Ectopic Heartbeats

Mechanisms of Ectopic Beat Formation

1. Abnormal Automaticity (Enhanced Ectopic Focus)

2. Reentry

Causes of Ectopic Foci

• Local areas of myocardial ischemia
• Small calcified plaques pressing on adjacent cardiac muscle
• Toxic irritation of the AV node, Purkinje system, or myocardium: infection, drugs, nicotine, caffeine, digitalis toxicity
• Mechanical irritation (e.g., catheter tip touching the endocardium during cardiac catheterization)
• Electrolyte imbalances (hypokalemia, hypomagnesemia)
• Hypoxia, sympathetic excess, thyrotoxicosis
• Guyton & Hall Textbook of Medical Physiology, p. 168

Classification by Site of Origin

1. Atrial Premature Contractions (PACs)

• Early P wave with an abnormal morphology (different from the sinus P wave)
• P wave is frequently inscribed within the preceding T wave, making morphology unclear
• PR interval may be shortened (if ectopic focus is near the AV node) or prolonged
• QRS is usually narrow (normal) - conducted normally through the bundle of His and ventricles
• Compensatory pause follows - the premature impulse discharged the sinus node early, resetting its timing

Atrial premature beat - Guyton & Hall, Fig. 13.9

Frequent atrial ectopics with varying conduction - some conducted with RBBB aberrancy, some nonconducted, some in pairs - Braunwald's Heart Disease, Fig. 65.1

• In the vast majority, PACs are benign and require only reassurance
• However, Haïssaguerre et al.'s landmark work showed PACs from pulmonary vein sleeves can trigger atrial fibrillation (AF)
• Excess PACs (>30/hour or runs >20 beats) are associated with incident AF, stroke, and death
• Patients with excess PACs and CHADS-VASc ≥ 2 have an annual stroke risk comparable to patients with known AF
• Very frequent PACs (20-40% daily burden) may cause reversible cardiomyopathy

2. Junctional (AV Nodal) Premature Contractions

• P wave is absent or hidden - the impulse travels retrogradely into the atria and forward into the ventricles simultaneously, superimposing the P wave onto the QRS-T complex
• The QRS complex is usually narrow (normal configuration)
• The P wave, if visible, appears just before or just after the QRS and is typically inverted in inferior leads

AV nodal premature contraction showing P wave hidden within QRS - Guyton & Hall, Fig. 13.10

3. Premature Ventricular Contractions (PVCs)

1. Wide, bizarre QRS complex (usually >120 ms) - the impulse travels through the ventricular myocardium rather than the fast-conducting Purkinje system
2. High voltage - in a normal beat, both ventricles depolarize nearly simultaneously so the vectors partially cancel out. In a PVC, one ventricle depolarizes ahead of the other, generating large electrical potentials
3. T wave polarity opposite to the QRS - because slow muscle conduction means the first areas to depolarize are also the first to repolarize, creating discordance
4. Full compensatory pause - the SA node timing is usually undisturbed; the post-PVC pause brings the next sinus beat back on schedule

PVCs alternating with normal beats (bigeminy). Vectorial analysis (lower panel) localizes the ectopic focus to the base of the ventricles - Guyton & Hall, Fig. 13.11

• Isolated, infrequent PVCs in an otherwise healthy heart are usually benign (nicotine, caffeine, fatigue, emotion)
• PVC burden >20% of beats is associated with cardiac dilation and cardiomyopathy - often reversible with treatment
• PVCs occurring in the vulnerable period (on the T wave, "R-on-T phenomenon") risk triggering ventricular fibrillation
• PVCs in the setting of ischemia, structural heart disease, or after MI carry significantly higher risk

Symptoms

• A sense that the heart gave an "extra beat" or "missed a beat"
• Palpitations or fluttering in the chest or throat
• A thudding or pounding sensation (the forceful beat after the pause)
• Occasional brief dizziness or faintness

Diagnosis

• 12-lead ECG - detects ectopic beats occurring at the time of recording
• Ambulatory Holter monitoring (24-48 hours) - quantifies ectopic burden; essential for assessing frequency and patterns
• Event recorder / loop recorder - for infrequent symptoms; allows patient-triggered recording
• Echocardiogram - to assess for underlying structural heart disease and cardiomyopathy (especially if PVC burden is high)

Treatment

• Eliminate triggers (caffeine, alcohol, sleep deprivation, stimulants)
• Beta-blocker or non-dihydropyridine calcium channel blocker (verapamil, diltiazem)
• Antiarrhythmic drugs (e.g., flecainide) in refractory cases
• Catheter ablation for high-burden, unifocal, drug-refractory symptomatic PACs

