INTRODUCTION TO SURGERY AND APPROACH TO SURGICAL PATIENT

1. INTRODUCTION TO SURGERY &
APPROACH TO THE SURGICAL
PATIENT
BY CHEBOI
LECTURER, KMTC

2. INTRODUCTION TO SURGERY

3. Definition:
•Is a branch of medicine that deals with physical
manipulation of body structures either to diagnose,
prevent or cure an ailment/disease.
•Sometimes surgeries like plastic surgery is not for
cure but rather for aesthetic purposes.
•Simply put, surgery is a branch of medicine that uses
some instruments to treat some pathological
conditions or injuries which help to improve body
functions.

4. Why Surgery?
•Surgery has a long history. In the 16th century there
was a French surgeon, Ambroise Pere, who stated
that surgery is performed for 5 basic reasons;
1. Eliminate some anomaly or pathology.
2. Restore what is dislocated.
3. To separated something that is united.
4. To join something which is divided.
5. Repair the defects of nature.

5. Historical challenges….
•Major hurdles in the past during surgery have
been due to;
•Management of pain during surgery,
•Bleeding / hemorrhage
•Infection of the surgical wounds.

6. Historical challenges….
• Better anesthetic and surgical techniques, including
antibiotic drug developments have minimized these
challenges over the years.
• Anesthetics – local, regional and general anesthesia to
manage pain
• Cauterization/diathermy to control bleeding
• Sterilization, antiseptics, scrubbing and a range of
antibiotics to control infections

7. Types of surgeries
• Elective surgery – is done to correct a non-life
threatening condition, and is carried out at the
patient’s request subject to the surgeon’s and the
surgical facility’s availability.
• Emergency surgery – is surgery which must be done
promptly to save life, limb or functional capacity.
• Semi-elective surgery - is one that must be done to
avoid permanent disability or death, but can be
postponed for a short time.

8. Purposes of surgery…..
• Surgeries are done for multiple purposes;
• Diagnostic – taking a sample from inside the body
• Explorative
• Reconstructive
• Curative
• Transplant surgery
• Previously large incisions were made e.g., in
laparotomies, nowadays minimally invasive
techniques like laparoscopic or laser surgeries are
employed to remove things like appendix.

9. APPROACH TO THE SURGICAL PATIENT

10. Introduction
• The management of surgical disorders requires;
• The application of technical skills and training in the basic
sciences to the problems of diagnosis and treatment.
• A genuine sympathy and indeed love for the patient.
• The surgeon must be a doctor in the old-fashioned sense,
an applied scientist, an engineer, an artist, and a minister
to his or her fellow human beings.
• Because life or death often depends upon the validity of
surgical decisions, the surgeon's judgment must be
matched by courage in action and by a high degree of
technical proficiency.

11. Approach
•The History
•Examinations
•Investigations
•Management

12. The History
• The key step in surgical diagnosis. Should be organized
• Varies according to diagnosis
• At their first contact, the surgeon must;
• gain the patient's confidence and convey the assurance that help is
available and will be provided.
• demonstrate concern for the patient as a person who needs help and
not just as a "case" to be processed
• It does not matter how it is done, so long as an atmosphere of
sympathy, personal interest, and understanding is created. Even
under emergency circumstances, this subtle message of
sympathetic concern must be conveyed.

13. Types of History
•There are two types of histories in surgical practice
• Outpatient or emergency room history
• Objective - diagnosis
• Clerking of patient admitted for elective surgery
• Objective – to asses that the treatment planned correctly
indicated and patient is suitable for that operation.

14. Building the History
• History taking is detective work.
• Preconceived ideas, snap judgments, and hasty conclusions
have no place in this process.
• The diagnosis must be established by inductive reasoning.
• The interviewer must first determine the facts and then search
for essential clues, realizing that the patient may conceal the
most important symptom e.g., the passage of blood by rectum,
in the hope (born of fear) that if it is not specifically inquired
about or if nothing is found to account for it in the physical
examination, it cannot be very serious.

