Explain in simple language

Here's a simple breakdown of everything on this surgery notes page:

Suturing Techniques (Ways to Stitch a Wound)

These are the different patterns a surgeon uses to close a cut or wound:

Stitch Type	What it means
Continuous Sutures	One long thread running in a line - like a running stitch in sewing. Fast to do.
Simple Interrupted	Separate individual stitches, each tied on its own. If one breaks, the rest hold.
Subcuticular Sutures	Hidden stitches just under the skin surface - leaves minimal scarring.
Horizontal Mattress	Stitches that go sideways in a "U" shape - good for holding tension.
Vertical Mattress	Stitches in a vertical "U" - specifically used to turn skin edges outward (eversion), which heals better.

Purse String Suture

A circular stitch that tightens like a drawstring bag. Used for:

Cervical incompetence (keeping the cervix closed during pregnancy)
Herniotomy (hernia repair)
Rectal prolapse (when the rectum slips out)

Rectal Prolapse Treatments

Perineal approach (from below): Thiersche cerclage, Altemeier's procedure, Delorme procedure
Abdominal approach (from the belly): Ripstein rectopexy, Wells procedure

Types of Surgical Knots

Surgeon's Knot - most secure, standard knot
Square/Reef Knot - flat, simple, common
Granny's Knot (Slip) - can slip, less preferred
Half-hitch - a simple loop knot
Crossed Half-hitch - variation, used in combination

Jenkin's Rules (Important Exam Facts)

Suture length should be 4x the length of the wound
Needle entry angle for IM injection: 90°
Veress needle (for laparoscopy) / SC injection: 45°
ID (intradermal) injection: 10-15°

Instruments Needed for Suturing

Scalpel Blades (attached to a BP Handle):

Blade	Used for
Blade 10	Skin & muscle
Blade 11	Incision & drainage (InD), vascular
Blade 15	Suture removal
Blade 10 (Minor OT)	Precise cuts
Blade 22	Abdominal incisions

Other Instruments:

BP Handle - holds the scalpel blade
Needle Holding Forceps - clamps the suture needle so you can stitch safely
Adson's Tissue Holding Forceps - fine-tipped tweezers to hold delicate tissue
Mayo Scissors - heavy scissors for cutting tough tissue
Metzenbaum Scissors - delicate scissors for fine, deep tissue dissection

In short: This page covers how wounds are closed (stitch patterns), the knots used to tie them, a memory rule for suture length and injection angles, and the key tools every surgeon needs on the table.

Search for clinical images showing proper suturing technique in practice

Reading File

Searching the Web

clinical images suturing technique proper wound closure steps

Finding Sources

Loading Image

Reading File

Loading Image

Here is a visual guide to proper suturing technique, drawing from clinical textbooks and medical illustrations:

Clinical Images: Proper Suturing Technique

1. Simple Interrupted Suture - Step by Step

Step-by-step interrupted suture technique

What you're seeing (Steps 1-10):

Steps 1-2: Load the needle onto the needle holder at a 90° angle
Steps 3-4: Pierce the skin on one side of the wound
Steps 5-6: Pass the needle through and exit the other side at equal depth
Steps 7-8: Pull the thread through and begin tying the knot
Step 9: Tie off the knot snugly (approximate, don't strangulate)
Step 10: Final result - evenly spaced individual stitches

2. Cross-Section: Correct vs. Wrong Placement

Correct vs incorrect suture placement showing spacing, tension, and skin eversion

Key lessons from this image:

	What it looks like	Why it matters
A - Correct	Even spacing, edges just touching	Heals flat, no scarring
B - Unequal spacing	Gaps between stitches	Wound may open between stitches
C - Excessive tension	Skin puckered and bunched	Can cut through skin, causes necrosis
D - Correct eversion	Edges slightly turned outward	As wound heals, it flattens out perfectly
E - Skin inversion	Edges turned inward	Creates a depressed, ugly scar
F - Skin overlap	One edge rides over the other	Heals poorly, uneven surface

3. Needle Path Through Tissue - Simple Interrupted

6-panel diagram showing how to place simple interrupted sutures correctly through skin layers

What this diagram teaches:

Panel 1: Hold the needle pointing downward, pronate the wrist to drive it deeper into the wound
Panel 2: Direct the needle toward the opposite side at the same skin level
Panel 3: Advance the needle upward to exit at equal distance from the wound edge
Panel 4: The final stitch should have more tissue at depth than at the surface - this creates eversion
Panel 5: Start from the center of the wound and work outward for a straight line
Panel 6 (A, B, C): Too few stitches gaps the wound, too many is unnecessary - use the correct number

4. The "Heart-Shaped" Buried Subcutaneous Suture (From Fitzpatrick's Dermatology)

Heart-shaped subcutaneous buried suture technique cross-section

This is the deep layer stitch placed under the skin before closing the surface.

