Comprehensive Surgical Training Data

Small Hospital/Clinic Protocol Manual

1. SURGICAL PRINCIPLES & BASIC TECHNIQUE

1.1 Aseptic Technique Foundation

Aseptic technique prevents surgical site infections (SSIs) through elimination of microorganisms from the surgical field. Key principles: (1) sterilization of instruments/equipment, (2) sterile field maintenance, (3) preventing microbial contamination, (4) limiting environmental shedding.

Sterile Field Principles:

Establish 1-inch perimeter around surgical field as non-sterile
Sterile fields contaminated by non-sterile items require replacement
Tables lower than waist height and above shoulder height are non-sterile
Non-sterile personnel must maintain distance; contact invalidates sterility
Moisture penetrates drapes; wet areas are considered contaminated
Movement in OR should be purposeful; air currents carry bacteria

1.2 Surgical Hand Scrub

5-Minute Traditional Scrub (Povidone-Iodine or Chlorhexidine):

Remove jewelry, watch, and rings (harbors bacteria in crevices)
Wash hands/forearms with soap under running water (75-105°F) for 30 seconds
Dry with paper towel
Apply antiseptic agent (5% povidone-iodine or 4% chlorhexidine gluconate)
Use soft brush on nails; stroke from fingertips to elbow in one direction
Each hand: 1 minute; forearms: 1.5 minutes each
Rinse under running water, allowing water to run from elbow downward
Avoid touching contaminated surfaces
Keep hands above elbows throughout
Pat dry with sterile towel using patting (not rubbing) motions

Alcohol-Based Scrub (Faster, 2-3 minutes):

Wet hands with water
Apply 6 mL alcohol-based antiseptic (62-71% alcohol content)
Rub hands for 3 minutes; ensure fingernails, palms, dorsal surfaces covered
Allow to air dry completely before gloving

1.3 Gowning and Gloving

Gowning Procedure:

Pick up gown from sterile field by holding shoulders
Step back into gown; nursing staff fastens back
Grasp inner surface of gown sleeves below cuff level
Insert arms in synchronized motion; nursing staff guides gown up shoulders
Ensure sterile field remains uncontaminated during process

Open Gloving (Most Common):

Remove first glove from package with dominant hand
Hold glove horizontally with thumb opening facing toward body
Slide non-dominant hand into glove; cuff will be turned down initially
Using gloved hand, slide fingers under cuff of second glove (non-gloved side)
Slide second hand into glove; keep thumb tucked inward
With first gloved hand (fingers under cuff), turn first glove cuff up
With second gloved hand, turn second glove cuff up by sliding fingers under cuff
Adjust glove fit; if break in glove detected, obtain new pair immediately

Closed Gloving (Preferred if Performing Gowning Yourself):

Keep hands inside gown sleeves
Pick up first glove with covered hand; position at wrist
Push hand upward through gown cuff into glove
Grasp glove cuff with opposite covered hand
Pull glove and cuff up together over forearm
Repeat process for second glove
Adjust finger position once both gloves on

1.4 Patient Draping

Principles:

Only sterile items contact surgical field
Drape from clean area toward contaminated area
Drape top to bottom
Drape close to body first, then extend outward
Secure with drape towels or sutures to prevent movement

Basic Extremity Drape (e.g., Hand/Arm Surgery):

Place patient supine or in optimal position
Cleanse skin with 10% povidone-iodine or 0.5% chlorhexidine (allow 30-second contact time minimum)
Dry with sterile towel
Place large sterile drape under extremity
Place split drape across operative site exposing only surgical area
Secure drape edges with towel clamps to operating table
Maintain minimum 6-inch margin around incision site

Abdominal Drape (e.g., Laparotomy):

Place first drape longitudinally along each side of abdomen
Place cross drape over upper abdomen below chin
Place cross drape over lower abdomen
Place abdomen-specific drape with opening sized to surgical area
Secure all drapes with nonpenetrating clamps

1.5 Timeout (Surgical Safety Checklist)

Required Before Incision (AORN/WHO Protocol):

Sign-In (Before Anesthesia):

Patient identity confirmed
Surgical site marked (if applicable)
Consent verified
NPO status confirmed
Allergies reviewed
Airway assessment completed
Blood products available (if needed)

Time-Out (Before Incision):

Entire team pauses
Surgeon, anesthesia provider, nursing staff confirm:
- Patient identity
- Operative procedure
- Surgical site/laterality
- Positioning confirmation
- Relevant imaging available
- Antibiotic prophylaxis administered (if required, within 60 minutes of incision)
- VTE prophylaxis ordered/given

Sign-Out (Before Patient Leaves OR):

Instrument/sponge/needle counts correct
Specimen labeled and processed
Equipment/implants recorded
Postop concerns verbalized

2. ANESTHESIA MANAGEMENT

2.1 Local Anesthesia Agents

Lidocaine (1% = 10 mg/mL)

Onset: 3-5 minutes
Duration: 30-120 minutes (plain); 2-6 hours (with epinephrine)
Max dose (plain): 4.5 mg/kg (not >300 mg)
Max dose (with epinephrine 1:100,000): 7 mg/kg (not >500 mg)
Used for: minor wound repair, skin lesions, minor procedures
Side effects: Hypersensitivity (rare with lidocaine), CNS toxicity at high doses
Toxicity signs: Circumoral numbness, metallic taste, tinnitus, seizures, bradycardia, cardiac arrest

Bupivacaine (0.25% = 2.5 mg/mL, 0.5% = 5 mg/mL)

Onset: 5-10 minutes
Duration: 3-12 hours (much longer than lidocaine)
Max dose (plain): 2.5 mg/kg (not >175 mg)
Max dose (with epinephrine): 3.5 mg/kg (not >225 mg)
Used for: nerve blocks, longer procedures, regional anesthesia
Toxicity risk higher than lidocaine; cardiotoxicity more common

Procaine (1% = 10 mg/mL)

Short acting; rarely used in modern practice
Max dose: 12 mg/kg (not >600 mg)
Metabolized quickly; lower toxicity risk

Epinephrine Addition (1:100,000 = 0.01 mg/mL):

Prolongs duration and reduces bleeding
Reduces systemic absorption of local anesthetic
Allows higher total doses to be used
Contraindicated in end-arterial territories (fingers, toes, nose, ears)
Causes vasoconstriction; pale, bloodless field

Local Anesthetic Toxicity Management:

CNS toxicity: Seizures, unconsciousness, tremor → benzodiazepines (midazolam 0.1-0.3 mg/kg IV)
Cardiac toxicity: Bradycardia, hypotension, ventricular dysrhythmia → lipid emulsion (20% Intralipid 1.5 mL/kg IV bolus, repeat every 3-5 min, max 10-12 mL/kg) + ACLS protocols
Stop injection immediately; assess airway; provide 100% O2
Monitor continuously for ≥4-6 hours

2.2 Regional Anesthesia Blocks

Digital Block (Fingers/Toes):

Indication: Laceration repair, nail removal, amputation, drainage
Anatomy: Two nerves (dorsal and volar) run along medial and lateral borders of digit
Technique:
1. Insert needle at medial aspect of digit proximal to web space
2. Advance needle perpendicular to digit (depth ~3-5 mm)
3. Inject 0.5-1 mL local anesthetic
4. Withdraw needle; angle 45 degrees laterally
5. Inject 0.5-1 mL laterally around opposite side of digit
6. Repeat technique at lateral web space border for second nerve pair
7. Total volume: 2-4 mL of 1% lidocaine
Onset: 5-10 minutes
Duration: 30 minutes (if plain); 2-3 hours (with epinephrine)
Contraindications: DO NOT use epinephrine (end-arterial supply risks digit loss)

Wrist/Carpal Tunnel Block:

Indication: Hand laceration, carpal tunnel release, forearm procedures
Three nerves: Radial, ulnar, median
Technique (at wrist crease):
1. Palpate palmaris longus tendon (central)
2. Median nerve: Insert needle medial to palmaris longus, advance until paresthesia; inject 5-7 mL
3. Ulnar nerve: Insert needle medial to flexor carpal ulnaris; inject 5-7 mL
4. Radial nerve: Inject subcutaneously across dorsal radial wrist (7-10 mL) lateral to radial artery
Total: 17-24 mL of 1% lidocaine
Onset: 10-20 minutes
Duration: 45-90 minutes (plain); 2-4 hours (with epinephrine)

Ankle Block (Foot/Ankle Surgery):

Five nerves: Posterior tibial, sural, deep peroneal, superficial peroneal, saphenous
Posterior tibial nerve: Posterior to medial malleolus in groove between malleolus and Achilles tendon; inject 5-7 mL
Sural nerve: Posterior lateral aspect near lateral malleolus; inject 3-5 mL
Deep peroneal nerve: Anterior ankle between tibia and fibula at ankle level; inject 3-5 mL
Superficial peroneal nerve: Subcutaneously lateral ankle; inject 3-5 mL
Saphenous nerve: Subcutaneously medial ankle; inject 3-5 mL
Total: 15-25 mL of 1% lidocaine
Onset: 15-30 minutes
Duration: 60-90 minutes (plain); 2-6 hours (with epinephrine)

Femoral Nerve Block (Lower Extremity):

Indication: Femur fracture, knee surgery, foot/leg trauma
Landmark technique:
1. Palpate inguinal ligament and femoral artery
2. Needle insertion point: Lateral to femoral artery pulse, below inguinal ligament
3. Insert needle at 45-degree angle cephalad
4. Advance until paresthesia (twitching of quadriceps indicates needle near nerve)
5. Inject 15-20 mL of 0.5% bupivacaine or 1% lidocaine
Onset: 10-20 minutes
Duration: 4-6 hours
Risks: Vascular puncture, retroperitoneal hematoma, femoral artery injection (rare but serious)

Intercostal Nerve Block (Chest Wall/Rib Procedures):

Indication: Rib fracture pain, chest wall laceration, thoracostomy
Anatomy: Nerve runs in groove on inferior aspect of rib
Technique:
1. Patient in lateral or prone position
2. Palpate inferior rib edge
3. Insert needle perpendicular to rib; advance until bone contact
4. Withdraw 2-3 mm; inject 3-5 mL per nerve
5. Must block two ribs above and below injury site (due to overlapping innervation)
Total volume: 15-30 mL of 1% lidocaine
Onset: 5-10 minutes
Duration: 60-90 minutes
Risks: Pneumothorax, hemothorax, intravascular injection

Bier Block (IV Regional Anesthesia):

Indication: Upper extremity procedures <60 minutes; hand/forearm surgery
Contraindications: Sickle cell disease, severe hypertension, cardiovascular disease
Technique:
1. Establish IV access distal to surgical site (dorsal hand/forearm)
2. Apply elastic bandage from distal to proximal limb (exsanguination)
3. Inflate upper arm tourniquet to 250 mmHg (or 50 mmHg above systolic BP)
4. Remove exsanguinating bandage
5. Inject 40-50 mL of 0.5% lidocaine through IV over 1-2 minutes
6. Onset: 3-5 minutes
7. Pain will develop in tourniquet area after 20-30 minutes; patient analgesia required
Maximum procedure time: 60 minutes with single inflation
Deflation:
1. At end of procedure, slowly deflate tourniquet (over 10-30 seconds)
2. Allow 1 minute of reperfusion
3. Re-inflate if required
4. Total tourniquet time: ≤2 hours
Toxicity: Release before 20 minutes allows rapid systemic absorption; monitor for lidocaine toxicity

2.3 Procedural Sedation & Analgesia

Midazolam (Benzodiazepine Sedative)

Onset: 1-2 minutes IV
Peak effect: 3-5 minutes
Duration: 30-60 minutes
Dosing:
- IV: 0.5-2 mg initially, titrate in 0.5-1 mg increments every 2-3 minutes (max 10 mg)
- Elderly/debilitated: Start 0.25-0.5 mg
- Maximum total dose: 10 mg (healthy adults); 5 mg (elderly)
Reversal: Flumazenil 0.2-0.5 mg IV over 15-30 seconds; repeat q1min (max 1 mg/dose, 3 mg/hour)
Advantages: Rapid onset/offset, rapid reversibility, amnestic properties
Disadvantages: Respiratory depression, hypotension with opioids
Monitoring: Continuous pulse oximetry, capnography, cardiac monitor, BP monitoring

