General Surgical Principles & Instruments

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, BorderStyle, WidthType, VerticalAlign,
  ShadingType, PageNumber, Header, Footer, PageBreak, UnderlineType
} = require('docx');
const fs = require('fs');

// ─── Helpers ────────────────────────────────────────────────────────────────

function h1(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 400, after: 200 },
    border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: '2E74B5' } },
  });
}

function h2(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_2,
    spacing: { before: 300, after: 150 },
  });
}

function h3(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_3,
    spacing: { before: 200, after: 100 },
  });
}

function para(text, options = {}) {
  return new Paragraph({
    children: [new TextRun({ text, size: 22, font: 'Calibri', ...options })],
    spacing: { after: 100 },
  });
}

function bullet(text, bold = false) {
  return new Paragraph({
    bullet: { level: 0 },
    children: [new TextRun({ text, size: 22, font: 'Calibri', bold })],
    spacing: { after: 80 },
  });
}

function subbullet(text) {
  return new Paragraph({
    bullet: { level: 1 },
    children: [new TextRun({ text, size: 21, font: 'Calibri' })],
    spacing: { after: 60 },
  });
}

function boldPara(label, value) {
  return new Paragraph({
    children: [
      new TextRun({ text: label + ': ', bold: true, size: 22, font: 'Calibri' }),
      new TextRun({ text: value, size: 22, font: 'Calibri' }),
    ],
    spacing: { after: 100 },
  });
}

function makeTable(headers, rows, colWidths) {
  const headerRow = new TableRow({
    children: headers.map((h, i) =>
      new TableCell({
        children: [new Paragraph({
          children: [new TextRun({ text: h, bold: true, color: 'FFFFFF', size: 20, font: 'Calibri' })],
          alignment: AlignmentType.CENTER,
        })],
        shading: { type: ShadingType.CLEAR, fill: '2E74B5' },
        width: { size: colWidths ? colWidths[i] : Math.floor(9000 / headers.length), type: WidthType.DXA },
        verticalAlign: VerticalAlign.CENTER,
      })
    ),
    tableHeader: true,
  });

  const dataRows = rows.map((row, ri) =>
    new TableRow({
      children: row.map((cell, i) =>
        new TableCell({
          children: [new Paragraph({
            children: [new TextRun({ text: cell, size: 20, font: 'Calibri' })],
          })],
          shading: { type: ShadingType.CLEAR, fill: ri % 2 === 0 ? 'EBF3FB' : 'FFFFFF' },
          width: { size: colWidths ? colWidths[i] : Math.floor(9000 / headers.length), type: WidthType.DXA },
        })
      ),
    })
  );

  return new Table({
    rows: [headerRow, ...dataRows],
    width: { size: 9000, type: WidthType.DXA },
    margins: { top: 80, bottom: 80, left: 100, right: 100 },
  });
}

function pageBreak() {
  return new Paragraph({ children: [new PageBreak()] });
}

function note(text) {
  return new Paragraph({
    children: [
      new TextRun({ text: '📌 Note: ', bold: true, size: 22, font: 'Calibri', color: 'C00000' }),
      new TextRun({ text, size: 22, font: 'Calibri', italics: true }),
    ],
    spacing: { after: 120 },
    border: { left: { style: BorderStyle.THICK, size: 8, color: 'C00000' } },
    indent: { left: 200 },
  });
}

// ─── Document ────────────────────────────────────────────────────────────────

const children = [

  // ── TITLE PAGE ──
  new Paragraph({
    children: [new TextRun({ text: 'GENERAL SURGICAL PRINCIPLES & INSTRUMENTS', bold: true, size: 52, font: 'Calibri', color: '1F3864' })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 2000, after: 400 },
  }),
  new Paragraph({
    children: [new TextRun({ text: 'Comprehensive University Examination Notes', size: 32, font: 'Calibri', color: '2E74B5', italics: true })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 200 },
  }),
  new Paragraph({
    children: [new TextRun({ text: 'Based on Standard Surgical Textbooks | Arora Surgical Instrument Series', size: 24, font: 'Calibri', color: '595959' })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 2000 },
  }),
  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 1: GENERAL PRINCIPLES OF SURGERY
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 1: GENERAL PRINCIPLES OF SURGERY'),

  h2('1.1 Definitions'),
  bullet('Surgery: Branch of medicine dealing with manual and operative procedures for diagnosis and treatment of disease, injury, or deformity.'),
  bullet('Asepsis: Complete absence of pathogenic microorganisms from the surgical field.'),
  bullet('Antisepsis: Use of chemical agents (antiseptics) to destroy or inhibit microorganism growth on living tissue.'),
  bullet('Disinfection: Destruction of pathogenic microorganisms (but NOT spores) from inanimate objects.'),
  bullet('Sterilisation: Complete destruction of ALL microorganisms including spores from inanimate objects.'),
  bullet('Contamination: Introduction of microorganisms into a wound or sterile field.'),
  bullet('Sepsis: Systemic inflammatory response to infection.'),