Why it's "heart-shaped":

The needle enters deep on one side, loops up to the shallow dermis, crosses the wound, and exits deep on the other side
When the knot is tied, the skin edges are pushed upward and outward (everted)
The knot ends up buried below the skin surface so it doesn't poke through

From Fitzpatrick's Dermatology: "An ideal wound closure consists of meticulous wound edge approximation and eversion. As wound contraction normally occurs during healing, wound edge eversion at the time of closure promotes the development of a flat, smooth, cosmetically-appropriate scar."

Key Principles to Remember

Needle enters at 90° to the skin surface
Equal bites on both sides of the wound - same distance, same depth
Approximate, don't strangulate - the edges should just touch, not be crushed
Evert the edges (turn slightly outward) - they will flatten as healing occurs
Suture length = 4x the wound length (Jenkin's Rule)
Start at the center of the wound, then bisect outward for even spacingThe image is upside down but I can read all the instruments. Here's a complete explanation of the "World of Forceps" page:

🔧 World of Forceps - Simple Explanations

The image shows two categories written at the top (when flipped right-side up):

To hold tubular structures (intestine, vessels)
In-hydraulic (atraumatic - gentle, no crushing)

ROW 1 - Top Row Forceps

Instrument	What it looks like	What it's used for
Babcock Forceps	Triangular/fan-shaped tip	Holds delicate tubular structures like intestine, fallopian tube, ureter - without crushing them
Rampley's Sponge Holding Forceps	Long, with ring tip	Holds sponges/gauze to clean the surgical field or prep the skin with antiseptic
Intestinal Clamps (Atraumatic)	Has ridged/serrated tip	Clamps the bowel/intestine temporarily without damaging it - atraumatic means no injury
Ovum Forceps	Two oval rings at tip	Used in gynaecology to remove products of conception (ovum/placental tissue)
Desjardins Forceps	Long, curved, narrow	Used for bile duct surgery - picks out gallstones from the common bile duct
Mayo's Towel Clip	Round rings, sharp tips	Clips surgical drapes/towels to the patient's skin to keep the sterile field in place

ROW 2 - Bottom Row Forceps

Instrument	What it looks like	Special feature	Used for
Kelly's Hemostatic Artery Forceps	Angled, serrated jaws	Shown in a set of 3 different angles	Clamping blood vessels to stop bleeding (hemostasis)
Mixter's Right Angled Forceps	Right-angle bend at tip	90° angle	Passing sutures or ties around blood vessels and deep structures
Kocher's Forceps	Toothed tip with interlocking teeth	Has a lock mechanism	Holding tough tissues like fascia; also used in ARM (ano-rectal) surgery
Allis' Forceps	Multiple small teeth at tip	Has a lock (noted as "lock" in image)	Gripping tissue edges firmly - used in LSCS (caesarean section)
Green Armytage Forceps	Broad, flat tip	Used specifically in LSCS	Controls bleeding from the uterine incision edges during caesarean

Memory Tips

Feature	Instrument
Fan/triangle tip = delicate bowel	Babcock
Ring tip + long handle = swab holder	Rampley's
Right angle = going around vessels	Mixter's
Teeth + lock = grip and hold	Allis / Kocher
Broad flat tip = uterus bleeding	Green Armytage
Two ovals = gynaec products	Ovum forceps
Long curved tip = gallstones	Desjardins
Towel pin = drape holder	Mayo's towel clip

Key Concept: Traumatic vs. Atraumatic

Atraumatic (Babcock, Intestinal clamps) = gentle grip, does NOT crush or cut tissue - used on bowel, vessels, delicate organs
Traumatic (Kocher's, Allis') = firm toothed grip, intended to hold tissue securely even if it causes minor damage - used on tougher structures like fascia or skin edges## World of Retractors - Simple Explanation

A retractor is a surgical instrument used to hold tissue, organs, or wound edges out of the way so the surgeon can see and work in the operating field. Think of it like holding open a door to look inside.

There are two types:

Hand-held - an assistant holds it during surgery
Self-retaining - has a locking mechanism, stays open on its own (no assistant needed)

The Retractors Explained

GROUP 1 - General Abdominal / Laparotomy Retractors

Instrument	Shape	Used for
Czerny	Small curved hook, like a bent finger	Retracts superficial/skin edges in small wounds
Deaver's	Large, wide, smooth curved blade (like a big spoon shape)	Retracts liver, bowel - used in deep abdominal surgery. Very commonly used in laparotomy
Morris'	Flat wide blade with a gentle curve	General abdominal wall retraction - holds the wound edges open during laparotomy

Note written on page: Czerny and Deaver's are used in laparotomy closure too - the curved blade sweeps under the abdominal wall to help place closure sutures.