Ketamine (Dissociative Anesthetic)

Onset: IV 30-60 seconds; IM 3-8 minutes
Duration: 10-20 minutes IV; 30-60 minutes IM
Dosing:
- IV: 0.5-2 mg/kg bolus (typically 1 mg/kg for sedation)
- IM: 4-5 mg/kg for procedural sedation
- Redose: 0.5-1 mg/kg IV if needed (repeat q10-15min)
Advantages: Maintains airway reflexes, preserves respiratory drive, analgesia, dissociation
Disadvantages: Increased salivation (treat with anticholinergic if needed), emergence reactions, hypertension, tachycardia
Emergence reactions managed with midazolam pretreatment (0.015 mg/kg IV) or benzodiazepine co-sedation
Ideal for: Minor lacerations, abscess drainage, orthopedic reduction, fracture manipulation
Monitoring: Continuous pulse oximetry, capnography, cardiac monitor, BP q5min

Propofol (IV Sedative-Hypnotic)

Onset: <1 minute IV
Duration: 5-10 minutes
Dosing:
- Induction: 1-2 mg/kg IV (reduce to 0.5-1 mg/kg in elderly)
- Maintenance: 25-100 mcg/kg/min infusion or 0.25-0.5 mg/kg bolus q5-10min
- Total dose typically 1-3 mg/kg for procedure
Advantages: Rapid onset/offset, smooth sedation, short duration
Disadvantages: Respiratory depression, hypotension, bradycardia, no analgesia, pain on injection (prevent with lidocaine IV or larger vein)
Monitoring: Continuous pulse oximetry, capnography, cardiac monitor, BP monitoring
Oxygen supplementation required; have suction/airway equipment available
NOT recommended for brief procedures due to respiratory depression risk without anesthesia support

Etomidate (Ketone Hypnotic)

Onset: <1 minute IV
Duration: 5-15 minutes
Dosing: 0.1-0.2 mg/kg IV (0.05-0.1 mg/kg in elderly)
Advantages: Minimal respiratory depression, maintains airway reflexes, cardiovascular stability, rapid offset
Disadvantages: Pain on injection, high cost, adrenal suppression with repeated doses, no analgesia
Best for: Older patients, hemodynamically unstable patients, procedural sedation requiring airway preservation
Monitoring: Continuous pulse oximetry, capnography, cardiac monitor, BP monitoring

Fentanyl (Opioid Analgesic)

Onset: 1-3 minutes IV
Duration: 30-60 minutes (longer with repeated dosing)
Dosing: 0.5-1 mcg/kg IV initially, repeat 0.25-0.5 mcg/kg q5-10min (typical procedure dose 1-2 mcg/kg)
Advantages: Potent analgesia, rapid onset, minimal cardiovascular effects at low doses
Disadvantages: Respiratory depression, hypotension, bradycardia, chest wall rigidity (rarely), abuse potential
Reversal: Naloxone 0.04-0.4 mg IV, repeat q2-3min (total max 10 mg)
ALWAYS co-administer with benzodiazepine for procedural sedation
Monitor: Respiratory rate, SpO2, capnography

Typical Sedation Combinations:

Midazolam + Fentanyl: Gold standard for minor procedures; 1-2 mg midazolam + 25-50 mcg fentanyl IV, titrate to effect
Ketamine monotherapy: Excellent for pediatric/uncooperative patients, maintains airway
Propofol + Fentanyl: Reserved for ICU/monitored settings with anesthesia provider
Etomidate: Preferred in hemodynamically unstable patients

Sedation Monitoring Standards (AAPD/ASA Guidelines):

Continuous pulse oximetry; capnography if available
Cardiac monitor for procedures >30 minutes or high-risk patients
Blood pressure monitoring every 5 minutes
Qualified personnel with emergency airway equipment at bedside
Fasting 2-6 hours depending on agent (NPO status)
Designated observer if provider is also performing procedure
Reversal agents immediately available
Emergency equipment (suction, oxygen, bag-valve-mask, emergency medications)

2.4 Spinal Anesthesia

Indications: Lower extremity surgery, lower abdominal surgery, cesarean section, orthopedic surgery

Technique:

Patient positioning: Sitting or lateral recumbent (flexed knees)
Identify L3-L4 or L4-L5 interspace (line between iliac crests = L4)
Prepare skin with 10% povidone-iodine; allow 30-second contact
Drape sterile field
Infiltrate skin/subcutaneous tissue with 1% lidocaine
Palpate superior aspect of lower interspace spinous process
Insert 25-27G spinal needle perpendicular to long axis of spine
Advance until dura puncture felt (“pop” sensation)
Withdraw stylet; ensure CSF flow
Inject local anesthetic slowly (0.5-1 mL/5 seconds)
For isobaric solutions: patient position doesn’t matter
For hyperbaric solutions (dextrose-added): patient head-down tilts drug cephalad
Withdraw needle carefully; dress puncture site

Drug Selection & Dosing:

Lidocaine 5% hyperbaric (45 mg/mL): 50-75 mg for lower extremity, 75-100 mg for lower abdomen
Bupivacaine 0.75% hyperbaric (7.5 mg/mL): 10-15 mg for lower extremity, 12-20 mg for lower abdomen (onset slower but longer duration; 3-6 hours)
Duration: Lidocaine 60-90 min; Bupivacaine 3-6 hours
Addition of epinephrine (1:100,000) prolongs duration by 25-50%

Complications:

Post-dural puncture headache (PDPH): 1-30% incidence; worse with large-gauge needle, multiple attempts, pregnancy
- Onset: 24-48 hours post-procedure
- Characteristic: Positional (worse upright, better supine), bilateral frontal/occipital headache
- Management: Bed rest, hydration, NSAIDs, caffeine (500 mg), epidural blood patch if severe/persistent (>1 week)
High spinal/total spinal anesthesia: Accidental injection into subarachnoid space causing respiratory paralysis, cardiovascular collapse
- Symptoms: Respiratory distress, hypotension, bradycardia, loss of consciousness
- Management: Secure airway, mechanical ventilation, IV fluids, vasopressors
Hypotension: Fluid administration, vasopressors (phenylephrine 50-200 mcg IV or norepinephrine)
Meningitis: Rare; ~1-5 cases per 1 million; use sterile technique
Transient neurologic symptoms: Radicular pain 24-48 hours post-procedure (self-limited, <1 week)

2.5 Epidural Anesthesia

Indications: Major abdominal/pelvic surgery, lower extremity surgery, labor analgesia

Technique:

Patient positioning: Sitting or lateral (thoracic/lumbar) or lateral with hip flexion (sacral)
Identify interspace (T12-L1 for abdominal, L2-L3 for lower extremity, S4-S5 for caudal)
Prepare skin with povidone-iodine; sterile draping
Infiltrate subcutaneous tissue with 1% lidocaine
Insert 16-18G Tuohy needle (beveled, blunt) perpendicular to spinal column
Advance through supraspinous ligament, interspinous ligament into epidural space
Use “loss of resistance” technique: Attach syringe of saline/air to needle; advance slowly while applying gentle pressure
When needle enters epidural space, resistance suddenly disappears (stylet should be in place initially)
Confirm position by:
- Loss of resistance to pressure
- Inability to aspirate CSF or blood
- Thread catheter 3-5 cm beyond needle tip into epidural space
Secure catheter with dressing; label clearly “EPIDURAL”

Drug Selection & Dosing:

Lidocaine 2%: 10-20 mL (200-400 mg) for anesthesia; onset 10-15 minutes; duration 60-90 minutes
Bupivacaine 0.5%: 15-25 mL (75-125 mg) for anesthesia; onset 15-30 minutes; duration 3-4 hours
Opioid addition (morphine 2-5 mg, fentanyl 50-100 mcg): Prolongs duration, enhances analgesia
Epidural test dose (3 mL of local anesthetic with 1:200,000 epinephrine or 45 mg lidocaine with epinephrine): Assess for intrathecal/intravascular placement (tachycardia or neurologic symptoms indicates inadvertent IV/IT injection)

Advantages over Spinal: Catheter allows repeated dosing, more flexible dosing control, lower risk of PDPH (needle gauge), gradual onset safer

Complications:

Inadvertent intrathecal injection: Excessive blockade; manage with airway support/mechanical ventilation
Intravascular injection: Toxic dose of local anesthetic; seizure/cardiac arrhythmia; treat with IV lipid emulsion and ACLS
Epidural hematoma: Rare but catastrophic if unrecognized; progressive neurologic deficit post-procedure
Epidural abscess: Meningitis, back pain, fever; requires urgent MRI and antibiotics
Failed block: Needle/catheter not in epidural space; reposition required

2.6 Monitoring Standards During Anesthesia

Minimum Monitoring (ASA Standards):

Pulse oximetry: SpO2 continuously; alarm set <90%
Capnography: End-tidal CO2 (if intubated); confirms proper ventilation
Cardiac monitor: Continuous for procedures >30 minutes or IV opioid/sedative use
Blood pressure: Every 5 minutes during procedure
Temperature: Monitor when procedure >30 minutes
Neuromuscular monitoring: If paralytic agents used
Ventilation: Observe chest rise/fall; assess for adequacy
Anesthetic depth: Clinical assessment; appropriate for agent used

Equipment Always Available:

Oxygen source and delivery devices (mask, nasal cannula, endotracheal tubes)
Airway equipment (laryngoscope, endotracheal tubes, LMA, supraglottic airway)
Suction functional
Emergency medications (epinephrine, atropine, vasopressors, benzodiazepine reversal agents)
Defibrillator/AED
IV access (two lines if major procedure)

3. MINOR PROCEDURES

3.1 Wound Debridement & Cleansing

Indications: Contaminated wounds, traumatic injuries, crush injuries, devitalized tissue removal

Technique:

Regional anesthesia or procedural sedation as appropriate
Irrigate copiously with sterile normal saline (500 mL minimum for moderate wounds)
- High-pressure irrigation (35 mL syringe with 18G needle on attached IV catheter) more effective for bacteria removal
- Gravity drip acceptable for clean wounds (low contamination risk)
Explore full wound depth and extent; gently probe with gloved finger to identify foreign bodies
Remove devitalized tissue using sterile scissors/scalpel; tissue should bleed when cut (indicates viability)
Assess for foreign material (glass, dirt, fabric); remove under magnification if necessary
Repeat irrigation after debridement
Assess skin margins; trim loose skin with scissors if >2 mm beyond wound edge
Final assessment: Viable tissue (bleeding, pink, maintains sensation/motor function)

Devitalized Tissue Indicators:

Dark gray/black discoloration (especially in muscle)
No bleeding when incised
Loss of normal muscle contractility
Loss of sensation (pinprick test)
Foul odor

3.2 Skin Lesion Excision

Indications: Suspicious nevi, cysts, lipomas, warts, benign skin growths

Technique:

Mark lesion with surgical marker before anesthesia (limits bleeding visualization)
Local anesthesia: Infiltrate 1-2 mL of 1% lidocaine with epinephrine; wait 5-10 minutes for vasoconstriction
Sterile preparation with povidone-iodine/chlorhexidine; allow contact time
Drape with sterile field
Excision approach depends on lesion type:
- Elliptical excision (most common):
  - Outline ellipse with long axis oriented along skin tension lines (Langer’s lines)
  - Ellipse length:width ratio = 3:1 (minimizes standing cones)
  - Remove ellipse with scalpel in single smooth stroke
  - Maintain 2-3 mm margins around visible lesion
- Punch biopsy (small lesions <8mm):
  - Use sterile 4-6 mm punch tool
  - Rotate tool perpendicular to skin, creating circular defect
  - Grasp tissue with forceps; cut deep tissue with scissors
  - Hemostasis with electrocautery or suture
- Shave/tangential excision (superficial lesions):
  - Hold scalpel at low angle parallel to skin
  - Slice lesion off tangentially
  - Hemostasis with electrocautery
Send specimen to pathology with proper labeling
Hemostasis: Electrocautery, topical thrombin, or suture ligation
Closure: Primary closure with 4-0 to 6-0 absorbable subcuticular suture + skin sutures or skin adhesive

