Common Surgical Procedures in Surgery

1. Appendectomy

• Open appendectomy: Right iliac fossa (McBurney's) incision, identification of the appendix at the convergence of taeniae coli, ligation and division of the mesoappendix (containing the appendicular artery), ligation of the base and removal.
• Laparoscopic appendectomy: Three-port technique; preferred for obese patients, females of childbearing age (to exclude gynaecological pathology), and when diagnosis is uncertain. Offers faster recovery and fewer wound infections.

2. Cholecystectomy

• Laparoscopic cholecystectomy (gold standard): Four-port approach. The critical view of safety (CVS) must be established before clipping — two structures enter the gallbladder, the cystic duct and cystic artery, clearly identified in the hepatocystic triangle. The cystic duct and artery are clipped and divided, and the gallbladder is dissected from the liver bed.
• Open cholecystectomy: Right subcostal (Kocher's) incision. Reserved for complicated cases or failed laparoscopy.

3. Hernia Repair (Herniorrhaphy / Hernioplasty)

• Inguinal hernia (most common):
  • Lichtenstein tension-free mesh repair: Onlay polypropylene mesh over the posterior inguinal canal floor — the most widely performed.
  • Laparoscopic repair (TAPP/TEP): Mesh placed in the preperitoneal space; advantages include less postoperative pain and quicker return to activity.
• Umbilical hernia: Primary suture repair (<2 cm) or mesh repair.
• Incisional hernia: Mesh repair (open or laparoscopic) with adequate overlap.

4. Bowel Resection

• Mobilization of the bowel segment with its mesentery.
• Division of the mesentery, securing vascular pedicles.
• Resection with adequate margins (e.g., 5 cm for cancer).
• Anastomosis: hand-sewn (two-layer) or stapled (end-to-end, end-to-side, or side-to-side).
• Stoma (colostomy/ileostomy) when a primary anastomosis is unsafe (peritonitis, poor nutrition, unprepared bowel).

5. Thyroidectomy

• RLN injury → hoarseness (unilateral) or respiratory distress (bilateral)
• Hypoparathyroidism → hypocalcaemia (tetany)
• Haemorrhage → airway compromise
• Thyroid storm (rare, in unprepared hyperthyroid patients)

6. Exploratory Laparotomy

7. Mastectomy

• Simple/total mastectomy: Removal of breast tissue, nipple-areolar complex, overlying skin.
• Modified radical mastectomy (MRM): Total mastectomy + axillary lymph node dissection (levels I–II); standard for breast cancer.
• Radical mastectomy (Halsted): Rarely performed today; adds pectoralis major resection.
• Breast-conserving surgery (lumpectomy/wide local excision): Removes tumour with clear margins, combined with radiotherapy.

8. Splenectomy

• Vaccinations: pneumococcus (Streptococcus pneumoniae), Haemophilus influenzae type B, Neisseria meningitidis (given ≥2 weeks pre-op electively, or post-op in emergencies).
• Life-long penicillin prophylaxis in children.
• OPSI (overwhelming post-splenectomy infection) — high mortality, caused most commonly by encapsulated organisms.

9. Tracheostomy

• Surgical tracheostomy: Open technique, typically between 2nd and 3rd tracheal rings.
• Percutaneous dilatational tracheostomy (PDT): Bedside procedure using Seldinger technique; preferred in ICU.

• Early: haemorrhage, tube displacement, subcutaneous emphysema, pneumothorax.
• Late: tracheal stenosis, tracheomalacia, tracheo-innominate fistula, swallowing difficulty.

10. Laparoscopic Surgery (General Principles)

Summary Table

Common Surgical Procedures — 8 Marks

🔑 Simple Way to Remember: "A C H B T M S L"

Appendectomy → Cholecystectomy → Hernia Repair → Bowel Resection → Thyroidectomy → Mastectomy → Splenectomy → Laparoscopy

1. 🔴 Appendectomy

• What: Remove the appendix
• Why: Acute appendicitis
• How: Laparoscopic (3 ports) OR open (McBurney's incision, RIF)
• Remember: Ligation of base → remove appendix → secure mesoappendix
• Complication: Wound infection, abscess

2. 🟡 Cholecystectomy

• What: Remove the gallbladder
• Why: Gallstones, cholecystitis
• How: Laparoscopic = gold standard (4 ports)
• Key rule: Always get Critical View of Safety (CVS) before clipping
• Complication: Bile duct injury ⚠️ (most feared)

3. 🟢 Hernia Repair

• What: Fix abnormal protrusion through abdominal wall
• Most common: Inguinal hernia
• Best technique: Lichtenstein mesh repair (tension-free)
• Laparoscopic: TAPP or TEP — better for bilateral/recurrent hernias
• Complication: Recurrence, chronic groin pain