GROUP 2 - LSCS (Caesarean Section) Retractors

Instrument	Shape	Used for
Doyen's Retractor	Wide, flat, curved blade with a long handle	Used in LSCS - retracts the bladder downward to expose the lower uterine segment before the incision
Balfour's Retractor	Large frame with a central blade + two side wings	Self-retaining abdominal retractor used in LSCS and laparotomy - holds the entire wound open by itself

GROUP 3 - Thyroid Surgery Retractors

Instrument	Shape	Used for
Langenbach's	Small flat blade with a right-angle tip	Hand-held retractor for thyroidectomy - retracts the strap muscles of the neck to expose the thyroid
Joll's Self-retaining Thyroid Retractor (x2)	Two curved frames that lock together in a ring/oval shape	Self-retaining - holds the neck wound open during thyroidectomy without an assistant. Comes as a pair (x2)

GROUP 4 - Mastoid / ENT Surgery Retractors

These are used in ear surgery (mastoidectomy - removal of mastoid bone behind the ear):

Instrument	Shape	Special Feature
Mollison Self-retaining Mastoid Retractor	Ratcheted frame with multiple prongs	Self-retaining; prongs grip the scalp/tissue behind the ear
Jansen Self-retaining Mastoid Retractor	Similar ratcheted frame, slightly different prong design	Self-retaining; standard retractor for mastoid surgery
Perkin's Self-retaining Mastoid Retractor	Smaller, angled design	Self-retaining; used for smaller/deeper mastoid exposures

Bottom of page - Karner Thyroid Dissector

A blunt dissecting instrument used during thyroidectomy to separate the thyroid gland from surrounding structures gently without cutting blood vessels.

Quick Memory Summary

Surgery	Retractor(s) to remember
Laparotomy	Czerny, Deaver's, Morris'
LSCS (C-section)	Doyen's (bladder down), Balfour's (whole wound)
Thyroidectomy	Langenbach's (hand-held), Joll's (self-retaining)
Mastoidectomy (ENT)	Mollison, Jansen, Perkin's

Hand-held vs. Self-retaining - at a glance

Hand-held	Self-retaining
Czerny, Deaver's, Morris', Langenbach's, Doyen's	Balfour's, Joll's, Mollison, Jansen, Perkin's
Needs an assistant to hold	Locks open by itself
More flexible positioning	Frees up hands in the surgical team

PART 1: Bags & Drains

A drain removes unwanted fluid (blood, pus, bile, urine) from inside the body after surgery or injury. A bag collects that fluid outside the body.

DRAINAGE BAGS

Device	What it does
Abdominal Drainage Bag	Collects fluid draining from the abdominal cavity after surgery (e.g., after appendix removal, bowel surgery)
Chest Drainage Bag	Connected to an underwater seal drain — removes air, blood, or fluid from the chest (pleural) cavity

CHEST DRAIN - How to Read It

The diagram shows an underwater seal drain with three important signs:

Sign	What it means
Oscillating column (water level moves up/down)	Normal - means the drain is working, lung is expanding
Persistent ↑ bubbles (constant bubbling)	Bronchopleural Fistula - abnormal air leak from the lung into the chest cavity

SUCTION DRAINS

Device	Shape/Feature	Used for
Romovac Suction Drain	Closed system with negative (-ve) pressure bulb	Post-op wound drainage - sucks fluid out actively (closed suction)
Jackson Pratt Suction Drain	Grenade-shaped bulb, also closed negative pressure	Same as Romovac - used after breast, abdominal, and neck surgeries

CATHETERS / TUBES

Device	Special Feature	Used for
Pigtail Catheter	Curls into a "pigtail" loop at the tip (so it stays in place)	Draining abscesses and fluid collections - inserted using Seldinger technique (wire-guided)
Malecot's Catheter	Has 4 "wings" at the tip that open up like a flower	Draining thick pus or used as SPC (Suprapubic Catheter) for urine when normal catheter can't pass
T-tube (Kehr's tube)	Shaped like a letter T	Placed in the common bile duct after bile duct surgery - allows bile to drain out while the duct heals

DJ STENT (Double J Stent) / Ureteric Stent

The X-ray shows a DJ stent inside the ureter (the tube from kidney to bladder):

Has a J-curl at both ends - one curl sits in the kidney, one in the bladder
Keeps the ureter open if it's blocked (by a stone, tumor, or after surgery)
Inserted via Cysto-Urethroscopy (a camera passed through the urethra into the bladder)

PART 2: Hemostatic Devices

A hemostatic device stops bleeding during surgery. Each works by a different method.