3.3 Foreign Body Removal

Indications: Embedded glass, metal, wood splinters

Technique:

Anesthesia: Local anesthesia or procedural sedation depending on depth/size
Localization: Palpation, visual inspection; ultrasound if radiopaque object suspected
Preparation: Sterile prep with povidone-iodine; drape
Wound exploration:
- Create small incision over foreign body location
- Blunt dissection with hemostat or scissors; visualize object
- Remove with forceps; may need two instruments (one to stabilize, one to remove)
- If object fragmented, ensure all pieces removed (gently probe tract)
Irrigation and final visualization
Closure: Primary closure if clean; delayed closure if contaminated

X-ray Indications:

Suspected glass or metal fragments
Inability to visualize object
Deep penetrating injury

3.4 Nail Removal (Onychectomy)

Indications: Ingrown toenail, fungal infection, subungual hematoma, tumor

Digital Block Anesthesia: (See section 2.2)

0.5-1 mL 1% lidocaine per web space (no epinephrine)
Wait 10 minutes for full effect

Technique for Ingrown Toenail:

Position patient supine; affected foot elevated
Administer digital block
Prepare nail bed with povidone-iodine; sterile field
Option 1 (Partial removal - preferred):
- Use nail splitter or careful scalpel to separate nail margin from lateral nail bed
- Extract nail segment with hemostat using rotation/traction
- Alternatively: Place dental floss under nail; extract nail while protecting nail bed
Option 2 (Total nail removal):
- Pass hemostat or instrument under entire nail plate
- Use rotation motion to separate nail from bed
- Lift nail plate away; extract with traction
Inspect nail bed for infection/granulation tissue
- If present: Curettage with curette; cauterize with silver nitrate or electrocautery
Hemostasis: Pressure with gauze; topical thrombin; or cautery
Dressing: Antibiotic ointment, gauze, bulky dressing
Discharge with tetanus prophylaxis if needed
Suture removal not needed; dressing change every 2-3 days

Post-Op Instructions:

Keep foot elevated 24 hours
Pain control: Acetaminophen 650 mg q4-6h or ibuprofen 400-600 mg q6h
Change dressing daily
Avoid soaking foot >10 minutes daily
Return if signs of infection (purulence, spreading erythema, fever)

3.5 Arthrocentesis (Joint Aspiration)

Indications: Diagnostic (fluid analysis for infection, crystal disease, bleeding), therapeutic (aspirate effusion), instillation of medications

Contraindications: Cellulitis over joint, bacteremia, joint prosthesis (relative), severe coagulopathy

Technique - Knee Aspiration:

Patient supine, knee extended or slightly flexed (30 degrees)
Medial approach: Palpate medial femoral condyle and patellar tendon
- Insert needle just medial to patellar tendon, at level of joint line
- Direct needle medially and slightly posterior, parallel to tibial plateau
- Alternatively: Lateral approach (lateral to patellar tendon, medial direction)
Use 18G needle for aspiration; 25G for injection
Prepare skin with povidone-iodine; allow 30-second contact
Use sterile technique throughout
Advance needle until loss of resistance (entering joint space)
Aspirate fluid slowly (may require negative pressure from syringe)
Withdraw needle; apply pressure with sterile gauze
Send fluid for:
- Cell count/differential
- Crystal analysis (polarized microscopy)
- Gram stain/culture
- Glucose (if systemic glucose known, joint fluid glucose <50% systemic = infection)
- Protein

Technique - Hip Aspiration (More Difficult):

Patient supine, hip flexed 45 degrees
Palpate femoral artery at inguinal crease
Insert needle medial to femoral artery, just below inguinal ligament
Advance at 45-degree angle cephalad; depth ~2-4 inches
Seek “pop” as capsule penetrated; aspirate

Arthrocentesis Fluid Interpretation:

Normal synovial fluid: Clear/pale yellow, <50 WBC/mm³, <25% PMNs, negative culture
Inflammatory (RA, gout, lupus, trauma): Cloudy, 200-2000 WBC/mm³, 50-75% PMNs, negative culture
- Gout: Needle-shaped crystals, negatively birefringent (monosodium urate)
- Pseudogout: Rhomboid crystals, positively birefringent (calcium pyrophosphate)
Infectious (septic joint): Cloudy/purulent, >50,000 WBC/mm³ (often >100,000), >90% PMNs, positive culture
- Joint fluid glucose <40 mg/dL and <50% serum glucose highly specific for infection
- Gram stain positive in 25-50% of bacterial infections
- Culture positive in 70-90% of cases
- Differential includes: Gonorrhea (gram-negative diplococci), Staphylococcus aureus (gram-positive cocci)

3.6 Paracentesis (Abdominal Fluid Aspiration)

Indications: Diagnostic (ascites analysis), therapeutic (symptomatic relief of ascites), suspected peritonitis

Technique:

Patient supine; bladder emptied (Foley catheter if needed)
Ultrasound location of fluid pocket (safer than blind landmarks)
- If not available, mark McBurney’s point (1/3 distance from anterior superior iliac spine to umbilicus) or lower quadrant location away from scars
Prepare skin with povidone-iodine; sterile field
Infiltrate subcutaneous tissue with 1% lidocaine
Use 18-20G needle attached to 50 mL syringe
Insert at angle perpendicular to skin, advancing slowly
Aspirate 10-20 mL for analysis (withdraw plunger gently to avoid collapse of needle)
Withdraw needle; apply pressure
Send fluid for:
- Cell count/differential
- Albumin (serum-ascites albumin gradient - SAAG >1.1 = portal hypertension)
- Protein (total protein <25 g/L = exudate, suggests spontaneous bacterial peritonitis)
- Culture (aerobic, anaerobic, fungal)
- Gram stain
- Glucose (low glucose <50 mg/dL = bacterial peritonitis)
- LDH, amylase (if malignancy/perforation suspected)

Complications:

Bowel perforation (0.1-1%): Usually self-limited; observe for peritonitis
Hemorrhage: Especially in coagulopathy; apply pressure
Infection: Rare with proper technique
Ascitic leak: Apply pressure, dressing

3.7 Thoracentesis (Pleural Fluid Aspiration)

Indications: Diagnostic (pleural fluid analysis), therapeutic (dyspnea relief)

Contraindications: Small effusion (<1 cm on ultrasound), severe coagulopathy, mechanical ventilation with positive pressure (relative)

Technique:

Ultrasound guidance preferred (reduces pneumothorax risk from ~5% to <1%)
Patient upright, leaning forward on table or sitting at edge of bed
- Mark puncture site at top of fluid on ultrasound (usually 6th-8th intercostal space)
Prepare skin with povidone-iodine; sterile field/drape
Infiltrate skin, subcutaneous tissue, and pleural space with 1% lidocaine
Insert 18-22G needle with attached syringe
- Advance perpendicular to ribs (avoid neurovascular bundle on inferior rib)
- Advance slowly while applying gentle negative pressure
- Aspirate fluid (should flow freely if needle in pleural space)
Send 20-50 mL fluid for:
- Cell count/differential
- Protein, LDH, glucose (compare to serum levels)
- pH (<7.2 = complicated parapneumonic/empyema)
- Gram stain/culture (aerobic/anaerobic/fungal)
- Cytology (if malignancy suspected)
- Amylase (if esophageal rupture suspected; elevated if rupture)
- Triglycerides (if chylous effusion suspected)

Light’s Criteria for Exudate vs Transudate:

Exudate if ≥1 of following:
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH >2/3 upper limit of normal serum LDH
Transudates: CHF, cirrhosis, renal disease, hypoalbuminemia
Exudates: Pneumonia, malignancy, PE, rheumatologic disease, pancreatitis

Complications:

Pneumothorax (0.5-5% without ultrasound): May require chest tube if >20% or symptomatic
Hemothorax: Usually self-limited
Pulmonary edema (reexpansion): Limit initial drainage to <1.5 L
Infection/empyema: Rare with sterile technique
Splenic/hepatic injury: Avoid lower zones

3.8 Central Line Placement (Internal Jugular Vein)

Indications: Hemodynamic monitoring, multiple medications, dialysis, difficult peripheral access, TPN

Contraindications: Infection over site, severe coagulopathy, mechanical obstruction (relative)

Technique - Ultrasound-Guided Preferred:

Head-down positioning (Trendelenburg); patient supine
Turn head away from puncture site; head roll under shoulders
Ultrasound imaging: Identify IJV lateral to carotid artery; compress vein to confirm compressibility
Prepare skin with chlorhexidine (superior to povidone-iodine for bacteremia reduction); allow 30-second contact
Sterile field; full body drape
Infiltrate skin with 1% lidocaine
Advance 18G needle under ultrasound visualization into vein
Aspirate blood return; withdraw needle leaving catheter in place (if using catheter-over-needle approach) OR pass guidewire through needle (Seldinger technique):
- Insert floppy guidewire through needle into vein
- Withdraw needle over guidewire
- Nick skin with scalpel (#11 blade) at guidewire site
- Pass dilator over guidewire; remove dilator
- Insert central line catheter over guidewire (holding guidewire in place)
- Withdraw guidewire; confirm blood return from catheter
- Secure catheter with sterile suture and dressing
Check position: Chest X-ray (ideal tip location: lower 1/3 SVC or cavoatrial junction)

Complications:

Arterial puncture: Withdraw needle; apply pressure 10-15 minutes
Hemothorax/pneumothorax: Rare with IJ; consider if chest pain/dyspnea post-placement
Thrombosis: Monitor for swelling, venous insufficiency
Infection: Maintain sterile dressing; change weekly or if soiled
Malposition: Verify with chest X-ray
Arrhythmias: Guidewire irritating atrium; withdraw slightly or remove if pacemaker present

Catheter Care:

Maintain sterile dressing; change if damp/soiled
Cap all lumens; change caps weekly
Avoid “triple-lumen” lines if possible (higher infection risk)
Remove as soon as possible (increased infection risk each day line remains)

3.9 Arterial Line (A-Line) Placement

Indications: Continuous blood pressure monitoring, frequent blood draws, hemodynamic monitoring

Site Selection: Radial artery (preferred), femoral, axillary, dorsalis pedis

Technique - Radial Artery:

Patient arm extended, palm up; wrist hyperextended slightly (small towel under wrist)
Perform Allen’s test: Occlude radial and ulnar arteries with fingers; have patient open/close fist; release pressure
- Normal: Hand flushes (ulnar patency confirmed)
- Abnormal: Pallor persists (inadequate collateral; avoid radial line)
Palpate radial artery pulse
Prepare skin with povidone-iodine; sterile field
Infiltrate skin with 1% lidocaine (1-2 mL)
Insert 20G catheter-over-needle at 30-45 degree angle, aiming for artery
Advance until blood return obtained
Lower needle/catheter angle; advance catheter over needle into artery
Withdraw needle; connect catheter to flush system (pressurized normal saline with heparin 1 unit/mL)
Secure with suture/tape; dress with sterile dressing
Connect to pressure monitor

Pressure Waveform Assessment:

Normal: Biphasic waveform with diastolic notch
Dampened: Kinked line, clot, transducer problem
Over-damped: Pressure appears falsely low
Under-damped: Exaggerated systolic peaks

Flush System Maintenance:

Check for patency hourly
Monitor for backflow of blood
Never flush if clot suspected (may embolize)
Keep syringe connected to prevent air entry

Complications:

Vascular insufficiency: Remove line immediately if hand becomes pale/cool
Thrombosis: Monitor hand color/temperature
Infection: Rare; remove if signs of infection
Bleeding: Apply pressure; check for anticoagulation
Distal embolization: Rare; remove line

3.10 Urinary Catheterization

Indications: Urinary retention, monitoring urine output, bladder dysfunction, comfort in dying

Contraindications: Suspected urethral injury (blood at meatus, perineal trauma), prostate obstruction (relative)

Technique - Female:

Position supine, hip/knee flexion; drape with absorbent pad
Clean with sterile gauze: Wipe labia majora bilaterally; separate labia minora with non-dominant hand
Cleanse urethra: Anterior to posterior with sterile swabs (3-5 swabs)
Insert 16-18Fr Foley catheter slowly through urethra (avoid forcing)
Advance until urine returns in tubing (usually 2-3 inches in female)
Inflate balloon with 5-10 mL sterile water (read catheter label for volume)
Gently retract catheter until balloon engages bladder neck
Secure catheter to medial thigh with tape/securement device (prevents traction)
Connect to sterile drainage bag; hang below bladder level

Technique - Male:

Position supine; drape with absorbent pad
Grasp penis with non-dominant hand; retract foreskin if uncircumcised
Clean with sterile gauze: Circular motions from meatus outward (5-7 swabs)
Insert 16-18Fr Foley catheter slowly (first 6-8 inches in male urethra; may have resistance at external sphincter - apply steady pressure)
Advance until urine returns in tubing (total insertion ~8-10 inches)
Continue advancing additional 2-3 inches to ensure bladder entry
Inflate balloon with 10-15 mL sterile water
Gently retract catheter until balloon engages bladder neck
Secure catheter with tape/securement device to lower abdomen/suprapubic area (prevents urethral injury)
Replace foreskin if retracted
Connect to sterile drainage bag

Catheter Care:

Daily cleansing with soap/water around catheter
Maintain bag below bladder level
Avoid kinks in tubing
Keep tubing unobstructed
Empty bag when 1/2-2/3 full
Change catheter every 30 days or if encrusted/obstructed
Monitor for signs of infection (fever, dysuria, pyuria)

Complications:

Infection: UTI/urosepsis (10-25% per day with indwelling catheter)
Urethral injury: Bleeding, false passage if forced insertion
Bladder perforation: Suprapubic pain, urine leakage
Encrustation/obstruction: Struvite deposition; change catheter, increase fluids
Hematuria: Usually self-limited; if persistent, assess for trauma/infection

4. MAJOR PROCEDURES

4.1 Open Appendectomy

Anatomy: Appendix arises from posteromedial cecum 2-3 cm below ileocecal valve

Indications: Acute appendicitis with peritonitis, complicated appendicitis with abscess/perforation (after source control), appendiceal malignancy

Preoperative Assessment:

Labs: CBC (elevated WBC), CMP, coagulation studies if indicated
Imaging: CT abdomen/pelvis with IV/oral contrast (98% sensitive for appendicitis)
Antibiotic prophylaxis: Cefoxitin 2 g IV or cefotetan 2 g IV (cover gram-negative and anaerobes)
NPO status: 6-8 hours

Technique:

General anesthesia; endotracheal intubation
Supine positioning; arms abducted on arm boards
Prep abdomen with povidone-iodine from xiphoid to groin; sterile draping
McBurney’s incision (muscle-splitting):
- Incision 1/3 distance from ASIS to umbilicus, perpendicular to line connecting these points
- Length: 2-3 inches
- Incise skin and subcutaneous tissue
- Split external oblique fascia along muscle fibers
- Split internal oblique and transversus abdominis muscles along fibers (avoid cutting)
Incise peritoneum carefully (avoid bowel injury)
Inspect abdomen for other pathology
Identify cecum: Follow taeniae coli (longitudinal muscle bands on colon) from cecal pole
Identify appendix: Usually lies posteromedially beneath cecum
If retrocecal: Carefully elevate cecum with retractor; bluntly dissect appendix free
Elevate appendix with Babcock clamp
Mesoappendix ligation:
- Divide mesoappendix (peritoneal fold) in small sections using cautery or ligatures
- Ligate with absorbable suture (2-0 or 3-0 Vicryl) - continue until appendiceal base exposed
- Do NOT ligate in single mass (risk of bleeding)
Appendiceal base: Three options for control:
- Ligature technique: Ligate base with 2-0 absorbable suture (most common)
- Stapler technique: Apply surgical stapler across base (TA-30); remove appendix
- Clamp-and-tie: Clamp with Kelly clamp, ligate, then tie with suture
Stump management:
- Invert stump into cecum using purse-string suture (old practice; now optional) OR
- Leave stump exposed (equally effective, no difference in complications)
Irrigate abdomen with normal saline if peritonitis present
Close peritoneum with running absorbable suture if desired (may decrease adhesions, not critical)
Close transversus/internal oblique together with running absorbable suture
Close external oblique fascia with running absorbable suture
Close subcutaneous tissue with absorbable sutures if >5 mm thick
Close skin with monofilament suture or staples; remove in 7-10 days

Closure by Layer:

Peritoneum: 3-0 Vicryl running (optional)
Internal oblique + transversus: 2-0 Vicryl running
External oblique: 2-0 Vicryl running
Subcutaneous: 3-0 Vicryl (if needed)
Skin: 3-0 Nylon or staples

Postoperative Management:

IV fluids: 1-2 L D5NS or normal saline on first postop day
Antibiotics: Continue until oral intake (typically cefoxitin 2 g q6h × 3-5 days or ceftriaxone 1 g q12h + metronidazole 500 mg q8h)
Bowel function: Usually return in 24 hours (uncomplicated); encourage ambulation
Pain control: Morphine 5-10 mg IV q4-6h or hydromorphone 0.5-1 mg IV q4h; transition to oral once tolerated
Diet: NPO until bowel sounds return; clear liquids, advance as tolerated
Discharge: POD #1-2 (uncomplicated); POD #3-5 (complicated)

Complications:

Appendiceal stump leak/fistula: Fever, abdominal pain POD #3-5; manage with percutaneous drainage and antibiotics
Bowel obstruction: Adhesions (delayed); symptom onset variable
Bleeding: From mesoappendix vessels; identified during surgery; ligate or cauterize
Injury to cecum/small bowel: Recognized intraoperatively; repair with full-thickness closure

4.2 Open Cholecystectomy

Anatomy: Gallbladder lies in fossa on undersurface of right lobe of liver; cystic artery from right hepatic; cystic duct joins common hepatic to form CBD

Indications: Acute/chronic cholecystitis, choledocholithiasis, gallstone pancreatitis, biliary dyskinesia (select cases), gallbladder malignancy

Preoperative Assessment:

Labs: CBC, CMP, LFTs (bilirubin, alkaline phosphatase, GGT), PT/INR
Imaging: RUQ ultrasound (gold standard; shows stones, wall thickening, pericholecystic fluid)
ERCP if CBD stones suspected
Antibiotic prophylaxis: Cefoxitin 2 g IV or ceftriaxone 1 g IV (cover gram-negative, anaerobes)
NPO 6-8 hours

Technique:

General anesthesia; endotracheal intubation
Supine positioning; arms abducted
Prep abdomen with povidone-iodine from nipple line to groin; sterile draping
Kocher incision (subcostal, preferred) or RUQ midline incision:
- Kocher: Incision parallel to right costal margin, 1-2 fingers below edge; provides excellent exposure
- Length: 4-6 inches
- Incise skin, subcutaneous tissue, anterior rectus fascia
- Retract rectus muscle medially
Incise peritoneum; inspect abdomen
Place self-retaining retractor; place pack above GB to isolate from upper abdomen
Identify structures:
- Locate fundus (usually extends below liver edge)
- Grasp fundus with Babcock clamp gently; elevate upward
- Visualize Hartmann’s pouch (superior to fundus)
- Identify cystic artery (first structure to control, runs in hepatocystic triangle)
Clear hepatocystic triangle:
- Carefully dissect peritoneum and fat with gauze on clamp (gentle, blunt dissection)
- Avoid excessive manipulation (risk of stones dropping into abdomen)
- Identify: Cystic artery, cystic duct, common hepatic duct
Ligate cystic artery:
- Once clearly identified, place two ligatures proximally and one distally
- First ligature (2-0 silk): Tie around cystic artery after positioning small clamp
- Second ligature: Tie distal to first
- Divide artery between ligatures with scissors
- Maintain proximal ligature to keep vessel visible if bleeding occurs
Identify cystic duct junction with common hepatic duct (critical - avoid CBD injury):
- Should see clear “critical view of safety”: cystic artery divided, clear view of hepatocystic triangle with <2 structures crossing triangle
- Verify structures: Common hepatic duct on medial side (larger); cystic duct on lateral side
Ligate cystic duct:
- Place clip or ligature on cystic duct close to gallbladder (not on common hepatic duct)
- Some surgeons perform cholangiogram if CBD stones suspected (clip distal CBD, inject contrast, take X-ray)
- If no clips available: Ligate with 3-0 or 4-0 absorbable suture using two ligatures
- Divide duct between ligatures with scissors
Remove gallbladder:
- Carefully dissect gallbladder off liver bed using cautery or scalpel
- Avoid perforation (spilled stones → bile peritonitis, granuloma formation)
- If gallbladder perforates: Place in specimen bag immediately; wash abdomen with saline
- Place specimen in basin; never drop on floor
Inspect liver bed:
- Should be hemostatic; small bleeders cauterized
- If large bile duct torn: Repair with 5-0 absorbable running suture over stent (advanced case; consider referral)
Irrigate abdomen with normal saline; ensure no stones in pelvis
Close abdomen:
- Peritoneum: Usually not closed (optional)
- Anterior rectus fascia: 1-0 or 2-0 absorbable (running or interrupted)
- Subcutaneous tissue: 3-0 absorbable
- Skin: 3-0 monofilament or staples

Postoperative Management:

NPO until bowel function returns
IV fluids: 1-2 L first day
Antibiotics: Continue until discharge (cefoxitin 2 g q6h or ceftriaxone 1 g q12h)
Pain control: Opioids as needed (morphine, hydromorphone)
Bowel function: Usually return POD #1
Diet: Clear liquids, advance as tolerated
Discharge: POD #1-2 (uncomplicated)

Complications:

Bile duct injury: Major complication; presents as jaundice, elevated bilirubin POD #1-3; requires urgent referral
Common bile duct stone: If discovered intraoperatively, perform choledochotomy (open bile duct, remove stone) and close over stent; OR place T-tube for postop drainage
Pancreatitis: From manipulation or ductal obstruction; manage supportively (NPO, fluids, pain control)
Bleeding from liver bed: Usually controlled with pressure; severe cases need packed RBCs
Bile leak/biloma: From cystic duct stump; usually manages with drain; ERCP + sphincterotomy if severe

4.3 Bowel Resection & Anastomosis

Indications: Perforated bowel, unresectable stricture, Crohn’s disease, ischemia, obstruction, malignancy

Technique - Small Bowel Resection:

General anesthesia; endotracheal intubation
Long midline abdominal incision (generous length for proper exploration)
Explore entire abdomen; identify segment requiring resection
Deliver segment out of abdomen onto moistened laparotomy pad
Isolate segment:
- Identify proximal and distal margins of disease
- Decide resection margins (typically 5 cm beyond visible disease for inflammation; margin depends on pathology)
Divide mesentery:
- Identify mesentery (peritoneal attachment containing blood vessels and lymphatics)
- Ligate mesenteric vessels with silk ties or absorbable sutures (2-0)
- Divide mesentery from bowel edge inward
- Continue until only bowel edges to be resected remain
Divide bowel:
- Clamp proximal bowel with vascular clamp (GIA stapler placed across, fired, or hand-sewing with purse-string)
- Clamp distal bowel
- Divide with scalpel between clamps
- Remove specimen
Prepare bowel for anastomosis:
- Milk proximal/distal bowel away from clamps
- Inspect lumen: clear of meconium, debris
- Assessment: Viability (pink, bleeding when cut, pliable)
Small bowel anastomosis (functional end-to-end, two-layer technique most common):
- Option 1 (Hand-sewn):
  - Place four corner stay sutures (3-0 absorbable, single-armed)
  - Approximate bowel ends in end-to-end fashion
  - Inner layer (mucosa): Running 4-0 absorbable suture, locking or simple running (starts at mesenteric border, runs opposite direction to antimesentric border)
  - Irrigate lumen to ensure patency
  - Outer layer (serosa/muscular): Running 3-0 absorbable suture, full thickness, incorporates all layers except mucosa
- Option 2 (Stapler):
  - Create functional end-to-end anastomosis using GIA stapler
  - Faster than hand-sewing; comparable outcomes
Test anastomosis: Gentle pressure with sponge stick; assess for leakage
Drain placement: Not routine (consider if gross spillage)
Irrigate abdomen: Normal saline thoroughly if perforation/contamination
Close abdomen:
- Peritoneum: Running absorbable suture
- Anterior rectus fascia: 1-0 absorbable running (essential layer)
- Subcutaneous: 3-0 absorbable if >5 mm
- Skin: 3-0 monofilament or staples