• Address reversible causes (ischemia, electrolyte abnormalities, thyrotoxicosis)
• Beta-blockers - first-line for symptomatic PVCs
• Antiarrhythmics (flecainide, propafenone for structurally normal heart; amiodarone, mexiletine if structural disease)
• Catheter ablation - highly effective, especially for unifocal PVCs; indicated for symptomatic or high-burden PVCs causing cardiomyopathy

Proximal Femur Nailing (Cephalomedullary Nailing)

Indications

• Miller's Review of Orthopaedics 9th Ed, p. 918
• Rockwood and Green's Fractures in Adults 10th Ed

Implant Principles

• Proximal entry angle: typically 4-6° valgus (trochanteric entry)
• Anterior bow: nail bow must match the anterior bow of the femur to avoid anterior cortex perforation distally
• Lag screw: single-screw design (e.g., PFNA, Gamma nail, TFN) or dual-screw design (e.g., InterTAN)
• Blade vs. screw: Cephalad blade has more medial migration risk than a cephalad screw

Surgical Setup and Positioning

• Flexed and abducted in a lithotomy stirrup (C-arm goes between legs)
• Extended in the "scissor" position (C-arm from opposite side) - preferred when contralateral hip motion is limited

Patient positioning on fracture table - Rockwood & Green, Fig. 54-22

Fracture Reduction - The Most Critical Step

AP view:

• Reduce to anatomical or slight valgus - valgus is associated with the lowest risk of implant cut-out and less limb shortening
• A slight medial cortex gap in valgus is acceptable - it closes rapidly with fracture collapse
• Varus must never be accepted - mechanically unstable, leads to progressive varus collapse and cut-out

Lateral view:

• Femoral head, neck, and trochanteric region must align in a straight line
• Sagittal sag is more common in bariatric patients, high-energy injuries, and comminuted fractures

Reduction aids when closed reduction fails:

• Posterior reduction aid (attached to fracture table - provides upward pressure)
• Vertical crutch/support under the fracture site
• Bone lever or clamp placed percutaneously
• Formal open reduction (rare - mainly for A3/reverse oblique/subtrochanteric)
• Cerclage wires after open reduction in selected cases

Fracture reduction: varus (A) must be corrected to valgus (B) - Rockwood & Green, Fig. 54-23

Surgical Technique - Step by Step

• Rockwood and Green's Fractures in Adults 10th Ed, p. 2726-2727

The Tip-Apex Distance (TAD)

Tip-Apex Distance (TAD) calculation - Miller's Review of Orthopaedics, Fig. 11.16

• TAD <25 mm - strongly associated with lowest cut-out rate
• TAD >25 mm - significantly higher risk of screw cut-out
• The ideal lag screw position is center-center on AP, center on lateral

Nail Length - Short vs. Long

Postoperative Care and Weight Bearing

• Immediate or early full weight bearing is the goal in elderly patients
• Physiotherapy and mobilization start on day 1 post-op
• Prophylactic anticoagulation for VTE prevention
• Transfer to a pressure-relieving mattress as soon as possible

Complications and Their Prevention

• Rockwood and Green's Fractures in Adults 10th Ed, p. 2730

Cut-out of cephalomedullary nail lag-bladed screw due to varus collapse. Revision arthroplasty required. - Rockwood & Green, Fig. 54-33

CM Nail vs. Sliding Hip Screw (SHS) - Decision Guide

• Miller's Review of Orthopaedics 9th Ed, p. 918

Varicose Vein Surgery

Indications for Intervention

• Persistent symptoms (aching, heaviness, throbbing, pruritus, swelling) despite conservative measures
• Complications: superficial vein thrombosis (thrombophlebitis), skin changes (lipodermatosclerosis, hyperpigmentation), venous ulceration, or bleeding
• Worsening symptoms or inadequate relief with compression hosiery
• Cosmetic concerns (patient-driven)

Preoperative Assessment

• The site(s) of junctional incompetence (SFJ, SPJ, perforators)
• The extent and caliber of superficial axial incompetence in the GSV and SSV
• Presence or absence of deep venous obstruction or reflux
• Tortuosity and diameter of target veins (critical for selecting technique)
• Thrombus within superficial veins
• Pelvic sources of reflux

Treatment Options

Overview Table

1. Endovenous Thermal Ablation

Shared Technique (EVLA and RFA)