  h2('1.2 Classification of Surgical Wounds'),
  makeTable(
    ['Class', 'Type', 'Description', 'Infection Rate'],
    [
      ['I', 'Clean', 'Non-infected, no viscus opened, no inflammation', '< 2%'],
      ['II', 'Clean-contaminated', 'Viscus opened under controlled conditions (e.g., elective bowel surgery)', '< 10%'],
      ['III', 'Contaminated', 'Open/traumatic wound, major spillage from GI tract', '~20%'],
      ['IV', 'Dirty/Infected', 'Old traumatic wound, perforated viscus, abscess', '> 30%'],
    ],
    [1000, 2000, 4500, 1500]
  ),

  new Paragraph({ spacing: { after: 200 } }),

  h2('1.3 Pre-operative Preparation'),
  h3('Patient Assessment'),
  bullet('Thorough history taking: presenting complaint, past surgical history, medications, allergies, social history'),
  bullet('Physical examination: general, systemic, local'),
  bullet('Investigations: CBC, LFT, RFT, blood glucose, coagulation profile, ECG, CXR, group & cross-match'),

  h3('Optimisation Before Surgery'),
  bullet('Correct anaemia (Hb should ideally be > 10 g/dL)'),
  bullet('Correct electrolyte imbalance (especially K+, Na+)'),
  bullet('Control diabetes: blood sugar < 200 mg/dL perioperatively'),
  bullet('Stop anticoagulants/antiplatelet agents as per protocol'),
  bullet('Nutritional optimisation — TPN or enteral feeding if malnourished'),
  bullet('Bowel preparation for colorectal surgery (mechanical or antibiotic)'),
  bullet('DVT prophylaxis: TED stockings, LMWH'),
  bullet('Antibiotic prophylaxis: given 30–60 minutes before incision'),

  h3('Informed Consent'),
  bullet('Procedure explained in patient\'s language'),
  bullet('Risks, benefits, alternatives discussed'),
  bullet('Written consent obtained; witnessed'),
  note('Consent is invalid if obtained under coercion, from an incompetent patient, or without proper explanation.'),

  h2('1.4 Intra-operative Principles'),
  bullet('Proper patient positioning to avoid pressure injuries and nerve damage'),
  bullet('Adequate draping to create sterile operative field'),
  bullet('Gentle tissue handling — avoid excessive retraction, crushing'),
  bullet('Meticulous haemostasis — ligate vessels, use diathermy appropriately'),
  bullet('Dead space obliteration to prevent seroma/haematoma formation'),
  bullet('Tension-free anastomosis with adequate blood supply'),
  bullet('Negative margins in cancer surgery'),
  bullet('Minimum 12 lymph nodes in colon cancer surgery'),
  bullet('Proper wound closure in layers'),

  h2('1.5 Post-operative Care'),
  bullet('Monitor vitals: BP, pulse, temperature, RR, SpO2, urine output'),
  bullet('IV fluids until patient tolerates oral intake'),
  bullet('Analgesia: WHO pain ladder — paracetamol → NSAIDs → opioids'),
  bullet('Early mobilisation to prevent DVT, chest complications, paralytic ileus'),
  bullet('Drain management: monitor output, remove when < 30 mL/24 hours'),
  bullet('Wound inspection on day 2–3; suture removal as appropriate'),
  bullet('Thromboprophylaxis continued until fully mobile'),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 2: WOUND HEALING
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 2: WOUND HEALING'),

  h2('2.1 Types of Wound Healing'),
  makeTable(
    ['Type', 'Also Known As', 'Description', 'Example'],
    [
      ['Primary Intention', 'Primary closure', 'Clean wound; edges approximated immediately', 'Clean surgical incision'],
      ['Secondary Intention', 'Healing by granulation', 'Wound left open; heals from base upward', 'Abscess cavity, pressure sore'],
      ['Tertiary Intention', 'Delayed primary closure', 'Wound left open 4–5 days then sutured', 'Contaminated wound after debridement'],
    ],
    [1800, 2000, 3000, 2200]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('2.2 Phases of Wound Healing'),
  h3('Phase 1: Haemostasis (0 – few hours)'),
  bullet('Immediate vasoconstriction'),
  bullet('Platelet adhesion and aggregation → platelet plug'),
  bullet('Coagulation cascade activation → fibrin clot'),
  bullet('Clot provides scaffold for cell migration'),

  h3('Phase 2: Inflammatory Phase (Day 1–4)'),
  bullet('Vasodilation → increased blood flow (rubor, calor, tumor, dolor)'),
  bullet('Neutrophils (first 24–48 hrs): phagocytosis, killing bacteria'),
  bullet('Macrophages (48–72 hrs): phagocytosis, release growth factors (PDGF, TGF-β)'),
  bullet('Macrophages are the most important cells in wound healing'),
  note('If macrophages are depleted (e.g., steroid use), wound healing is severely impaired.'),

  h3('Phase 3: Proliferative Phase (Day 4–21)'),
  bullet('Fibroblasts: synthesise collagen (Type III initially → remodelled to Type I)'),
  bullet('Angiogenesis: new blood vessel formation'),
  bullet('Granulation tissue formation: collagen + blood vessels + myofibroblasts'),
  bullet('Epithelialisation: keratinocytes migrate across wound surface'),
  bullet('Wound contraction: myofibroblasts contract wound edges'),