Postoperative Management:

NPO initially; gradual advancement based on bowel function
IV fluids: TPN or high-dose IVF if extensive resection
Bowel rest critical in first 5-7 days
Antibiotic coverage for 24 hours post-op (cefoxitin or ceftriaxone + metronidazole)
Pain control: Opioids; transition to PO
Monitor anastomosis: Watch for peritonitis (fever, rigidity, elevated WBC)

Complications:

Anastomotic leak: Usually POD #3-5; fever, peritonitis, sepsis; requires reoperation and drainage
Bowel obstruction: Adhesions (early or late); manage conservatively if early
Bleeding: From anastomosis or mesenteric vessels

4.4 Hernia Repair

Inguinal Hernia (Open Tissue Repair):

Anatomy: Inguinal canal bounded by inguinal ligament inferiorly, internal oblique/transversus medially, contains spermatic cord (males) or round ligament (females)

Indications: Symptomatic hernia, increasing size, risk of incarceration

Technique (Lichtenstein tension-free repair - gold standard):

Local anesthesia: Infiltrate spermatic cord with 10-15 mL of 1% lidocaine (avoid intratesticular injection)
Supine positioning; small roll under surgical hip
Prep with povidone-iodine; sterile draping
Incision: 3-4 inch incision parallel to and above inguinal ligament, starting 0.5 inch medial to pubic tubercle
Incise skin and subcutaneous tissue
Incise external oblique fascia in line with skin incision
Elevate and retract external oblique flaps
Identify spermatic cord; separate gently from surrounding tissue with finger (blunt dissection)
Identify hernia sac:
- For indirect hernia: Located anteromedial to cord; grasp with fingers; dissect off cord carefully
- For direct hernia: Emerges directly through transversus fascia in Hesselbach’s triangle (medial, inferior epigastric vessels, lateral ligament)
Reduce hernia: Gently push sac contents back through defect into abdomen
Sac management:
- For indirect: Ligate at internal ring with absorbable suture (purse-string); leave sac open distally (allows fluid drainage, prevents seroma)
- For direct: May leave sac alone (usually small, contents often omentum) or open and reduce
Mesh placement (tension-free repair):
- Measure defect; select mesh size (should overlap defect by 3 cm all directions)
- Position mesh over spermatic cord (cord lies on top of mesh)
- Secure mesh medially with two sutures (1-0 monofilament) to rectus fascia/periosteum below pubic tubercle (avoid nerves)
- Secure superiorly to internal oblique aponeurosis with interrupted sutures (1-0)
- Secure laterally to inguinal ligament with interrupted sutures
- Cut mesh around cord (leave slit) OR apply mesh over cord
- Secure interior oblique flap over mesh if possible (decreases seroma, pain)
Close external oblique: Running absorbable suture over mesh
Close subcutaneous tissue and skin

Postoperative Management:

Local anesthesia cases discharge same day
Rest 1 week; avoid heavy lifting 4-6 weeks
Pain control: Acetaminophen, NSAIDs, opioids if needed
Return to work: 2-3 weeks (lighter duty), 6 weeks (full duty)
Suture removal: 7-10 days (if non-absorbable used)

Incisional Hernia (Ventral):

Indications: Failed primary closure, infection, improper closure technique, patient factors (obesity, smoking, chronic cough, COPD)

Technique (Primary repair if small <2 cm):

Approach through previous incision or new incision over hernia
Dissect sac off skin/subcutaneous tissue
Open sac; inspect for adhesions
Reduce contents; resect sac
Assess fascial edges: May need to separate subcutaneous tissue from fascia to achieve closure without tension
Close fascia in two layers:
- Inner layer: Interrupted absorbable suture, full thickness
- Outer layer: Running or interrupted absorbable
Reapproximate external oblique/anterior rectus fascia
Drain if seromas anticipated (place Jackson-Pratt drain if necessary)
Close skin

Complicated Incisional Hernia (Large, Recurrent):

Often requires mesh (tension-free repair similar to inguinal repair)
Some surgeons prefer inlay mesh (mesh sewn into fascial defect)
Alternative: Component separation technique (release external oblique fascia medially; allows primary closure)

4.5 Cesarean Section (Lower Segment Transverse, LSCS)

Indications: Failed labor, fetal distress, placental abruption, preeclampsia, breech presentation, prior classical cesarean

Preoperative Preparation:

Regional anesthesia (neuraxial) preferred: Spinal or epidural
General anesthesia if urgent/contraindication to regional
NPO 2-6 hours if planned; if emergent, assume full stomach (rapid sequence intubation)
Antibiotic prophylaxis: Cefazolin 2 g IV (give before skin incision) or clindamycin 600 mg IV if penicillin-allergic
Oxytocin 20 units in 500 mL normal saline prepared for after placental delivery

Technique:

Spinal anesthesia (preferred): 12 mg bupivacaine hyperbaric + 10 mcg fentanyl + 0.1 mg morphine (allows block to T5 level, prevents nausea)
Supine position; slight left uterine displacement (roll under left hip, or position left lateral)
Prep abdomen with povidone-iodine from xiphoid to pubic symphysis; sterile draping
Pfannenstiel incision (most common):
- Transverse incision 2-3 inches above pubic symphysis, slightly curved
- Length: 5-6 inches
- Incise skin and subcutaneous tissue
- Separate rectus muscles vertically (not cut)
- Incise peritoneum carefully
Explore abdomen; clear bladder, bowel
Inspect uterus; identify fetal position
Place bladder blade to protect bladder
Make uterine incision:
- Incision in lower segment (area of uterine body 2-3 inches above bladder reflection)
- Make small transverse incision with scalpel through uterine wall (avascular layer - low in segment)
- Extend incision with scissors or bluntly pushing fingers through incision (lateral direction preferred - stretches incision)
- Avoid extending into uterine vessels laterally
- Incision length: 3-4 inches
Deliver fetus:
- Insert hand under fetal head or buttocks (depending on presentation)
- Assist delivery gently
- Place cord clamp across umbilical cord, allow placental circulation to continue briefly (fetal resuscitation in background)
- Hand infant to waiting personnel for evaluation
- Cut cord; place infant under warmer
Deliver placenta:
- Wait for uterine contraction (or inject oxytocin IV)
- Apply gentle traction on cord; support uterine fundus
- Placenta usually delivers within 1-5 minutes
- Once delivered: Check placenta for retained portions, membranes
Myometrial repair (uterine closure):
- Inspect for bleeding; note any extensions of incision
- Suture uterine incision in two layers using 1-0 or 2-0 absorbable suture:
  - First layer: Interrupted sutures incorporating 1/2 to 2/3 of myometrial thickness (do NOT perforate into uterine cavity completely - avoid amniotic leak into abdomen if residual pregnancy)
  - Second layer: Interrupted sutures in outer myometrium (reinforcing layer)
- Some surgeons use running locked suture (faster)
Inspect abdomen:
- Wipe away blood; inspect for bleeding from uterine incision edges
- Irrigate pelvis with normal saline
Close peritoneum: Running absorbable suture (some surgeons skip this step)
Bladder blade removal; inspect
Close rectus fascia: 1-0 or 2-0 absorbable running suture (critical layer)
Close subcutaneous tissue and skin

Postoperative Management:

Oxytocin infusion: 20 units in 500 mL NS at 200 mL/hour for 4 hours to maintain uterine contraction
IV fluids: 1-2 L day one (less if neuraxial anesthesia; risk hypervolemia)
Antibiotics: Continue cefazolin 1 g q8h × 24 hours (or cephalothin q6h) post-op
Pain control: Morphine 2-4 mg IV q4h or epidural catheter analgesia (if epidural); advance to PO (acetaminophen, NSAIDs, opioids as needed)
Bowel function: Usually POD #1-2; encourage ambulation
Catheter removal: If spinal anesthesia, remove catheter when sensation/motor returning
Diet: NPO briefly, advance to clear liquids, then regular as tolerated
Breastfeeding: Encourage starting in recovery room
Discharge: POD #2-3 if uncomplicated vaginal delivery; POD #3-4 if prior classical cesarean
Activity: Avoid heavy lifting, strenuous exercise for 6 weeks

Complications:

Uterine atony: Increased bleeding; manage with oxytocin, massage uterine fundus, consider methylergonovine 0.2 mg IM/IV (avoid if hypertension), misoprostol 800 mcg PR
Bladder injury: Rare; if occurs, repair with running absorbable suture
Bowel injury: Rare; repair if recognized intraoperatively
Postpartum hemorrhage: Uterine atony, placental retention, coagulopathy; manage with transfusion, hemostatic measures
Infection/endometritis: Fever POD #2-3; treat with antibiotics (ampicillin + gentamicin ± clindamycin)
Thromboembolism: VTE prophylaxis important; mechanical (SCDs) and chemical (heparin 5000 units SC q12h)

4.6 Tracheostomy

Indications: Prolonged mechanical ventilation (>7-10 days anticipated), upper airway obstruction, aspiration prevention in neurologically impaired

Timing: Often performed after 3-5 days of endotracheal intubation when clear need for prolonged ventilation established

Technique (Percutaneous Dilatational, Ciaglia - most common in ICU):

Confirm recent CXR, neck CT (if anatomy abnormal)
Endotracheal tube position: Confirm at 21-23 cm at lips (with tube already intubated)
Prep: Supine, extended neck, shoulders rolled under
Identify anatomy: Palpate cricoid cartilage, thyroid, trachea
Intended stoma site: 1-2 cm below cricoid (between 1st-2nd tracheal rings typically)
Local anesthesia: Infiltrate skin with 1% lidocaine (1% epinephrine)
Small skin incision (1-1.5 cm) with #11 blade
Advance 18G needle under direct visualization (endoscopy) into trachea
Pass guidewire through needle; withdraw needle
Serial dilators (9-32 Fr) passed over guidewire, each time widening tract
Tracheostomy tube (typically 8 Fr) passed over final dilator/guidewire
Secure tube with flanges and neck tether
Confirm position: Capnography, air exchange bilaterally
Ventilator connected; secure settings
Verify cuff seal (adequate on vent, no significant air leak)

Open Surgical Technique (if percutaneous contraindicated):

Prone position supine, neck extended
Incision: Transverse, 1.5-2 cm between 1st-3rd tracheal rings
Identify trachea, divide between rings
Dilate opening with dilators
Insert tube; secure with ties/sutures
Loose packing around tube, no sutures through trachea

Post-Tracheostomy Management:

Confirmed position: CXR, clinical assessment
Suction PRN: Only insert to depth of tube + 2 cm (avoid subglottic suctioning causing tracheal damage)
Humidified air: Always provide (prevents secretion crusting)
Tube changes: First change at 7 days; then q21 days or per protocol
Deflate cuff if long-term (>1-2 weeks) and no aspiration risk (frees glottis, allows phonation)
Cuff pressure: Monitor with manometer; keep <25 cm H2O (prevents tracheal stenosis)
Secretions: Copious initially; decrease over time
Speaking valve: Can place on tube after cuff deflated (restores phonation)
Weaning: Once respiratory status improves, trial cap (plug) the tracheostomy

Complications:

Early hemorrhage (POD #0-3): Occurs from anterior tracheal wall vessel erosion; managed with pressure, local thrombin, or suture ligation
Tube obstruction: Secretion crusting; change tube, increase humidification
Tube malposition: Subcutaneous, into esophagus; reposition or replace
Tracheal stenosis: Late complication; prevent by keeping cuff pressure <25 cm H2O
Tracheal necrosis: From high cuff pressure
Subglottic stenosis: If tube too high
Tracheoinnominate fistula: Rare, catastrophic; eroding tube into anterior wall; massive hemorrhage; emergency tracheostomy tube repositioning + surgical repair

