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PERIOPERATIVE PROCEDURES

A GUIDE TO

WESTERN HEALTH

A GUIDE TO PERIOPERATIVE PROCEDURES

EDITION 1

WESTERN Health has used its best endeavours to ensure that the information contained in this guide is correct and current at the time of publication, but takes no responsibility for any error, omission or defect therein. Changes in circumstance after publication may impact on the information contained herein, and the reader is reminded to consider the information in the context of current practice.

Edition 1

First Published Compiled by Vicki McGowan

September 2007

Acknowledgments

This document has been adapted from an information manual entitled "Information for RMO's who need to obtain Informed Consent" produced by The Royal Brisbane Hospital in Queensland. The Royal Brisbane Hospital has endorsed Western Health to utilise this manual. Each of the specialty sections have been reviewed by the following medical staff Informed Consent: Breast Surgery: Colorectal Surgery: Endocrine Surgery: ENT Surgery: General Surgery: Hepatobiliary Surgery: Maxillo-facial Surgery: Neurosurgery: Orthopaedic Surgery: Dr Mark Adams Mr Trevor Jones Mr Stephen McLaughlin Mr Trevor Jones Dr Adnan Safdar Dr Hudaifa Ismail Mr Stephen McLaughlin Professor Stephen Chan Mr Graham Thompson Not Revised RBH 1998 Mr Bhadu Kavar Dr Hudaifa Ismail Mr Chris Haw Dr Rohan Price Dr Vicky Kim Mr Mark Baldwin Dr Dean Trotter Dr Vicky Kim Dr Tien Koo Professor Stephen Chan Mr Douglas Travis Mr Barry Beiles Vicki McGowan Coordinator Continuing Education Nursing & MidwiferyWestern Hospital

Plastic Surgery:

Thoracic Surgery: Upper GI Urology Surgery: Vascular Surgery:

Project Coordinator:

Contents

INFORMED CONSENT ..................................................................................................... 9 Informed Consent .......................................................................................................... 10 Risks and Benefits .......................................................................................................... 11 How do I communicate these risks? ................................................................................ 11 ANAESTHETIC RISKS .................................................................................................... 13 Anaesthetic risks ............................................................................................................ 14 BREAST SURGERY ......................................................................................................... 17 Breast Biopsy (± wire localisation) .................................................................................. 18 Breast Wide Local Excision (± wire localisation) ............................................................ 18 Breast Wide Local Excision and Axillary Dissection....................................................... 18 Mastectomy ................................................................................................................... 19 COLORECTAL SURGERY .............................................................................................. 21 Large Bowel Resection/Anastomosis ............................................................................. 22 Anterior Resection ......................................................................................................... 24 Abdominoperineal Excision of the Rectum..................................................................... 25 Small Bowel Resection and Anastomosis........................................................................ 25 Drainage of Perianal Abscess.......................................................................................... 26 Laying Open Fistulo-in-ano............................................................................................ 27 Haemorrhoidectomy ...................................................................................................... 27 ENDOCRINE SURGERY................................................................................................. 29 Adrenalectomy............................................................................................................... 30 Parathyroidectomy......................................................................................................... 31 Thyroidectomy............................................................................................................... 31 ENT SURGERY ................................................................................................................ 33 Myringoplasty/Tympanoplasty/Canalplasty .................................................................. 34 Stapedectomy................................................................................................................. 34 Modified Radical Mastoidectomy................................................................................... 35 Parotidectomy................................................................................................................ 36 Functional Endoscopic Sinus Surgery (FESS) ................................................................. 37 Rhinoplasty.................................................................................................................... 38 Septoplasty/Turbinectomy ............................................................................................. 38 Tonsillectomy/Adenoidectomy ...................................................................................... 39 Excision of Pharyngeal Pouch ........................................................................................ 40 Neck Dissection ............................................................................................................. 41 Laryngectomy/Pharyngolaryngectomy........................................................................... 42 Panendoscopy/Microlaryngoscopy ................................................................................ 43 GENERAL SURGERY ..................................................................................................... 45 Open Surgery ................................................................................................................. 46 Laparoscopic Surgery ..................................................................................................... 46 Appendicectomy ............................................................................................................ 47 Block Dissection of Groin .............................................................................................. 48 Block Dissection of Axilla .............................................................................................. 49 Excision of Pilonidal Sinus ............................................................................................. 49 Epigastric Hernia Repair ................................................................................................ 50 Femoral Hernia Repair................................................................................................... 50 Incisional Hernia Repair................................................................................................. 51

Inguinal Hernia Repair................................................................................................... 51 Umbilical Hernia Repair ................................................................................................ 52 Splenectomy .................................................................................................................. 53 HEPATOBILIARY SURGERY ......................................................................................... 55 Cholecystectomy............................................................................................................ 56 Whipples Procedure (Pancreaticoduodenectomy) ........................................................... 57 Distal Pancreatectomy.................................................................................................... 58 Endoscopic Retrograde Cholangio Pancreatography (ERCP) .......................................... 58 MAXILLO-FACIAL SURGERY....................................................................................... 61 Dentoalveolar Surgery.................................................................................................... 62 Dental Clearance and Local Flap Repair Prior to Head and Neck Radiotherapy ............. 62 Tempora-Mandibular Joint Surgery ................................................................................ 63 Arthroscopy/Arthrocentesis and Lavarge ....................................................................... 63 Closure of Oro-Antral Fistula (OAF) .............................................................................. 63 Caldwell Luc Procedure ................................................................................................. 64 Mandibular/Maxillary Fractures .................................................................................... 64 Orthognathic Surgery ..................................................................................................... 65 Maxillary Osteotomy ..................................................................................................... 65 NEUROSURGERY ........................................................................................................... 67 Cerebral Aneurysms....................................................................................................... 68 Cerebral Angiogram....................................................................................................... 69 Craniotomy/Stereotactic/Head Trauma/SDH ............................................................... 70 Myelogram .................................................................................................................... 70 Cervical Discectomy ­ Anterior or Posterior Approach................................................... 71 Pituitary Tumour ­ Excision Transsphenoidal Approach ................................................ 71 Lumbar Spine Surgery.................................................................................................... 72 ORTHOPAEDIC PROCEDURES..................................................................................... 77 Total Hip Replacement .................................................................................................. 78 Total Knee Replacement ................................................................................................ 79 Knee Arthroscopy .......................................................................................................... 80 Anterior Cruciate Ligament Reconstruction.................................................................... 80 High Tibial Osteotomy................................................................................................... 81 Correction of Bunion...................................................................................................... 81 Removal of Intramedullary Metal or Diastasis Screw...................................................... 82 Arthrodesis .................................................................................................................... 83 Open Reduction and Internal Fixation ­ Femur (Fractured Neck of Femur).................... 83 Open Reduction and Internal Fixation ­ Femur (Femoral Shaft Fracture ­ Intramedullary Nail).................................................................................................. 84 Open Reduction and Internal Fixation ­ Tibia (Tibial Plateau Fracture).......................... 84 Open Reduction and Internal Fixation ­ Tibia (Fracture of Shaft of Tibia ­ Intramedullary Nail).................................................................................................. 85 Open Reduction and Internal Fixation ­ Ankle Fractures................................................ 85 Shoulder Arthroscopy .................................................................................................... 86 Open Reduction and Internal Fixation ­ Fractures of Proximal Humerus........................ 87 Hemiarthroplasty of Shoulder......................................................................................... 87 Fractures of Humeral Shafts ........................................................................................... 89 Open Reduction and Internal Fixation ­ Supracondylar Fracture of Humerus................. 89 Fractures of Olecranon ­ Tension Band Wiring .............................................................. 90 Displaced Fractures of the Radial Head .......................................................................... 90

Fractures of Radial and Ulnar Shafts .............................................................................. 91 General Anaesthetic Manipulation Procedure (GAMP) and K-wire of Distal Radial and Ulnar Fractures................................................................................................... 91 Open Reduction and Internal Fixation ­ Fracture Waist of Scaphoid .............................. 92 Manipulation under Anaesthesia .................................................................................... 92 Intra-articular Injection of Anaesthetic/Steroid............................................................... 92 Cervical Discectomy and Fusion .................................................................................... 93 Laminectomy................................................................................................................. 94 Lumbar/Thoracolumbar Instrumented Fusion ............................................................... 94 Myelogram .................................................................................................................... 95 PLASTIC SURGERY ........................................................................................................ 97 Excision of Lesion with Primary Local Closure .............................................................. 98 Keystone Design Perforator Island Flap.......................................................................... 98 Split Skin Grafting.......................................................................................................... 99 Breast Reduction Mammoplasty (Hall Findlay Technique) ........................................... 100 Removal of Breast Prostheses ....................................................................................... 101 Carpal Tunnel Release ................................................................................................. 102 Excision of Ganglion.................................................................................................... 103 Open Reduction and Internal Fixation ­ Metacarpal Shaft Fractures............................. 103 Dupuytren's Fasciectomy ............................................................................................. 104 Trigger Finger Release.................................................................................................. 105 Open Extensor Tendon Repair (Mallet Finger) ............................................................. 106 Finger Tip Reconstruction ­ Local Neurovascular Island Flap and Full-Thickness Skin Graft................................................................................................................ 106 General Anaesthetic Manipulation Procedure ­ Nose Fracture ..................................... 107 THORACIC SURGERY.................................................................................................. 109 Video Assisted Thoracic Surgery .................................................................................. 110 Lobectomy................................................................................................................... 110 Intercostal Chest Tube Insertion ................................................................................... 111 Mediastinoscopy .......................................................................................................... 112 UPPER GI SURGERY .................................................................................................... 113 Fundoplication............................................................................................................. 114 Partial Gastrectomy ­ Gastroduodenal Anastomosis (Bilroth 1 type)............................. 114 Partial Gastrectomy ­ Gastrojejunal Anastomosis (Bilroth 11 or Polya type) ................. 116 Total Gastrectomy ....................................................................................................... 117 Oesophagectomy.......................................................................................................... 118 UROLOGY...................................................................................................................... 121 Cystoscopy/Cystourethroscopy/Transurethral Resection of Bladder Tumours (TURBT)................................................................................................................. 122 Prostatic Surgery .......................................................................................................... 122 Nephrectomy ............................................................................................................... 123 Orchidectomy .............................................................................................................. 124 Hydrocelectomy........................................................................................................... 124 VASCULAR PROCEDURES .......................................................................................... 125 Repair of AAA............................................................................................................. 126 Femoro-popliteal Bypass .............................................................................................. 126 Carotid Endarterectomy ............................................................................................... 127 Arteriovenous Fistula ................................................................................................... 128 Varicose Veins ............................................................................................................. 129

Informed Consent

INFORMED CONSENT

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Informed Consent

Informed Consent

What is `Informed Consent'? Informed consent is an interactive process between the doctor providing the treatment or performing the proposed procedure or research (or their delegate), and a patient, culminating in a signed consent form. The patient's signature on the consent form does not in itself constitute informed consent, but rather is a record, for institutional and legal purposes, that some form of consent process has taken place If an individual has been delegated the task of obtaining informed consent, it is conditional that the individual make themselves aware of the nature, consequences and risks associated with the particular procedure. In medicine and research, the rights of the individual have been increasingly acknowledged over the last few decades. In medicine assent, the agreement of a patient to have a treatment, a procedure or to participate in research, has changed to informed consent, an autonomous authorisation by a patient to have a treatment, a procedure or to participate in research. The key elements of informed consent include a discussion about: · the nature of the treatment or procedure; · what the reasonable alternatives are, including non-treatment; · the relevant risks and benefits associated with each alternative; (see later in text) · an assessment of the patient's understanding; · an acceptance of the treatment/procedure by the patient. In order for it to be valid, the patient must be considered competent to make the decision and offer the consent voluntarily. Assessment of competency can be complex especially in relation to age, chronic or acute medical conditions or in the presence of drugs or other substances. There is legislation governing who can consent when the patient is unable or deemed `incompetent' and in relation to guardianship. The Ethical Principles that form the foundations of healthcare ethics are equally important in the area of consent. These are: · Autonomy: encompasses a person's unique set of goals, values, desires and experiences and is the right to self-determination. Autonomy recognises the rights of patients to make decisions for themselves. For example, you may believe that a person will benefit from a blood transfusion, but a Jehovah's Witness patient has a deeply held religious objection to the use of blood products and has the right to refuse the recommended transfusion, even where the refusal may result in injury or death. Doctors also have their own unique set of values, and have the right for these to be respected. But where these may compromise a patient's care, referral to another health professional is appropriate · Non-maleficence: implies the duty not to harm patients, either by acts of commission or omission. As most treatments have the potential to cause harm, this principle involves consideration of the risk of harm over the expected benefits, from a particular treatment or procedure · Beneficence: is the duty to pursue what is in the patient's best interests · Justice: in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due". It incorporates the notions that equals should be treated equally and that there is fair distribution and access to health resources.

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Informed Consent

A vital component of the informed consent process is that of Communication. Effective communication requires that the patient understands the nature of the treatment and it's alternatives and the associated risks and benefits. The barriers to effective communication are many: · Language: here in Melbourne we have a significant population who have little or no English or speak English as their second language · The literacy levels are variable. According to OECD (2000) Literacy in the Information Age 17% of Australians have a literacy of level 1 with the highest being level 4/5, with level 3 considered the minimum for a modern society. (Contrast this with Sweden with 6%, USA 24% at level 1) · Highest level of Education achieved can also have an influence on people's understanding. The latest Census figures give us very specific figures about our population's demographics. http://www.abs.gov.au · Medical language is complex so the use of terms and expressions that we understand as health professionals may not be understood in the say way by our non-medical patients. · The ways in which we communicate Risk (see below) Therefore when we are engaging in the Informed Consent Process, we need to focus on ensuring that our patients understand what we are discussing with them and that in some cases we may need to use appropriate interpreters and even written information to have effective communication.

Risks and Benefits

Within Informed Consent, one of the most complex areas is, what risks do I communicate to the patient and their family and how do I express this risk. It has become clear that we have a duty to inform patients about the risks involved with a procedure or treatment and the benchmark is what risks would a reasonable person in the position of the patient consider significant, or what risks would a reasonable doctor, knowing the circumstances for this patient, consider significant. " Known risks should be disclosed when an adverse outcome is common even though the detriment is slight, or when an adverse outcome is severe even though its occurrence is rare." Australian National Health and Medical Research Council (NHMRC) General Guidelines for http://www.nhmrc.gov.au/publications/synopses/_files/e57.pdf So we should discuss the common surgical or anaesthetic risks: bleeding, infection, pain etc but also include a mention of those rare but serious outcomes such as death, paralysis, blindness etc placing these risks in context, plus anything that the patient may raise as significant to them.

Medical Practitioners on Providing Information to Patient

How do I communicate these risks?