  h3('Phase 4: Remodelling Phase (Day 21 – 2 years)'),
  bullet('Type III collagen replaced by stronger Type I collagen'),
  bullet('Collagen fibres reorganised along lines of stress'),
  bullet('Tensile strength increases — reaches maximum 80% of normal by 3 months'),
  bullet('Scar matures: becomes pale, flat, soft'),
  note('A wound never regains 100% tensile strength of normal skin.'),

  h2('2.3 Factors Affecting Wound Healing'),
  h3('Local Factors'),
  bullet('Infection: most common cause of delayed healing'),
  bullet('Poor blood supply / ischaemia'),
  bullet('Haematoma / seroma formation'),
  bullet('Foreign body in wound'),
  bullet('Technique: tension, dead space, poor technique'),

  h3('Systemic Factors'),
  bullet('Malnutrition (protein, Vitamin C, Zinc deficiency)'),
  bullet('Diabetes mellitus: impaired neutrophil function, neuropathy, poor vascularity'),
  bullet('Steroids / immunosuppressants: suppress inflammatory phase'),
  bullet('Chemotherapy / radiotherapy'),
  bullet('Jaundice, uraemia, anaemia'),
  bullet('Age: elderly patients have impaired healing'),

  h2('2.4 Abnormal Wound Healing'),
  makeTable(
    ['Type', 'Description', 'Key Feature'],
    [
      ['Keloid', 'Scar grows beyond wound margins; does NOT regress', 'Hereditary; darker skin; sternum, deltoid'],
      ['Hypertrophic scar', 'Raised scar within wound margins; may regress', 'Resolves over time; different from keloid'],
      ['Contracture', 'Excessive wound contraction causing deformity', 'Burns, palmar fibromatosis'],
      ['Wound dehiscence', 'Wound breaks open (usually day 5–9)', 'Often due to infection, poor nutrition'],
      ['Incisional hernia', 'Late complication of wound dehiscence', 'Bulge at scar site'],
    ],
    [2000, 4000, 3000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 3: SUTURES & NEEDLES
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 3: SUTURES AND NEEDLES'),

  h2('3.1 Classification of Sutures'),
  h3('A. By Absorbability'),
  makeTable(
    ['Type', 'Material', 'Absorption Time', 'Uses'],
    [
      ['Natural Absorbable', 'Plain catgut', '10–14 days', 'Ligation of small vessels (rarely used now)'],
      ['Natural Absorbable', 'Chromic catgut', '21–28 days', 'Bowel, subcutaneous tissue'],
      ['Synthetic Absorbable', 'Vicryl (Polyglactin 910)', '56–70 days', 'Fascia, deep tissue, bowel anastomosis'],
      ['Synthetic Absorbable', 'PDS (Polydioxanone)', '180–210 days', 'Mass closure of abdomen, fascia'],
      ['Synthetic Absorbable', 'Monocryl (Poliglecaprone)', '90–120 days', 'Subcuticular skin closure'],
      ['Non-Absorbable', 'Silk', 'Permanent', 'Skin, ligation; causes tissue reaction'],
      ['Non-Absorbable', 'Prolene (Polypropylene)', 'Permanent', 'Vascular anastomosis, hernia repair'],
      ['Non-Absorbable', 'Nylon (Ethilon)', 'Permanent', 'Skin closure, tension sutures'],
      ['Non-Absorbable', 'Stainless steel wire', 'Permanent', 'Sternal closure, orthopaedics'],
    ],
    [2000, 2000, 1800, 3200]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h3('B. By Structure'),
  makeTable(
    ['Structure', 'Examples', 'Advantages', 'Disadvantages'],
    [
      ['Monofilament', 'Prolene, Nylon, PDS, Monocryl', 'Low infection risk, smooth passage', 'Difficult to tie, memory'],
      ['Multifilament (Braided)', 'Vicryl, Silk, Ethibond', 'Easy to handle, secure knots', 'Higher infection risk (bacteria harbour in interstices)'],
    ],
    [2000, 2000, 2500, 2500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h3('C. Suture Size (USP system)'),
  bullet('Larger number → finer suture (e.g., 4-0 is finer than 2-0)'),
  bullet('Numbers with 0 (zeros): 0, 2-0, 3-0, 4-0, 5-0 → progressively finer'),
  bullet('Positive numbers: 1, 2, 3 → progressively thicker'),
  makeTable(
    ['Body Area', 'Recommended Suture Size'],
    [
      ['Scalp', '3-0 or 4-0'],
      ['Face / Cosmetic', '5-0 or 6-0'],
      ['Skin (general)', '3-0 or 4-0'],
      ['Fascia / Abdomen (mass closure)', '1 or loop PDS'],
      ['Bowel anastomosis', '3-0 Vicryl'],
      ['Vascular anastomosis', '5-0 to 7-0 Prolene'],
    ],
    [4500, 4500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('3.2 Types of Suturing Techniques'),
  h3('Interrupted Sutures'),
  bullet('Each stitch is tied separately'),
  bullet('If one fails, rest hold; easy to remove selectively'),
  bullet('Example: simple interrupted, vertical mattress, horizontal mattress, figure-of-8'),