4.7 Lower Extremity Amputation

Indications: Severe tissue loss (diabetic/arterial ulcer), non-viable limb, gangrene, severe trauma, malignancy, infection (necrotizing fasciitis), vascular insufficiency

Levels:

Below-knee (BKA): More functional for prosthetic; better ambulation
Above-knee (AKA): Higher oxygen cost for prosthetic; often necessary if extensive thigh involvement
Knee disarticulation: Rarely done; good prosthetic fit
Foot/ankle disarticulation: Preserve knee; preserves length

Technique - Below-Knee Amputation (BKA):

General anesthesia; regional block often added (nerve blocks for pain control post-op)
Supine positioning; affected limb exposed and prepped
Mark amputation level (usually 4-6 inches below knee joint, or at maximum viable tissue)
Incision planning:
- Anterior flap longer than posterior (anterior 50%, posterior 50% total length creates better prosthetic fit)
- Or: Modified circular technique
Anterior flap (skin to depth of muscle):
- Incise skin, fascia, muscle anteriorly
- Extend distally to plantar surface; curve posteriorly
- Depth: Full muscle layer (anterior compartment)
Posterior flap (shorter):
- Incise gastrocnemius-soleus bulk
- This provides cushion for prosthetic socket
Bone division:
- Clamp anterior/posterior tibial vessels and peroneal vessel separately (tie or cauterize)
- Clamp nerves separately, divide slightly above bone to allow retraction (nerves shrink)
- Use oscillating saw perpendicular to bone (creates clean edge)
- Divide fibula 1 inch shorter than tibia (prevents prominence)
- Ream bone edge with burr (smooth, no sharp edges for prosthetic irritation)
Irrigate, achieve hemostasis:
- Copious saline irrigation
- Hemostasis critical (drains increase phantom limb pain)
Close in two layers:
- Deeper layer: Anterior muscle to posterior fascia with interrupted absorbable sutures
- Skin: 3-0 monofilament, non-absorbable; remove POD #5-7 (early removal decreases seroma)
Bulky dressing: Soft wrapped dressing; some surgeons apply rigid dressing immediately (decreases swelling, allows earlier prosthetic fitting)

Postoperative Management:

Phantom pain extremely common (75%+); manage with opioids, NSAIDs, tricyclic antidepressants (amitriptyline), gabapentin
Prone positioning 2-4 times daily (if patient tolerates) prevents hip flexion contracture; sit with hip extended at least 2 hours daily
Stump care: Wash daily with mild soap; dry completely
Stump wrapping: Ace bandage; remove q2-4h to check skin integrity
Pain control: Opioids as needed; transition to chronic pain management
Early prosthetic fitting encouraged (within 2-4 weeks of suture removal if stump stable)
Physical therapy: Critical for prosthetic training
DVT prophylaxis: SCDs, heparin 5000 units SC q12h

Above-Knee Amputation (AKA):

Shorter surgical time; less tissue handling
Higher metabolic cost for prosthetic ambulation (10-15% vs 3-5% for BKA)
Otherwise similar closure principles
Higher risk hip flexion contracture; emphasize prone positioning

Complications:

Hemorrhage: Usually recognized intraoperatively
Seroma formation: Commonly occurs; usually self-limited (resorption); aspiration if persistent and symptomatic
Infection: Treat with antibiotics; may require regraft if necrotic tissue
Neuroma: Painful nerve scar; treated with nerve blocks, local anesthetic injections, or surgical resection if severe
Contracture: Hip/knee flexion contracture; prevented with positioning, splinting, PT
Inadequate pain control: Multimodal approach essential
Prosthetic fitting difficulties: Due to contracture, pain, medical status

4.8 Exploratory Laparotomy (Ex-Lap)

Indications: Acute abdomen with peritonitis (perforated viscus, perforation), abdominal trauma with peritoneal signs, sepsis of unknown source, acute mesenteric ischemia (possible salvage)

Technique:

General anesthesia; endotracheal intubation
Supine; arms abducted
Rapid prep: Povidone-iodine from niplines to knees; minimal draping (efficient for unstable patient)
Midline incision: From xiphoid to below umbilicus (can extend to pubic symphysis if needed)
- Incise skin/subcutaneous tissue rapidly
- Incise fascia cephalad and caudad (allow inspection before full opening)
- Open peritoneum
Rapid inspection for source:
- Quadrant by quadrant assessment
- Note: Free fluid, feces, blood, pus, bile
- Palpate for perforation
Common findings and immediate management:
- Perforated peptic ulcer: Stomach, duodenum; treat with control of bleeding vessel (underrun with suture), close with patch (omentum - Graham patch technique)
- Perforated diverticulitis: Sigmoid; if confined, perform primary repair; if soiling massive, consider Hartmann’s (proximal colostomy + distal mucous fistula, reversal later)
- Perforated appendicitis: Appendectomy (see section 4.1)
- Ischemic bowel: Black/dusky bowel; assess viability; resect if non-viable; perform second-look surgery in 24 hours if boundary areas question
- Free blood: Identify source (splenic vs hepatic laceration vs vessel); control bleeding (splenectomy if splenic injury; suturing if hepatic/mesenteric)
Irrigate abdomen copiously with normal saline (3-4 liters minimum for contamination)
Achieve hemostasis throughout
Source control complete, close abdomen (see closure technique above under appendectomy)

Postoperative Management:

ICU admission common (sepsis, hemodynamic instability)
High-dose IV antibiotics: Ceftriaxone 2 g q12h + metronidazole 500 mg q8h (broader if fecal peritonitis)
IV fluids: 2-4 L/day based on urine output, lactate clearance
Pain control: Opioids; epidural if available
Bowel rest: NPO initially
Reassess for need for re-operation: Fever POD #2-3 may indicate anastomotic leak, abscess; consider CT and possible reoperation
Second-look laparotomy: Consider if marginal bowel viability noted at initial surgery; planned return in 24 hours

Mortality/Morbidity: High mortality (10-40%) depending on pathology and patient factors; significant morbidity (infection, sepsis, multiorgan failure)

5. WOUND MANAGEMENT

5.1 Wound Classification

Clean: Uninfected operative wounds with no break in technique; no entry into GI/biliary/urinary/respiratory tracts; <2 hours from injury (traumatic wounds)

SSI rate: <2%
Antibiotics: Prophylaxis only (single dose pre-op)

Clean-Contaminated: Operative wounds with minor break in technique; minor entry into biliary/respiratory/urinary/GI tracts without significant spillage

SSI rate: 5-15%
Antibiotics: Prophylaxis (single pre-op dose or single dose post-op for GI cases)

Contaminated: Major break in sterile technique; minor spillage from biliary/respiratory/urinary/GI tracts; major traumatic wounds <6 hours; elective procedure in emergency setting without major pre-existing infection

SSI rate: 15-30%
Antibiotics: Prophylaxis + treatment (start intraoperatively, continue post-op)

Dirty: Pre-existing infection present; major delay between injury and treatment (>6-12 hours); major breach of sterile technique; traumatic wound with gross contamination/devitalization

SSI rate: 30-40%+
Antibiotics: Therapeutic (full course, not prophylaxis)

5.2 Irrigation and Debridement

Irrigation Pressure and Method:

High-pressure irrigation most effective: 35 mL syringe with 18G needle/catheter (removes bacteria, foreign material)
Volume: 500 mL minimum for minor; 1-3 L for heavily contaminated wounds
Solution: Normal saline (isotonic, doesn’t damage tissues)
Avoid hydrogen peroxide, Betadine (can damage tissue; only for surface cleansing)

Debridement Principles:

Remove ALL devitalized tissue (non-bleeding tissue, necrotic muscle, tendon, fat)
Viable tissue: Bleeds when cut, retracts when stimulated, maintains sensation/motor
Extent: Must expose clean, bleeding tissue
Repeat debridement necessary if contamination massive or if question of viability

5.3 Primary, Secondary, Delayed Closure

Primary Closure: Closure of fresh wound <6-12 hours old, clean/clean-contaminated, no contamination

Most wounds repaired at time of injury
Technique: Two-layer closure (deep layer absorbs tension, skin layer provides seal)

Delayed Primary (Tertiary) Closure: Wound left open 48-72 hours; closed once infection risk decreased

Used for: Moderately contaminated wounds where infection risk unknown, heavily traumatic wounds
Technique: Leave wound open with moist packing (normal saline gauze); reassess at 48-72 hours; if clean/no infection → close
Advantage: Allows assessment for infection before closure; decreases infection risk vs leaving open
Disadvantage: Additional intervention needed

Secondary Closure: Wound left open to granulate (heal by secondary intention)

Used for: Heavily contaminated/infected wounds, wounds with large tissue loss, wounds that dehisce
Technique: Open to air or covered with moist dressing; change dressing BID; allow granulation tissue to form
Time frame: Weeks to months depending on size
Advantage: Lower infection rate; allows observation for complications
Disadvantage: Slower healing; larger scars

5.4 Wound Healing Phases

Hemostasis (0 seconds - minutes):

Platelet aggregation, fibrin clot formation
Seals wound

Inflammation (0-3 days, peaks day 2):

Neutrophils migrate to wound
Macrophages appear (day 2+), remove debris
Cytokine release stimulates fibroblasts
Swelling, erythema, increased exudate
Pain present

Proliferation (3-21 days, peaks day 5-7):

Fibroblast collagen deposition (weak collagen initially)
Angiogenesis (new capillaries form)
Epithelialization (epithelial cells migrate from wound edges)
Granulation tissue (red, bumpy tissue; bleeds easily; appears friable)
Strength increases daily (reaches 20% at 2 weeks, 50% at 4-6 weeks)
Reduced drainage

Remodeling (weeks 3 - 2 years, peaks month 3):

Collagen cross-linking increases strength
Excess collagen removed; scar matures
Neovascularization regresses
At 3 weeks: 25% strength; at 6 weeks: 50%; at 3 months: 80%; >1 year: 100% (but scar remains less elastic)
Scar matures (pales, flattens)

5.5 Negative Pressure Wound Therapy (NPWT)

Indications: Complex wounds, large area tissue loss, chronic wounds, grafts, flaps, contaminated/infected wounds (prepare for closure)

Mechanism: Continuous negative pressure (50-125 mm Hg, typically 75-125 mm Hg) removes exudate, reduces bacterial load, promotes angiogenesis, promotes granulation

Application:

Clean wound thoroughly; remove debris
Measure wound dimensions
Cut foam to fit wound bed (avoid air leak; foam should fit snugly)
Place foam in wound; cover with adhesive drape (seal around foam)
Place drain tube through drape into foam
Connect to negative pressure unit
Set pressure: Typically 75-125 mm Hg continuous or intermittent pattern
Monitor for seal integrity daily

Dressing Changes: Every 48-72 hours (or more frequently if soaked with exudate)

Healing Indicator: Granulation tissue formation, reduced wound size, decreased drainage

Duration: Until wound ready for closure (usually 2-4 weeks for large wounds)

5.6 Skin Grafting (Split-Thickness)

Indications: Large surface area loss (burns, trauma), wounds with exposed bone/tendon but good blood supply, traumatic abrasions

Technique:

Prepare wound bed: Remove all devitalized tissue; achieve hemostasis (bleeding prevents graft adherence)
Clean wound with normal saline; dry carefully
Harvest skin graft:
- Dermatome (electric or manual) set to 0.010-0.015 inches (split thickness)
- Donor sites: Thigh, arm, abdomen (avoid extremities if possible; heals slower)
- Stretch donor skin (drum-tight) with assistant
- Pass dermatome slowly and smoothly across skin
- Harvest graft onto silicone liner (keeps moist)
Graft placement:
- Lay graft on wound bed
- Smooth out wrinkles/bubbles (use dermatome handle to gently roll out air)
- Secure with sutures (4-0 or 5-0) at corners and edges, or with topical adhesive
- Minimize movement (critical for graft take)
Bolster dressing:
- Apply non-stick gauze over graft
- Layer of gauze or cotton (absorbs exudate)
- Tie over with sutures or tape (maintains pressure on graft; ensures contact with wound bed)
Immobilize graft area (no movement for 5-7 days)