The risks need to be expressed not in a generic way, but must take into account those factors that are pertinent to the individual patient we are consenting such as whether they are an emergency or an elective case; their age; their co-morbidities as well as the nature of the procedure/treatment. So for two patients, one 17 and the other 70, having laparotomies, some

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Informed Consent

risks will be the same while others such as post-op confusion or cardio-respiratory events will be different. I would commend you to read: Risk, language and dialect by K C Calman and G Royston, published BMJ Vol 315, October 1997: 939 ­ 42. In this paper the language of communicating risks is explored looking at the use of probability (1 in 10 000); or a Logarithmic risk scale, similar to that used with earthquakes; visual or distance analogue scales; or relating it to a community scale (this event is likely to happen to one person in your village or to one person in this city of 4 million). I find the use of probabilities unhelpful when explaining risk to patients. Quoting a phonebook number at them for a risk (your chance of going blind is 1 in 50 000) doesn't convey any useful information to the patient unless we offer them another probability, which they may have a perspective on. So relating a particular risk to say dying in a road accident in a vehicle is a more useful way of representing this probability (you are 500 times more likely to die in motor vehicle accident than go blind with this operation.) However sometimes finding and verifying these relative risk comparisons can be difficult. Using language such as very common, common, rare or extremely remote may convey more to patients than probabilities. The other aspect that needs to be kept in mind is that at an individual patient level, these risks either occur or don't occur. If we do 25 carotid endarterectomies this month with the probability of operative and late stroke for this patient group being 4% then we could expect one patient to suffer a stroke and 24 patients not to. So for one patient the incidence of stroke was 100%, the remainder 0%! Lastly, Financial Consent should be sort, where there will be direct financial costs to the patient.

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Anaesthetic Risks

ANAESTHETIC RISKS

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Anaesthetic Risks

Anaesthetic risks

The Australian and New Zealand College of Anaesthetists publish a large number of professional documents covering training, education and standards. Included is `Guidelines on Consent for Anaesthesia or Sedation' PS26 (2005) http://www.anzca.edu.au/infocentres/pdfdocs/PS26_2005.PDF In some hospitals, Anaesthetists have moved to have a separate signed consent form in relation to the provision of anaesthetic services, separate from the surgical consent. Most hospitals, however, continue with a single signed consent form with the provision of information about the Anaesthetic coming from multiple sources: · the patient having had a previous anaesthetic; · the patient obtaining information from family, friends, media or the internet; · written information provided by the institution; · through information provided when obtaining the signed consent form; · a face-to-face meeting with an anaesthetist as part of a Pre-Anaesthetic Consultation; · direct contact with the Anaesthetist providing the anaesthetic service There are four broad factors that influence the risks associated with an anaesthetic: the patient's age, their co-morbidities and limitations, whether it is an elective or an emergency case and the type of anaesthetic to be provided, such that the use of local anaesthetic only is safer than other forms of anaesthetic such as regional anaesthesia and general anaesthesia. Some of this information can be summarised by using the ASA Physical Status Classification System: 1 2 3 4 5 6 purposes A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor

With the addition of an E denoting an Emergency case Example: patient with stable asthma having an appendicectomy: ASA 2E In a general sense, with increasing ASA rating, and when the case is an emergency, there is an anticipated increase in both morbidity and mortality. What are the risks associated with Anaesthesia? For a detailed review see: Consent and Anaesthetic Risk; Jenkins and Baker, Anaesthesia, 2003, 58: 962 ­84 It is generally recognised that with the advances in our understanding of pharmacology and physiology; the improvements in patient safety and training and the advances in monitoring techniques, that the provision of anaesthetic services is considered to be very safe, with Anaesthetic related mortality being rare.

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Anaesthetic Risks

The risks associated with Anaesthesia are related to the type of anaesthetic provided and any specific interventions used such as regional, spinal or epidural anaesthetics; the overall health status and co-morbidities of the patient and the operation itself. So when consenting patients for a procedure that will require the services of an anaesthetist, remember that the Anaesthetist involved will see the patient beforehand and discuss with the patient the relative risks based on the procedure, patient factors and the anaesthetic technique recommended. Common risks with a General Anaesthetic: · sore throat, pain, nausea and vomiting, fatigue, disturbed sleep, confusion, headache complications from iv's, arterial lines etc Less common: · dental damage, nerve injury, airway/respiratory or cardiovascular problems Rare: · such as anaphylaxis, awareness, hearing loss, death, permanent nerve damage. Specific regional techniques such as nerve blocks, spinals and epidurals carry with them separate risks such as failure of technique, nerve injury (temporary or permanent), spinal headache, infection, haematoma and possible local anaesthetic related toxicity. As an HMO, patients may ask you what are the risks with a spinal or an epidural, while you are undertaking the general surgical/anaesthetic consent. While you can explain the general principles of the technique, I would suggest that the most appropriate person to outline the specific risks and benefits is the Anaesthetist performing the procedure. Patient co-morbidities and health status also have an influence on risks and their likely occurrence: A patient with a significant history of ischaemic heart disease should be advised of the risks of arrhythmias, myocardial ischaemia and infarct as well as the other risks inherent to the technique. An 80-year-old patient is at significantly increased risk of post-operative confusion (as well as other risks) A patient with a dilated cardiomyopathy presenting for an emergency AAA repair should be made aware of the high associated morbidity and mortality as well as the need for ICU postoperative care. Where you obtain a signed consent covering both surgical and anaesthetic risk, you should have an understanding of the more common risks associated with a general anaesthetic and the rare but serious complications when obtaining informed consent.

Mark Adams Staff Specialist Department of Anaesthesia and Pain Management Western Health

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Breast Surgery

BREAST SURGERY

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Breast Surgery

Breast Biopsy (± wire localisation)

Procedure in brief

Removal of lesion only. May require insertion of a needle into the lesion with x-ray guidance to localise.

Risks and complications

As for Breast biopsy.

Breast Wide Local Excision (± wire localisation)

Procedure in brief

Removal of lesion with a margin of breast tissue. Incision is made over the lump if palpable. If impalpable may require insertion of a needle into the lesion with x-ray guidance to localise the lesion preoperatively.

Risks and complications

Anaesthetic complications. Medical complications. Wound haematoma (most common). Wound infection. Cosmetic deformity. Scar related problems.

Breast Wide Local Excision and Axillary Dissection

Procedure in brief

Removal of lesion (as above). Axillary dissection (see General Surgery).

Risks and complications

As for local excision. Complications of an axillary dissection.

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Breast Surgery

Mastectomy

Procedure in brief

Total mastectomy

Removal of entire breast and nipple. Incision is made elliptical to include the nipple and the tumour position. Skin flaps are raised. Dissection continues to the muscle fascia of the chest wall and the entire breast is removed.

Total mastectomy and axillary dissection

In addition to the above procedure, an axillary dissection is performed.

Risks and complications

Anaesthetic complications. Medical complications. Mortality rate <1%.

Early

Seroma, a collection of serum and/or lymph beneath the wound. Haematoma. Wound infection. Cellulitis. Skin flap ischaemia.

Late

Arm lymphoedema (especially if axillary dissection and radiotherapy). Scar-related problems. Cosmetic deformity. Breast oedema. Atrophy of pectoralis major due to nerve damage. Shoulder stiffness. Sensory disturbance in distribution of intercostobrachial nerve(s). Atrophy of serratus anterior due to nerve damage winged scapula (rare, but important complication). Psychological disturbance.

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Colorectal Surgery

COLORECTAL SURGERY

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Colorectal Surgery

Many bowel resections are now performed using telescopes, which allow the same procedure to be performed with smaller incisions, reducing postoperative pain and allowing earlier recovery from surgery. Most colorectal surgery requires 1-2 hours of operating time and patients usually require hospitalisation for 7-10 days. At Western Health, colorectal resections are done using open and laparoscopic techniques.

Incision sites for left laparoscopic surgery Refer to general information on laparoscopic surgery.

Incision sites for right laparoscopic surgery

Large Bowel Resection/Anastomosis

Procedure in brief

Left Hemicolectomy Right Hemicolectomy (www.christie.nhs.uk/.../surgery/images/fig4.gif) (www.christie.nhs.uk/.../surg/images/fig2.gif)

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Colorectal Surgery

Right hemi-colectomy

Midline or transverse incision. Excision of the caecum, ascending colon, hepatic flexure to the mid-transverse colon. Iiio-transverse anastomosis.

Transverse colectomy

Midline or transverse. Wedge resection including the transverse colon, omentum and mesentery. End to end anastomosis.

Left hemi-colectomy

Midline incision. Anastomosis usually between the transverse colon and the sigmoid colon.

Sigmoid colectomy

Incision is made in the lower midline. The ureter must be identified and preserved. Sigmoid loop is then removed. Anastomosis between descending colon and upper rectum.

Sigmoid colectomy (www.christie.nhs.uk/.../surgery/images/fig3.gif)

Total colectomy

Full length mid-line incision. Combination of R) and L) colectomy. An ileorectal anastomosis, or a J or W pouch can be performed. Alternatively the ileum can be brought out as a RIF ileostomy.

Hartmann Procedure

Affected colon is excised through a lower midline incision. The proximal colon is brought out through the abdominal wall as a colostomy. The distal stump is either over-sewn or brought out as a mucous fistula.

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Colorectal Surgery

Risks and complications

Anaesthetic complications. Medical complications.

Early

Anastomosis not possible ­ unexpected stoma. Anastomotic leak or breakdown (up to 5%). Intra-abdominal abscess/peritonitis. Wound infection (up to 10%, despite prophylactic antibiotics). Systemic sepsis. Multi-organ failure. Damage to other intra-abdominal structures ­ specifically spleen or ureters. Retraction of the stoma. Necrosis of stoma.

Late

Division of pelvic parasympathetic nerves: · Impotence in a male (<5%). · Urinary dysfunction (incontinence or retention). Anastomotic stricture. Recurrence of the disease (up to 10% of local recurrence). Adhesions causing small bowel obstruction (up to 20%, but less with laparoscopic approach). Incisional hernia (up to 20%, but less with laparoscopic approach). Parastomal hernia (up to 20%).

Anterior Resection

Procedure in brief

This procedure is undertaken most often for malignant disease of the rectum. Incision is in the midline or lower transverse if laparoscopic approach used. The anastomosis is between the descending colon and the rectum. Low and ultralow anastomosis is possible ­ colorectal units can decrease the incidence of abdomino-perineal resection and colostomy in carcinoma of the rectum to approximately 10%. With coloanal anastomosis a colonic J pouch is often constructed. Often a covering stoma is necessary.

Risks and complications

Anaesthetic complications. Medical complications. Infection with anastomotic leak. Others see Large Bowel Anastomosis.

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Colorectal Surgery

Abdominoperineal Excision of the Rectum

Procedure in brief

Indicated for rectal disease that is too close to the anal margin to all for adequate clearance by anterior resection. Preoperatively, LIF is marked for an end colostomy. Incisions are made in the lower abdomen and perineum (perianally). The large bowel is mobilised, lower margin reached through the perineal incision, and the excised portion removed.

Risks and complications

Anaesthetic complications. Medical complications. Necrosis of the colostomy/bleeding/retraction. Breakdown of the perineal wound: · requires daily irrigation and dressings with antiseptic packs until healing occurs · risk of breakdown is increased in patients having preop radio/chemotherapy Damage to urethra in males. Bladder dysfunction. Others as for Large Bowel Resection.

Small Bowel Resection and Anastomosis

Procedure in brief

The section of bowel to be resected is selected. A V-shaped portion of the mesentery is included in the resection. For benign disease mesenteric vessels are ligated and divided close to the bowel. For malignant disease a wider mesenteric excision is required. After division of the mesentery, the small bowel is resected between crushing clamps. Continuity is restored by end to end anastomosis with absorbable sutures (PDS or Maxon) or by using a bowel stapling machine. The mesenteric defect is closed to prevent internal herniation.

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Colorectal Surgery

Before and after resections (www.nlm.nih.gov)

Risks and complications

Anaesthetic risks. Operative risks. Anastomotic leakage. Haemorrhage from mesentery. Haemorrhage at anastomosis GIT bleed. Wound infection. Wound haematoma. Stenosis at anstomosis. Adhesions.

Drainage of Perianal Abscess

Procedure in brief

Abscess is recognised as a swelling at the anal margin. Excise over the swelling and drain pus. Pack with gauze soaked with Normal Saline.

Postoperative

Remove dressing on the second day post-op. Twice daily baths with irrigation of the wound.

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Colorectal Surgery

Risks and complications

Anaesthetic complications. Medical complications. Recurrence. Fistula in ano ­ approximately 30% will develop after perianal abscess.

Laying Open Fistulo-in-ano

Procedure in brief

Sigmoidoscopy performed first, especially looking for inflammatory bowel disease. Localise the tact ­ palpating for induration, and the abscess of origin. A probe may be passed into the external opening. Drainage of tract ­ primary and secondary, and the abscess of origin. May require tract to be laid open. Pack with gauze. For high anal fistulae, a seton (eg, vascular loop) or rectal flap advancement repair are options.

Postoperative

Twice daily salt baths with tuck-in dressings usually with alginate. May require ultrasound for MRI scan, if complex fistula.

Risks and complications

Anaesthetic complications. Medical complications. Failure to heal. Recurrence. Secondary haemorrhage. Faecal incontinence ­ risk minimised by use of seton for high fistula.

Haemorrhoidectomy

Injection Therapy

Patient in (L) lateral position. Sigmoidoscopy and proctoscopy. Injection of Phenol in almond oil.

Banding of haemorrhoids

Patient in (L) lateral position or lithotomy position. Firing of the rubber band over the haemorrhoid.

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Colorectal Surgery

Haemorrhoidectomy

Patient in the lithotomy position. Sigmoidoscopy, EUA. Apply forceps to the internal and external components of each haemorrhoid and pull downwards. Make an incision at the base of each haemorrhoid and identify the internal sphincter. Excise haemorrhoidal tissue. A bridge of skin is left between each excised area. Haemostasis with diathermy.

Stapled Haemorrhoidectomy ­ for circumferential prolapsed haemorrhoids

Lithotomy position. Sigmoidoscopy, EUA. Reduce haemorrhoids with reducer. Suture placed into rectal wall. Stapling gun fired to excise a ring of tissue above haemorrhoids. Haemostasis with sutures.

Postoperative

Analgesia. Sitz baths (salt). Metamucil/stool softeners.

Risks and complications

Anaesthetic complications. Medical complications. Haemorrhage ­ reactionary or secondary. Acute urinary retention. Faecal impaction. Chronic pain associated with fissure. Incontinence. Anal stenosis, if too much skin removed. Rectovaginal fistula in female patients.

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Endocrine Surgery

ENDOCRINE SURGERY

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Endocrine Surgery

Adrenalectomy

Bilateral

Procedure in brief

Anterior transperitoneal approach

(L) adrenal: · Ligate and divide 10­15cm greater omentum. · Retract stomach upwards. · Mobilise pancreas and splenic vein upwards to display upper pole of kidney. · Ligate and divide the adrenal vein entering the (L) renal vein. · Mobilise and remove adrenal gland. ® adrenal: · Mobilise right colic flexure. · Displace colon down and liver upwards. · Identify right kidney. · Ligate and divide short adrenal vein entering the IVC. · Mobilise and remove the gland. Search for ectopic adrenal tissue. Closure.

Unilateral

Procedure in brief

Patient in lateral position. Incise over the 12th rib. Resect the rib and extend the incision through origin of the diaphragm and the muscles of the anterior abdominal wall. Expose upper pole of kidney. Remove adrenal gland as described above.