  h3('Continuous Sutures'),
  bullet('Single thread runs throughout the wound'),
  bullet('Faster; more haemostatic; everts wound edges well'),
  bullet('Example: simple continuous (running), locking continuous, subcuticular'),

  h2('3.3 Types of Surgical Needles'),
  makeTable(
    ['Needle Type', 'Cross-section', 'Use'],
    [
      ['Round-bodied (taper point)', 'Round', 'Soft tissue — bowel, muscle, peritoneum'],
      ['Cutting (reverse cutting)', 'Triangular', 'Skin, tough tissue'],
      ['Blunt', 'Round/blunt tip', 'Liver, spleen — reduces needlestick injury'],
      ['Trocar point', 'Triangular tip + round body', 'Dense connective tissue'],
    ],
    [2500, 2500, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 4: SURGICAL INSTRUMENTS
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 4: SURGICAL INSTRUMENTS'),
  para('Surgical instruments are broadly classified into:'),
  bullet('Cutting & Dissecting instruments'),
  bullet('Grasping & Holding instruments'),
  bullet('Haemostatic instruments (Artery forceps / clamps)'),
  bullet('Retracting instruments'),
  bullet('Suturing instruments'),
  bullet('Drainage instruments'),
  bullet('Miscellaneous instruments'),

  h2('4.1 Cutting & Dissecting Instruments'),
  h3('A. Scalpel (Surgical Knife)'),
  bullet('Consists of: Blade + Handle (Bard-Parker handle)'),
  bullet('Disposable blades, reusable handle'),
  makeTable(
    ['Blade No.', 'Shape', 'Common Use'],
    [
      ['No. 10', 'Large curved blade', 'General incisions (commonest)'],
      ['No. 11', 'Pointed/triangular', 'Stab incisions, draining abscesses, tenotomy'],
      ['No. 12', 'Hook-shaped', 'ENT procedures, paediatric surgery'],
      ['No. 15', 'Small curved blade', 'Fine/delicate incisions, plastic surgery, paediatric'],
      ['No. 20, 22, 23', 'Large belly', 'Larger incisions — abdominal, orthopaedic'],
    ],
    [1500, 2500, 5000]
  ),
  new Paragraph({ spacing: { after: 200 } }),
  note('Blade No. 22 is used with Handle No. 4; Blade No. 10/15/11 with Handle No. 3.'),

  h3('B. Scissors'),
  makeTable(
    ['Name', 'Features', 'Use'],
    [
      ['Mayo scissors', 'Straight or curved, heavy blades', 'Cutting sutures, fascia, tough tissue'],
      ['Metzenbaum scissors', 'Long handle, short blades, curved', 'Delicate tissue dissection'],
      ['Iris scissors', 'Small, fine, straight or curved', 'Fine eye/plastic surgery'],
      ['Stitch scissors (Littauer)', 'One blade with hook', 'Removing skin sutures'],
      ['Bandage scissors (Lister)', 'Angled tip, blunt bottom blade', 'Cutting bandages safely'],
    ],
    [2000, 3000, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('4.2 Grasping & Holding Instruments'),
  h3('A. Tissue Forceps'),
  makeTable(
    ['Name', 'Type', 'Use'],
    [
      ['Rat-tooth forceps (Adson)', 'Toothed (1×2 teeth)', 'Holding skin edges during suturing'],
      ['Non-toothed (thumb) forceps', 'Smooth', 'Handling delicate structures — bowel, vessels'],
      ['DeBakey forceps', 'Smooth, atraumatic', 'Vascular surgery, delicate tissue'],
      ['Russian forceps', 'Broad serrated tip', 'Strong grip on tough tissue'],
      ['Bonney\'s forceps', 'Strong toothed', 'Gynaecological surgery — uterus, dense tissue'],
    ],
    [2000, 2000, 5000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h3('B. Intestinal / Visceral Clamps & Forceps'),
  makeTable(
    ['Name', 'Features', 'Use'],
    [
      ['Babcock\'s forceps', 'Atraumatic, broad curved jaws', 'Holding bowel, appendix, fallopian tube without crushing'],
      ['Allis forceps', 'Toothed interlocking jaws', 'Grasping fascia, holding wound edges'],
      ['Duval\'s forceps', 'Triangular fenestrated jaws', 'Holding lung tissue (atraumatic)'],
      ['Doyen\'s forceps', 'Long straight/curved, crushing', 'Bowel clamp (crushing)'],
      ['Parker-Kerr clamp', 'Non-crushing', 'Bowel anastomosis'],
      ['Sponge-holding forceps (Rampley\'s)', 'Ring handles, serrated jaws', 'Holding swabs for skin prep; retracting tissue'],
    ],
    [2000, 2500, 4500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('4.3 Haemostatic Instruments (Artery Forceps)'),
  para('Artery forceps are used to clamp blood vessels to achieve haemostasis. All have ratchet (locking) mechanism.'),
  makeTable(
    ['Name', 'Features', 'Use'],
    [
      ['Halsted mosquito forceps', 'Very small, straight or curved', 'Clamping tiny vessels in delicate surgery'],
      ['Spencer Wells forceps', 'Larger, straight or curved, transverse serrations', 'Clamping medium-sized vessels; general surgery'],
      ['Kocher\'s forceps', 'Heavy, toothed tip', 'Clamping tough tissue, thyroid, fascia (traumatic)'],
      ['Kelly\'s forceps', 'Heavier than mosquito, no teeth', 'Clamping larger vessels'],
      ['Mixter (right-angle) forceps', 'Right-angle jaw', 'Passing ligatures behind vessels/ducts (e.g., cystic duct)'],
      ['Lahey forceps', 'Curved, right-angle', 'Thyroid surgery — rotating thyroid lobe'],
    ],
    [2500, 3000, 3500]
  ),
  new Paragraph({ spacing: { after: 200 } }),
  note('Kocher\'s forceps are traumatic due to teeth — NOT to be used on bowel or vessels.'),

