Surgery 2 Module 2

Question 1

How to close reduce a dislocated hip?

Answer 1

Most commonly craniodorsal dislocation with luxation of the coxofemoral joint - 50% effective if corrected unless dysplastic

1. Adequate depth of anaesthesia to give
   necessary muscle relaxtion
2. Assisstant loops a strap or towel under the affected leg in the groin and applies counter-traction from the dorsal side of the patient
3. Externally rotate the leg (stifle pointed at the ceiling) to allow the femoral head to clear the ilial body
4. Apply steady traction to the limb in a caudo-ventral direction for a few mins to fatigue the muscles
5. Whilst maintaining traction internally rotate the limb and concurrently push medially on the greater trochanter to push the femoral head in to the acetabulum

compare the greater trochanters on both legs
put thumb behind the greater trochanter and externally rotate the limb - this should push out finger between the trochanter and ischium

Once reduced repeatedly move the hip with firm downward pressure on the hip to squeeze out haematoma/damaged joint capsule from the joint cavity - 5-10mins

Question 2

How to diagnose a cranio-lateral hip luxation?

Answer 2

Femoral head lies over the ilial body

• Limb will be held off the ground and turned
  inwards
• On palpation : the greater trochanter of the luxated hip will be higher than the contra-lateral side and have an altered position relative to the wing ilium
• The affected limb will appear shortened if both hips are gently extended and examined and assessed from behind
• Under GA/Sedation lack of thumb displacement confirms the luxation (place thumb into gap between the greater trochanter and ischial tuberosity, then externally rotate hip)
• x-ray orthogonal views

Question 3

When is joint flushing suggested for?

Answer 3

• Post op wound infection
• Septic joints that hav ebeen untreated for 72hrs or
  more
• Septic joints that hav enot responded to conservative
  treatment after 48-72hrs
• Penetrating wounds to the joint

Question 4

Indications for emergency thoracic surgery?

Answer 4

• Repair of diaphragm rupture
• Traumatic injury to the thoracic wall/lung
• Open chest CPR

Question 5

How to drain the chest effectively?

Answer 5

• Avoid aggressive use of large (50ml) syringes as they
  create substantial negative pressure that can damage
  the lungs
• Moving patients in to several different positions to
  remove all accumulated fluid
• If tube blocked: flushing with a small volume of saline

Question 6

When to remove a thoracostomy tube?

Answer 6

• When negligible (<20-30mls) production of air in the last 24 hours or fluid production is equal to or less than what is expected by the tube being present itself
  
  • 2-5mls/kg/day

Question 7

What are the surgical approaches to the thorax?

Answer 7

Lateral intercostal thoracotomy: only allows a one sided narrow view

Median sternotomy: complete thoracic exploration

Question 8

What is the pathophysiology of diaphragmatic rupture?

Answer 8

Rupture occurs when there is a blow to the abdomen in the presence of an open glottis –> the lungs deflate as the air is force through the airway and the force of the abdominal organs moving cranially exceeds the strength and distensibility of the diaphragm - creating a tear

Strangulation of organs within the thoracic cavity

Stomach being trapped in the thorax and a gastric dilation in the pleural space can occur

Question 9

How to diagnose a diaphragmatic rupture?

Answer 9

• Borborygmi may be detected
• Heart and lungs sounds may be dull
• Abdo cavity feeling empty
• Radiography: line of diaphragm cannot be followed
  across the entire body and abdominal viscera seen in
  the thorax

Question 10

What is the best to explore the neck?

Answer 10

Neck exploration is carried out by midline approach
Trachea is displaced to the side and the oesophagus is identified slightly to the left of midline

Question 11

Post op care for a thoracostomy?

Answer 11

• Analgesia
  
  • Opioids
  • Local analgesia: intra operative intercostal blocks,
    post operative bupivacaine down the chest drain
    every 6-8 hrs
  • wound soak catheters
  • lidocaine patches
  • CRI: lidocaine/ketamine/opiate
• Chest tube care
  
  • Drained hourly for the first 2-4 hrs then every 4
    hours
  • If minimal production of air/fluid can be removed
  • Cytology of fluid can be useful to monitor response
    to antimicrobial therapy
  • Submit catheter tip for culture

Question 12

Common causes for hepatic surgery?

Answer 12

• Masses: Adenoma, HCC
• Hepatic abscesses
• Liver lobe torsion (LL most mobile)

Question 13

Ways to improve hepatic exposure?

Answer 13

• Packing swabs behind liver to lift up
• Cut triangular ligaments
• Diaphragm myotomy

Question 14

Liver biopsy options?

Answer 14

Guillotine technique
Artery forcep crush
Wedge resection - overlapping sutures around the area of interest
Punch biopsy
Lap biopsy

Question 15

Reason for nephrectomies?

Answer 15

• Trauma
• Masses
• Persistent infection
• Obstructive calculi with hydronephrosis
• Renomegaly

Question 16

How to do a nephrectomy?

Answer 16

Incise peritoneum around kidney
elevate medially
ligate renal A and V
Tie ureter at level of bladder and incise

Question 17

Surgery options for prostatic abscesses and cysts?

Answer 17

• Marsupialisation
• Partial or complete prostatectomy
• Abscess/cyst debridement/resection and omentalisation

Question 18

How to deal with haemorrhage of liver?

Answer 18

Capsular bleed
- Pressure
- Topical haemostatic agents

Severe bleeding
- Pringle manoeuvre - 20 mins max: hepatoduodenal ligament is clamped through epiploic foramen reducing blood into hepatic artery
- Occluding vena cava cranial to liver
- Hepatic artery ligation

Question 19

Indications of dystocia?

Answer 19

1. Lack of progression from stage 1 –> 2 in 12-24 hrs
2. More than 4hrs between pups
3. Strong contractions more than 30mins with no pup
4. Rads to aid foetal malposition and counting
   
   • If inter-uterine gas = foetal death

Question 20

Treatment of dystocia?

Answer 20

• Rule out birth canal obstruction
• U/S foetal heartbeat - Normal 220, 180-150 if distressed
• Oxytocin q30mins
• Finger repositioning with finger
• C - section

Question 21

How to resus a neonate?

Answer 21

• Clear oral and nasal cavities of excretions
• Vigorous external rubbing
• Intubate only if all else fails
• Naloxone - sublingual
• If asystole - adrenaline and gentle lateral thoracic
  compressions

Question 22

Indications on radiographs of obstruction

Answer 22

Up to 1.6x body of L5
>2 indicative of obstruction

Question 23

Most common stomach tumors?

Answer 23

Adenocarcinoma - mets likely at diagnosis 70-80%
Sarcoma/GIST/Leiomyoma
Lymphoma