Risks and complications

Haemorrhage, particularly venous if right adrenal vein is avulsed from the IVC. Splenic injury. Respiratory complications. Wound infection. Reactive haemorrhage. Sepsis. Impaired wound healing. Nelson's syndrome (if bilateral): · Pituitary oversecretion. · Hyperpigmentation · Headache. If for a phaeochromocytoma, intraoperative hypertension, myocardial infarction and postoperative shock very (rare with modern anaesthesia).

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Endocrine Surgery

Parathyroidectomy

Procedure in brief

Transverse skin incision, transverse or vertical fascial incision. Identify recurrent laryngeal nerve. Systematic search for all (three, four or five) parathyroid glands around thyroid, superior mediastinum, thymus, carotid sheath, etc. Identify adenoma V's hyperplasia involving all glands (macroscopically and sometimes using biopsy). Remove adenomatous or enlarge gland(s). (A portion of one gland may be left in situ when all glands are involved). Normal glands are usually left in place. Occasionally parathyroid may be transplanted into the forearm. Closure.

Risks and complications

Anaesthetic complications. Medical complications. Haemorrhage or haematoma. Recurrent laryngeal nerve palsy. Hypoparathyroidism. Persistent hyperparathyroidism. Infection (rare).

Thyroidectomy

Procedure in brief

Partial or total. Transverse collar skin incision above suprasternal notch. Transverse or vertical incision through fascia. Mobilise thyroid gland, identifying recurrent laryngeal nerve and parathyroid. Ligate/clip vascular supply to gland. Remove appropriate portion of thyroid tissue. Closure.

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Endocrine Surgery

Risks and complications

Anaesthetic complications. Medical complications. Recurrent laryngeal nerve palsy ­unilateral or bilateral rare). Haemorrhage may require emergency operation. Wound infection. Tracheal or oesophageal injury: · Laryngeal oedema ­ respiratory distress. · Tracheomalacia. Hypothyroidism. Hyoparathyroidism. Horner's Syndrome (sympathetic chain injury). Recurrence of thyroidtoxicosis. Tracheostomy, rare but important: · Damage to external branch of the superior laryngeal nerve ­ this is important for people who use their voices a lot, eg, teachers and singers.

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ENT Surgery

ENT SURGERY

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ENT Surgery

Myringoplasty/Tympanoplasty/Canalplasty

Procedure in brief

Myringoplasty ­ repair of tympanic membrane

Post­auricular or transcanal incision. Canal skin and tympanic membrane elevated using the operating microscope. Temporalis fascia or perichondrial graft harvested and laid under tympanic membrane.

Tympanoplasty ­ myringoplasty plus reconstruction of middle ear

As above. Reconstruction of oscular chain ­ main options depending on patient case, eg. Incus interposition, TOPP, PORP.

Canalplasty ­ removal of bone from the external ear canal

May be required additionally. Involves widening of the ear canal to allow better surgical access.

Post-op

External ear canal packed for three weeks. Head bandage for one week.

Risks and complications

Anaesthetic complications. Medical complications. Dead ear <1%. Facial nerve damage ­ chorda tympani may be sacrificed, main trunk less commonly. Post-operative dizziness, vertigo, tinnitus. Conductive hearing deficit. Repair of perforation successful in 80­90%, therefore, some patients require re-operation. Infection. Keloid or hypertrophic scar. Cholesteatoma.

Stapedectomy

Procedure in brief

Transcanal approach. Elevation of tympanomeatal flap to expose middle ear. Stapes superstructure removed. Footplate perforated. Prosthesis (stainless steel, Teflon) is placed and attached to the long process of incus with its distal end in the oval window. Haemostasis and closure. Operation time one hour.

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ENT Surgery

Risks and complications

Anaesthetic complications. Facial nerve injury. Dead ear (1%). Post-op dizziness, vertigo, tinnitus. Prosthesis dislodgment. Taste disturbance ­ usually temporary.

Modified Radical Mastoidectomy

Pre-op

Recent CT and audiogram (within six months).

Procedure in brief

Post-auricular incision using operative microscope. Removal of pathology (eg, cholesteotoma) and mastoid air cells. Packing of mastoid cavity. Operation time 2.5 hours.

Post-op

Overnight admission. Head bandage removed day one post-op. Mastoid cavity packing removed two weeks post-op (note: should packing partially dislodge, may be cut flush with the ear, NOT repacked), then Sofradex steroid ear drops commenced. Audiogram eight weeks post-op. Post-op care (lifelong): Keep ear dry at all times Meatoplast to enlarge earhole to the size of index finger. Cleaning of affected ear every 6-12 months.

Risks and complications

Anaesthetic complications. Dead ear <1%. Facial nerve damage <1%­ chorda tympani may be sacrificed, main truck less commonly. Post-operative dizziness, vertigo­ usually improves in a few days, tinnitus ­ may be permanent. Conductive hearing deficit. Infection. Discharging cavity. Altered taste. Possible need for second procedure. Recurrence of primary disease process.

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ENT Surgery

Parotidectomy

Partial parotidectomy (superficial lobe)

Procedure in brief

Skin incision. Expose greater auricular nerve and sternomastoid muscle. Identify main trunk of facial nerve. Follow facial nerve and identify divisions, mobilising and freeing the parotid gland. Remove superficial lobe of parotid. Suction drain and wound closure.

Post-op

Most require 24-48 hours admission. Removal of drain.

Risks and complications

Infection. Haemorrhage. Haematoma. Nerve damage: · Facial weakness ­ 15-20%, usually temporary but may take more than six months to recover, 1% permanent. · Impaired lip control, unilateral drooping of the angle of the mouth. · Anaesthesia in preauricular region and outer, lower half of pinna ­ can last for some weeks post-op, often permanent numbness of ear lobe. · Hyperaesthesia due to neuromatous expansion of distal cut end of nerve. Salivary fistula. Gustatory sweating (common 2-3 months after operation). Alteration to taste.

Total conservative parotidectomy

(Superficial and deep lobe with preservation of the facial nerve).

Procedure in brief

As per partial parotidectomy. Dissect branches and trunk of facial nerve off deep lobe. Separate deep lobe from ascending ramus of mandible. Divide branches of external carotid artery. Remove gland. Closure.

Risks and complications

Facial weakness (a higher incidence than in partial parotidectomy). As for partial parotidectomy.

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ENT Surgery

Radical parotidectomy (includes removal of facial nerve)

Procedure in brief

Larger incision. As for procedure total conservative parotidectomy, but includes removal of facial nerve. Often part of a neck dissection. Can use a nerve graft from branches of the cervical plexus.

Risks and complications

Complete hemifacial paralysis (depends on success of nerve graft): · Poor lip movement. · Failure of the eye to close. · Complete drooping on one side of the face. Sepsis and wound breakdown. As for parotidectomy.

Functional Endoscopic Sinus Surgery (FESS)

Pre-op

Paranasal sinus CT. Prednisolone 25mg and Roxithromycin 300mg for five days.

Procedure in brief

General anaesthetic. Intranasal approach using endoscope. Removal of diseased tissue and bone. Sinuses opened. Insertion of intranasal pack.

Post-op

Overnight admission. Pack removed day one. Avoid blowing nose for 48 hours post-op. Normal saline intranasal spray to irrigate note. Avoid dusty and smoke environments. Avoid flying for at least two weeks post-op. Expected convalescence period 7-10 days.

Risks and complications

Anaesthetic complications. Bleeding. Periorbital bruising 1:500. CSF leak 1:1000.

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ENT Surgery

Rhinoplasty

Pre-op

Clinical photos.

Procedure in brief

Incision: · Closed technique ­ incisions made intra-nasally, leaving no visible scars. · Open technique ­ incision of the columella between the nasal openings, leaving a small scar that is minimal months post-op. Elevation of skin from the nasal skeleton. Mobilisation of nasal bones by lateral saw cuts. Realignment. Occasional transcolumellar incision, if booked as external rhinoplasty. External thermoplastic splint. Total operation time two hours.

Risks and complications

Suboptimal cosmetic or functional result: · 90% cosmetic improvement (not perfect, just better). · 10% require second operation to correct minor imperfection. · 3% will look worse cosmetically. Bleeding. Infection. Septal perforation or haematoma. Altered sensation of nasal tip or incisor teeth.

Septoplasty/Turbinectomy

The aim is to improve nasal airway with no visual changes to the external appearance of the nose.

Pre-op

Photos required (usually done in outpatient clinic).

Procedure in brief

Elevation of musco-perichondrium flaps on either side of septal skeleton. Cartilage and bone removal. Repositioning of septal skeleton in midline after straightening or removing spurs and convexities. Mucosal flap repositioned in midline. Intranasal pack. Total operation time 40 minutes.

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ENT Surgery

Post-op

Overnight admission. Intranasal packs removed day one post-op. Saline spray for four weeks. Avoid heavy lifting for two weeks. Avoid nasal occlusion or contact with nose for four weeks. Avoid smoking.

Risks and complications

Suboptimal cosmetic or functional result: · 90% cosmetic improvement (not perfect, just better). · 10% require second operation to correct minor imperfection. · 3% will look worse cosmetically. Bleeding. Infection. Septal perforation or haematoma. Altered sensation of nasal tip or incisor teeth.

Tonsillectomy/Adenoidectomy

Procedure in brief

Procedure takes about 20 minutes. Anaesthetic review if there is a history of obstructive sleep apnoea, as URCU or HDU monitoring may be required post-op. Patient supine with head extended. Mouth retracted open. Mucosa surrounding tonsil incised. Tonsil and capsule dissected bluntly from mucosa. Adenoids curetted from behind the soft palate. Haemostasis ­ dissolving sutures may be used to tie off bleeding vessels.

Post-op

Requires overnight admission. Normal diet post-op.

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ENT Surgery

Risks and complications

Anaesthetic complications. Medical complications. Haemorrhage 1-2% - 1/5000 requiring blood transfusion: · Primary ­ reactionary haemorrhage within six hours of operation. · Secondary ­ post-op day 5-14, protective slough separates from granulating fossa. Lower respiratory complication due to inhalation of blood and mucus ­ bronchitis, pneumonia, lung abscess. Upper respiratory complications ­ sinusitis, otitis media, earache (referred otalgia). Otalgia for two weeks ­ peaks on day five. Dental injuries (especially if loose/crowns). Infection ­ including acute otitis media. Diathermy burns.

Excision of Pharyngeal Pouch

Procedure in brief

Open procedure

Skin incision at level of cricoid cartilage. Exposure and division of infrahyoid muscles. Retract thyroid gland medially. Pouch lies in front of the cervical spine, behind the thyroid gland, trachea and oesophagus. Locate and dissect pouch. Neck of pouch divided and oversewn. Repair musculature of pharyngeal wall. Cricopharyngeal myotomy. Closure of layers. Suction drainage.

Endoscopic procedure

Stapling of the pouch via an endoscope.

Post-op

Antibiotic cover for seven days. Nasogastric feeding for seven days.

Risks and complications

Anaesthetic complications. Medical complications. Surgical emphysema. Fistula with salivary leak. Vocal cord paralysis secondary to recurrent laryngeal nerve injury. Local, pulmonary or mediastinal infection. Recurrence and stenosis (both less if cricopharyngeus divided).

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ENT Surgery

Neck Dissection

This entails excision of tumour and removal of lymph notes (Head and Neck, ENT team), as determined by pre-op CT scan, and then reconstruction and closure of the defect (Plastics surgical team). Radical neck dissection involves sacrifice of the internal jugular vein, the accessory nerve (cranial nerve XI) and sternocleidomastoid. Radical modified neck dissection preserves at least one of these structures.

Procedure in brief

Neck incision. Identification ± preservation of accessory nerve. Identification and ligation of internal jugular vein. Removal of all lymph nodes on that side of the neck en bloc, including the internal jugular vein and sternomastoid. Surgical drains. Haemostasis. Closure as determined by the Plastic Surgeon ­ usually free flap or Keystone Perforator Design Island Flap. Total operation time at least 2.5 hours.

Post-op

May require HDU monitoring. Drains usually removed after 48 hours. At least 4-5 days admission. IV antibiotics. May require post-op radiotherapy. Follow up depends on underlying histopathology.

Risks and complications

Anaesthetic complications. Medical complications. Bleeding ­ may require transfusion. Haematoma ­ may require surgical evacuation. Wound infection. Nerve damage: · Accessory shoulder stiffness · Hypoglossal (very rare) difficulty in clearing food from one side of the mouth, difficulty in swallowing. · Marginal mandibular weakness of the corner of the mouth. · Lingual. · Vagus, phrenic ­ very rare, unless tumour is invasive. Chyle leak from neck wound due to thoracic duct injury ­ may require surgical closure, but usually resolves with keeping the drain tube in situ for a longer period.

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ENT Surgery

Swelling of neck and face. Rarely laryngeal oedema or dysphagia. Neck stiffness. Suboptimal cosmetic result. Death. Possible need for tracheostomy if the tumour is near the airway. Recurrence of tumour.

Laryngectomy/Pharyngolaryngectomy

Pre-op

PEG tube insertion.

Procedure in brief

Neck incision. Elevation of skin flaps. Separation of the larynx/pharynx from lateral structures (ie, sternomasoid muscle and carotid sheath). Identification of the superior and inferior thyroid artery and vein. Ligation on one side and preservation on the other. Separation of preserved lobe of thyroid from trachea. Division of suprahyoid musculatures from hyoid bone. Entry into pharynx from above hyoid. Complete removal of larynx by division at 2nd tracheal ring. Fashioning of stoma. Closure of pharynx. Reduction of drains. Closure of wounds. Naso-gastric tube. Occasional 1º tracheo oesophageal puncture.

Post-op

ICU/HDU monitoring.

Risks and complications

Bleeding. Infection. Loss of voice (speech valve may be inserted into tracheo-oesophageal puncture few weeks post-op to allow alaryngeal oral speech). Difficulty swallowing. Leakage from neck wound ­ saliva/lymph. Hormone/metabolic imbalance. · Hypothyroidism. · Hypocalaemia. Depression day five. Problems with fistula Free flap failure. Recurrence of original disorder.

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ENT Surgery

Panendoscopy/Microlaryngoscopy

Procedure in brief

Rigid scope: · Bronchoscopy. · Oesophagescopy. · Laryngoscopy. Biopsy may be required.

Post-op

Avoid narcotics. Monitor for odynophagia.

Risks and complications

Bleeding from biopsy site. Perforation of oesophagus or lung (Panendoscopy only). Injury to teeth. Sore throat. Difficult swallowing. Persistent discomfort. Impairment of voice. Infection. Airway obstruction.

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General Surgery

GENERAL SURGERY

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General Surgery

Open Surgery

Peri-operative requirements: · Shaving of body hair. · Need for nasogastric tubes, IDC, drains, etc. · Pain management.

General complications

Inadvertent damage to adjacent structures. Haemorrhage ­ need for transfusion/use of blood products. Fever. Sepsis: · Chest infection. · UTI. · Wound, body cavity or joint. Deep Vein Thrombosis. Pulmonary Embolism. Wound complications: · Haematoma. · Infection. · Dehiscence ­ superficial/deep. Scarring: · Peri-incisional altered sensation or numbness. · Hypertrophic scars. · Keloid. Abdominal surgery: · Peritonitis. · Intra abdominal/pelvic abscess. · Abdominal distension. · Paralytic ileus. · Parotitis. · Adhesions. · Incisional hernia.