CAUTERY (Burning to stop bleeding)

Device	How it works	Key difference
Monopolar Cautery	Electric current flows from the instrument through the patient's body to a grounding pad	Needs a grounding pad on the patient's thigh/back. Use distilled water/glycine to irrigate (NOT RL/NS - they conduct electricity and disperse the current)
Bipolar Cautery	Current flows only between the two tips of the forceps - doesn't travel through the body	No grounding pad needed. Safe near nerves/brain. Irrigate with RL or NS

Simple rule: Monopolar = current travels far (needs grounding), Bipolar = current stays local (safer)

LIGASURE / HARMONIC SCALPEL / THUNDERBEAT

These are advanced sealing devices that cut AND seal blood vessels simultaneously:

Device	Mechanism	Simple explanation
LigaSure	Pressure + RF (radiofrequency) waves	Squeezes the vessel + uses heat to fuse the walls together permanently
Harmonic Scalpel	Ultrasonic oscillation (vibration)	Vibrates at 55,000 times/second - friction creates heat that cuts and seals
ThunderBeat	Oscillation + RF waves combined	Best of both - cuts faster AND seals more securely. Most advanced of the three

CUSA (Cavitatory Ultrasound Surgical Aspirator)

Uses ultrasonic vibrations to break up and suck out tissue
Targets soft tissue (like tumors) while sparing blood vessels and bile ducts (which are more elastic)
Used in liver surgery, brain surgery, and complex tumor removal

STAPLERS (Mechanical stitching devices)

Device	What it does	Used for
Linear Stapler	Fires a straight row of staples and cuts in between	Zenker's Diverticulum (pouch in the throat/oesophagus) - staples across the neck of the pouch
Circular Stapler	Fires a circular ring of staples to join two hollow organs end-to-end	Haemorrhoids (PPH - stapled haemorrhoidopexy) - pulls the haemorrhoids back up and staples them

Quick Summary Table

Category	Device	One-line purpose
Drain	Romovac / Jackson Pratt	Suck out post-op wound fluid
Drain	Pigtail catheter	Drain abscess via wire technique
Drain	Malecot's	Thick pus / suprapubic urine
Drain	T-tube	Bile duct decompression
Stent	DJ stent	Keep ureter open
Cautery	Monopolar	General surgery cutting/burning
Cautery	Bipolar	Delicate/near-nerve surgery
Seal+Cut	LigaSure	Pressure + RF sealing
Seal+Cut	Harmonic	Vibration sealing
Seal+Cut	ThunderBeat	Combined best of both
Aspirator	CUSA	Remove tumors, spare vessels
Stapler	Linear	Zenker's diverticulum
Stapler	Circular	Haemorrhoids (PPH)

PART 1: Surgical Safety Checklist (WHO Checklist)

This is the WHO Surgical Safety Checklist — a mandatory step-by-step verbal check done before every surgery to prevent wrong-site surgery, infections, and deaths. It has 3 phases:

PHASE 1 — SIGN IN

(Before the patient goes to sleep / before anesthesia)

Check	What happens
Patient has confirmed	Patient verbally confirms their Identity, Procedure, and Site (which side/organ)
Written Consent	Consent form has been signed
Site Marked	The correct surgical site is marked on the body (e.g., "LEFT knee")
Anesthesia safety check completed	Anesthesia machine and drugs are checked
Pulse oximeter on patient & functioning	The oxygen monitor is attached and working
Does patient have known allergy?	Yes/No - allergy history confirmed
Difficult Airway?	Is intubation likely to be hard? Equipment ready?
Risk of >500 mL blood loss?	If yes - IV access, blood products ready

PHASE 2 — TIME OUT

(Just before skin incision - the most important pause)

Everyone in the OT stops and confirms together:

Check	What happens
All team members introduced	Everyone says their name and role
Surgeon + Anesthesia + Nurse confirm:	Patient name, Site, Procedure
Antibiotic prophylaxis given?	Cefazolin must be given 30-60 minutes before incision
Anticipated Critical Events	Surgeon mentions any expected difficult steps
Essential imaging displayed	X-rays, scans are visible on the screen

PHASE 3 — SIGN OUT

(Before patient leaves the operating room)

Check	What happens
Nurse verbally confirms with team	Name of procedure actually performed is recorded
Instrument, sponge and needle counts correct	Nothing is left inside the patient
Specimen labelled	Any tissue removed is correctly labelled with patient name
Any equipment issues?	Problems with instruments are noted
Surgeon + Anesthesia + Nurse review	Key concerns for recovery and post-op management discussed

Why this matters: The WHO checklist has been shown to reduce surgical deaths by up to 40% worldwide.