  h2('4.4 Retractors'),
  h3('A. Hand-held Retractors'),
  makeTable(
    ['Name', 'Shape', 'Use'],
    [
      ['Langenbeck retractor', 'L-shaped, flat blade', 'General retraction in abdominal, pelvic surgery'],
      ['Deaver retractor', 'Curved wide blade', 'Deep abdominal cavity retraction (liver, biliary)'],
      ['Morris retractor', 'Broader than Deaver', 'Large abdominal incisions'],
      ['Cat\'s paw retractor', 'Small clawed prongs', 'Superficial small wound retraction'],
      ['Ribbon retractor', 'Malleable flat ribbon', 'Shaped to fit specific anatomy'],
      ['Brain retractor', 'Flat, wide spatula', 'Neurosurgery — retracting brain tissue'],
    ],
    [2500, 2000, 4500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h3('B. Self-retaining Retractors'),
  makeTable(
    ['Name', 'Mechanism', 'Surgery'],
    [
      ['Balfour retractor', 'Frame + lateral blades + central blade', 'Abdominal surgery (most common)'],
      ['Finochietto retractor', 'Ratchet spreader', 'Thoracic surgery (rib spreader)'],
      ['Weitlaner retractor', 'Ratchet, toothed prongs', 'Superficial/orthopaedic, neck surgery'],
      ['Gelpi retractor', 'Sharp prongs, ratchet', 'Spine surgery, small deep wounds'],
      ['Travers retractor', 'Curved prongs', 'General surgery, small incisions'],
    ],
    [2500, 3000, 3500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('4.5 Suturing Instruments'),
  makeTable(
    ['Name', 'Features', 'Use'],
    [
      ['Mayo-Hegar needle holder', 'No scissors, tungsten carbide jaws', 'Standard needle holder for suturing'],
      ['Gillies needle holder', 'Combined with scissors', 'Fine suturing + cutting suture in one instrument'],
      ['Webster needle holder', 'Small, delicate', 'Plastic surgery, fine sutures'],
      ['Heaney needle holder', 'Heavy angled jaws', 'Deep pelvic/vaginal suturing'],
    ],
    [2500, 3000, 3500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('4.6 Drainage Instruments'),
  makeTable(
    ['Drain', 'Type', 'Use'],
    [
      ['Corrugated rubber drain', 'Open passive', 'Superficial wounds, abscess cavities'],
      ['Robinson (tube) drain', 'Closed passive', 'Abdominal and thoracic cavities'],
      ['Redivac (Haemovac)', 'Closed active suction', 'Post-mastectomy, neck dissection, joint surgery'],
      ['Jackson-Pratt drain', 'Closed active suction (bulb)', 'Abdominal surgery'],
      ['T-tube (Kehr\'s T-tube)', 'Specialised', 'Common bile duct after CBD exploration'],
      ['Chest (intercostal) drain', 'Closed with underwater seal', 'Pneumothorax, haemothorax, pleural effusion'],
      ['Penrose drain', 'Open passive (flat latex)', 'Superficial wound drainage'],
    ],
    [2500, 2500, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 5: DIATHERMY (ELECTROSURGERY)
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 5: DIATHERMY (ELECTROSURGERY)'),

  h2('5.1 Principle'),
  para('Diathermy uses high-frequency alternating electric current (300 kHz – 3 MHz) to generate heat in tissue, causing cutting or coagulation.'),
  note('Household current (50 Hz) causes electrocution; diathermy frequencies are too high to stimulate nerves/muscles.'),