Laparoscopic Surgery

Procedure in brief

3­4 small incisions in abdomen. Laparoscope inserted through umbilical incision. Gas (C02) used to inflate abdominal cavity. Camera attached to laparoscope for vision. Remaining incisions used for insertion of instruments.

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General Surgery

Benefits

Reduced postoperative discomfort and pain. Shorter hospital stay. Smaller wound scars. Fewer adhesions. Earlier recovery, marked reduction of wound related complications.

Risks

Damage to viscera/major vessels on insertion of trocar. Gas embolism. Subcutaneous emphysema/pneumomediastinum. Diaphragmatic injury tension pneumothorax. Bowel damage by diathermy. Increased risk of DVT in some procedures, such as lap fundoplication. Herniation through trocar entry points (0.1-0.3%). Shoulder tip pain. Wound infections. Cardiac dysrhythmias. In general, risks as above are rare in experienced hands.

Appendicectomy

Procedure in brief

Laparoscopic

Laparoscopic exploration. Appendix removed, if looks abnormal. If appendix looks normal, alternative causes for pain need to be excluded, eg, gynaecological, Meckels. Peritoneal cavity irrigated. Port incisions closed.

Open

RIF incision in skin crease (sometimes lower midline, if diagnosis uncertain). Explore iliocaecal region, exclude Meckel's, check ovary, etc (if appendix looks normal). Deliver and remove appendix. Close wound.

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General Surgery

Risks and complications

Early ­ within hours or a few days of operation

Anaesthetic complications. Medical complications. Laparoscopic complications. Stump leak. Bleeding from appendicular artery. Peritonitis. Wound haematoma. Wound infection. Pelvic abscess/intra abdominal abscess (usually RIF). Adhesions/small bowel obstruction.

Late ­ within weeks/months/years (after discharge from hospital)

Wound infection. Intra abdominal abscess. Adhesive small bowel obstruction. Incisional hernia.

Block Dissection of Groin

Inguinal Lymph Nodes

Procedure in brief

`Lazy S' incision from midpoint of a line joining umbilicus and ASIS, finishing at apex of femoral triangle. Raise skin flaps. Dissect femoral triangle. Remove superficial tissues and lymph nodes. May transpose Sartorius muscle over Femoral vessels. Drain. Closure.

Lilac Nodes

Procedure in brief

Same incision as for inguinal node resection. Enter iliac region above inguinal region. Sweep out connective tissue and lymph nodes from iliac vessels and their branches. Remove glands at obturator foramen. Repair inguinal region. Drain. Closure.

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General Surgery

Risks and complications

Lymphoedema of leg (more common with iliac node dissection). Failure of skin flaps to heal (ischaemia). Infection. Lymphocele under flap. Anaesthesia of anterior thigh (division cutaneous nerves). Urinary retention (secondary to pain) ­ avoid by IDC insertion preoperatively. Scrotal oedema. Secondary haemorrhage major vessels.

Block Dissection of Axilla

Procedure in brief

Shave axilla. Transverse incision. Dissect contents of axilla to level desired: · Level 1 Lateral to pectoralis minor. · Level 11 Up to medial border of pectoralis minor. · Level 111 Up to apex of axilla. Insert drain (closed low pressure suction). Closure.

Risks and complications

Wound infection/bleeding. Injury to Axillary vein. Injury to N. to Serratus Anterior. Injury to N. to Latisimus Dorsi. Numbness upper inner arm due to division of intercostobrachial nerve(s). Haematoma, wound infection, seroma. Lymphoedema of arm (uncommon).

Excision of Pilonidal Sinus

Procedure in brief

Extent of the sepsis is determined through palpation. The skin of the septic area may need to be completely excised. Granulation tissue and embedded hairs removed. Wound may be closed primarily. If deep and large the wound is left open to heal by secondary intention. Packed with normal saline gauze.

Post-operative

Acute pain control. Removal of pack on second day post-operative. Edges of the wound will need frequent shaving (up to six months).

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General Surgery

Risks and complications

Anaesthetic complications. Medical complications. Wound infection. Haemorrhage. Delayed healing. Recurrence ­ may need re-operation.

Epigastric Hernia Repair

Procedure in brief

Incision through skin over hernia. Reduce or excise hernia (usually extraperitoneal fat). Repair defect. Closure.

Risks and complications

Medical complications. Anaesthetic complications. Wound haematoma/infection. Recurrence of hernia.

Femoral Hernia Repair

Procedure in brief

Skin incision in groin crease (low approach) used for elective repair. Expose hernial sac. Open and reduce/excise contents of sac. Transfix and ligate neck of sac. Excise sac. Repair defect with sutures or mesh plus (ensure femoral vein is retracted laterally out of the way). Closure.

Risks and complications

Medical complications. Anaesthetic complications. Wound haematoma/infection. Damage to femoral vein. Damage to structures within the hernial sac, eg, bowel, bladder. Recurrence of hernia.

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General Surgery

Incisional Hernia Repair

Procedure in brief

Incision over hernia. Define sac and margins of defect. Inspect contents of hernia and reduce viscera (if contained). Excise or reduce sac. Repair abdominal defect, with mesh reinforcement, unless very small. Closure of soft tissue layers. May use drain.

Risks and complications

(Depend on size and contents of hernia) Anaesthetic complications. Medical complications. Wound infection/haematoma. Damage to visceral contents of hernia. GIT perforation. Paralytic ileus. Recurrence of hernia (5­10%, as tissues are generally weak).

Inguinal Hernia Repair

Procedure in brief

Laparoscopic

Extraperitoneal approach via umbilical incision. Expose defect (may be indirect or direct hernia). Reduce/excise hernial sac. Mesh repair over defect. Closure.

Open

Skin crease incision above inguinal ligament. Dissection of inguinal canal to expose internal ring and whole cord. Hernial sac reduced/excised (direct or indirect). Repair and reinforce transversalis fascia/deep ring. May use mesh reinforcement, which is sutured in situ. Careful closure of layers.

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General Surgery

Risks and complications

Anaesthetic complications. Medical complications. Laparoscopic complications (rare using extraperitoneal technique). Wound infection (superficial or deep). Wound haematoma. Structures at risk: · Cord structures ­ vas deferens and testicular vessels. · Local nerves ­ iliohypogastric, ilioinguinal, genitofemoral. · Femoral vein. · Inferior epigastric vessels. Scrotal oedema (especially with bilateral repair). Scrotal haematoma. Transient impotence: · Urinary retention. · Post-operative pain ­ nerve entrapment neuralgia. · Testicular atrophy/pain. · Migration of mesh. Recurrence of hernia (2-5%, at five years).

Umbilical Hernia Repair

Procedure in brief

Transverse incision over hernia. Dissect down to aponeurosis, exposing neck of hernial sac and defect. Sac opened, inspect contents. Excise sac, reduce visceral herniation. Repair defect and close.

Risks and complications

(Depend on size and contents of hernia) Anaesthetic complications. Medical complications. Wound infection. Wound haematoma. Ileus. Damage to GIT if contained in sac. Recurrence of hernia.

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General Surgery

Splenectomy

Procedure in brief

Open

LUQ incision (or long midline if staging laparotomy, trauma, etc). Mobilise spleen. Explore for accessory splenic tissue. Ligate short gastric vessels. Divide gastrosplenic and lienorenal ligaments. Ligate or clip splenic artery and vein. Remove spleen. Haemostasis and closure (rarely use drain).

Laparoscopic

Mobilise and ligate vessels as per open procedure. Spleen retrieved in endocatch bag and removed piecemeal via port after fragmentation.

Risks and complications

Anaesthetic complications. Medical complications. Laparoscopic complications. Subphrenic haematoma or abscess. Wound infection. Left lower lobe atelectasis/pneumonia. Pancreatitis or pancreatic fistula owing to injury to tail of pancreas. Thombocytosis/thrombotic complications. Acute gastric dilation. Inadvertent damage to stomach.

Late complication

Increased risk of overwhelming sepsis (0.5-1%, although still very rare): · Meningococcus. · Pneumococcus. Vaccination is available to reduce this risk.

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Hepatobiliary Surgery

HEPATOBILIARY SURGERY

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Hepatobiliary Surgery

Cholecystectomy

Procedure in brief

Laparoscopic

4-port procedure. Identify cystic artery and duct, the perform intraoperative cholangiogram. Ligate cystic artery and duct. Mobilise and remove gallbladder. Drain tube in situ.

Open

Similar procedure via RUQ incision.

Risks and complications

Overall mortality 0%-0.9%. Anaesthetic complications. Medical complications. Laparoscopic complications. Wound complications: · Haematoma. · Infection. · Hernia. Bile duct injury (0.1%-0.5%). Gallbladder perforation with spillage of stones into abdomen. Post operative bile leak (usually Cystic duct) 0.2%-1.5%. Bleeding (0.1%-0.5%): · Cystic artery. · Hepatic vessels. · Gallbladder bed Bile duct stones (2%-4%). T-tubes/stents are used only if the bile duct is explored. Conversation to open procedure is necessary in 2-5% owing to obscure anatomy, technical difficulties, bleeding, etc. Retained CBD stones (0.3%-0.7%). Post­cholecystectomy syndrome.

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Hepatobiliary Surgery

Whipples Procedure (Pancreaticoduodenectomy)

Procedure in brief

Laparoscopy to exclude metastases. Large abdominal incision (usually Chevron `rooftop' incision). Resection: · Distal stomach. · Duodenum. · Head of pancreas. · Proximal jejunum. Reanastomosis: · Pancreaticojejunostomy. · Choledochojejunostomy. · Gastroenterostomy. Drain tube in situ. Closure.

Risks and complications

20­30% morbidity. 5% mortality. Anaesthetic complications. Medical complications (especially respiratory). Leakage at anastomoses ­ most dangerous is pancreaticojejunostomy, leading to peritonitis and/or pancreatic fistula. Bile/GIT leak ­ peritonitis Bleeding/malaena/haemoperitoneum Wound infection or haematoma. Acute pancreatitis. May cause diabetes (if done for chronic pancreatitis). GIT mucosal effects ­ stress ulceration. Pancreatic fistula. Drainage to hepatic and splenic vessels, IVC or other vital structures. Hepatorenal failure.

Risks reduced by

Perioperative hydration and/or mannitol in jaundiced patients. Vitamin K to correct coagulation derangement. Octreotide (decrease incidence or pancreatic fistula).

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Hepatobiliary Surgery

Distal Pancreatectomy

Procedure in brief

Incision ­ transverse abdominal. Mobilse spleen upwards from its bed. Transect the pancreas at portal vein. Remove distal pancreas and spleen.

Risks and complications

Anaesthetic complications. Medical complications. Complications of a splenectomy (see splenectomy). Haematoma in splenic bed. Left subphrenic abscess. Pancreatic fistula.

Endoscopic Retrograde Cholangio Pancreatography (ERCP)

Procedure in brief

Usually GA or LA spray to the back of the throat with sedation. Endoscope passed down into the stomach and duodenum. Air is filtered down the endoscopy to assist with a clear view of the lining of these organs. Via a side channel of the endoscope, a number of procedures can be carried out.

Types of procedures performed

Injecting contrast dye into the bile and pancreatic ducts. X-rays are taken immediately after the injection of the dye. This may show stricture, gallstones, or tumours pressing on the ducts, etc. Taking a biopsy from the lining of the duodenum, stomach or pancreatic or bile duct near the papilla. If the x-ray shows a gallstone lodged in the ducts, a sphincterotomy will be performed. If there is narrowing or blockage of the bile duct, a stent will be inserted.

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Hepatobiliary Surgery

Risks and complications

Early

Pancreatitis occurs in around 1 in 20 patients, usually mild to moderate and may require medical treatment and hospitalisation. Bleeding and perforation of tissue after sphincterotomy. Complications are usually treated endoscopically and rarely requires surgery. Aspiration pneumonia is very uncommon but may require medical treatment and hospitalisation. Bile duct infection (Cholangitis) is uncommon. Antibiotics prior to the procedureminimise this complication. May occur within 48 hours after an ERCP. Abdominal pain. Fever. Shortness of breath. Haematemesis.

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Maxillo-Facial Surgery

MAXILLO-FACIAL SURGERY

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Maxillo-Facial Surgery

Dentoalveolar Surgery

Removal of impacted third molars, teeth and supernumeries, intravony cycts and tumours.

Procedure in brief

GA (nasal/LA). Mouth held open with rubber mouth props. Injection of local anaesthetic to inferior dental nerve and lingual nerve, maxillary nerves. Mucosal flap raised. Drilling of mandibular bone and loosening the periodontal ligaments. Tooth extracted (occasionally cut before extracted) or pathology enucleated. Inspection of tooth root, socket ± inferior dental nerve is seen. Haemostasis. Mucosal flap closed in some operations.

Risks and complications

Anaesthetic risks. Pain and swelling post-op. Inferior alveolar nerve damage. Lingual nerve damage. Retained tooth root. Wound infection (rarely osteomyelitis). Wound bleeding. Possible damage to nearby tooth/fillings. Oro-antral fistulae. Dislodged tooth/tooth root into sinus requiring sinus surgery.

Dental Clearance and Local Flap Repair Prior to Head and Neck Radiotherapy

Procedure in brief

Similar to above except try to preserve as much bone as possible. There must be adequate mucosal closure.

Risks and complications

Post-radiotherpay: · Osteoradionecrosis. · Salivery gland atrophy and xerostomia. · End arteritis. · Mucositis. · Increased susceptibility to dental caries and periodontal disease.

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Maxillo-Facial Surgery

Tempora-Mandibular Joint Surgery

Open joint

Procedure in brief

GA. Skin incision. Division of fascia and muscle dissection. Capsule opened. Debridement of joint ± condylectomy ± menisectomy/meniscoplast. Drain. Closure of fascia. Skin closure.

Risks and complications

Scar ­ preauricular and temporal hairline. Neuropraxia of temporo-facial division of CN V11. Recurrence of problem. Frey's syndrome (rare) ­ gustatory sweating. Wound infection.

Arthroscopy/Arthrocentesis and Lavarge

Procedure in brief

Upper joint space or lower joint space. Instrumentation. Wash out.

Risks and complications

As above.

Closure of Oro-Antral Fistula (OAF)

Procedure in brief

GA/LA. Excision of fistula tract and debridement of the lining of the tract. +/- buccal fat flap deep closure. Closure of mucosa via periosteal release undermining and advancement.

Risks and complications

Recurrence of fistula (risk can be decreased by asking patient not to blow their nose for at least two weeks and prescribing a nasal decongestant). Teeth may need to be removed occasionally. Wound infection/bleeding.

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Maxillo-Facial Surgery

Caldwell Luc Procedure

Procedure in brief

Removal of pathology, tooth, root fragment. Incision via OAF or sublabial antrostomy. Retrieval. Repair as above either by direct closure or flaps.