PART 2: OT Zones (Operating Theatre Zones)

The OT is divided into 4 zones based on how clean/sterile they need to be. As you go from Zone 1 → Zone 3, the area becomes progressively more sterile.

Zone	Name	What's in it	Who can enter
Zone 1	Protective area	Reception, waiting area, trolley bay, change rooms	Everyone (patients, visitors, staff in normal clothes)
Zone 2	Clean area	Pre-op room, recovery room, staff lounge, plaster room, stores	Staff in scrubs
Zone 3	Sterile area	Operating Room, Anesthesia room	Staff in full scrub suit, cap, mask
Zone 4	Disposal area	Dirty utility room, disposal corridor	Waste and used instruments exit here

Think of it like layers of an onion - the operating table is at the cleanest center (Zone 3), and the outside world is the outermost layer (Zone 1).

PART 3: Hand Hygiene

Hand Hygiene is the single most effective method to prevent SSI (Surgical Site Infection)

Two Methods:

Method	When to use
Alcohol Rub	When hands look clean - quick and effective
Soap & Water	When hands are visibly soiled (dirty, blood, body fluids)

The 11 Steps of Hand Hygiene (WHO Technique):

Step	Action
0	Wet hands with water
1	Apply enough soap to cover all surfaces
2	Rub palm to palm
3	Right palm over left back, fingers interlaced - then vice versa
4	Palm to palm, fingers interlaced
5	Backs of fingers to opposing palms, fingers interlocked
6	Rotational rubbing of left thumb clasped in right palm - then vice versa
7	Rotational rubbing backwards and forwards with clasped fingers of right hand in left palm - then vice versa
8	Rinse hands with water
9	Dry hands thoroughly with a single-use towel
10	Use towel to turn off faucet
11	Your hands are now safe

Duration: At least 20-30 seconds for alcohol rub, 40-60 seconds for soap and water.

Quick Exam Summary

Topic	Key Point
Antibiotic prophylaxis	Cefazolin, given 30-60 min before incision
Most sterile OT zone	Zone 3 (Operating Room)
Disposal zone	Zone 4
Best method to prevent SSI	Hand Hygiene
Visibly soiled hands	Use Soap & Water (not alcohol)
Sign In timing	Before anesthesia
Time Out timing	Just before skin incision
Sign Out timing	Before patient leaves OT

What is Laparoscopy?

Instead of making a large cut to open the abdomen, the surgeon makes 2-4 tiny holes (ports), inserts a camera (telescope) and long instruments, and operates while watching a screen. Less pain, faster recovery, smaller scars.

STEP 1: Getting INTO the Abdomen (Access Techniques)

Before surgery can start, the surgeon needs to safely enter the abdomen. There are two ways:

METHOD A — Veress Needle (Closed Technique)

A Veress needle is a special spring-loaded needle inserted blindly into the abdomen to pump in CO₂ gas first (creating space), then the camera port is inserted.

Where to insert it:

Site	When to use
Umbilicus	Standard first choice
Palmer's Point	Left upper abdomen (below left ribcage) - used when there are previous scars around the umbilicus
Jain's Point	Alternative entry point
Palmer's / Jain's Point	If patient has prior surgery / adhesions around the umbilicus - too risky to enter there

Rule: If previous surgery → avoid umbilicus → use Palmer's Point

Confirming You're in the Right Place (Intraperitoneal Position):

Before pumping gas in, you must confirm the needle tip is inside the abdominal cavity (not in bowel or a vessel):

Test	How it works
Push Saline (Free Flow)	Inject saline - if it flows in freely with no resistance, you're in the right place
Aspirate (Air Bubble)	Pull back the syringe - if no blood or bowel content comes back, it's safe
Hanging Drop Method	A drop of saline is placed at the needle hub - negative pressure inside the abdomen sucks it in

METHOD B — Hasson Technique (Open Technique)

Instead of a blind needle, the surgeon cuts down directly to the abdominal wall under vision and inserts the port under direct sight. Safer in patients with previous surgery.