4. 🔵 Bowel Resection

• What: Cut out a diseased bowel segment + join the ends (anastomosis)
• Why: Colorectal cancer, Crohn's disease, obstruction, ischaemia
• If unsafe to join: Make a stoma instead (colostomy/ileostomy)
• Complication: Anastomotic leak ⚠️ (most serious)

5. 🟠 Thyroidectomy

• What: Remove part/all of thyroid
• Why: Thyroid cancer, goitre, Graves' disease
• Incision: Kocher's collar incision
• Two things to protect:
  • RLN (recurrent laryngeal nerve) → injury = hoarseness
  • Parathyroids → injury = hypocalcaemia (tetany)

6. 🩷 Mastectomy

• What: Remove breast tissue
• Standard for cancer: Modified Radical Mastectomy (MRM) = breast + axillary nodes
• Less invasive: Lumpectomy + radiotherapy (breast-conserving)
• Key step: Sentinel lymph node biopsy (SLNB) to check axilla
• Complication: Seroma (most common), lymphoedema

7. 🟣 Splenectomy

• What: Remove the spleen
• Why: Trauma (#1 emergency), ITP, hereditary spherocytosis
• Post-op rule: Vaccinate against 3 encapsulated organisms:
  • S. pneumoniae, H. influenzae B, N. meningitidis
• Danger: OPSI = Overwhelming Post-Splenectomy Infection (high mortality)

8. ⚪ Laparoscopy (Minimally Invasive Surgery)

• What: Surgery via small ports using camera + instruments
• Gas used: CO₂ at 12–15 mmHg pressure
• Advantages over open: Less pain ✅ Faster recovery ✅ Less infection ✅ Better cosmesis ✅
• Complication: Port-site hernia, gas (CO₂) embolism

⚡ Quick Revision Table

🧠 Memory Tips

Common Surgical Procedures — 8 Marks

1. Appendectomy

• Removal of the appendix
• Done for acute appendicitis
• Open method: incision at right iliac fossa (McBurney's point)
• Laparoscopic method is now preferred
• Complication: wound infection, abscess formation

2. Cholecystectomy

• Removal of the gallbladder
• Done for gallstones and cholecystitis
• Laparoscopic cholecystectomy is the gold standard
• Critical View of Safety must be confirmed before cutting
• Complication: bile duct injury

3. Hernia Repair

• Repair of a defect in the abdominal wall
• Most common type is inguinal hernia
• Lichtenstein tension-free mesh repair is the standard method
• Laparoscopic repair (TAPP or TEP) used for bilateral or recurrent cases
• Complication: recurrence, chronic pain

4. Bowel Resection and Anastomosis

• Removal of a diseased segment of intestine
• Done for colorectal cancer, Crohn's disease, obstruction
• Cut ends are joined together — this is called anastomosis
• If joining is unsafe, a stoma (colostomy or ileostomy) is made
• Complication: anastomotic leak

5. Thyroidectomy

• Removal of part or whole thyroid gland
• Done for thyroid cancer, goitre, Graves' disease
• Incision: Kocher's collar incision in the neck
• Two structures must be protected during surgery:
  • Recurrent laryngeal nerve — injury causes hoarseness
  • Parathyroid glands — injury causes low calcium (tetany)

6. Mastectomy

• Removal of breast tissue
• Done for breast cancer
• Modified Radical Mastectomy removes the breast along with axillary lymph nodes
• Breast-conserving surgery (lumpectomy) removes only the tumour with clear margins
• Sentinel lymph node biopsy is done to check spread to axilla
• Complication: seroma, lymphoedema

7. Splenectomy

• Removal of the spleen
• Emergency indication: splenic trauma
• Elective indication: ITP, hereditary spherocytosis, hypersplenism
• After surgery, patient must be vaccinated against three organisms:
  • Streptococcus pneumoniae
  • Haemophilus influenzae type B
  • Neisseria meningitidis
• Main risk after surgery: Overwhelming Post-Splenectomy Infection (OPSI)

8. Tracheostomy

• Surgical opening made in the trachea with a tube inserted
• Done for prolonged ventilation, airway obstruction, failed intubation
• Opening is made between the 2nd and 3rd tracheal rings
• Percutaneous method can be done at the bedside in ICU
• Early complication: bleeding, tube displacement
• Late complication: tracheal stenosis

Important Points to Remember

Intravenous (IV) Fluid Administration — 10 Marks

Definition

I. Body Fluid Compartments (Why IV Fluids Matter)

II. Indications for IV Fluid Therapy

1. Hypovolaemia (dehydration, haemorrhage, burns, sepsis)
2. Maintenance of fluid balance during surgery or fasting (nil by mouth patients)
3. Replacement of ongoing losses (vomiting, diarrhoea, fistula, nasogastric drainage)
4. Correction of electrolyte imbalances
5. As a vehicle for drug administration (antibiotics, chemotherapy)
6. Resuscitation in shock (haemorrhagic, septic, hypovolaemic)