1. Access: Percutaneous catheter/fibre insertion into the target vein (usually at the knee) under duplex ultrasound guidance
2. Advance to 2-3 cm distal to the SFJ or SPJ termination
3. Confirm position on ultrasound (longitudinal B-mode)
4. Perivenous tumescent anaesthesia infiltrated under ultrasound guidance into the saphenous compartment - serves as heat sink, compresses vein onto device, protects surrounding tissues, and allows immediate ambulation
5. Deliver thermal energy while slowly withdrawing the catheter/fibre
6. Thermal damage destroys intima and causes collagen denaturation of the media → fibrotic occlusion
7. Compression applied after procedure

Endovenous laser ablation of an incompetent GSV - Fitzpatrick's Dermatology, Fig. 212-16

EVLA (Endovenous Laser Ablation)

• Wavelengths: 810, 940, 980 nm (haemoglobin-targeting) or 1320, 1470 nm (water-targeting - longer wavelengths cause less postoperative bruising/pain)
• Thermal damage via heat transfer from a hot fibre tip through residual intraluminal blood + photothermal absorption
• Energy delivery typically 60-80 J/cm for durable closure
• 5-year efficacy: ~90% closure rate
• EVLA requires operator knowledge of power settings and pullback speed; allows direct catheter delivery of adjuvant foam sclerotherapy via a 0.035-in lumen

RFA (Radiofrequency Ablation)

• Most popular device: ClosureFAST™ (Medtronic) - wire coil on end of catheter
• Generator heats surrounding tissue to 120°C for 20-second treatment cycles
• Catheter withdrawn by set length (3 cm or 7 cm coil) after each cycle
• More forgiving for novice users - single button press per cycle
• Automatic treatment cycle frees surgeon to concurrently perform tumescent infiltration and phlebectomy
• 2-year efficacy: 90%; 5-year: 80%

• Bailey and Love's Surgery 28th Ed, p. 1055-1056

2. Ultrasound-Guided Foam Sclerotherapy (UGFS)

• Patient positioned supine with leg elevated
• Under continuous duplex guidance, foam injected into the incompetent axial vein
• When foam is visualised at the site of junctional incompetence, injection stops
• Maximum volume per session: 10-12 mL (complication risk increases with higher volumes)
• Compression applied after procedure
• 1-year occlusion: ~81%; 5-year: ~74%

• No tumescent anaesthesia required (less painful procedure)
• No limitation due to vein tortuosity
• Can treat calf veins beneath damaged skin/ulcers without skin puncture
• Very low consumable cost
• Suitable as an adjunct for neovascularisation or residual varicosities

• Bailey and Love's Surgery 28th Ed, p. 1061-1062

3. Non-Thermal, Non-Tumescent Techniques

Cyanoacrylate Adhesive (e.g., VenaSeal™)

• Catheter placed in target vein; glue delivered in aliquots as catheter withdrawn
• Glue causes acute inflammatory fibrosis → permanent vein occlusion
• No tumescent anaesthesia required; no compression mandatory
• 1-year occlusion: ~90%
• Adverse effects: superficial thrombophlebitis, local hypersensitivity reactions

MOCA - Mechanochemical Ablation (e.g., ClariVein™)

• Rotating wire deployed from end of catheter physically damages endothelium
• Liquid sclerosant infused simultaneously during catheter withdrawal
• No tumescent anaesthesia (some patient discomfort; occasional vein tearing)
• Early efficacy comparable to thermal methods, but higher medium/long-term recanalisation rates
• Bailey and Love's Surgery 28th Ed, p. 1062

4. Open Surgery: Saphenofemoral Ligation + GSV Stripping (Trendelenburg Operation)

GSV (Great Saphenous Vein) - Surgical Steps

1. Incision: Oblique groin incision at the level of, and lateral to, the pubic tubercle - ideally above the groin crease
2. Dissection: Identify and dissect the GSV to the SFJ - clearly establish the junction before dividing (risk of inadvertent femoral vein transection)
3. Tributaries: Six tributaries may be encountered near the SFJ:
   • Lateral: superficial inferior epigastric vein; superficial circumflex iliac vein
   • Medial: superficial external pudendal vein; deep external pudendal vein
   • Distal: anterior accessory GSV; posteromedial thigh vein
   • All tributaries ligated distal to their divisions
4. Flush SFJ ligation performed
5. Stripping: GSV stripped retrogradely to approximately the knee using a blunt-tip catheter or invagination pin stripper
   • Stripping to the ankle is NOT recommended (high saphenous nerve injury risk)
   • Stripping below the knee carries up to 7% saphenous nerve neuralgia risk
6. Phlebectomy of tributary varicosities performed concurrently