STEP 2: The Gas Used

Once inside, gas is pumped in to inflate the abdomen (create a working space):

Feature	Detail
Best gas	CO₂ (carbon dioxide) — safest, absorbed by the body
Why not others?	CO₂ > N₂O > Air > He (Helium) — order of preference
Ideal pressure	12-15 mmHg
Flow rate	1 L/min
Volume needed	2 litres to create adequate space
Side effect of CO₂	J-reflex — transient (temporary) increase in Heart Rate and possible Heart Block due to CO₂ absorption

STEP 3: Camera and Instrument Angles

The diagram shows the three angles that matter in laparoscopy:

Angle	What it means
Azimuth angle	The horizontal angle between the working instruments - ideally 60° between the two working ports and the telescope
Manipulation angle	The angle at which instruments can be moved - wider is better for freedom of movement
Elevation angle	The vertical angle of the telescope - affects the view

Ideal port placement: Telescope in the middle, two working ports on either side like a triangle - this gives the best azimuth angle and avoids the "chopstick effect" (instruments crossing each other)

STEP 4: SILS (Single Incision Laparoscopic Surgery)

Only ONE hole (usually at the umbilicus) instead of multiple ports. All instruments go through one incision.

Advantages:

Faster recovery
No visible scar (hidden in umbilicus)
Reduced risk of incisional hernia

STEP 5: Da Vinci Robotic Surgery

A robotic system controlled by the surgeon from a console. The robot arms hold and move the instruments with extreme precision.

Feature	Laparoscopic Surgery	Robotic Surgery (Da Vinci)
DOF (Degrees of Freedom)	4	7 (more movement = more precise)
Tremor	Surgeon's hand tremor transmitted	Tremor filtered out by robot
Precision	Good	Better
Tactile feedback	Present (can feel tissue resistance)	Lost (surgeon cannot "feel")

Key exam point: Robotic surgery has 7 DOF (vs 4 in standard laparoscopy) and no tactile feedback — the surgeon cannot feel how hard they are gripping

Quick Summary Table

Topic	Key Fact
Standard access point	Umbilicus
Previous surgery → use	Palmer's Point
Confirm needle position	Saline free flow + Aspirate + Hanging drop
Best gas	CO₂
Ideal pressure	12-15 mmHg
CO₂ side effect	Transient ↑ HR / Heart Block (J-reflex)
Single port technique	SILS
Robotic DOF	7 (vs 4 in laparoscopy)
Robotic disadvantage	Loss of tactile feedback

PART 1: ERAS Protocol

ERAS = Enhanced Recovery After Surgery

The idea is simple: instead of keeping patients fasting for long, resting in bed, and on IV drips for days — ERAS gets patients eating, moving, and recovering faster with less stress on the body. It is a set of evidence-based steps done before, during, and after surgery.

PRE-OP (Before Surgery)

What	Why
No prolonged fasting - Solids allowed up to 6 hours before, clear liquids up to 2 hours before	Old practice of "nothing after midnight" is unnecessary and causes dehydration and insulin resistance
Carbohydrate loading - a carb drink given the night before surgery	Reduces post-op insulin resistance, nausea, and anxiety. Body starts surgery in a "fed" state
No bowel prep	Traditional bowel prep (laxatives) caused dehydration and discomfort with no proven benefit

INTRA-OP (During Surgery)

What	Why
Minimal access (laparoscopy where possible)	Smaller cuts = less pain, faster healing
Maintenance fluids only	Avoid fluid overload - too much IV fluid causes bowel swelling and delays recovery
Normothermia (keep body temperature normal)	Cold patients have more bleeding, infections, and delayed healing - use warming blankets
PONV prophylaxis (2 classes of drugs)	PONV = Post-Operative Nausea & Vomiting. Give Ondansetron + Steroids together to prevent it
Long-acting LA (Bupivacaine) or epidural analgesia	Give local anaesthetic at the wound site or epidural to reduce pain without opioids

POST-OP (After Surgery)

What	Why
Early feeding within 24 hours	Gut starts working sooner, reduces infections, shorter hospital stay
Early ambulation (walking early)	Prevents DVT (blood clots in legs), pneumonia, and muscle wasting
Discontinue IV fluids	Get patient eating/drinking instead - IV fluids are not needed once patient can eat
Multimodal analgesia (opioid-sparing)	Use combinations of paracetamol, NSAIDs, local anaesthetic - reduce or avoid opioids (which cause constipation, nausea, drowsiness)
Early catheter removal	Urinary catheter out as soon as possible - reduces UTI risk and helps patient mobilise

ERAS in one sentence: Get the patient eating, moving, and off drips as fast as safely possible.

PART 2: Classification of Surgeries (Wound Classification)

This is the Altemeier / CDC wound classification — it classifies surgeries by how contaminated/infected the surgical field is, and predicts the risk of SSI (Surgical Site Infection).

The 4 Classes (Decision Flowchart Logic):

Ask Question 1: Is there gross pus, existing infection, perforated viscera >4hrs, traumatic wound >4hrs, or penetrating injury >4hrs?