  h2('5.2 Types of Diathermy'),
  makeTable(
    ['Feature', 'Monopolar', 'Bipolar'],
    [
      ['Circuit', 'Active electrode → patient → return pad (plate)', 'Current flows between two tips of forceps only'],
      ['Return pad needed?', 'Yes', 'No'],
      ['Precision', 'Less precise', 'Very precise'],
      ['Risk', 'Burn at return pad site if poor contact', 'Much safer; less collateral damage'],
      ['Use', 'General surgery — cutting, coagulation', 'Near nerves, vessels, in ENT, neurosurgery'],
    ],
    [2500, 3250, 3250]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('5.3 Modes of Diathermy'),
  makeTable(
    ['Mode', 'Current Type', 'Effect on Tissue'],
    [
      ['Cutting', 'Continuous sine wave', 'Rapid vaporisation of intracellular water; cuts cleanly'],
      ['Coagulation (Fulguration)', 'Pulsed/interrupted', 'Slower heating → desiccation, char, haemostasis'],
      ['Blend', 'Mix of both', 'Cutting with some haemostasis'],
    ],
    [2000, 3000, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('5.4 Complications of Diathermy'),
  bullet('Burns at return pad site (if poor contact — monopolar)'),
  bullet('Burns at skin preparation pooling sites (spirit/alcohol catches fire)'),
  bullet('Interference with pacemakers (use bipolar instead)'),
  bullet('Bowel perforation if used near viscera'),
  bullet('Diathermy plume inhalation risk to theatre staff'),
  bullet('Channelling effect along narrow pedicles (e.g., fingers, penis)'),
  note('Avoid monopolar diathermy in patients with cardiac pacemakers. Use bipolar if unavoidable.'),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 6: STERILISATION & DISINFECTION
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 6: STERILISATION AND DISINFECTION'),

  h2('6.1 Definitions'),
  bullet('Sterilisation: Destruction of ALL microorganisms including bacterial spores'),
  bullet('Disinfection: Elimination of most pathogenic microorganisms (NOT spores) from inanimate surfaces'),
  bullet('Decontamination: Process of removing contamination (cleaning + disinfection + sterilisation)'),
  bullet('Antiseptic: Chemical agent used on living tissue to kill/inhibit microorganisms'),
  bullet('Disinfectant: Chemical agent used on inanimate objects'),

  h2('6.2 Methods of Sterilisation'),
  h3('A. Physical Methods'),
  makeTable(
    ['Method', 'Conditions', 'Suitable For'],
    [
      ['Autoclaving (steam under pressure)', '134°C for 3 min OR 121°C for 15 min', 'Metal instruments, gowns, drapes, glass — MOST COMMON'],
      ['Dry heat oven', '160°C for 1 hour OR 170°C for 30 min', 'Glassware, oils, powders, sharp instruments (no rust)'],
      ['Boiling', '100°C — NOT sterilisation', 'Emergency only — kills most organisms but NOT spores'],
      ['Infrared radiation', 'Conveyor belt through infrared', 'Syringes, glass items'],
      ['Gamma irradiation', '2.5 Mrad dose', 'Factory sterilisation of single-use disposables (syringes, sutures, gloves)'],
    ],
    [2500, 2500, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h3('B. Chemical Methods'),
  makeTable(
    ['Agent', 'Method', 'Use', 'Time'],
    [
      ['Ethylene oxide (EO) gas', 'Gas sterilisation', 'Heat-sensitive instruments (endoscopes, plastics, catheters)', '2–5 hours + aeration'],
      ['Glutaraldehyde (Cidex 2%)', 'Cold chemical', 'Endoscopes, fibreoptic instruments', '3 hrs (sterilisation); 20 min (high-level disinfection)'],
      ['Formaldehyde (40% = Formalin)', 'Vapour/solution', 'Instruments, tissue preservation', '24 hours'],
      ['Hydrogen peroxide plasma', 'Low-temp plasma', 'Delicate heat-sensitive equipment', '45–75 min'],
    ],
    [2000, 1800, 3500, 1700]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('6.3 Levels of Disinfection (Spaulding Classification)'),
  makeTable(
    ['Level', 'Method', 'Items'],
    [
      ['High-level disinfection', 'Glutaraldehyde, H2O2, Cidex', 'Semi-critical: endoscopes, respiratory equipment'],
      ['Intermediate-level', 'Alcohol 70%, iodophors', 'Some medical devices, skin surfaces'],
      ['Low-level', 'Quaternary ammonium compounds', 'Non-critical: floors, furniture, stethoscopes'],
    ],
    [2500, 3000, 3500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('6.4 Antiseptics Used in Surgery'),
  makeTable(
    ['Antiseptic', 'Mechanism', 'Use'],
    [
      ['Povidone-iodine (Betadine)', 'Releases free iodine → oxidises proteins', 'Skin preparation, wound cleaning'],
      ['Chlorhexidine gluconate', 'Disrupts cell membrane', 'Surgical hand scrub, skin prep, mouth wash'],
      ['Isopropyl alcohol 70%', 'Denatures proteins', 'Skin prep, instrument wipes'],
      ['Cetrimide + Chlorhexidine (Savlon)', 'Detergent + membrane damage', 'Wound cleaning, skin antisepsis'],
      ['Hydrogen peroxide 3%', 'Oxidation, free radical release', 'Wound irrigation, anaerobic organisms'],
      ['Potassium permanganate', 'Oxidising agent', 'Foot soaks, infected wounds'],
    ],
    [2500, 2500, 4000]
  ),
  new Paragraph({ spacing: { after: 200 } }),
  note('Chlorhexidine is the preferred agent for surgical hand scrub and skin preparation before central line insertion (NICE guidelines).'),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 7: HAEMOSTASIS
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 7: HAEMOSTASIS IN SURGERY'),