Saphenofemoral junction ligation - Bailey and Love's Surgery 28th Ed, Fig. 62.24

GSV stripping via stab avulsion technique - Schwartz's Surgery, Fig. 24-14

SSV (Small Saphenous Vein) Surgery - Saphenopopliteal Junction (SPJ) Ligation

• Preoperative duplex marking of the SPJ is mandatory - anatomy is highly variable
• Patient positioned prone
• Transverse incision over the premarked SPJ in the popliteal fossa
• Fascia divided; SSV exposed and ligated (flush ligation vs. proximal ligation - both debated)
• SSV may then be stripped or the proximal section resected
• Sural nerve injury risk with stripping; popliteal vein injury risk with flush ligation
• Sural nerve neuropraxia incidence may be as high as 20% following SSV surgery

5. Ambulatory Phlebectomy (Stab Avulsion)

• Pre-procedure: varicosities marked with patient standing
• 2-mm stab incisions made directly over branch varicosities
• Vein dissected/hooked from subcutaneous tissue and avulsed without ligation
• Performed under local anaesthetic (tumescent)
• Bleeding controlled by leg elevation, manual compression, and tumescent effect
• Can be combined with any axial treatment in the same session

6. Perforator Vein Surgery

• SEPS (Subfascial Endoscopic Perforator Surgery): Endoscopic identification and occlusion of incompetent perforating veins - largely replaced by ablative techniques
• Duplex-guided direct ablation (thermal or foam) of incompetent perforators - preferred in patients with skin changes
• Indicated when perforators are identified as a significant source of reflux, especially in recurrent or complex cases

Sclerotherapy (Liquid)

Complications

Complications of Standard Open Surgery

Complications of Endovenous Techniques

Recurrent Varicose Veins

• Neovascularisation (most important after open surgery) - new avalvular veins bridge ligated junction to tributaries
• Reflux in residual axial vein (inadequate stripping)
• Inadequate initial surgery
• New junctional reflux
• Progression of venous disease

• Bailey and Love's Surgery 28th Ed, p. 1063-1064

Varicose Vein Surgery - Summary

Definition & Background

Indications

• Persistent symptoms (aching, heaviness, pruritus, swelling) despite compression
• Complications: thrombophlebitis, skin changes (lipodermatosclerosis), venous ulceration, bleeding
• Cosmetic reasons

Treatment Options (Proximal-to-Distal Strategy)

1. Endovenous Laser Ablation (EVLA)

• Laser fibre advanced to 2-3 cm from SFJ under duplex guidance
• Perivenous tumescent anaesthesia injected first (heat sink + vein compression)
• Fibre withdrawn slowly while delivering laser energy (60-80 J/cm)
• 5-year occlusion ~90%

2. Radiofrequency Ablation (RFA)

• ClosureFAST™ catheter heats tissue to 120°C in 20-second cycles
• Simpler to operate than EVLA; 7 cm coil speeds treatment
• 5-year efficacy ~80%; evidence broadly equivalent to EVLA

3. Ultrasound-Guided Foam Sclerotherapy (UGFS)

• Foam sclerosant (polidocanol/STS) injected under duplex guidance
• Maximum 10-12 mL per session
• No tumescent anaesthesia; can treat tortuous veins and veins beneath ulcers
• Lower efficacy than thermal methods; higher retreatment rates
• Rare risk: TIA/stroke (especially if patent foramen ovale present)

4. Non-Thermal Options

• Cyanoacrylate glue (VenaSeal™): ~90% 1-year occlusion; no tumescent required
• MOCA (ClariVein™): Rotating wire + liquid sclerosant; no tumescent; higher recanalisation rates long-term

5. Open Surgery: SFJ Ligation + GSV Stripping (Trendelenburg)

• Oblique groin incision above the groin crease
• Dissect GSV to SFJ; ligate all 6 tributaries; flush SFJ ligation
• Strip GSV retrogradely to the knee (not to ankle - saphenous nerve risk)
• Stripping gives lower recurrence than ligation alone
• Indicated for very large GSV (>2 cm), recurrences, or endovenous failure

6. SSV Surgery (Saphenopopliteal Junction)

• Preoperative duplex marking mandatory (variable anatomy)
• Patient prone; transverse popliteal incision over premarked SPJ
• Flush ligation or proximal ligation then strip/resect SSV

7. Ambulatory Phlebectomy (Stab Avulsion)

• 2-mm stab incisions over tributary varicosities; veins avulsed with hook
• Done under tumescent local anaesthesia; adjunct to all axial treatments