YES →

🔴 CLASS IV — Dirty / Infected

Feature	Detail
Definition	Active infection or old contamination already present before surgery
Examples	Drainage of abscess, repair of perforated bowel (>4hrs old), Gangrene surgery
SSI risk without antibiotics	>20%
SSI risk with antibiotics	9%

NO → Ask Question 2: Is there acute non-purulent inflammation, unplanned entry into bowel/lung/gut, or major break in sterile technique?

YES →

🟠 CLASS III — Contaminated

Feature	Detail
Definition	Surgery where contamination occurred but not yet infected
Examples	Cholecystectomy with bile spillage, open cardiac massage, acute appendicitis (non-perforated)
SSI risk without antibiotics	10-20%
SSI risk with antibiotics	6%

NO → Ask Question 3: Was there controlled/intentional entry into respiratory tract, GIT, or GUT?

YES →

🟡 CLASS II — Clean-Contaminated

Feature	Detail
Definition	Planned entry into a hollow organ (bowel, lung, bladder) under controlled conditions, no spillage
Examples	Hysterectomy, Lobectomy (lung), Laryngectomy, Small bowel resection, TURP, LSCS
SSI risk without antibiotics	2-10%
SSI risk with antibiotics	3%

NO →

🟢 CLASS I — Clean

Feature	Detail
Definition	No hollow organ entered, no inflammation, perfect sterile technique
Examples	Mastectomy, Hernia repair, Thyroidectomy, TKR (knee replacement), THR (hip replacement), CABG (heart bypass)
SSI risk without antibiotics	<2%
SSI risk with antibiotics	<2% (antibiotics make little difference here)

SSI Risk Summary Table

Class	Type	SSI without AB	SSI with AB	Examples
I	Clean	<2%	<2%	Mastectomy, Hernia, Thyroidectomy, CABG
II	Clean-Contaminated	2-10%	3%	Hysterectomy, LSCS, Bowel resection
III	Contaminated	10-20%	6%	Bile spillage, Acute appendix
IV	Dirty/Infected	>20%	9%	Abscess, Perforated bowel, Gangrene

Key Exam Points

Fact	Answer
ERAS carb loading: when?	Night before surgery
Clear liquids allowed until?	2 hours before surgery
Solids allowed until?	6 hours before surgery
PONV drugs used	Ondansetron + Steroids
Cleanest wound class	Class I (<2% SSI)
Dirtiest wound class	Class IV (>20% SSI)
LSCS wound class	Class II (Clean-contaminated)
Cholecystectomy with bile spillage	Class III (Contaminated)
Perforated bowel repair	Class IV (Dirty)

PART 1: Post-Operative Fever

When a patient gets fever after surgery, the timing tells you the cause. This is remembered with the "5 W's" mnemonic (Wonder drugs, Wind, Water, Walking, Wound).

The 5 W's of Post-Op Fever

Day (POD)	Cause	Mnemonic	Prevention
Any time	Drug reaction / Malignant Hyperthermia	Wonder drugs	Stop the offending drug immediately
POD 1-3	Atelectasis (MCC on Day 1) = lung collapse	Wind	Incentive spirometry, Early mobilisation, Antibiotics
POD 3-4	UTI (MCC overall)	Water	Short-term Foley catheter use only
POD 4-5	DVT (Deep Vein Thrombosis)	Walking	Early mobilisation, Compression stockings, LMWH (most effective)
POD 7+	SSI (Surgical Site Infection)	Wound	Dressing changes, Pre-op antibiotics

Simple Way to Remember:

"Wonder drugs blow Wind into Water while Walking to the Wound" Anytime → POD1-3 → POD3-4 → POD4-5 → POD7+

DVT Prevention Devices (shown in images):

Device	What it does
Incentive Spirometer	Patient breathes into it to expand lungs and prevent atelectasis
Intermittent Pneumatic Compression (IPC) Stocking	Inflates and deflates around the legs rhythmically - pumps blood back up to prevent clots
Military Anti-Shock Garment (MASG)	Compresses the legs and abdomen - used in shock and also DVT prevention

PART 2: Surgical Site Infections (SSI)

Definition:

Infection occurring within 30 days of surgery
Within 1 year if an implant (mesh, prosthesis) was placed

Southampton Grading (How bad is the wound?)