15. How to take the history
• Personal information – age, sex, marital status, occupation….e.t.c,
• History should be taken in the following order:
• The present complaint (c/o)
• History of present complaint – onset, progression, duration, associated
symptoms, risk factors.
• Elaboration of the system involved (systemic inquiry)
• Past history
• Surgical history
• Medical history
• Drug history
• Allergy history
• Family history
• Social history

16. Systemic inquiry
• GIT – appetite, vomiting, regurgitation…… etc
• RS – cough, hemoptysis, dyspnea……….. etc
• CVS – breathlessness, palpitations, chest pain…..
• Peripheral vessels – intermittent claudication, rest pain
• Urogenital system – micturition, loin pain, suprapubic pain…
• Nervous system – tremor, fainting attacks, fits, weakness…
• MSS – muscle pain, joint swelling…..

17. Common symptoms of surgical conditions
•Pain
•Lumps/swelling
•Vomiting
•Change of bowel habits
•Hematemesis
•Hematochezia
•Trauma / injury
•Stiffness
•Swelling
•Deformity
•Weakness
•Instability
•Changes in sensibility
•Loss of function

18. Pain
• A careful analysis of the nature of pain is one of the
most important features of a surgical history.
• The examiner must first ascertain how the pain began.
• Was it explosive in onset, rapid, or gradual?
• What is the precise character of the pain?
• Is it so severe that it cannot be relieved by medication?
• Is it constant or intermittent?
• Are there classic associations, such as the rhythmic pattern
of small bowel obstruction or the onset of pain preceding
the limp of intermittent claudication?

19. Pain……….
SORTSARA
• Site
• Onset
• Radiation
• Timing
• Severity/ Character – wake
him up, need analgesics
rather than mild, severe
• Aggravating factors
• Relieving factors
• Associate symptoms
SOCRATES
• Site
• Onset
• Character
• Radiation
• Aggravating factors
• Timing
• Exacerbating factors
• Severity

20. Pain……
• One of the most important aspects of pain is the patient's
reaction to it.
• The overreactor's description of pain is often obviously
inappropriate, and so is a description of "excruciating" pain offered
in a casual or jovial manner.
• A patient who shrieks and thrashes about is either grossly
overreacting or suffering from renal or biliary colic.
• Very severe pain—due to infection, inflammation, or vascular
disease—usually forces the patient to restrict all movement as much
as possible.
• Moderate pain is made agonizing by fear and anxiety. Reassurance
of a sort calculated to restore the patient's confidence in the care
being given is often a more effective analgesic than an injection of
morphine.

21. Pain grading
• Severity is even more subjective. High and low pain thresholds
undoubtedly exist, but to the patient pain is as bad as it feels, and any
system of ‘pain grading’ must take this into account.
• The main value of estimating severity is in assessing the progress of the
disorder or the response to treatment.
• The commonest method is to invite the patient to mark the severity on
an analogue scale of 1–10, with 1 being mild and easily ignored and 10
being totally unbearable.
• The problem about this type of grading is that patients who have never
experienced very severe pain simply do not know what 8 or 9 or 10
would feel like.

22. Pain grading……….
The following is suggested as a simpler system:
•Grade I (mild) - Pain that can easily be ignored.
•Grade II (moderate) - Pain that cannot be ignored,
interferes with function and needs attention or
treatment from time to time.
•Grade III (severe) - Pain that is present most of the
time, demanding constant attention or treatment.
•Grade IV (excruciating) - Totally incapacitating pain

23. Lump / swelling
•History of a lump
• Duration
• Symptoms
• Pain
• Changes in size
• Other lumps
• Any cause
• Trauma

24. Lump / swelling…………
• Examination of a lump – look, feel & move
• Position
• Color and texture of the skin
• Temperature
• Tenderness
• Shape
• Size
• Surface
• Edge
• Consistency
• Pulsatile, compressibility (venous malformations)
• Reducibility

25. Lump / swelling……..
• Inspection (look)
• Site, size, shape, surface, skin
• Margins
• Number
• Cough, color, impulse
• Pulsatile, peristalsis
• Palpation (feel & move)
• Temperature, tenderness
• Fluctuations, fixity
• Trans-illumination test, thrill
• Consistency, compressibility
• Auscultation

26. Vomiting
• What did the patient vomit?
• How much?
• How often?
• What did the vomitus look like?
• Was vomiting projectile?
• It is especially helpful for the examiner to see the
vomitus.

27. Change in Bowel Habits
• A change in bowel habits is a common complaint that
is often of no significance.
• However, when a person who has always had regular
evacuations notices a distinct change, particularly
toward intermittent alternations of constipation and
diarrhea, colon cancer must be suspected.
• Too much emphasis is placed on the size and shape of
the stool e.g., many patients who normally have well-
formed stools may complain of irregular small stools
when their routine is disturbed by travel or a change
in diet.