8. Perforator Ligation

• Duplex-guided foam or thermal ablation of incompetent perforators
• SEPS (subfascial endoscopic perforator surgery) largely replaced by ablative methods

Tip-Apex Sclerotherapy Concentrations

Key Complications

Inguinal Hernioplasty

Anatomy Review - The Myopectineal Orifice

• Hesselbach's Triangle (medial/direct hernia zone): bounded by inferior epigastric vessels laterally, inguinal ligament inferiorly, lateral border of rectus medially
• Deep inguinal ring (lateral/indirect hernia zone)
• Femoral canal (femoral hernia zone)

• Medially: Inferior epigastric vessels, vas deferens, Cooper's ligament, bladder
• Laterally (the "triangle of doom" and "triangle of pain"): External iliac vessels, lateral femoral cutaneous nerve, femoral nerve, genitofemoral nerve

Critical preperitoneal anatomy after dissection - Mulholland & Greenfield's Surgery, Fig. 72.30

Classification of Repairs

Part 1: Open Tension-Free Hernioplasty

A. Lichtenstein Tension-Free Repair (Gold Standard)

1. Incision: Skin incision 2 cm above and parallel to the inguinal ligament, from the pubic tubercle to just lateral to the deep ring
2. External oblique aponeurosis (EOA): Incised in the direction of its fibres from the external ring to just beyond the internal ring; superior and inferior flaps raised
3. Identify and protect nerves: Ilioinguinal nerve (runs on the cord), iliohypogastric nerve (in the superior flap), and genital branch of genitofemoral nerve (on the cord)
4. Spermatic cord/round ligament: Isolated and lifted using a soft tissue retractor; cremaster divided longitudinally to expose the cord structures
5. Hernia sac:
   • Indirect sac: Located anteromedial to the cord; dissected free and inverted or ligated flush at the deep ring
   • Direct sac: Inverted with a purse-string suture or simply reduced
6. Mesh placement: "Flat iron" or keyhole-shaped mesh (typically 7.5 × 15 cm polypropylene):
   • Medial edge overlaps the pubic tubercle by 1.5-2 cm (critical - prevents medial recurrence)
   • Mesh extends 2-3 cm above Hesselbach's triangle superiorly
   • Inferior edge fixed to the shelving edge of the inguinal ligament with a permanent monofilament suture (e.g., Prolene)
   • A slit cut at the lateral end creates a narrow lower tail (1/3) and a wider upper tail (2/3); spermatic cord passes between the two tails; tails crossed and fixed - creating a new internal ring
   • Mesh tails tucked under the EOA to the anterior superior iliac spine
7. Wound closure: EOA closed from medial to lateral; external ring reconstructed snugly around cord; Scarpa's fascia and skin closed

Lichtenstein tension-free hernioplasty showing mesh placement and key nerves - Schwartz's Surgery, Fig. 37-19

Lichtenstein hernioplasty: A. Initial exposure, B. Mesh secured to inguinal floor - Mulholland & Greenfield, Fig. 72.28

B. Plug-and-Patch Repair (Rutkow-Robbins / Gilbert)

• Fast and easy to teach
• No demonstrated advantage over Lichtenstein in recurrence rate or chronic pain
• Disadvantages: Higher mesh burden; plug can migrate causing bowel obstruction; makes redo surgery more challenging

C. Tissue Repairs (Historical, Still Used in Select Cases)

McVay (Cooper ligament) repair - Schwartz's Surgery, Fig. 37-17

Part 2: Laparoscopic Hernioplasty

• Less acute and chronic postoperative pain
• Faster return to full activity
• Lower wound complication rate (infection, seroma, haematoma)
• Superior for bilateral hernias (both repaired through same trocar sites) and recurrence after open anterior repair
• Better cosmesis

• Requires general anaesthesia (GA mandatory; patient cannot tolerate CO₂ insufflation awake)
• Longer learning curve
• Higher cost
• Risk of intra-abdominal injury (TAPP)

TEP (Totally Extraperitoneal Repair)

Laparoscopic view of right direct inguinal hernia - Bailey & Love's Surgery, Fig. 64.16