Mandibular/Maxillary Fractures

Procedure in brief

OPG must be available. GA (nasal intubation). Application of arch bars and establish maxillo-mandible fixation. Occlusion checked. Mucosal incision and stripping of periosteum at site of fracture. Bone aligned and plated with titanium plate. Occlusion rechecked. Application of elastics in ward as appropriate.

Post-op

OPG to check alignment. IV antibiotics. Pureed diet for six weeks.

Risks and complications

Pain and swelling. Malocclusion requiring long duration of elastics. Removal of teeth. Wound bleeding and infection. Inferior dental nerve anaesthesia: · Pre-morbid. · Operative.

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Maxillo-Facial Surgery

Orthognathic Surgery

Bilateral Sagital Split Osteotomy

Procedure in brief

GA. Mucosal incision and stripping of the periosteum. Sagittal split osteotomy of the mandible. Advancement, setback or rotation of the distal dental bearing inner segment. Outer joint bearing proximal segment is stationary. Assess viability of blood supply. Assess occlusion. Jaws held together by orthodontic appliances and elastics. May have drains. Ward with special nursing care or ICU post-op.

Risks and complications

Pain and swelling. Lower lip, jaw, chin and side of tongue numbness, which can last many months, years or permanent (5% chance that sensation may never return). Early or late relapse to an undesirable position requiring further surgery. TMJ discomfort. Wound infection/haematoma. Accidental loss or damage to teeth. Loss of prominence of the angles of the jaw. Potential permanent change in the structure of the jaws joints requiring treatment in the future.

Maxillary Osteotomy

Procedure in brief

GA. Mucosal incision and stripping of periosteum. Dislocation of the maxilla at suture line. Repositioning of the maxilla to the desired position. Occasionally bone grafts from the hip or calvarium are necessary. Bone fragments held in position by titanium plates and screws. Occlusion checked. Jaws held in position by arch bars and elastics. May have drains.

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Maxillo-Facial Surgery

Risks and complications

Pain and swelling. Temporary or permanent loss of feeling in upper lip. Loss of upper teeth, gums and bone due to complications with blood supply to the upper jaw. Possible damage to the teeth and/or the gum. Early or late relapse of upper jaw to an undesirable position. Wound infection and haematoma.

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Neurosurgery

NEUROSURGERY

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Neurosurgery

Cerebral Aneurysms

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Procedure in brief

Surgical approach depends on location of aneurysm: · Anterior circulation ­ pterion approach. · Posterior circulation ­ subtemporal, subocciputal or modified pterion approach. Craniotomy. Brain retracted and circle of Willis exposed. Temporary clip may be applied, proximal to occlusion to aid in dissection and clipping. Permanent clip applied to base of aneurysm. Closure of craniotomy.

Risks and complications

Anaesthetic complications. Medical complications. Death. Clipping and occlusion of perforating vessels cerebral ischaemia. Stroke ­ hemiparesis/speech if dominant hemisphere. Residual neck: · If near anterior communicating or ophthalmic artery ­ risk to vision. · If posterior communicating (iii) nerve ­ ptosis. · If posterior circulation ­ swallowing problems ­ speaking problems. Rupture of aneurysm during procedure. Inability to clip (uncommon). Hydrocephalus. Recurrent SAH. Vasospasm. Subdural, epidural or intracranial haemorrhage. Intracranial infection including meningitis. Seizures. Electrolyte imbalance.

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Neurosurgery

Cerebral Angiogram

Procedure in brief

Pre-op steroid, if asthmatic. Groin shave. Catheterisation of common femoral artery. Catheter advanced into ascending arch of aorta. Introduction of contrast medium into desired extra/intracranial artery. Radiographic films taken in various projections. After procedure, catheter completely removed. Pressure on puncture site for 10­20 minutes.

Risks and complications

Stroke 1/100­1/500. Damage to intracranial arterial wall ­ may lead to partial/complete arterial occlusion with neurological deficit. Embolisation: · Dislodged fragments of atheroma. · Catheter acts as nidus for thrombus formation. Reaction to contrast (in 3%): · Contrast medium toxicity: · Cerebral oedema. · Transient cortical blindness. · Pulmonary oedema. · Cardiac arrest. · Vasovagal reaction. · Cardiac arrhythmia. · Contrast hypersensitivity: · Urticaria. · Bronchospasm. · Laryngo-oedema. · Anaphylaxis. Complications at puncture site (in 5%): · Haematoma and haemorrhage. · Thrombosis. · Local sepsis. · A-V fistula. · Arterial spasm. · Subintimal dissection. · Nerve trauma. · Perivascular extravasation of contrast.

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Neurosurgery

Craniotomy/Stereotactic/Head Trauma/SDH

Procedure in brief

General anaesthetic. Scalp flap incised and reflected. Bone flap fashioned and reflected. Dura opened as a flap. Lesion removed. Closure in layers. May have drain under scalp, arterial line. Usually in hospital 5-7 days.

Risks and complications

· · · · · · · · Death. Stroke. Bleeding. Intracerebral infection. Seizures. Cerebral compression from bleeding or oedema. Wound infection, including bone flap ­may require removal with longer operations. Thromboembolism.

Myelogram

Procedure in brief

Usually via lumbar spine. Lumbar puncture at L3/4 intervertebral space. Introduce contrast medium into lumbar puncture needle. Needle withdrawn after injection. Skin puncture dressed. Imaging commenced ­ plain x-ray projections or CT imaging.

Risks and complications

Post-myelographic headache in 20­30%. Nausea, vomiting and dizziness. Lower back pain. Meningitis. Small risk of neurologic deterioration. Epileptic fits (very rare when using water-soluble contrast). Subdural and epidural injection of contrast.

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Neurosurgery

Cervical Discectomy ­ Anterior or Posterior Approach

Posterior approach

Usually midline muscles dissected away. Some of lamina/foramina removed with aid of microscope. Disk fragments removed until nerve root decompressed (only if disc fragment is lateral enough and spinal cord does not have to retracted).

Risks and complications

Risks of damage to nerve root/spinal cord very low. Failure to improve. Pain. Infection and discitis. Small risk of bleeding.

Anterior approach

Transverse right side between carotid sheath and trachea/oesophagus. Disc removed. Bone graft from hip, bone replacement or cage place into disc space. Occasionally a plate will be used Drain(occasionally).

Risk and complications

As per posterior. Vocal cord injury Airway oedema Sore throat. Oesophageal perforation. Bone graft can become dislodged ­ uncommon.

Pituitary Tumour ­ Excision Transsphenoidal Approach

Procedure in brief

Perioperative glucocorticoids ­ day before and two days after procedure. Enter nares and displace septum to left. Fracture nasal septum at base and displace. Reach and fracture vomer, exposing anterior wall of sphenoid sinus. Open anterior wall of sinus to expose the sellar floor. Fracture sellar floor. Incise dura covering pituitary gland and tumour. Remove tumour. Close sella. Pack nose with nasal airway tubes ­ normally 48 hours.

Risks and complications

Death. Parasellar:

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CSF rhinorrhoea. Hypopituitarism. Diabetes insipidus. Cavernous sinus damage ­ haemorrhage. Cranial nerve injury (CN III & VI). Internal carotid artery injury. Intracranial: · Haemorrhage. · Hypothalamic damage. · Meningitis. · Visual loss · Cerebral ischaemia. Nasal/Sphenoidal: · Sinusitis. · Mucocele. · Palate/Cribriform plate fracture. · Septal perforation. · Nasal deformity ­ not usually a problem. · Epistaxis. · Denervation/desensitization of teeth-not with nasal approach.

· · · · · ·

Lumbar Spine Surgery.

Lumbar Laminectomy.

Procedure in brief

Prone position. Posterior approach. The Surgeon makes a 5-10 cm cut through the skin over the lower back where the nerve is compressed. Dissect through skin, lateral musculature. Surgical instruments are used to push the aside fat and muscle until the spinal column can be seen. The surgeon removes the spinous process. A fine drill is used to cut away all or part of the lamina. This allow the surgeon to see the spinal canal, ligamentum flavum, dura and the nerve root. Then the pressure can be relieved on the nerve root either by removing the bone spur, enlarging the spinal canal, or by widening the intervertebral foramen.

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Neurosurgery

Microdiscectomy.

Procedure in brief.

The procedure relieves compression of a spinal nerve or nerve root caused by a herniated disc. It is similar to lumbar laminectomy but is less invasive, a unilateral dissection After removing part of the lamina and ligamentum flavum ,the surgeon pushes aside the nerve root with a special instrument. The portion of the disc that is compressing the nerve is removed.

Spinal fusion.

To stop adjacent vertebrae from slipping over each another (Spondylolisthesis). An incision and exposure greater than for a laminectomy, Remove lamina, ligamentum flavum an hypertrophied joints Decompress dura and nerve roots Bone graft chips in cages placed between the vertebrae after harvesting it from the iliac spine to create a fusion. The surgeon puts a metal implants to prevent any motion between the vertebrae.

Procedure in brief.

Risks and complications.

· · · · · · · · · ·

Leg symptoms may improve in 65-80% Most patients do have some degree of ongoing back pain Numbness may improve Anaesthetic complications/DVT/PE Dural tear 1 in 20 patients with CSF leak Wound infection. Bleeding, Epidural haematoma. Nerve root damage. No improvement, recurrence of pain due to scaring in 5-10%. Need for blood transfusion

Peripheral Nerve Surgery.

Carpal Tunnel Release(CTR).

Procedure in brief.

Day procedure. GA or LA LA pre and post procedure. IV antibiotics. Tourniquet (surgeon preference) Mid palmar incision.

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Neurosurgery

Flexor retinaculum released under direct vision. Recurrent branch of median nerve identified. Haemostasis. Closure-sutures. Tourniquet released. Dressing-Jelonet,gauze,crepe. Hand elevation. Mobilise as tolerated. Wound review by LMO 3-5 days post op.

Risk and Complications.

· · · ·

· · · · ·

Anaesthetic complication. Bleeding. Infection. Nerve damage: Risk of median nerve damage very low <1/1000. Recurrent branch. Palmar cutaneous branch. Ulnar artery damage. Scar may be tender or irregular. Hand numbness my persist for up to 3 months. Chronic pain. Recurrence of symptoms.

Peroneal Nerve Syndrome.

The common peroneal nerve is located on the outside of the knee joint supplying muscles and skin of the lower leg .If it becomes compressed,foot weakness and numbness occur.

Cubital Tunnel Syndrome.

Procedure In brief.

The ulnar nerve is compressed where is passes behind the elbow. Compression of the nerve can cause hand pain particularly in the ring and little finger and general weakness of the hand.

Surgery involves freeing the nerve from compression and/or transposing it. Day procedure. GA. LA pre and post procedure. IV antibiotics. Tourniquet (surgeon preference) unlikely Haemostasis. Closure-sutures. Tourniquet released. Dressing-Jelonet,gauze,crepe. Elevation. Mobilise as tolerated. Wound review by LMO 3-5 days post op.

Risk and Complications .

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· · · · · · · Anaesthetic complication. Bleeding. Infection. Nerve damage. Numbness my persist. Chronic pain. Recurrence of symptoms.

Nerve Root Block.

Procedure in brief.

Day procedure. Under CT guidance. LA Performed by radiologist.

Risk and Complications.

· · · · · · ·

Infection Bleeding. Nerve damage. Epidural abscess. No benefit and persistence of symptoms. My need repeat of injection. Does not help for numbness or weakness but helps for pain.

VP Shunt .

A Silastic tube is passed from the lateral ventricle ( water buffer system of the brain) to the peritoneal cavity in the abdomen It is to treat hydrocephalus from raised pressure or normal pressure hydrocephalus

Procedure In brief.

GA Right occipital incision and burr hole Subcostal or midline supraumbilical abdominal incision Shunt with a special valve mechanism passed from the ventricle to the peritoneal cavity Wounds closed with absorbable and non-absorbable sutures Prophylactic antibiotics used Post op CT and shunt series performed

o o o o o o o

Anaesthetic risks Intracranial haemorrhage ­ intracerebral, subdural, extradural haematoma Infection Malposition of shunt Seizures Bowel injury Injury, bruising or haematoma along tract

Risk and Complications .

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Orthopaedic Procedures

ORTHOPAEDIC PROCEDURES

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Orthopaedic Procedures

Total Hip Replacement

Procedure in brief

IV antibiotics one hour pre-op. Lateral incision, various approaches. Dissect through fascia, muscle and joint capsule. Dislocate hip and remove femoral head. Trial articulation. Place femoral prosthesis (cemented or uncemented, cabled or non-cabled). Ream acetabulum, insertion of cup (cemented or uncemented). Closure including drains.

Post-op

IV antibiotics, Clexane. Usually mobilising day 1 ­ WBAT, ROM exercises. May require inpatient rehab.

Risks and complications

Anaesthetic complications. Medical complications.

Acute

Blood loss ­ may require transfusion. Infection. DVT/PE ­ possible up to six weeks post surgery. Sciatic nerve palsy/femoral nerve palsy: · Due to retraction (recovers spontaneously). · Intra-operative injury (rare).

Chronic

Wound infection. Infection of prosthesis: · Uncommon (<1%), but serious. · Requires removal of metal plus antibiotics, then later replacement or arthrodesis. Aseptic loosening/wear and tear of metal prosthesis: · Most common problem. · Usual lifespan of THR 10-15 years, revision may be required. Heterotopic bone formation ­ can cause pain and stiffness in severe cases. Dislocation ­ 1-5%. Anibiotic prophylaxis required with major dental procedures.

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Orthopaedic Procedures

Total Knee Replacement

Procedure in brief

IV antibiotics one hour pre-op. Tourniquet. Anterior vertical incision. Dissect through fascia, joint capsule, and patellar tendon. Bone cuts to femur and tibia to align with prothesis. Fix in place femoral and tibial components of prosthesis (usually cemented). Patella usually preserved. Trial articulation and check ROM. Closure including drains. Compression bandage. Zimmer knee splint (remove when quads control is adequate).

Post-op

IV antibiotics, Clexane. Usually mobilising day 1 ­ WBAT, ROM exercises. May require inpatient rehab.

Risks and complications

Anaesthetic complications. Medical complications.

Acute

Blood loss ­ may require transfusion. Infection. DVT/PE ­ risk up to six weeks post surgery. Joint stiffness (permanent). Wound infection.

Chronic

Infection of prosthesis: · Uncommon (<1%), but serious. · Requires removal of metal plus antibiotics, then later replacement or arthrodesis. Aseptic loosening/wear and tear of metal prosthesis: · Most common problem ­ chronic low grade. · Usual lifespan of TKR >10-15 years, revision then required. · After 10 years ­ wear producing instability. Malposition of component requiring revision. Patella maltracking causing pain. Reflex sympathetic dystrophy. Antibiotic prophylaxis required with major dental procedures.

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Orthopaedic Procedures

Knee Arthroscopy

Procedure in brief

Examination under anaesthetic. Tourniquet. Anterior incisions 2-3mm each x three. Inspect all compartments of knee: · Medial, lateral, patello-femoral. · Inspect meniscal, cruciate ligaments, articular cartilage. Debride or suture miniscal tears, debride worn articular cartilage, remove foreign body. Irrigate joint with copious sterile water. Closure. Compression bandage ± Zimmer knee splint or Hinge knee brace.