28. Hematemesis or Hematochezia
• Bleeding from any orifice demands the most critical
analysis and can never be dismissed as due to some
immediately obvious cause.
• The most common error is to assume that bleeding from
the rectum is attributable to hemorrhoids.
• The character of the blood can be of great significance.
• Does it clot?
• Is it bright or dark red?
• Is it changed in any way, as in the coffee-ground vomitus of
slow gastric bleeding or the dark, tarry stool of upper
gastrointestinal bleeding?

29. Trauma/Injury
• When there is a history of trauma, the details must be
established as precisely as possible.
• What was the patient's position when the accident
occurred?
• Was consciousness lost?
• Retrograde amnesia (inability to remember events just
preceding the accident) always indicates some degree of
cerebral damage.
• If a patient can remember every detail of an accident, has not
lost consciousness, and has no evidence of external injury to
the head, brain damage can be excluded.

30. Trauma/Injury……..
• In the case of gunshot wounds and stab wounds,
knowing the nature of the weapon, its size and shape,
the probable trajectory, and the position of the patient
when hit may be very helpful in evaluating the nature of
the resultant injury.
• The possibility that an accident might have been caused
by preexisting disease such as epilepsy, diabetes,
coronary artery disease, or hypoglycemia must be
explored.

31. Examinations
•Approach to physical examinations
•Consent
•Inspection
•Palpation
•Percussion
•Auscultation

32. General examination
•Posture
•Speech, etc
•Vital signs
•Pulse
•BP
•Temperature
•RR
•Parameters – jaundice, palor, cyanosis etc

33. Systemic examinations
•CNS
•CVS
•RS
•GIT
•MSS / Locomotor

34. List of differential diagnosis
VITAMIN C D E F
• Vascular
• Infection / Inflammation
• Trauma
• Autoimmune
• Metabolic
• Idiopathic
• Neoplastic
• Congenital
• Degenerative
• Endocrine
• Functional

35. Investigations
• Bedside tests
• Blood tests
• Microbiology
• Imaging
• Specialty tests, pathologies

36. Management…….
• Immediate interventions
• Does the patient need oxygen?
• Fluid balance: IV fluids? Urinary catheter?
• Drugs: Analgesics, Anti-emetics, Antibiotics
• VTE prophylaxis
• Escalation
• Pre-op management
• Operative procedure
• Post-op management
• Follow up

37. Emergency cases
•Triage
• ABCDE approach
• A – Airway
• B – Breathing
• C – Circulation
• D – Disability
• E – Exposure

38. Airway
•Assessment –
• any signs of airway obstruction? Ascertain patency
•Management –
• establish a patent airway
•Key:
• protect cervical spine if injury possible, especially in the
presence of a change in mental status.

39. Breathing
•Assessment:
• Determine RR, check bilateral chest movement, percuss, and
auscultate.
•Management:
• If no respiratory effort, treat as arrest, intubate and ventilate.
• If breathing is compromised, give high concentration oxygen,
manage according to findings, e.g., relieve tension
pneumothorax.

40. Circulation
•Assessment –
• check pulse and BP, check capillary refill, look for evidence of
hypoperfusion.
•Management:
• peripheral or central IV catheters,
• fluids (crystalloids or blood products),
• measure urine output,
• consider central venous pressure measurement,
• consider pressors
• if no cardiac output, treat as arrest.

41. Disability
•Assess level of consciousness with AVPU score
•(Alert? Responds to Voice? To Pain? Unresponsive?).
•Check pupils:
•size, equality, reactions.
•GCS if time allows.

42. Exposure
• Undress the patient, but cover to avoid hypothermia.
• Quick history with relatives or significant others may assist with
diagnosis:
• events surrounding onset of illness, contributing issues, evidence of
overdose/suicide attempt, any suggestion of trauma?
• Past medical history:
• especially diabetes, asthma, COPD, alcohol, opiates or street drug abuse, epilepsy,
or recent head injury; recent travel.
• Medication: current drugs, allergies.
• Once appropriate ventilation and circulation support are adequate, a more
complete history, examination, along with more thorough investigations,
should be undertaken as part of the appropriate management.
• Stabilization of spine.