1. Position: Supine, Trendelenburg; surgeon stands contralateral to hernia; arms tucked; screens at foot of bed
2. Access: Umbilical incision; anterior rectus sheath opened ipsilaterally; rectus muscle retracted laterally; blunt finger dissection begins in space between rectus muscle and posterior rectus sheath
3. Balloon dissection: Balloon dissector (or direct blunt dissection) develops the preperitoneal space under direct vision
4. Trocars: 2 additional midline trocars - one ~5 cm above symphysis pubis, one midway between umbilicus and symphysis (or lateral paraumbilical trocars)
5. Dissection: Complete development of retrorectus and preperitoneal space; identify Cooper ligament, inferior epigastric vessels, vas deferens, spermatic vessels
6. Hernia sac: Direct sac inverted; indirect sac dissected from cord and reduced
7. Mesh placement: Large mesh (≥10 × 15 cm or 14 × 11 cm) placed to cover entire MPO, extending:
   • ≥2 cm above the defect superiorly
   • To anterior superior iliac spine laterally
   • To Cooper's ligament medially
8. Fixation: Tacks, staples, or glue - or no fixation if large mesh used
   • Critical: No tacks/staples placed below the iliopubic tract lateral to the internal spermatic vessels (risk of lateral femoral cutaneous nerve and femoral branch of genitofemoral nerve injury)
9. Closure: No peritoneal closure needed (unlike TAPP); deflation; port site fascia of 12-mm port closed

TAPP (Transabdominal Preperitoneal Repair)

1. Peritoneal access: Hasson or trocar technique; pneumoperitoneum to 15 mmHg
2. Trocar placement: 12-mm umbilical trocar; two 5-mm trocars lateral and slightly inferior to umbilicus (avoiding inferior epigastric vessels)
3. Peritoneal incision: Made at the medial umbilical ligament, 3-4 cm superior to the hernia defect, extended laterally to the ASIS
   • For bilateral: bilateral incisions leaving a midline peritoneal bridge (avoids injuring patent urachus)
4. Dissection: Preperitoneum developed inferiorly; cord skeletonized; sacs managed as above
5. Mesh: 10 × 15 cm mesh covers entire MPO; fixed to Cooper's ligament medially and ASIS laterally
6. Peritoneal closure: Mandatory - tacks, sutures, or glue; inferior peritoneal flap secured to transversalis fascia above mesh; prevents bowel contact with mesh

TEP vs. TAPP Comparison

Robotic Repair (rTEP / rTAPP)

Recurrence

• Inadequate mesh overlap (medial edge not reaching pubic tubercle)
• Missed hernia at initial repair (e.g., femoral hernia after Lichtenstein - femoral canal not routinely covered)
• Mesh migration or rolled edge
• Technical failure during learning curve (especially TEP)
• Seroma, haematoma, or infection around mesh

• After previous anterior open repair → preperitoneal repair (TEP/TAPP)
• After previous preperitoneal repair → anterior open repair (Lichtenstein)
• Rule: use the undissected space to avoid dangerous redo dissection

Chronic Postherniorrhaphy Groin Pain

• Incidence: up to 10-15% of all repairs; severe pain in 2-5%
• Mechanism: nerve entrapment (ilioinguinal, iliohypogastric, genitofemoral), mesh contraction, neuromas
• Risk factors: preoperative pain, young age, open repair (higher than laparoscopic), nerve division/suture entrapment
• Prevention: Careful nerve identification and preservation intraoperatively; consideration of nerve division if nerve is at high risk of entrapment
• Treatment: physiotherapy, analgesics, nerve blocks, triple neurectomy, mesh removal

Other Complications

Choice of Repair - Summary Algorithm

Primary inguinal hernia
├── Fit for GA + laparoscopic experience available?
│   ├── Bilateral → TEP or TAPP preferred
│   ├── Unilateral → Lichtenstein (open) or TEP/TAPP (equivalent outcomes)
│   └── Patient prefers local anaesthesia → Lichtenstein
│
├── Recurrent after open anterior repair → TEP or TAPP (Grade A)
├── Recurrent after preperitoneal repair → Open Lichtenstein
│
└── Mesh refused / contaminated field → Shouldice or Desarda (tissue repair)

• Schwartz's Principles of Surgery 11th Ed; Mulholland & Greenfield's Surgery 7th Ed; Bailey and Love's Surgery 28th Ed

LSCS - Lower Segment Caesarean Section

Indications

Absolute Indications (Caesarean mandatory)

• Placenta praevia (major/grade III-IV)
• Placenta accreta/increta/percreta
• Cephalopelvic disproportion (CPD) - documented radiographically
• Cord prolapse with viable fetus
• Previous classical (vertical) uterine scar (risk of uterine rupture with labour)
• Transverse lie with ruptured membranes