  h2('7.1 Types of Surgical Haemostasis'),
  makeTable(
    ['Method', 'Details'],
    [
      ['Direct pressure', 'Gauze/swab applied with pressure for 3–5 minutes'],
      ['Ligation', 'Tie suture around vessel (most reliable)'],
      ['Suture ligation (transfixion)', 'Suture passed through vessel before tying — prevents slippage'],
      ['Diathermy (electrocautery)', 'Monopolar coagulation or bipolar for precision'],
      ['Topical agents', 'Surgicel (oxidised cellulose), Gelfoam (gelatin sponge), Bone wax'],
      ['Vascular clamps', 'Bulldog clamps, Satinsky clamp for major vessels'],
      ['Argon beam coagulator', 'For liver, spleen surface ooze'],
    ],
    [3500, 5500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  h2('7.2 Tourniquets'),
  bullet('Used in limb surgery to provide bloodless field'),
  bullet('Types: Pneumatic (gold standard), Rubber (Esmarch bandage)'),
  bullet('Safe time: Upper limb — 1.5 to 2 hours; Lower limb — 1.5 hours'),
  bullet('Pressure: Upper limb: systolic BP + 50 mmHg; Lower limb: systolic BP + 100 mmHg'),
  note('Prolonged tourniquet use causes tourniquet paralysis (neuropraxia) and reperfusion injury.'),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 8: COMMON SURGICAL INCISIONS
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 8: COMMON SURGICAL INCISIONS'),

  makeTable(
    ['Incision', 'Location', 'Surgery Used For'],
    [
      ['Midline (median laparotomy)', 'Vertical midline — above/below umbilicus', 'General laparotomy, bowel surgery, aortic surgery'],
      ['Paramedian', 'Vertical, 2.5 cm lateral to midline', 'Was common; less used now'],
      ['Kocher\'s (subcostal)', 'Right oblique below costal margin', 'Open cholecystectomy, liver surgery'],
      ['Pfannenstiel', 'Transverse, above pubic symphysis', 'Caesarean section, pelvic surgery, prostatectomy'],
      ['Lanz (modified Gridiron)', 'Transverse, McBurney\'s point', 'Appendicectomy (best cosmesis)'],
      ['Gridiron (McBurney\'s)', 'Oblique at McBurney\'s point', 'Appendicectomy (classic)'],
      ['Rooftop (Chevron)', 'Bilateral subcostal', 'Liver transplant, total gastrectomy, oesophagectomy'],
      ['Thoracotomy', 'Lateral chest', 'Lung, oesophageal surgery'],
      ['Sternotomy', 'Midline sternum split', 'Cardiac surgery'],
    ],
    [2500, 3000, 3500]
  ),
  new Paragraph({ spacing: { after: 200 } }),
  note('McBurney\'s point: junction of lateral 1/3 and medial 2/3 of a line drawn from ASIS to umbilicus.'),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // CHAPTER 9: ABSCESSES & INFECTIONS
  // ════════════════════════════════════════════════════════════════
  h1('CHAPTER 9: SURGICAL INFECTIONS & ABSCESS'),

  h2('9.1 Abscess'),
  boldPara('Definition', 'A localised collection of pus within a cavity, formed by tissue disintegration and surrounded by a pyogenic membrane.'),
  h3('Signs'),
  bullet('Classical signs of inflammation: Rubor (redness), Calor (heat), Tumor (swelling), Dolor (pain), Functio laesa (loss of function)'),
  bullet('Fluctuation: positive on palpation — diagnostic of pus'),
  bullet('Pointing: skin becomes thinned and discoloured centrally'),

  h3('Treatment: "Ubi pus, ibi evacua" — Where there is pus, evacuate it'),
  bullet('Incision and drainage (I&D): under LA or GA'),
  bullet('Cruciate (cross) incision to prevent premature closure'),
  bullet('Break up loculations with finger'),
  bullet('Cavity irrigated with saline'),
  bullet('Pack with ribbon gauze / leave drain'),
  bullet('Antibiotics alone are NOT sufficient for a formed abscess'),

  h2('9.2 Common Surgical Infections'),
  makeTable(
    ['Condition', 'Organism', 'Management'],
    [
      ['Cellulitis', 'Strep. pyogenes, Staph. aureus', 'IV antibiotics, elevation, mark margins'],
      ['Carbuncle', 'Staph. aureus (multiple follicles)', 'I&D + antibiotics, check for diabetes'],
      ['Necrotising fasciitis', 'Polymicrobial or Group A Strep', 'URGENT surgical debridement + IV antibiotics — life-threatening'],
      ['Gas gangrene', 'Clostridium perfringens', 'Debridement, penicillin, hyperbaric oxygen'],
      ['Tetanus', 'Clostridium tetani', 'Wound debridement, human anti-tetanus Ig, penicillin, muscle relaxants'],
    ],
    [2000, 2500, 4500]
  ),
  new Paragraph({ spacing: { after: 200 } }),