III. Types of IV Fluids

A. Crystalloids

1. Normal Saline (0.9% NaCl)

• Na⁺ = 154 mEq/L, Cl⁻ = 154 mEq/L
• Osmolality = 308 mOsm/kg (slightly hypertonic)
• Uses: Volume replacement, metabolic alkalosis, hyponatraemia correction, drug dilution
• Side effect: Hyperchloraemic metabolic acidosis if given in large volumes

2. Lactated Ringer's Solution (Hartmann's Solution)

• Contains Na⁺, K⁺, Ca²⁺, Cl⁻, and lactate (converted to bicarbonate in liver)
• Osmolality = 273 mOsm/kg (slightly hypotonic)
• Most physiological crystalloid — closest to plasma composition
• Uses: Surgical fluid replacement, burns, trauma resuscitation
• Avoid in: Severe liver disease (cannot metabolize lactate), hyperkalaemia

3. Dextrose 5% (D5W)

• 5 g glucose per 100 mL in water
• Osmolality = 252 mOsm/kg (initially isotonic, becomes hypotonic once glucose is metabolised)
• Distributes into all body water compartments
• Uses: Free water replacement, hypoglycaemia, hyperosmolar states, drug delivery
• Avoid in: Head injury (worsens cerebral oedema), resuscitation (ineffective volume expander)

4. Dextrose 5% in Normal Saline (D5NS) / Dextrose in 0.45% NaCl

• Uses: Maintenance fluid, post-operative hydration
• Provides both free water and electrolytes

5. Hypertonic Saline (3%, 7.5%)

• Draws water from intracellular to extracellular space
• Uses: Severe hyponatraemia, cerebral oedema, raised intracranial pressure (ICP)
• Caution: Rapid correction of hyponatraemia → central pontine myelinolysis

B. Colloids

1. Albumin (4% or 20%)

• Most physiological colloid — reflection coefficient (σ) for albumin = 0.6–0.9
• Uses: Hypoalbuminaemia, large-volume paracentesis, spontaneous bacterial peritonitis
• Evidence shows no survival benefit over crystalloids in critical illness

2. Synthetic Colloids — Hydroxyethyl Starch (HES), Dextrans, Gelatin

• HES: Associated with acute kidney injury and coagulopathy — no longer recommended in sepsis/ICU
• Dextrans: Also used as anticoagulants; risk of anaphylaxis
• Cochrane review of 69 studies (30,020 patients): No overall advantage of colloid over crystalloid in resuscitation

IV. Fluid Resuscitation Strategies

1. 4-2-1 Rule (Maintenance Fluid Calculation — Holliday-Segar Method)

• First 10 kg body weight: 4 mL/kg/hour
• Next 10 kg: 2 mL/kg/hour
• Every kg beyond 20 kg: 1 mL/kg/hour

2. Fluid Resuscitation in Shock

• Start with 500 mL to 1 L bolus of isotonic crystalloid
• Reassess after each bolus — heart rate, blood pressure, urine output, capillary refill
• Urine output target: 0.5 mL/kg/hour in adults

3. Fluid Strategies in Surgery

• Liberal strategy: More fluid → higher risk of pulmonary oedema, pneumonia, prolonged hospital stay
• Restrictive strategy: Less fluid → risk of acute kidney injury (AKI)
• Goal-directed therapy (GDT): Best outcomes — titrate fluid to dynamic haemodynamic markers (stroke volume variation, pulse pressure variation)

V. Assessment of Fluid Status

Signs of Hypovolaemia

• Tachycardia, hypotension, oliguria (<0.5 mL/kg/hr)
• Dry mucous membranes, poor skin turgor
• Positive tilt test: ↑HR ≥20 bpm + ↓systolic BP ≥20 mmHg on standing
• BUN:Creatinine ratio >20 (suggests dehydration)
• Urine Na⁺ <20 mEq/L, urine osmolality >400 mOsm/kg

Signs of Fluid Overload

• Raised JVP, pulmonary oedema, peripheral oedema
• Hypertension, S3 gallop
• SpO₂ decrease, bilateral basal crepitations

VI. Complications of IV Fluid Therapy

VII. Monitoring During IV Fluid Therapy

• Vital signs: BP, HR, RR, temperature
• Urine output (hourly in critical patients)
• Serum electrolytes (Na⁺, K⁺, Cl⁻, HCO₃⁻)
• Serum osmolality, BUN, creatinine
• Central venous pressure (CVP) — target 8–12 mmHg
• In ICU: Stroke volume variation (SVV) and pulse pressure variation (PPV) — best dynamic markers

Summary Table