Relative Indications

• Dystocia (failure of progress/labour) - single largest contributor to rising caesarean rates (~30% of increase in the USA)
• Non-reassuring fetal heart rate (fetal distress)
• Breech presentation (especially footling breech)
• Previous caesarean section (repeat LSCS - though VBAC is an option in selected patients)
• Pre-eclampsia/eclampsia when induction fails or is contraindicated
• Active genital herpes simplex (protects neonate)
• Fetal anomalies (e.g., hydrocephalus, gastroschisis)
• Failed induction of labour
• Multiple pregnancy (depending on presentation)
• Maternal request (elective primary caesarean)

Types of Uterine Incisions

Preoperative Preparation

• Nil by mouth (6 hours solids; 2 hours clear fluids for elective)
• IV access, blood group and crossmatch
• Antacid prophylaxis: Sodium citrate (non-particulate) ± H₂ blocker (ranitidine) - reduces aspiration risk under GA
• Urethral catheter (Foley) to drain bladder and monitor urine output
• Prophylactic antibiotics (reduces wound infection and endometritis rates to <3%)
• DVT prophylaxis (TED stockings ± LMWH)
• Left lateral tilt (15°) - prevents aortocaval compression by the gravid uterus

Anaesthesia

Surgical Technique - Step by Step (Kerr/Low Transverse LSCS)

Position

Step 1 - Skin Incision (Pfannenstiel)

Pfannenstiel skin incision - Pfenninger & Fowler's Procedures, Fig. 162-1

• Incision carried down through subcutaneous fat to the rectus sheath (anterior rectus fascia)
• Midline fascial incision 2 cm with scalpel, then extended laterally and superiorly in a curvilinear fashion using curved Mayo scissors

Step 2 - Fascial Layer

Dissection of the linea alba through fascia - Pfenninger & Fowler, Fig. 162-3

• Superior edge of fascia grasped with two Kocher clamps; fascia elevated off the underlying rectus muscle by blunt finger dissection along the midline (linea alba fibres)
• Same dissection repeated on the inferior edge of the fascia, clearing it from muscle and pubis
• In repeat LSCS: adhesions cut with Mayo scissors

Step 3 - Muscle Separation and Peritoneal Entry

• Rectus abdominis muscles separated bluntly in the midline in a vertical direction to expose the parietal peritoneum
• Peritoneum grasped with two haemostats/tissue forceps at its peak, tented upward, and a small incision made to confirm entry into the peritoneal cavity
• Peritoneal incision extended vertically to expose the lower uterine segment
• DeLee retractor (bladder blade) placed to retract bladder

Step 4 - Bladder Flap (Vesicouterine Peritoneal Flap)

• The vesicouterine serosa (peritoneum overlying the LUS) is identified, picked up with tissue forceps, and incised transversely ~2 cm above the bladder reflection
• Incision extended laterally to ~12 cm
• Bladder dissected off the lower uterine segment bluntly with fingers, pushed inferiorly
• DeLee bladder blade repositioned to include and retract the newly created bladder flap

Bladder flap development and dissection off the lower uterine segment - Pfenninger & Fowler, Fig. 162-7

Step 5 - Uterine Incision (Hysterotomy)

• Identify the lateral uterine vessels and confirm uterine orientation
• "Score" the LUS over the presenting fetal part with a No. 20 blade using a 2-3 cm incision, going millimetre by millimetre in depth to avoid fetal injury - announce "uterine incision" to anaesthesiologist and paediatrician
• Extend bluntly with fingers in a curvilinear direction
• Alternatively, use bandage scissors protected by two fingers placed inside the uterine opening to extend laterally for a total incision of ~10-11 cm
• Rupture membranes with an Allis clamp if intact

Step 6 - Delivery of the Baby

• Surgeon inserts a cupped hand under the fetal head and occiput, wrist kept straight; gently lifts upward bringing the head out of the incision
• Assistant applies gentle fundal pressure once the occiput clears the incision
• Head flexed to minimise the diameter
• If the head is deeply engaged (arrest of descent/CPD): an assistant disimpacts the head vaginally while the surgeon delivers it abdominally

• Assistant pushes head up vaginally (Patwardhan's manoeuvre for deeply engaged head)
• Use of a fetal pillow or vacuum cup to elevate the head

• Feet/buttocks delivered first; then shoulders and head delivered using McRoberts-type flexion and gentle traction

• Cord clamped and cut; neonate handed to paediatrician
• Oxytocin (syntocinon) 5-10 units IV slowly given immediately after delivery of the baby to stimulate uterine contraction and minimise haemorrhage

Step 7 - Placenta and Uterine Cavity

• Controlled cord traction to deliver the placenta (preferred over manual removal - lower infection and haemorrhage rates)
• Uterine cavity cleared of clots and membranes with moist lap sponges
• If cervix is closed: cervical os dilated with dilators to allow lochia drainage
• Optional uterine externalisation for better visualization and access during closure; uterus wrapped in moist lap sponge during repair