Risks and complications

Anaesthetic complications. Medical complications. Septic arthritis (very rare 1:10 000). Deep vein thrombosis (very rare). Damage to infrapatellar branch saphenous nerve.

Anterior Cruciate Ligament Reconstruction

Procedure in brief

Examination under anaesthetic. Tourniquet. Incisions ­ three anterior 2-3mm (as per arthroscopy) and 3cm longitudinal medial to proximal tibia for harvesting of graft. Harvesting of graft (usually hamstrings tendon). Graft anchored with screws to tibia and femur. Saline irrigation of joint. Closure. Compression bandage and Zimmer knee splint.

Post-op

Usually WB in Zimmer knee splint for six weeks. Rehabilitation protocol dependent on surgeon: · ROM exercises immediately post-op ­ progress to full ROM by six weeks. · Quads exercises within 2-4 weeks. · Closed chain exercises, including aquatic exercises by 4-6 weeks. · Open chain exercises >3 months. · Swimming >3 months. · Straight line running at four months, if quads strength is adequate. · Contact sports at six months if ROM, quads and hamstrings strength and proprioception adequate.

Risks and complications

Anaesthetic complications.

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Medical complications. Rupture ­ highest in six weeks post-op. Graft donor site pain. Deep vein thrombosis (very rare).

High Tibial Osteotomy

Procedure in brief

Tourniquet knee flexed 90°. Incision laterally for varus deformity, ie, valgarising osteotomy. Identify common peroneal nerve. Release fibular head. Remove wedge of bone proximal to attachment of patellar ligament with saw cuts. Base of wedge is lateral in correction of varus. Defect closed and stapled in position. Closure.

Risks and complications

Anaesthetic complications. Medical complications. Failure to relieve symptoms. Wound or deep infection. Common peroneal nerve injury. Popliteal artery, nerve, vein injury. Compartment syndrome (windswept appearance), especially short limbed females.

Correction of Bunion

Procedures

Soft tissue release ­ modified McBride procedure: · Release of contracted lateral structures (lateral capsule, adductor tendon, intermetatarsal ligament) and partial excision of medial joint capsule. · Chevron osteotomy: · V-shaped cut in metatarsal head, allowing lateral displacement · K-wire fixation. · Proximal osteotomy and soft tissue release:

·

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Orthopaedic Procedures

Procedure in brief

GA/Spinal. Assess circulation to foot. Tourniquet to thigh. Incision over medical aspect of 1st metatarsal/MTPJ/1st phalanx. Reflection of tendons. Osteotomy and/or K-wire. Re-suturing of tendons. Sometimes 2nd toe also corrected. Closure.

Post-op

Plaster she/boot to stabilise for six weeks. Mobilising day 1 ­ FWB or heel WB. Removal of wire at a later date.

Risks and complications

Recurrence/failure to fully correct deformity. Wound infection. Painful neuroma (division of dorsal branch of digital nerve). Osteonecrosis of metatarsal head (Chevron osteotomy).

Removal of Intramedullary Metal or Diastasis Screw

Procedure in brief

Tourniquet. Incision over proximal and distal screw(s) via old scars. Dissect onto and remove screws. Dissect onto proximal end of intramedullary nail. Engage extension devise and hammer nail from medullary canal. Close.

Risks and complications

Wound infection. Deep vein thrombosis. Fracture through screw holes. Part of broken screw may be retained.

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Orthopaedic Procedures

Arthrodesis

Procedure in brief

Fuse a joint to prevent all movement. Procedure varies for each joint. Internal fixation ± bone graft.

Risks and complications

Non-union. Malunion. Bone graft/donor site problems.

Open Reduction and Internal Fixation ­ Femur (Fractured Neck of Femur)

Procedures

Dynamic hip screw. Gamma nial. Reconstrjuction nail. Hemiathroplasty.

Procedure in brief

Traction. Attempt external reduction ­ check with image intensifier. Incision over lateral aspect of hip. Division of fascia and muscles. Guide wire passed over front of femoral neck to check alignment. Screws inserted. Image intensifier to confirm position of screws. Removal of guide wire. Repositioning of neck and insertion of screws Screw position checked using image intensifier. Skin closure ± drain.

Post-op

IV antibiotics, Clexane. Usually WBAT ­ may be TWB/PWB, depending on fracture.

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Risks and complications

Anaesthetic complications. Medical complications. Avascular necrosis of head of femur. Infection. DVT/PE. Hematoma. Malunion/non-union/delayed union. Loss of fixation (screws pulling out of porotic bone). Deformity. Fracture below the plate.

Open Reduction and Internal Fixation ­ Femur (Femoral Shaft Fracture ­ Intramedullary Nail)

Procedure in brief

Traction. Reduction under image intensifier. Lateral incision 6-8cm. Insertion of guide wire under image intensifier. Insertion of nail (usually reamed). 2-3mm incisions for insertion of proximal and distal interlocking screws. Image intensifier to confirm position. Skin closure.

Post-op

IV antibiotics, Clexane. Mobilising NWB day 1. NWB with crutches 8-10 weeks. Supported quads exercises.

Risks and complications

Anaesthetic complications. Medical complications. Bleeding/haematoma. Infection. DVT/PE. Compartment syndrome. Malunion/non-union/delayed union. Knee stiffness.

Open Reduction and Internal Fixation ­ Tibia (Tibial Plateau Fracture)

Procedure in brief

Midline incision or incision centred over tibial tubercle and curved over affected condyle.

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Knee joint entered, washed out. Meniscus elevated. Defect in articular surface of condyle reconstructed ± bone graft from iliac crest. Fracture fixed with screw Closure. Zimmer knee splint.

Post-op

NWB with crutches, ROM exercises for six weeks. PWB to FWB at 8-12 weeks.

Risks and complications

Degenerative arthritis in long term. Knee stiffness. Infection. Hematoma. Bone graft donor site problems ­ pain, infection.

Open Reduction and Internal Fixation ­ Tibia (Fracture of Shaft of Tibia ­ Intramedullary Nail)

Procedure in brief

Tourniquet. Reduction under image intensifier. Intrapatellar incision. Retraction of patellar tendon. Insertion of nail (reamed). Insertion of proximal and distal locking screws via small medial incisions. Closure. POP back slab.

Post-op

NWB for at least 6-8 weeks.

Risks and complications

Knee pain 40% - indication for removal of nail. Slow union ­ average 16 weeks. Compartment syndrome. Infection.

Open Reduction and Internal Fixation ­ Ankle Fractures

Procedure in brief

Tourniquet. Reduction. Skin incision ­ lateral/medial. Type of fixation dependent on fracture ­ compression plate, screws, diastasis screw. Insertion under image intensifier.

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Skin closure. POP back slab.

Post-op

NWB for at least six weeks. If diastasis screw used, needs removal at 6-8 weeks. Return to activities: Swimming once POP removed. Stationary cycling once knee flexion will allow (110°). High impact once callous has fully developed, knee flexion is near normal 130°) and quads power is restored. Work as soon as possible, within limitations.

Risks and complications

Degenerative arthritis. Wound infection and hematoma. Stiffness. Non/Mal/delayed union. Long recovery perceived.

Shoulder Arthroscopy

± Subacromial Decompression/Rotator Cuff Repair/ Bankart

Lesion Repair

Procedure in brief

Lateral decubitus or beach chair position. Examination under anaesthetic. Three incisions 2-3 mm each ­ anterior superior, posterior. Inspection: · Superior, posterior, inferior. · Inspect articular cartilage, tendons, labrum. Debride tears and worn articular cartilage, remove foreign body. Repair tears with sutures/anchors ­ usually done through mini-open (3cm) incision. Decompression (shave bone from acromion) if repair performed. Saline irrigation of joint. Closure. May require conversion to open ­ incision along lateral border of acromion.

Post-op

Mobilise immediately if no repairs performed, otherwise sling immobilisation 4-6 weeks. Rehabilitation protocol dependent on procedure: · Active finger, wrist and elbow ROM once pain allows. · Pendular movements at 2-4 weeks. · ROM exercises by 4-6 weeks. · Abduction and external rotation at six weeks. · Lifting and loading at six weeks. · Contact sports >3-6 months.

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Risks and complications

Anaesthetic complications. Medical complications. Shoulder stiffness. Wound infection, if conversion to open (1-5%) Septic arthritis (very rare 1:10 000). Post-operative pain (fluid distension of tissues). Slow healing. Recurrence of symptoms.

Open Reduction and Internal Fixation ­ Fractures of Proximal Humerus

Procedure in brief

Supine. Lateral incision over deltoid. Protect and ligate cephalic vein. Detach deltoid from clavicle. Identify long head of biceps. Fixation with compression plate and srews. Reattach the deltoid using Vicryl sutures. Close in layers over a suction drain. May require conversion to hemiarthroplasty.

Post-op

Immobilise in sling/brace for two weeks. Active finger/wrist movements once pain allows. Commence pendular movement at two weeks. Commence ROM exercises 2-4 weeks.

Risks and complications

Avascular necrosis of head. Head dislocation. Wound infection. Non-union/malunion. Stiff shoulder.

Hemiarthroplasty of Shoulder

Procedure in brief

Supine or beach chair position. Deltopectoral incision. Retract deltoid. Capsulotomy. Remove humeral head. Insert prosthesis (may be cemented). Chondrosplasty. Reduce the prosthesis and suture the defect in the rotator cuff (attach cuff to prosthesis).

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Orthopaedic Procedures

Perform a partial subacromial decompression to prevent post-operative impingement. Close in layers over a suction drain.

Post-op

IV antibiotics. Active finger, wrist and elbow ROM once pain allows. Commence pendular movements immediately. No external rotation or loading until six weeks (to avoid tearing of muscle repairs).

Risks and complications

Acute

Anaesthetic complications. Medical complications. Wound infection. Bleeding. Nerve injury ­ particularly axillary nerve. Impingement. Prosthesis dislocation and infection.

Chronic

Aseptic loosening causing pain ­ may necessitate revision. Infection ­ if severe may require revision or replacement of prosthesis. Stiff shoulder. Shoulder instability. Antibiotic prophylaxis required with major dental procedures.

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Orthopaedic Procedures

Fractures of Humeral Shafts

Indications

Segmental fracture. Multiple injuries. Pathological fracture. Radial nerve palsy Non-union.

Procedure in brief

Anterolateral skin incision. Division of fascia. Deltoid retracted laterally and biceps medially. Brachialis muscle retracted. Fracture reduced. Insertion of plate and screws or intramedullary nail with interlocking screws. Cancellous bone graft is packed around the fracture, if there is non-union. Wound closed in layers over a suction drain.

Post-op

Active finger/wrist movements once pain allows. Commence pendular movements immediately. Commence ROM exercises 2-4 weeks. Lifting and loading at six weeks.

Risks and complications

Radial nerve palsy. Wound infection. Wound haematoma. Non-union.

Open Reduction and Internal Fixation ­ Supracondylar Fracture of Humerus

Procedure in brief

Lateral position with the affect arm uppermost and resting in a support. Midline incision over the olecranon. Triceps reflected to expose fracture. Ulnar nerve identified and preserved. Fracture reduced. Reduction maintained by a cancellous screw. Both condyles are reattached to the shaft using well-contoured DCP plates. Triceps flap repaired. Closure.

Risks and complications

Failure of fixation. Injury to the ulnar/radial nerve.

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Wound infection. Wound haematoma. Non-union/malunion. Stiffness. Heterotopic ossification.

Fractures of Olecranon ­ Tension Band Wiring

Procedure in brief

Tourniquet. Supine with arm across the chest. Incision over the olecranon and distally for 5cm. Fracture cleaned and reduced. Two parallel K-wires inserted. A flexible wire is passed deep to the K-wires. The wire is tightened to achieve compression of the fracture. Skin closure. POP back slab.

Post-op

Back slab for two weeks. Commence ROM exercises at two weeks. Lifting and loading at six weeks.

Risks and complications

Failure of fixation. Wound infection/haematoma. Non-union/malunion. Heterotopic ossification.

Displaced Fractures of the Radial Head

Procedure in brief

Supine with arm on arm board and pronated. Incision from lateral epicondyle to subcutaneous border of the ulna below the olecranon. Dissect between origin of ECU and anconeus. Posterior interosseous nerve identified. Incision of joint capsule parallel and proximal to nerve. If there is wide displacement, excision of the whole head preserving the annular ligament. Radial head may be replaced with prosthesis if there is valgus instability. If internal fixation required, a lag screw is used. Closure.

Post-op

Immobilisation in sling for 2-3 weeks.

Risks and complications

Posterior interosseous nerve damage.

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Wound infection and haematoma. Stiffness. Late excision of radial head (after union) if ROM severely restricted ­ reassessment at 2-3 months.

Fractures of Radial and Ulnar Shafts

Procedure in brief

Tourniquet. Separate longitudinal skin incisions to expose fracture. Dissect between muscle bellies. Identify brachioradialis and protect radial nerve. Identify and protect posterior interosseous nerve. Elevate or dissect supinator at the base. Fractures exposed and reduced. Reduction is maintained by small dynamic compression plates with interfragmentary compression with or without lag screws. Closure. POP back slab.

Risks and complications

Compartment syndrome. Radial nerve palsy. Posterior interosseous nerve damage. Non-union/malunion. Wound infection.

General Anaesthetic Manipulation Procedure (GAMP) and K-wire of Distal Radial and Ulnar Fractures

Procedure in brief

GA. Tourniquet. Close reduction. Percutaneous insertion of 2-3 K-wires under image intensifier guidance. Alcohol-soaked gauze applied to K-wire sites. Below-elbow POP applied.

Post-op

Usually requires overnight admission. Removal of K-wires at six weeks.

Risks and complications

Non-union/malunion. K-wire site infection. Wrist stiffness.

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Orthopaedic Procedures

Open Reduction and Internal Fixation ­ Fracture Waist of Scaphoid

Procedure in brief

Supinate forearm. Volar incision on the radial side of and parallel to the tendon of FCR. Distally, incision curves in line with the thumb. Incise the joint capsule. Expose scaphoid fracture. Fix fracture with Herbert screw or an AO small-fragment screw ± bone graft from distal radius or iliac crest. POP back slab applied.

Risks and complications

Wound infection. Damage to the recurrent branch of median nerve. Damage to deep branch of the radial artery. Non-union. Recurrent pain and persisting instability. Avascular necrosis of proximal fragment. Donor graft site pain/infection.

Manipulation under Anaesthesia

Frozen Shoulder

Procedure in brief

Light sedation/GA. Passive movement of shoulder in all ranges of movement. ± injection local anaesthetic and steroid.

Risks and complications

Recurrence requiring further manipulation. Theoretical risk of dislocation/fracture. Pain.

Intra-articular Injection of Anaesthetic/Steroid

Procedure in brief

Palpation. May require ultrasound guidance. Often requires a series of treatment.

Risks and complications

For short term symptomatic relief, not curative. Temporary pain post injection (1-2 days).

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Orthopaedic Procedures

Ineffectiveness and persistence of symptoms. Tendon rupture (large amount of steroids injected). Infection. Injection into spinal canal (in spinal facet joint injections).

