteral feeding is either inadequate or impossible. Given the risks of various metabolic and mechanical complications, parenteral feeding should only be prescribed when absolutely necessary (Ong et al. 2000). Oral or enteral feeding should be restored as soon as possible to prevent mucosal atrophy of the digestive tract. Given via central line (subclavian or internal jugular vein) as the risk of thrombophlebitis is high if infused peripherally (due to high osmolality of TPN)

Indications
Failure of bowel absorption, e.g.: radiation damage, severe acute enteritis, malabsorption syndromes Failure of adequate length of bowel for absorption, e.g.: short bowel syndrome due to Chrons disease or after massive intestinal resection GIT no accessible for enteral route, e.g.: acute severe pancreatitis, oesophagogastric surgery or when tube feeding is no possible Failure of enteral feeding to meet nutritional targets

Contents
Carbohydrates
Provide calories to the body. They supply most of the energy or fuel the body needs to run The main energy source in TPN is dextrose (sugar)

Protein

Amino acids = building blocks of life The body uses protein to build muscle, repair tissue, fight infections and carry nutrients through the body

Fat or Lipids

Are another source of calories and energy Fat also helps carry vitamins in the blood stream Fat supports and protects some of your organs and insulates your body against heat loss. Fat is white in color.

Vitamins

Added to the TPN provide the needed daily amounts of vitamins A, B, C, D, E and K It is the vitamins that are added to the TPN mixture that turns it yellow The body also needs minerals (zinc, copper, chromium, manganese and selenium) The vitamins and minerals in the TPN are needed for the bodys growth and good health 26

SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

Electrolytes

Are important for bone, nerve, organ and muscle function Electrolytes, such as calcium, potassium, phosphorus, magnesium, sodium, chloride and acetate, are also added to the TPN mixture.

Water

Is a vital part of TPN It prevents patients from becoming dehydrated (too little fluid) The amount of water in the TPN is based on your childs height and weight.

Contraindication
Absolute Enteral nutrition possible with nutritional targets possibly met Severe shock Absence of central venous access Relative Electrolyte or fluid intolerance Incompatibility of TPN and IV drugs

Complications
Complications related to the central venous catheter o Immediate damage to nearby structures, bleeding, air embolism o Late sepsis, thromboembolism, AV fistula formation Late complications: sepsis, dislodgement, erosion, DVT, occlusion Metabolic complications: glucose, K, Na Ca PO, Zn, Mg, folate Fluid overload

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SURGERY POSTING 1st ROTATION 8th BATCH 2013/2014

TRACHEOSTOMY Indications
Congenital anomaly (eg, laryngeal hypoplasia, vascular web) Foreign body that cannot be dislodged with Heimlich and basic cardiac life support maneuvers Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord paralysis) Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or great vessels Subcutaneous emphysema Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the mid face and mandible) Edema from trauma, burns, infection, or anaphylaxis Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period) Severe sleep apnea not amendable to continuous positive airway pressure devices or other less invasive surgery

Contraindications
Strong relative contraindication: Blockage due to laryngeal carcinoma Traumatic injury at the lower external larynx *no absolute contraindication

Complications
Immediate Apnea Bleeding Pneumothorax, pneumomediastinum Injury to adjacent structures Post-obstructive pulmonary edema Early Bleeding Plugging with mucus Tracheitis Cellulitis Displacement Subcutaneous emphysema Atelectasis Late Bleeding Tracheomalacia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring

http://www.tracheostomy.com/resources/articles/tracheostomy/index.htm

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