Graft Assessment:

Day 1-3: Edema expected; graft appears pale
Day 3-5: Progressive color improvement
Day 5-7: Sutures removed; graft now adherent
Day 7-14: Graft matures (neovascularization complete); pink color indicates successful take
Graft take success: >90% expected with good technique
Failure indicators: Black color (necrosis), fluid collection (seroma prevents take)

Donor Site Care:

Cover with non-stick dressing
Keep moist with topical ointment
Heals by secondary intention (epithelialization from edges)
Complete healing: 10-14 days
Can reharvest same site after healing (epidermal regeneration)

6. SURGICAL COMPLICATIONS

6.1 Surgical Site Infection (SSI) Prevention and Management

Prevention Bundles:

Preoperative: Antibiotic prophylaxis (within 60 minutes of incision; within 120 minutes for vancomycin/clindamycin)
Prophylaxis duration: Single dose typically sufficient; redose if prolonged surgery (>2 half-lives of antibiotic)
Skin antisepsis: Povidone-iodine or chlorhexidine (allow full contact time - 30 seconds minimum)
Normothermia: Maintain core temperature >36.5°C (active warming during surgery)
Blood glucose control: Keep <180 mg/dL perioperatively (especially post-op)
Oxygenation: FiO2 >30% during surgery
Sterile technique: Asepsis, proper draping, gloving

Antibiotic Prophylaxis (Most Common Regimens):

Clean cases: Cefazolin 1-2 g IV (renal dosing if needed)
Clean-contaminated GI: Cefoxitin 2 g IV or ceftriaxone 1 g + metronidazole 500 mg
Vascular: Cefazolin 2 g IV
Orthopedic: Cefazolin 2 g IV
Penicillin-allergic: Clindamycin 600 mg IV or vancomycin 15-20 mg/kg IV

Diagnosis of SSI:

Superficial: Infection in skin/subcutaneous tissue; fever, purulence, erythema, warmth POD #3-7
Deep: Fascia/muscle; fever, pain, dehiscence, purulence from wound POD #3-14
Organ/space: Deep to muscular fascia; fever, sepsis without localized findings POD #5-30

Management of SSI:

Superficial: Open wound, drain pus, culture, irrigate, dress with antibiotic ointment
Deep: Return to OR; open incision, explore, irrigate, drain pus
Start antibiotics: Broad-spectrum (empiric) until culture results; adjust based on sensitivity
- Typical: Clindamycin 600 mg q6h or cefoxitin 2 g q6h
- If MRSA risk: Vancomycin 15-20 mg/kg q8-12h (goal trough 15-20)
- Anaerobic coverage: Metronidazole 500 mg q8h
Duration: 5-7 days post-drainage if superficial; 7-10 days if deep
Repeat irrigation/debridement if non-improving

SSI Risk Stratification (NNIS):

Clean procedure, ASA ≤2, duration <2 hrs: 1% risk
Add wound class contamination: 5-15%
Add patient comorbidities: 10-30%
Add procedure complexity/duration: 20-40%

6.2 Wound Dehiscence

Definition: Separation of fascial closure (full-thickness wound)

Timing:

Early (POD #3-14): Usually technical (poor closure, excessive tension, infection)
Late (>2 weeks): Usually from infection, chronic comorbidities, patient activity

Risk Factors: Obesity, chronic corticosteroid use, smoking, COPD, advanced age, infection

Presentation: Sudden drainage (serosanguineous), visible fascia, bulging, pain

Management:

Immediate: Support wound; patient should splint when moving/coughing
Assess: Is this complete (full-thickness) or superficial (skin only)?
If complete: Return to OR for re-closure (within 24-48 hours)
Irrigate, debride edges, re-close fascia (use full-thickness stitches; mass closure technique - each stitch grasps fascia only, not deeper layers)
If delayed presentation (>48 hours): May require NPWT, delayed closure if infection present

Prevention: Proper closure technique, tension-free approximation, adequate sized sutures, consider retention sutures for high-risk patients (large loops of suture material, not too tight)

6.3 Hemorrhage

Classification:

Primary (intraoperative): Bleeding during procedure; should be controlled before closure
Reactionary (first few hours post-op): Usually technical, incomplete hemostasis
Secondary (after hours to days): Usually from infection, anticoagulation, retraction of vessel

Management:

Minor bleeding: Pressure with sponge, local hemostasis agents (topical thrombin, gelatin sponges)
Major bleeding: Return to OR, identify source, control with sutures/cautery
Supportive: IV access ×2, type & cross, transfuse PRBCs (target Hb >7-8 for stable; >10 for cardiac/extensive surgery)
Coagulopathy correction: PT prolonged → FFP; PTT prolonged → cryoprecipitate/FFP; low platelets → transfuse to >50,000

Complications: Hypovolemia, organ dysfunction, DIC (in massive transfusion)

6.4 Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Risk Factors: Immobility, surgery duration >30 minutes, cancer, prior VTE, obesity, hypercoagulable state

Prophylaxis (Universal for Post-Op):

Mechanical: Sequential compression devices (SCDs) while immobile
Chemical: Heparin 5000 units SC q8-12h (unfractionated) starting POD #0 or POD #1
- Continue until full mobility OR until discharge
- Higher risk patients: LMWH (enoxaparin 30 mg SC q12h) preferred

DVT Presentation:

Calf swelling, pain, tenderness, warmth
Diagnosis: Venous duplex (gold standard)
Management: Start heparin 80 units/kg IV bolus, then 18 units/kg/hr infusion (goal PTT 60-85); transition to warfarin (goal INR 2-3) for long-term

PE Presentation:

Dyspnea, chest pain, hypoxia, tachycardia
Diagnosis: CXR (usually normal), ABG (hypoxia), CT pulmonary angiography
Management: Heparin immediately; supplemental oxygen; ICU monitoring; consider IVC filter if contraindication to anticoagulation

Mortality: PE ~30% untreated; <5% with treatment

6.5 Postoperative Fever (The “5 W’s”)

Etiology Framework (Mnemonic “5 W’s”):

Wound (SSI, hematoma, seroma)
Water (UTI, urinary retention)
Wind (atelectasis, aspiration pneumonia, ARDS)
Walk (DVT/PE)
What did you do? (Occult abscess, anastomotic leak, organ injury)
Other: Transfusion reaction, drug reaction, malignant hyperthermia (during anesthesia)

Timing Correlates to Diagnosis:

POD #0-1: Malignant hyperthermia (intraop), atelectasis, aspiration
POD #1-3: Wound infection, UTI, atelectasis, pneumonia
POD #3-7: SSI, anastomotic leak, abscess formation, DVT/PE
POD #7-14: Anastomotic leak, abscess, delayed infection

Workup:

History: Review operative report, timing of fever onset, medications
Exam: Wound assessment (drainage, dehiscence, erythema), abdomen (guarding, distension), leg exam (swelling), lung exam
Labs: CBC (elevated WBC suggests infection), CMP (acidosis suggests intestinal ischemia), LFTs, lactate (elevated suggests sepsis/ischemia)
Imaging: CXR (infiltrate, atelectasis), CT abdomen/pelvis (abscess, leak), venous duplex (DVT), CT PE (if high suspicion)
Cultures: Blood cultures, wound culture if drainage, urine culture

Management: Directed at underlying cause (antibiotics for infection, respiratory therapy for atelectasis, etc.)

6.6 Anastomotic Leak

Pathophysiology: Breakdown of anastomosis; intestinal contents leak into peritoneal cavity

Presentation: Variable; POD #3-14 most common

Subtle: Fever, tachycardia, elevated lactate, without localized signs
Dramatic: Peritonitis (fever, severe abdominal pain, peritoneal signs, sepsis, shock)

Risk Factors: Tension at anastomosis, poor blood supply, malnutrition, immunosuppression, peritoneal contamination, poor surgical technique

Diagnosis:

Imaging: CT abdomen/pelvis with IV contrast (looks for free air, abscess, contrast extravasation)
Labs: Elevated WBC, metabolic acidosis, elevated lactate
Clinical suspicion: Fever + abdominal pain POD #3-14

Management:

Contained leak (localized abscess, no peritonitis): CT-guided percutaneous drain, antibiotics, NPO/TPN, monitor closely (may heal spontaneously)
Free leak (peritonitis): Return to OR urgent → take down anastomosis, divert with colostomy/ileostomy (proximal), drain distal limb, extensive irrigation
Supportive: IV fluids, broad-spectrum antibiotics, pain control, nutritional support

Mortality: 10-30% depending on presentation and management

6.7 Compartment Syndrome

Definition: Increased pressure within fascial compartment compromises perfusion; tissue necrosis/rhabdomyolysis occurs

Most Common Sites: Leg (anterior/lateral compartments after crush injury, vascular injury repair), arm (brachial artery injury)

Presentation (Pain disproportionate to injury is key finding):

Severe pain out of proportion to apparent injury
Pain with passive stretch of muscles in compartment (most specific finding)
Paresthesias (late finding)
Pallor (late finding)
Pulselessness (very late, indicates significant tissue death)
Paralysis (very late)

Diagnosis:

Clinical (key) - do NOT wait for compartment pressure measurement
Compartment pressures: >30 mm Hg or within 30 mm Hg of diastolic BP considered pathologic
Imaging: MRI (shows muscle edema) useful in unclear cases but should not delay fasciotomy

Management:

Emergency fasciotomy (within 6-12 hours of symptom onset)
Release all compartments in affected leg/arm
Incisions: Lateral leg approach for anterior/lateral compartments; medial approach for posterior
Incisions made through skin and fascia; muscle left undisturbed initially
Leave wounds open; repeat irrigation and assessment in 24-48 hours
Re-assessment: If muscle necrosis present, debride; if viable, can close or skin graft
Prevention of contracture: Maintain limb position, PT/OT
Complications: Skin loss requiring graft, chronic disability

Outcomes: Early fasciotomy: Minimal morbidity; delayed: Rhabdomyolysis → acute kidney injury, hyperkalemia, cardiac arrhythmia, death

7. PRE-OP & POST-OP MANAGEMENT

7.1 Preoperative Assessment

History:

Present illness; prior surgeries/anesthetics (complications?)
Medications: Anticoagulants, antiplatelets, diabetic agents (hold metformin day of surgery)
Allergies: Drug, food, latex
Social: Smoking, alcohol, recreational drugs
Systemic: Cardiac (MI, angina, arrhythmia), pulmonary (asthma, COPD, OSA), renal, liver disease

Physical Exam:

Vital signs, weight, BMI
Airway exam: Mallampati score (predicts difficult intubation), mouth opening, cervical spine mobility
Cardiac: Murmurs, arrhythmias, edema (fluid status)
Pulmonary: Rales, wheezes (optimization needed?)
Abdomen: Distension, guarding, prior scars (anticipate adhesions)
Extremities: Asymmetric swelling (DVT risk), pulses

Labs (Selective Based on Age/Comorbidities):

Age >50 or cardiac/pulmonary history: ECG, CXR
Baseline renal function: Creatinine, BUN
Baseline hepatic: Liver function tests if heavy alcohol use
Hemoglobin: All patients (anticipate blood loss)
Coagulation studies: If anticoagulated or liver disease
Type & screen: If significant blood loss anticipated

Risk Assessment:

ASA physical status classification (I-V; predicts periop risk)
Cardiac risk: Lee’s cardiac risk index (predicts MACE)
Pulmonary: Prior COPD exacerbations, current respiratory status

Optimization:

HTN: Periop beta-blockers considered (reduce MACE)
Diabetes: Periop glycemic control <180 mg/dL
Smoking: Cessation 2-4 weeks improved wound healing
Obesity: Increased anesthetic/operative risk; avoid if possible

7.2 NPO Guidelines

Aspiration Prevention:

NPO 6 hours for solid food/dairy
NPO 4 hours for non-clear liquids (milk-based)
NPO 2 hours for clear liquids
Gastric emptying delayed in pregnancy, obesity, GERD, DM; consider H2-blocker/metoclopramide preop

Preoperative Medications:

Continue: Antihypertensives, beta-blockers, cardiac meds, seizure meds
Hold: ACE-I (may cause intraop hypotension; many surgeons hold; some continue), diuretics (POD #0-1 due to fluid restriction)
Hold: Metformin (lactic acidosis risk if renal compromise post-op); NSAIDs (bleeding risk)
Hold: Anticoagulants - timing depends on agent (warfarin 3-5 days pre-op; DOAC 24-48 hours pre-op depending on renal function; aspirin/clopidogrel continued for most cases)

7.3 Antibiotic Prophylaxis

Timing: Within 60 minutes of incision (120 min if vancomycin/clindamycin)

Redosing During Case: If >2 half-lives elapsed (cefazolin q2h; gentamicin once; vancomycin once if >120 min)

Surgical Site: Most common pathogens by procedure type

Clean (cardiac, vascular, ortho): Skin flora (staph), gram-negative enterics
Clean-contaminated (biliary, GI): Gram-negative (E. coli, Klebsiella), anaerobes (Bacteroides, peptostreptococcus)
Contaminated: Mix of above

Duration: Single preop dose; no doses >24 hours post-op (or 48 hours if cardiac surgery)

7.4 VTE Prophylaxis

Mechanical (All Post-Op Patients):

Sequential compression devices (SCDs) to legs while hospitalized
Early ambulation
Leg elevation when resting

Chemical (Risk-Stratified):

Moderate risk (age >40, minor surgery, major surgery <30 min): Mechanical alone sufficient
High risk (major surgery >30 min, cancer, prior VTE, obesity): Add chemical
- Heparin 5000 units SC q8h (unfractionated) starting POD #0 or #1
- Or LMWH enoxaparin 30 mg SC q12h
- Continue until discharge or full mobility
Very high risk (extensive pelvic/abdominal surgery, prior VTE, hypercoagulable): Consider extended prophylaxis (10-14 days post-op)

Relative Contraindications to Chemical Prophylaxis:

Active bleeding, recent major hemorrhage
Thrombocytopenia <50,000
Epidural catheter (start heparin 24 hours post-epidural removal)

7.5 Postoperative Pain Management

Multimodal Approach (Superior to Single Agent):

Acetaminophen: 650-1000 mg q6h PO/IV (max 3-4 g/day)
- Opioid-sparing; well-tolerated
- No GI upset, no bleeding risk
- Liver toxicity if >4 g/day
NSAIDs: Ibuprofen 400-600 mg q6h PO or IV ketorolac 15-30 mg q6h
- Potent analgesics; reduce opioid requirement by 30%
- Avoid if renal insufficiency, GI bleed risk, cardiac risk
- Limit 5-7 days (increased renal/GI toxicity beyond)
Opioids: Main analgesic post-op
- Morphine: 5-10 mg IV q4h; oral 10-30 mg q4h
- Hydromorphone: 0.5-1 mg IV q4h; oral 2-4 mg q4h (more potent, shorter acting)
- Oxycodone: 5-10 mg PO q4h (good for oral transition)
- Titrate to pain level; encourage non-opioid adjuncts
- Monitor: Respiratory rate, sedation, constipation
Adjunctive Agents:
- Gabapentin: 300 mg TID (reduces neuropathic pain component)
- Tricyclic antidepressants: Amitriptyline 25 mg hs (reduces pain, promotes sleep)
- Topical: Lidocaine patches 5% to surgical area (local analgesia)
Regional Anesthesia:
- Peripheral nerve blocks provide extended analgesia (can last 12-24 hours+)
- Epidural analgesia: Patient-controlled (PCA) with opioid/local anesthetic combination
- Superior pain control, opioid-sparing, lower addiction risk

Monitoring:

Assess pain q2-4h initially; adjust medications
Screen for addiction risk; opioid contracts if high-risk patient
Transition to PO when tolerating oral intake
Discontinue opioids as soon as adequate pain control with non-opioid agents

7.6 Fluid & Electrolyte Management

Postoperative Fluid Requirements:

Maintenance: 4 mL/kg/hour for first 10 kg, 2 mL/kg/hour for next 10 kg, 1 mL/kg/hour for each additional kg
- Example 70 kg patient: 40 + 20 + 60 = 120 mL/hour baseline
Add back: Estimated operative blood loss (typically 500-1000 mL for major surgery)
Add back: Third-space losses (peritonitis, major surgery) - 4-8 mL/kg/hour extravasated fluid
Monitor: Urine output (goal 0.5 mL/kg/hour), BP, HR, clinical assessment

Fluid Selection:

LR (Lactated Ringer’s) vs Normal Saline:
- LR: More physiologic (contains K, lactate metabolized to bicarbonate); preferred for large volume resuscitation
- NS: Higher chloride (can cause hyperchloremic acidosis if large volumes); acceptable for routine
D5 solutions: Hypotonic; avoid in periop (can cause hyponatremia); use for maintenance only if significant insensible losses
Blood products: Type O- if urgent/massive transfusion protocol; type-specific if available; crossmatched if time permits

Monitoring Labs:

Electrolytes: POD #1 if major surgery or anticipated imbalance
Calcium, magnesium: If prolonged surgery or TPN anticipated
Lactate: If sepsis/shock suspected (should trend toward normal with resuscitation)

Common Postop Electrolyte Abnormalities:

Hyponatremia (dilutional): Restrict fluids; hypertonic saline if symptomatic seizures
Hyperkalemia (transfusion, hemolysis): Insulin 10 units + dextrose 25 g, calcium gluconate for cardiac protection
Hypomagnesemia (common; worsens arrhythmias): Repletion 1-2 g IV q6h

7.7 Drain Management

Purpose: Remove seroma, hematoma, bile, pancreatic fluid, pus

Types:

Passive (Penrose): Large rubber tube; allows gravity drainage; require dressing changes; limit use (obsolete mostly)
Active (JP/Jackson-Pratt, Blake, Hemovac): Suction drainage; more effective; bulb creates negative pressure
- JP drains: Low profile; squeeze bulb maintains suction
- Hemovac: Larger capacity; good for high-output drains

Placement:

Positioned in dependent area where fluid collection anticipated
Tunneled through separate incision to minimize SSI
Secured to skin with suture; tubing clamped near skin
Connected to collection container

Monitoring:

Output: Measure daily; document color, character, quantity
Normal: Serosanguineous, decreasing daily; POD #1 may be 50-100 mL, POD #5 may be 10-20 mL
Abnormal: High output (>200 mL/day past POD #3 suggests leak or fistula); purulent (infection); feculent (bowel perforation)
Keep drain dependent; prevent kinks/clots

Removal:

Remove when low output (<25-50 mL/day for >24 hours) and no signs of collection
Timing: Varies; JP drains typically POD #3-7; some remain until discharge if persistent output
Removal technique: Cut suture, withdraw gently; apply dressing

Complications:

Clogging: Irrigate with normal saline using 20cc syringe/18G needle carefully (avoid breaking drain)
Dislodgement: Reposition or reinsertion if important collection area
Infection: Drain acts as foreign body; remove as soon as feasible
Fistula: Persistent high output suggests leak; imaging (fistulography) and possible reoperation

QUICK REFERENCE: COMMON DOSING & CONVERSIONS

Local Anesthetics - Maximum Doses:

Lidocaine plain: 4.5 mg/kg (max 300 mg)
Lidocaine + epi: 7 mg/kg (max 500 mg)
Bupivacaine plain: 2.5 mg/kg (max 175 mg)
Bupivacaine + epi: 3.5 mg/kg (max 225 mg)

Sedation Dosing:

Midazolam: 0.5-2 mg IV titrate q2min to effect (max 10 mg)
Ketamine: 1-2 mg/kg IV for sedation; 4-5 mg/kg IM
Propofol: 1-2 mg/kg IV bolus; 25-100 mcg/kg/min infusion
Etomidate: 0.1-0.2 mg/kg IV bolus
Fentanyl: 0.5-1 mcg/kg IV, repeat 0.25-0.5 mcg/kg q5-10min

Spinal Anesthesia:

Lidocaine 5% hyperbaric: 50-100 mg
Bupivacaine 0.75% hyperbaric: 10-20 mg

Antibiotics - SSI Prophylaxis:

Cefazolin: 1-2 g IV (20 mg/kg if weight <80 kg)
Cefoxitin: 2 g IV
Vancomycin: 15-20 mg/kg IV
Clindamycin: 600 mg IV
Metronidazole: 500 mg IV

Vasopressors (if hypotension during anesthesia):

Phenylephrine: 50-200 mcg IV bolus or 0.5-1.4 mcg/kg/min infusion
Ephedrine: 5-10 mg IV bolus or 0.5-1.4 mg/kg/min infusion
Norepinephrine: 0.5-2 mcg/kg/min infusion

Oxytocin (post-placental delivery - cesarean):

20 units in 500 mL NS at 200 mL/hour (or 10 units IV bolus)

Anticoagulation:

Heparin prophylaxis: 5000 units SC q8-12h
Heparin treatment: 80 units/kg IV bolus + 18 units/kg/min infusion

Document Completion Status: Comprehensive surgical training document covering 7 major topic areas with clinical depth appropriate for small hospital/clinic staff education. All sections include specific drugs, dosages, step-by-step techniques, and complication management within 25,000 token limit.

Comprehensive Surgical Training Data

Small Hospital/Clinic Protocol Manual

1. SURGICAL PRINCIPLES & BASIC TECHNIQUE

1.1 Aseptic Technique Foundation

1.2 Surgical Hand Scrub

1.3 Gowning and Gloving

1.4 Patient Draping

1.5 Timeout (Surgical Safety Checklist)

2. ANESTHESIA MANAGEMENT

2.1 Local Anesthesia Agents

2.2 Regional Anesthesia Blocks

2.3 Procedural Sedation & Analgesia

2.4 Spinal Anesthesia

2.5 Epidural Anesthesia

2.6 Monitoring Standards During Anesthesia

3. MINOR PROCEDURES

3.1 Wound Debridement & Cleansing

3.2 Skin Lesion Excision

3.3 Foreign Body Removal

3.4 Nail Removal (Onychectomy)

3.5 Arthrocentesis (Joint Aspiration)

3.6 Paracentesis (Abdominal Fluid Aspiration)

3.7 Thoracentesis (Pleural Fluid Aspiration)

3.8 Central Line Placement (Internal Jugular Vein)

3.9 Arterial Line (A-Line) Placement

3.10 Urinary Catheterization

4. MAJOR PROCEDURES

4.1 Open Appendectomy

4.2 Open Cholecystectomy

4.3 Bowel Resection & Anastomosis

4.4 Hernia Repair

Inguinal Hernia (Open Tissue Repair):

Incisional Hernia (Ventral):

4.5 Cesarean Section (Lower Segment Transverse, LSCS)

4.6 Tracheostomy

4.7 Lower Extremity Amputation

4.8 Exploratory Laparotomy (Ex-Lap)

5. WOUND MANAGEMENT

5.1 Wound Classification

5.2 Irrigation and Debridement

5.3 Primary, Secondary, Delayed Closure

5.4 Wound Healing Phases

5.5 Negative Pressure Wound Therapy (NPWT)

5.6 Skin Grafting (Split-Thickness)

6. SURGICAL COMPLICATIONS

6.1 Surgical Site Infection (SSI) Prevention and Management

6.2 Wound Dehiscence

6.3 Hemorrhage

6.4 Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

6.5 Postoperative Fever (The “5 W’s”)

6.6 Anastomotic Leak

6.7 Compartment Syndrome

7. PRE-OP & POST-OP MANAGEMENT

7.1 Preoperative Assessment

7.2 NPO Guidelines

7.3 Antibiotic Prophylaxis

7.4 VTE Prophylaxis

7.5 Postoperative Pain Management

7.6 Fluid & Electrolyte Management

7.7 Drain Management

QUICK REFERENCE: COMMON DOSING & CONVERSIONS

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