Cervical Discectomy and Fusion

Procedure in brief

Supine position. Anterolateral approach via transverse incision. Dissect carefully through skin and neck structures onto cervical spine anteriorly between carotid and trachea. Disc substance and adjacent bone removed. Bone graft taken (usually from iliac crest) and vertebrae fused. Alternatively, metal interbody prosthesis plus bone graft may be applied. Closure. Neck brace for 12 weeks.

Risks and complications

Anaesthetic complications. Medical complications. Infection in graft or metal. Wound infection or haematoma: · Neck wound. · Iliac crest graft site. Failure of procedure to rectify pain. Damage to vital neck structures ­ especially VOICE problems. Post operative dysphagia (temporary). Failure of fusion (10%).

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Orthopaedic Procedures

Laminectomy

Procedure in brief

Prone position. Posterior approach. Dissect through skin, lateral musculature and ligamentum flavum. Identify and expose nerve root and dura, retract medially. Remove all stenotic osteophytic and fibrous material, over multiple levels, if necessary. Laminectomy performed ­ partial or complete removal of lamina ± iskectomy. Haemostasis and closure.

Risks and complications

Anaesthetic complications. Damage to nerve root. Epidural haematoma. Wound infection. Paraplegia if surgery above L3. Latest recurrence of pain and problems due to permanent scaring. Procedure produces resolution of leg pain but back pain may persist. Occasionally causes instability of spine requiring fusion. Dural tear with CSF leak.

Lumbar/Thoracolumbar Instrumented Fusion

Procedure in brief

Prone position. Posterior approach. Dissect through skin and lateral musculature. Remove any pathology, eg, vertebral tumour, disc or reduce spondylolisthesis. Expose transverse process of proximal and distal vertebral anchor points. Screw rod supports in correct alignment on transverse process. Bend longitudinal rods into correct alignment and bolt onto rod supports. Add bone graft from iliac crest as appropriate. Closure of layers. Anterolateral approach via abdomen can also be used. In this case, an interbody "cage" prosthesis and bone graft is used (no rods or screws).

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Orthopaedic Procedures

Risks and complications

Anaesthetic complications. Medical complications. Wound infection or haematoma: · Operative wound. · Iliac crest bone graft site. Damage to nerve roots or spinal cord. Infection of metal instrumentation. Failure of procedure to rectify pain. Failure of fusion: · 1 level 10%. · 2 levels 20%. If anterolateral approach used: · Damage to intra-abdominal or retroperitoneal structures including GIT and IVC/Aorta. · Damage to cutaneous sensory nerves (temporary or permanent) by retraction.

Myelogram

Procedure in brief

Usually via lumber spine. Lumbar puncture at L3/4 intervertebral space. Introduce contrast medium into lumbar puncture needle. Needle withdrawn after injection. Skin puncture dressed. Imaging commenced ­ plain x-ray projections or CT imaging.

Risks and complications

Post-myelographic headache in 20-30%. Nausea, vomiting, dizziness. Lower back pain. Meningitis. Small risk of neurologic deterioration. Epileptic fits (very rare when using water-soluble contrast). Subdural and epidural injection of contrast. Dural leak (rare).

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Plastic Surgery

PLASTIC SURGERY

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Plastic Surgery

Excision of Lesion with Primary Local Closure

Procedure in brief

LA or GA. Tourniquet if site is on limb. IV antibiotics. Excision of lesion with adequate macroscopic margins. Specimen sent for histopathology. Haemostasis. Closure. Tourniquet released. Dressing ­ steristrips, gauze, micropore.

Post-op

Usually day procedure. Wound review in dressing clinic.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Neurovascular damage ­ depending on area. Scar. Dehiscence. Need for re-excision if margins inadequate. Note: may require secondary closure after histological confirmation of diagnosis and adequate excision margins.

Keystone Design Perforator Island Flap

Procedure in brief

GA. Tourniquet if site is on limb. IV antibiotics. KDPIF raised and mobilised with blunt dissection. Meticulour haemostasis. Irrigation. May require skin graft or free flap for closure of secondary defect. Closure. Redivac drain. Tourniquet released. Dressing ­ jelonet, gauze, crepe ± backslab/splint.

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Plastic Surgery

Post-op

Positioning to reduce pressure on flap site. ± immobilisation with backslab/splint. IV antibiotics. DVT prophylaxis. Progressive removal of sutures: Loops cut at two weeks. Tension sutures at three weeks. Final sutures at 3-4 weeks.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Neurovascular damage. Dehiscence. Flap failure. Suboptimal cosmetic result. Potential involvement in clinical trial/study at Western Hospital. CT angiogram will be needed: · To define the vascular supply pre-op. · To review the flap vascularity post-op.

Split Skin Grafting

Procedure in brief

GA. IV antibiotics. Debridement ± excision. Haemostasis. Graft harvested with Brathwaite or Dermatome ­ donor site usually anterolateral thigh. Graft fenestrated or meshed. Graft positioned and secured with staples Dressing to graft site ­ jelonet, gauze, mefix. Dressing to donor site ­ Kaltostate, gauze, mefix.

Post-op

Positioning to reduce pressure on graft site. IV antibiotics. DVT prophylaxis. Adequate nutrition. Rest in bed until graft taken (five days). Change of donor site dressing at day two and day 12.

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Plastic Surgery

Risks and complications

Anaesthetic complications. Bleeding (graft and donor site). Infection (graft and donor site). Graft failure and need for re-operation. Suboptimal cosmetic result.

Breast Reduction Mammoplasty (Hall Findlay Technique)

Pre-op

Stop smoking. Weight reduction.

Procedure in brief

GA. LA pre and post procedure. IV antibiotics. Skin incision ­ either vertical or anchor. Removal of breast tissue. Excised tissue weighed and sent for histopathology. Copious irrigation. Haemostasis. Closure in layers with nomocryl. Drain. Dressing ­ steristrips, gauze, microfoam. Nipple viability checked.

Post-op

Usually discharged day one or two. May be discharged with drain tubes in situ to be removed in clinic. Dressing left intact until outpatient review 5-7 days post-op. Usually requires two weeks sick leave from work. Firms sports bra for six weeks. Avoid tennis/golf for six weeks.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Seroma. Suboptimal cosmetic result ­ scar, shape/size asymmetry.

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Plastic Surgery

Nipple: · Abnormal shape. · Change in sensation ­ loss or increased sensibility. · Future breastfeeding may or may not be possible. Death.

Removal of Breast Prostheses

Procedure in brief

GA. LA pre and post procedure. Scar excised. Capsule exposed. Implants removed. Capsule debrided ± excised. Mastopexy may be required, depending on position. Irrigation. IV antibiotics. Drain tube. Closure in layers with monocryl. Dressing ­ steristrips, gauze, microfoam.

Post-op

Day procedure or discharged day one post-op. May be discharged with drain tube in situ, to be removed in clinic. Firms sports bra for six weeks. Avoid tennis/golf for six weeks if mastopexy performed.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Pneumothorax. Suboptimal cosmetic result ­ scar, shape/size asymmetry.

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Plastic Surgery

Carpal Tunnel Release

Procedure in brief

GA. LA pre and post procedure. IV antibiotics. Tourniquet. Mid palmar incision. Flexor retinaculum released under vision. Recurrent branch of median nerve identified. Haemostasis. Penrose drain. Closure ­ catgut sutures. Tourniquet released. Dressing ­ jelonet, gauze, crepe. Backslab.

Post-op

Day procedure. Sling elevation. Wound review 3-5 days post-op. Removal of drain in clinic at one week. Removal of backslab and sutures at two weeks. Mobilise hand once wound healed.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Nerve damage: · Risk of median nerve damage very low <1/1000. · Recurrent branch. · Palmar cutaneous branch. Scar ­ may be tender or irregular. Hand numbness ­ may persist for up to three moths (but pain free). Recurrence of symptoms. Chronic pain.

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Plastic Surgery

Excision of Ganglion

Procedure in brief

GA. LA pre and post-procedure. Tourniquet. Incision. Meticulous dissection, identifying and preserving neurovascular structures. Ganglion excised and sent for histopathology. Closure ­ catgut sutures. Tourniquet released. Dressing ­ jelonet, gauze, crepe. May require local flap or skin graft if ganglion is on finger.

Post-op

Elevate hand. Dressing to remain intact until wound review in clinic within one week.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Neurovascular and tendon damage. Scar. Recurrence ­ up to 30%. Failure to relieve symptoms of pain/discomfort.

Open Reduction and Internal Fixation ­ Metacarpal Shaft Fractures

Procedure in brief

GA. IV antibiotics. Tourniquet. Dorsal skin incision in line with the affected metacarpal or between the metacarpals. Periosteum stripped from fracture. Fracture reduced. Fixation with small fragment plate or compression screws. Confirmation of position with image intensifier. Closure of periosteum. Skin closure. Tourniquet released. Dressing ­ jelonet, gauze, crepe. POP backslab or radial/ulnar gutter splint, depending on which metacarpal is fractured (wrist in slight extension, MCP flexion to 70, IP joints neutral, free to mobilise within splint).

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Plastic Surgery

Alternative procedure is GAMP and K-wire, with removal of the wires at three weeks.

Post-op

Day procedure. Sling elevation of hand. Oral antibiotics 3-5 days, if open fracture. Dressing to remain intact until clinic review. Commence early mobilisation at day 3-5 with hand therapist ­ splintage for protection between exercises. Removal of stitches at two weeks. Splint for total of 3-4 weeks. GAMP and K-wire ­ K-wires removed at three weeks, immobilise in splint for 4-6 weeks. Post-K-wire removal x-ray not required, unless fracture is complex.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Stiffness of the hand. Wound infection ­ including of K-wire site. Scar. Nerve damage. Non-union/malunion. Chronic pain.

Dupuytren's Fasciectomy

Procedure in brief

GA or nerve block. Tourniquet. Incision (several methods). Meticulous dissection and preservation of neurovascular bundle. Palmar fasciectomy of affected fingers. Z-plasty or flap closure. Axial K-wire may be inserted for immobilisation. Penrose drains. Closure. Tourniquet released. Dressing ­ jelonet, gauze, crepe, backslab.

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Plastic Surgery

Post-op

Overnight stay if multiple fingers. IV antibiotics, then discharged with oral antibiotics if diabetic. Hand elevation. Removal of sutures ± K-wire at two weeks. Wound dressings for 2-4 weeks. Splint immobilisation for two weeks, night splint for six weeks. Hand therapy.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Neurovascular damage, including possibility of requiring amputation if severe. Recurrence. Scar. Suboptimal cosmetic result. Failure to correct deformity completely. Hand stiffness. Chronic regional pain syndrome.

Trigger Finger Release

Procedure in brief

LA or nerve block. Tourniquet. Transverse incision 2cm, just distal to palmar crease at affected finger. Dissection ­ identification and preservation of neurovascular bundle. Release of tendon sheath using scalpel or scissors. Confirmation by passive flexion and extension of fingers. Closure. Tourniquet released. Dressing ­ jelonet, gauze, crepe, backslab.

Post-op

Day procedure. Removal of sutures at two weeks. Normal use of finger after wound has healed.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Digital nerve and artery damage. Tendon injury. Scar. Symptom recurrence, if release incomplete.

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Plastic Surgery

Open Extensor Tendon Repair (Mallet Finger)

Procedure in brief

GA or LA. Tourniquet. May require proximal extension of skin laceration. Debridement and washout. Identification and preservation of neurovascular bundle. Tendon repair ­ roll suture. Axial K-wire may be inserted for immobilisation (particularly if avulsion fracture present). Closure. Tourniquet released. Dressing ­ jelonet, gauze, crepe. Backslab/splint.

Post-op

Day procedure. Removal of sutures at three weeks. Removal of K-wire at four weeks. Finger splint immobilisation for 6-8 weeks full-time. Progressive exercise program with hand therapy.

Risks and complications

Anaesthetic complications. Infection. Neurovascular damage. Tendon rupture. Swan neck deformity. Residual DIP extensor lag. Chronic regional pain syndrome. May require future arthrodesis.

Finger Tip Reconstruction ­ Local Neurovascular Island Flap and Full-Thickness Skin Graft

Procedure in brief

GA. IV antibiotics. Tourniquet. Debridement. Neurovascular island flap raised and advanced into defect. Full-thickness skin graft harvested from forearm (usually ulnar wrist or below the elbow). Graft positioned over secondary defect. Closure of graft and donor sites. Tourniquet released. Dressing ­ jelonet, gauze, crepe, backslab.

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Plastic Surgery

Post-op

Overnight admission. IV antibiotics. Elevate hand. Frequent dressing changes. Finger splint.

Risks and complications

Anaesthetic complications. Bleeding. Infection. Suboptimal cosmetic result. Flap failure. Pain, including chronic regional pain syndrome. Numbness. Slow healing.

General Anaesthetic Manipulation Procedure ­ Nose Fracture

Procedure in brief

GA. Closed reduction. May require osteotomy ­ small incision along nasal side wall. Application of thermoplastic splint.

Post-op

Splint to remain in situ for 10-14 days. Avoid blowing nose for two weeks. Splint removed in clinic. Avoid contact sports for at least six weeks.

Risks and complications

Anaesthetic complications. Bleeding. Septal haematoma. Incomplete reduction. Suboptimal cosmetic result ­ deviation, bump, saddle nose (bridge collapse).

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Thoracic Surgery

THORACIC SURGERY

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Thoracic Surgery

Video Assisted Thoracic Surgery Lobectomy

Procedure in brief

Establish single lung ventilation. Lateral decubitus position. Ports inserted (camera port usually eighth intercostal space). Upper lobe retracted laterally to allow exposure of superior pulmonary vein. For right upper lobectomy Superior pulmonary vein is dissected from pleura and then divided using cutting stapling device. Transection of arterial branch using stapler. Transection of right upper lobe bronchus and recurrent branch of pulmonary aratery. Middle and lower lobes retracted inferiorly and upper lobe retracted superiorly. Fissure is exposed and stapler is used to divide the upper lobe. For right lower lobectomy Lower lobe retracted superiorly and pulmonary ligament transacted. Inferior pulmonary vein dissected and transacted using stapler. Lower lobe bronchus and then pulmonary artery transacted. Division of fissure. For right middle lobectomy Middle lobe retracted laterally. Middle lobe vein transacted exposing middle lobe bronchus. Bronchus transacted followed by middle lobe arteries. For left upper lobectomy Left upper lobe retracted laterally. Transection of vein, artery and then bronchus. For left lobectomy Lower lobe retracted superiorly. Pulmonary ligament transacted. Pulmonary vein, artery and then bronchus transacted. Intercostal chest tubes inserted and attached to underwater seal. Recovery post-op chest x-ray before patient is returned to ward.

Post-op

TEDS stockings and clexane. Daily chest x-rays to assess for lung re-inflation, pneumothorax, hemothorax, atelectasis and empyema. Early chest physiotherapy and mobilisation. Good analgesia with Pain Team referral (patient may have epidural). Daily measurement of drainage and assessment of underwater seal.

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Thoracic Surgery

Risks and complications

Anaesthetic complications. Medical complications (eg, AMI, stroke, confusion, hypoxia, etc). Acute: Blood loss, infection (empyema), pneumothorax, hemothorax, DVT/PE, wound site infection, pneumonia. Chronic: Pain, persistent pleural effusion.