Step 8 - Uterine Closure (Hysterotomy Repair)

• First layer (full thickness of myometrium): Running locked stitch with 0 chromic or 1 Vicryl from one angle to the other - do NOT include the endometrium in this layer
• If haemostasis is inadequate: second imbricating layer of 0 chromic over the first
• Any extensions of the incision (usually inferiorly toward the cervix) are repaired first before the main hysterotomy
• Check haemostasis; figure-of-8 stitches for bleeding points

Step 9 - Abdominal Closure

Step 10 - Final Checks

• Inspect uterus, tubes, and ovaries (opportunity for bilateral tubal ligation if desired)
• Irrigate pouch of Douglas with warm saline; suction clots
• Palpate colic gutters, inspect appendix and gallbladder
• Ensure blood loss accounted for; lap sponge count confirmed correct

Decision-to-Delivery Time

VBAC (Vaginal Birth After Caesarean Section)

• VBAC is possible and appropriate in selected patients (hospitals must have facilities for emergency CS)
• Success rates are higher if: non-recurrent indication, one prior vaginal birth, spontaneous onset of labour
• Risk of uterine scar rupture: 0.5-1% during TOLAC (trial of labour after caesarean) - serious, potentially fatal emergency
• Contraindications to TOLAC: Previous classical/vertical scar, previous uterine rupture, >2 previous caesareans, placenta praevia

Complications

Maternal Complications

Neonatal Complications

• Transient tachypnoea of the newborn (TTN) - more common after elective CS before 39 weeks (absence of labour reduces fetal lung fluid clearance)
• Surgical trauma (fetal lacerations - rare, ~1-2%)
• Respiratory distress syndrome (if preterm)

Reducing Morbidity - Key Principles (Creasy & Resnik)

1. Anaesthesia by a skilled anaesthesiologist
2. Maternal left lateral tilt; attention to blood volume
3. Prophylactic antibiotics (single dose, given before incision)
4. Use a transverse uterine incision whenever possible
5. Await onset of labour before elective repeat CS when feasible (reduces neonatal TTN)
6. Skilled neonatologist present for resuscitation
7. Prompt delivery of infant after spinal/epidural - uteroplacental hypoperfusion begins even in a normotensive patient

• Creasy & Resnik's Maternal-Fetal Medicine; Pfenninger & Fowler's Procedures for Primary Care

LSCS (Lower Segment Caesarean Section) - Summary

Definition

Indications

Absolute

• Placenta praevia (major)
• Placenta accreta/increta/percreta
• CPD (cephalopelvic disproportion)
• Cord prolapse (viable fetus)
• Previous classical uterine scar
• Transverse lie with ruptured membranes

Relative

• Dystocia / failure to progress (30% of increased CS rates)
• Non-reassuring fetal heart rate (fetal distress)
• Breech presentation
• Repeat LSCS
• Pre-eclampsia / failed induction
• Active genital herpes
• Maternal request

Types of Uterine Incisions

Preoperative Preparation

• Informed consent
• IV access, blood group & crossmatch
• Antacid: Sodium citrate ± ranitidine (GA aspiration prophylaxis)
• Foley catheter to drain bladder
• Prophylactic antibiotics (single dose before incision)
• DVT prophylaxis
• Left lateral tilt 15° (aortocaval decompression)

Anaesthesia

Operative Steps (Kerr LSCS)

Decision-to-Delivery Time

• Emergency (cord prolapse, acute fetal compromise): ≤30 minutes
• Urgent: 30-75 minutes
• Elective: At 39 weeks (prevents neonatal TTN)

VBAC (Vaginal Birth After Caesarean)

• Possible after one previous LSCS with low transverse scar
• Uterine rupture risk during TOLAC: 0.5-1%
• Good candidates: non-recurrent indication, prior vaginal birth, spontaneous labour
• Contraindicated: Previous classical scar, >2 prior CS, prior uterine rupture

Complications

Maternal - Intraoperative

Maternal - Postoperative

Neonatal

• TTN (transient tachypnoea of newborn) - elective CS before 39 weeks
• Fetal laceration (rare)
• RDS if preterm

5 Principles to Minimise Morbidity (Creasy & Resnik)

1. Skilled anaesthesiologist
2. Left lateral tilt + adequate blood volume
3. Prophylactic antibiotics
4. Transverse uterine incision whenever possible
5. Skilled neonatologist present