  pageBreak(),

  // ════════════════════════════════════════════════════════════════
  // QUICK REVISION TABLE
  // ════════════════════════════════════════════════════════════════
  h1('QUICK REVISION: IMPORTANT EXAM FACTS'),

  makeTable(
    ['Topic', 'Key Fact'],
    [
      ['Most important cell in wound healing', 'Macrophage'],
      ['First cell to arrive at wound', 'Neutrophil (within 24–48 hours)'],
      ['Collagen type in early wound healing', 'Type III (later replaced by Type I)'],
      ['Maximum tensile strength of healed wound', '80% of normal skin (never 100%)'],
      ['Most common cause of delayed wound healing', 'Infection'],
      ['Keloid vs hypertrophic scar', 'Keloid grows beyond margins; hypertrophic stays within margins'],
      ['BP handle No. 3 + blade', 'Blades 10, 11, 12, 15 (small)'],
      ['BP handle No. 4 + blade', 'Blades 20, 21, 22, 23 (large)'],
      ['Scalpel blade for stab incision', 'No. 11'],
      ['Commonest self-retaining retractor (abdomen)', 'Balfour retractor'],
      ['Self-retaining retractor for thorax', 'Finochietto retractor'],
      ['Atraumatic bowel clamp', 'Babcock\'s forceps'],
      ['Traumatic artery forceps (toothed)', 'Kocher\'s forceps'],
      ['Forceps for passing ligatures behind vessels', 'Mixter (right-angle) forceps'],
      ['Drain for CBD after exploration', 'T-tube (Kehr\'s T-tube)'],
      ['Closed suction drain (post-mastectomy)', 'Redivac drain'],
      ['Preferred surgical hand scrub agent', 'Chlorhexidine gluconate'],
      ['Sterilisation method for endoscopes', 'Ethylene oxide OR Glutaraldehyde (Cidex)'],
      ['Gold standard sterilisation', 'Autoclaving (steam under pressure)'],
      ['Diathermy mode for cutting', 'Continuous sine wave current'],
      ['Diathermy — use near pacemaker', 'Bipolar (NOT monopolar)'],
      ['Suture for vascular anastomosis', 'Prolene (polypropylene) — non-absorbable, monofilament'],
      ['Mass closure of abdomen', 'Loop PDS (polydioxanone) — 1 PDS'],
      ['Subcuticular skin closure suture', 'Monocryl (poliglecaprone)'],
      ['Suture principle "Ubi pus ibi evacua"', 'Where there is pus, evacuate it'],
      ['McBurney\'s point', 'Junction of lateral 1/3 and medial 2/3 of ASIS to umbilicus line'],
      ['Incision for C-section', 'Pfannenstiel incision'],
      ['Incision for appendicectomy (cosmetic)', 'Lanz incision'],
    ],
    [4000, 5000]
  ),
  new Paragraph({ spacing: { after: 400 } }),

  // Footer note
  new Paragraph({
    children: [new TextRun({ text: '— End of Notes — Good Luck with Your Exams! —', bold: true, size: 24, font: 'Calibri', color: '2E74B5', italics: true })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 400, after: 200 },
  }),
];

// Build document
const doc = new Document({
  styles: {
    paragraphStyles: [
      {
        id: 'Heading1',
        name: 'Heading 1',
        basedOn: 'Normal',
        next: 'Normal',
        quickFormat: true,
        run: { size: 32, bold: true, color: '1F3864', font: 'Calibri' },
        paragraph: { spacing: { before: 400, after: 200 } },
      },
      {
        id: 'Heading2',
        name: 'Heading 2',
        basedOn: 'Normal',
        next: 'Normal',
        quickFormat: true,
        run: { size: 26, bold: true, color: '2E74B5', font: 'Calibri' },
        paragraph: { spacing: { before: 300, after: 150 } },
      },
      {
        id: 'Heading3',
        name: 'Heading 3',
        basedOn: 'Normal',
        next: 'Normal',
        quickFormat: true,
        run: { size: 24, bold: true, color: '2E74B5', font: 'Calibri', italics: true },
        paragraph: { spacing: { before: 200, after: 100 } },
      },
    ],
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 1080, bottom: 1080, left: 1080, right: 1080 },
      },
    },
    headers: {
      default: new Header({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'General Surgical Principles & Instruments — University Exam Notes', size: 18, color: '595959', font: 'Calibri' }),
            ],
            alignment: AlignmentType.RIGHT,
            border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: 'AAAAAA' } },
          }),
        ],
      }),
    },
    footers: {
      default: new Footer({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'Page ', size: 18, color: '595959', font: 'Calibri' }),
              new TextRun({ children: [PageNumber.CURRENT], size: 18, color: '595959', font: 'Calibri' }),
              new TextRun({ text: ' of ', size: 18, color: '595959', font: 'Calibri' }),
              new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 18, color: '595959', font: 'Calibri' }),
            ],
            alignment: AlignmentType.CENTER,
            border: { top: { style: BorderStyle.SINGLE, size: 4, color: 'AAAAAA' } },
          }),
        ],
      }),
    },
    children,
  }],
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/surgical-notes/Surgical_Principles_and_Instruments_Exam_Notes.docx', buffer);
  console.log('Document created successfully!');
});