Intercostal Chest Tube Insertion

Procedure in brief

Good positioning of patient (either supine or lying in bed at 45 degrees). Adequate exposure of chest and surface marking (5th intercostal space of affected lung, anterior to the mid-axillary line, roughly around the level of the nipple). Good premedication (short acting midazolam 1-5mg iv and/or morphine, unless patient is dyspneic). Infiltration of skin with lignocaine and adrenaline. Prep and drape. Skin incision (1.5 times tube diameter) over rib to avoid neurovascular bundle (located underside of each rib). Blunt dissection using hemostat and index finger towards pleura. Tunnel above the rib to avoid neurovascular bundle. Once `pop' sound heard, pleura cavity is entered. Gush of air or fluid out of incision can also occur. Insert chest tube by guiding it into cavity carefully with hemostat. Do not use Trocar. Position chest tube until last perforation is inserted. Secure chest tube with purse string. Connect tube to underwater seal and to wall suction. Bubbling indicates adequate suction to remove gas and will continue as long as there is air leak. Tape tube to chest and confirm placement with chest x-ray.

Risks and complications

Acute: Blood loss, injury to intercostal nerves, perforation to lung, large vessels, heart, abdominal viscera. Chronic: Infection (empyema), persistent pain, persistent air leak if tube is not inserted properly or if there is defect in tubing/connection.

Indications

Pneuothorax. Pyothorax. Hemlothorax. Pleural effusion.

Precautions

Coagulopathy. Skin infection over propose insertion site.

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Thoracic Surgery

Mediastinoscopy

Procedure in brief

Patient is placed under general anaesthesia with neck hyperextended. Prep and drape entire sternum and anterior cervical region. Approximately 2cm above sternal notch, a 3cm wide incision is made transversely. Platysma divided transversely. A vertical plane is developed between strap muscles down to level of trachea. Division of pretracheal fascia in caudal direction. Insertion of mediastinoscope in the pretracheal plane.

Post-op

Chest x-ray in recovery area to exclude pneumothorax or oesophageal perforation (subcutaneous emphysema with poor clinical picture). Monitor oxygen saturations closely. Beware of bleeding, especially if haematoma is compressing airway. Review wound site daily. Usually an overnight stay in hospital. Review in 2-3 weeks at outpatients department.

Risks and complications

Haemorrhage: aorta, innominate artery, pulmonary artery, bronchial artery, vena cava, azygous vein. Oesophageal perforation. Stroke. Left recurrent nerve laryngeal injury. Phrenic nerve injury. Pneumothorax. Wound infection. Chylothorax. Air embolism. Sore throat. Chest soreness. Rare: tumour spread to neck incision.

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Upper GI Surgery

UPPER GI SURGERY

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Upper GI Surgery

Fundoplication

Procedure in brief

Laparoscopic

4-ports/incisions in abdomen. Bougie may be placed in oesophagus (via oropharynx) as template for repair. Liver and omentum retracted. Lower oesophagus and proximal stomach mobilised. Fundus of stomach wrapped and sutured around distal oesophagus to create new sphincter. Diaphragmatic hiatus narrowed. Closure.

Open

Similar procedure through upper abdominal incision.

Risks and complications

Anaesthetic complications. Medical complications, especially respiratory. Laparoscopic complications.

Early

Inadvertent splenic injury. Perforation oesophagus/fundus stomach. Postoperative dysphagia, bloating, flatulence (usually resolve 2-6 weeks). Deep vein thrombosis.

Late

Failure of procedure. · Recurrence of reflux. · Recurrence of herniation. · Breakdown of repair. Excessively tight or long repair may be symptomatic. Slipping of fundoplication.

Partial Gastrectomy ­ Gastroduodenal Anastomosis (Bilroth 1 type)

Procedure in brief

Upper midline incision or bilateral subcostal. Mobilise duodenum. Mobilise greater and lesser curves. Transect duodenum just distal to pylorus. Transect stomach between lesser and greater curve. Create gastroduodenal anastomosis. Drain tube in situ.

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Upper GI Surgery

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Risks and complications

Refer to Total Gastrectomy section.

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Upper GI Surgery

Partial Gastrectomy ­ Gastrojejunal Anastomosis (Bilroth 11 or Polya type)

Procedure in brief

Mobilise stomach and duodenum. Transect duodenum just distal to the pylorus. Close duodenal stump. Transect stomach at level required. Create a gastrojejunal anastomosis with the afferent loop jointed to lesser curve. Drain tube in situ.

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Risks and complications

Refer to section Total Gastrectomy section.

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Upper GI Surgery

Total Gastrectomy

Procedure in brief

Upper midline incision. Rarely, left thoracoabdominal approach. Separate greater omentum from transverse colon. Mobilise duodenum. Ligate vessels to stomach and duodenum. Transect duodenum beyond pylorus and close stump. Free stomach. Mobilise lower oesophagus. Divide vagi. Transect oesophagojejunal anastomosis. Join duodenal loop end­to­side to the jejunum. Drain tube in situ. Closure. Note: Patient will require in jejunostomy feeding.

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Upper GI Surgery

Risks and complications

Respiratory complications. Haemorrhage. Anastomotic leakage. Anastomotic stricture. Bilious vomiting. Dumping syndrome. Gastric retention with postprandial bloating, regurgitation and vomiting. Diarrhoea. Metabolic complications. Damage to adjacent structures ­ spleen, common bile duct, pancreas.

Oesophagectomy

Transthoracic approach

Procedure in brief

Involves two incisions. Abdominal incision made in the midline of upper abdomen. Mobilise stomach and lower oesophagus. Pyloroplasty usual (as Vagus nerves are divided). Thoracic incision made, with patient on L) side. R/ thoracotomy at level of R/5th or 6th rib. Dissect and mobilise oesophagus from thoracic bed. Transect oesophagus at cardia and above the tumour. Anastomose oesophagus to fundas of stomach in upper chest. Drain ­ ICC (chest). Close.

Transhiatal approach

Procedure in brief

Abdominal midline incision and incision along anterior border of sternomastoid muscle. Entire thoracic oesophagus excised after blunt transhiatal mobilisation of oesophagus. Create oesphophagogastric anastomosis in neck. Closure.

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Upper GI Surgery

Risks and complications

Death ­ mortality rate 5%-10% Morbidity 50%: · Most will be respiratory complications: · Bronchopneumonia. · Aspiration pneumonia. · Atelectasis. · Pleural effusion. · Anastomotic leak. · Reflux/dumping syndromes/delayed gastric emptying. · Venous thromboembolism.

Late

Dysphagia secondary to tumour recurrence or anastomotic stricture.

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Urology

UROLOGY

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Urology

Cystoscopy/Cystourethroscopy/Transurethral Resection of Bladder Tumours (TURBT)

Procedure in brief

Direct visualisation of urethra and bladder using fibre optic scope. Genitalia cleansed, urethra lubricated. Insertion of the scope with irrigation fluid running. Examination of the mucosa.

Manouevres

Biopsy of suspicious lesions. Diathermy of bladder tumours (TURBT). Diathermy of bleeding points. Bladder washout. Ureteroscopy: · Catheterisation of ureter to all for injection of radio-opaque contrast for x-ray studies (ie, retrograde pyelogram). · Bypass of suspicious ureteric lesions. · Passage of stone basket to remove small stones from lower ureter.

Risks and complications

Anaesthetic complications. Medical complications. Damage to urethra adhesions poor urinary stream. Damage to bladder wall: · Mucosal surface causing bleeding. · Perforation of the bladder causing bleeding and requiring immediate repair (both may cause the need to proceed to open operation). Infection. Ureteric perforation.

Prostatic Surgery

Procedure in brief

Transurethral resection of the prostate (TURP)

Cystoscopy performed first to assess size of the prostate and to exclude bladder stones or tumours. Resection uses the "cutting" diathermy current of the resectoscope. Wash out of the bladder. Insert a catheter, usually a three- way allowing for irrigation.

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Urology

Open prostatectomy

Incision one finger breadth above the pubic bone. Separation of the rectus muscles in the midline. The bladder is held away from the prostate. Incision into the prostatic capsule. The lobes of the prostate are then separated from the false capsule. A drain is inserted into the retropubic space. A three-way catheter is inserted as for TURP.

Risks and complications

Anaesthetic complications. Medical complications. Infection and septicaemia. Haemorrhage ­ reactionary and secondary (5% require return to theatre). Incontinence due to sphincter damage. Urethral stricture formation, affecting urinary stream. Bladder neck stenosis due to severe fibrous of the bladder neck Impotence 4­10% of men ­ cause multifactorial, psychological, vascular damage, nerve damage. Bladder perforation. Retrograde ejaculation.

Nephrectomy

Procedure in brief

Simple nephrectomy

Removal of kidney and upper ureter without removing perinephric fate or Gerotas fascia. Flank incision. Dissect to the kidney and mobilise. Ligate vessels within the renal pedicle. Suction drain inserted.

Radical nephrectomy

Flank incision or transabdominal approach. Removal of the kidney and upper ureter including the perinephric fate and Gerotas fascia.

Risks and complications

Anaesthetic complications. Medical complications. Damage to surrounding organs: · Duodenum. · Inferior vena cava. · Adrenal gland. Haemorrhage ­ particularly in relation to renal arteries and veins. Infection.

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Urology

Orchidectomy

Procedure in brief

Incision typically inguinal. Inguinal canal is opened to display the spermatic cord, which is divided at the level of the internal ring. Removal of spermatic cord and testis. Closure.

Risks and complications

Anaesthetic complications. Medical complications. Haemorrhage and haematoma (may require return to theatre). Infection. Damage to nearby structures: · Local nerves ­ iliohypogastric, ilioinguinal, genitofemoral. · Femoral vein. · Inferior epigastric vessels. Genital oedema or hydrocele.

Hydrocelectomy

Procedure in brief

Scrotal incision. Exposes dartos muscle and the coverings of the cyst (cremasteric muscle and connective tissue). Cyst wall incised and the fluid drained. The hydrocele sac can be excised, over-run or turned inside out and sutured. Haemostasis is achieved to avoid using a drain.

Post-op

Use of a scrotal support will increase patient comfort and reduce the risk of bleeding.

Risks and complications

Anaesthetic complications. Medical complications. Haematoma. Infection. Recurrence of the hydrocele.

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Vascular Procedures

VASCULAR PROCEDURES

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Vascular Procedures

Repair of AAA

Procedure in brief

Longnitudinal incision ­ thoracoabdominal if the AAA is suprarenal, abdominal if infrarenal. Identify and ligate major vessels. Cross clamp aorta proximally and both common iliac arteries distally. Intraluminal insertion of graft. Anastomosis of graft to vessels ­ aorta, common femoral or iliac depending on type of graft. Suture of wall of aneurysms over graft.

Risks and complications

Mortality 2­5%. Complications 5­10%. Anaesthetic complications. Medical complications.

Short term

Bleeding: · Intraoperative. · Postoperative requiring return to theatre. Renal failure. Peri-operative AMI/CVA. Limb ischaemia ­ intraoperative. Early postoperative course due to early thrombosis of graft can lead to limb loss. Bowel ischaemia. Impotence and retrograde ejaculation. Paraplegia ­ spinal cord ischaemia.

Longer term

Graft occlusion. Graft infection.

Femoro-popliteal Bypass

Procedure in brief

Expose the femoral artery at the groin and popliteal artery above the knee medially with a 10cm incision. Identify the major vessels and structures.

In situ graft

Formation of a subcutaneous tunnel initially using finger dissection then with a rigid devise. The graft is passed through the tunnel and anastomosed with the popliteal and femoral arteries respectively.

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Vascular Procedures

Synthetic graft (PTFE)

Expose the long saphenous vein and anastomose to the proximal end of the common femoral artery. The valves of the vein are then stripped and the major tributaries identified and ligated. The distal end of the graft is then anastomosed to a suitable site on the popliteal artery or one of its branches.

Risks and complications

Anaesthetic complications. Medical complications.

Short term

Bleeding intraoperative and postoperative requiring return to theatre. Early thrombosis of graft limb ischaemia limb compromise. Possible loss of limb. Wound infection. Perioperative AMI/CVA.

Long term

Graft occlusion. Infection. False aneurysm.

Carotid Endarterectomy

Procedure in brief

Incision along the anterior border of sternocleidomastoid muscle. Carotid bifurcation exposed. Internal carotid, common carotid, external carotid clamped respectively. Some patients may require a shunt ­ it is placed between the internal carotid distal to the diseased portion and the common carotid. Removal of the atheroma. Once the plaque is removed there may be direct closure of the vessel or the use of an oblong shaped patch graft ­ either synthetic or vein. Release of clamps.

Risk and complications

Anaesthetic complications. Medical complications.

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Vascular Procedures

AMI. CVA 2%: · Postoperative due to early thrombosis of the artery. · Usually does not happen intraoperatively because patients with an incomplete Circle of Willis are identified by measuring the pressure in the common carotid artery with occlusion and if indicated a shunt is used, therefore, maintaining blood flow throughout operation. Damage to vagus nerve vocal cord paralysis (usually temporary). Compression of submental branch of facial nerve against the mandible weakness of the lower lip. Haemorrhage ­ severe haemorrhage into the neck causing a tense haematoma with tracheal deviation return to theatre. Postoperative hypertension.

Arteriovenous Fistula

Procedure in brief

Incision over radial artery at the wrist (can be other sites ­ radio-cephalic most common). Mobilise artery and vein, and clamp. Anastomose artery to vein. Release clamp. Should be an easily palpable thrill over fistula.

Risks and complications

Anaesthetic complications. Medical complications.

Short term

Haematoma causing compression of the venous part of the A-V fistula. Thrombosis. Failure due to a kink or twist interfering with blood flow (check intraoperatively for palpable thrill and audible bruit). `Stealing' = the AV fistula stealing blood from the hand requires re-operation immediately to salvage the hand.

Long term

Graft stenosis. Failure of fistula due to thrombosis or infection from repeated cannulation. `High output' cardiac failure ­ usually occurs in people who are predisposed with severe myocardial and valvular disease. "Steal' may require further surgery to correct this.

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Vascular Procedures

Varicose Veins

Procedure in brief

Incision is medial to the femoral pulse, 5cm long and below the parallel to the inguinal ligament. The long saphenous vein is identified and all of its tributaries ligated and divided. The long saphenous is then divided (after identifying the femoral vein). A vertical incision is made below the knee and the distal end of the saphenous vein is then identified through the incision. A vein stripper is passed through the vein and brought out through the other incision. An olive is placed over the end of the stripper, which is then gently pulled, avulsing the vein. Individual tributaries are then identified and avulsed. Pressure pads are applied to each site, and compression bandages applied to the entire leg.

Post-op

Immediately post-operative the leg should be elevated. Walking should begin on the first post-operative day. Supportive bandages should be worn for at least four weeks.

Risks and complications

Anaesthetic complications. Medical complications. Haemorrhage. Bruising. Recurrence. Failure to successfully avulse the varices. Damage to other structures: · Femoral artery/nerve. · Femoral nerve. · Saphenous nerve.

A Guide to Perioperative Procedures

129

Produced by: Department of Postgraduate Medical Education Western Health Gordon Street FOOTSCRAY VIC 3011

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