Grade	What it looks like	Simple meaning
Grade I	Mild bruising or redness only	Normal healing - just a bit red
Grade II	Redness + other signs of inflammation (swelling, warmth)	Getting worse - early infection
Grade III	Clear or blood-stained (haemoserous) discharge	Fluid leaking - not yet pus
Grade IV	Pus coming out	Definite infection - needs antibiotics/drainage
Grade V	Deep infection, tissue breakdown, or hematoma needing drainage	Worst - may need surgical re-opening

ASEPSIS Criterion (Scoring System for SSI)

Each letter scores points - the higher the score, the worse the infection:

Letter	Stands for
A	Additional treatment needed (antibiotics / Incision & Drainage)
S	Serous discharge
E	Erythema (redness)
P	Purulent exudates (pus)
S	Separation of deep tissues
I	Isolation of bacteria from wound
S	Stay in hospital prolonged beyond 14 days

Memory: All Surgeons Expect Perfect Sterile Incisions to Succeed

Burst Abdomen (Wound Dehiscence)

This is when the abdominal wound completely breaks open after surgery - a surgical emergency.

Feature	Detail
Timing	Typically Day 6 post-op
Pathognomonic sign	Salmon-colored (sero-sanguinous) fluid leaking from the wound - this is the warning sign BEFORE the wound bursts open
Management	Cover the bowel with a Bagota Bag or Urobag (sterile bag to protect exposed bowel) and take back to OT immediately

Key exam point: Salmon-coloured discharge from wound on Day 6 = Burst abdomen until proven otherwise

Intra-abdominal Abscess (Pus pocket inside the abdomen)

Feature	Detail
Most common site	Supine position: Morrison's Pouch (between liver and right kidney)
Most common overall / ambulatory	Pelvis (because fluid drains down by gravity when standing)
Investigation of choice (IOC)	CECT (Contrast-Enhanced CT scan)
Treatment of choice (TOC)	Pigtail Catheter drainage (percutaneous - through the skin, guided by ultrasound/CT)

Quick Exam Bullet Points

Fact	Answer
MCC fever on Day 1	Atelectasis
MCC fever overall	UTI
Best DVT prevention drug	LMWH
Burst abdomen timing	Day 6
Burst abdomen fluid colour	Salmon / sero-sanguinous
Burst abdomen emergency cover	Bagota Bag / Urobag
SSI definition window	30 days (1 year if implant)
MC site of abscess (supine)	Morrison's Pouch
MC site of abscess (overall)	Pelvis
Investigation for abscess	CECT
Treatment for abscess	Pigtail Catheter
Grade IV Southampton	Pus
Grade V Southampton	Deep infection / tissue breakdown

PART 1: SEPSIS

What is SIRS?

SIRS = Systemic Inflammatory Response Syndrome — the body's exaggerated response to stress (infection OR non-infection like trauma, burns, pancreatitis).

Diagnosis: ≥ 2 of the following (mnemonic: White THR):

Parameter	Abnormal value
Temperature (Core)	<36°C or >38°C
Heart Rate	>90 bpm
Respiratory Rate	>20/min OR PaCO₂ <32 mmHg
WBC	>12,000 OR <4,000 OR >10% band forms

The Spectrum (OLD definitions):

Term	Meaning
SIRS	≥2 SIRS criteria (any cause)
Sepsis	SIRS + Infection
Severe Sepsis	Sepsis + Organ Dysfunction
Septic Shock	Severe Sepsis + ↓BP → needs IV fluids + Vasopressors

NEW Definitions (Sepsis-3):

Term	Meaning
Sepsis	Life-threatening organ dysfunction caused by infection → SOFA score ≥ 2
Septic Shock	Sepsis + needs IV fluids + vasopressors AND MAP ≥ 65 AND Lactate > 2 mmol/L

qSOFA (quick bedside screen): Altered mental status + RR ≥22 + SBP ≤100 → score 0-3. Score ≥2 = likely sepsis

Surviving Sepsis Guidelines — TARGETS:

Parameter	Target
CVP (Central Venous Pressure)	8-12 mmHg
MAP (Mean Arterial Pressure)	>65 mmHg
MvO₂ (Mixed venous oxygen saturation)	>70%
Urine Output	>0.5 mL/kg/hr in adults (>1 in children)

THE SEPSIS SIX — "Give 3, Take 3"

Give 3:

Give O₂ (keep SpO₂ >94%)
Give IV antibiotics
Give IV fluid challenge

Take 3: 4. Take blood cultures 5. Measure lactate 6. Measure urine output

Do all 6 within 1 hour of recognising sepsis

Trauma Scores (briefly mentioned):

Score	What it is
RTS	Revised Trauma Score - based on GCS, BP, RR
TRISS	RTS + ISS (Injury Severity Score) + MOI (mechanism of injury) + age = predicts survival probability

PART 2: SHOCK

Shock = inadequate tissue perfusion — cells not getting enough oxygen.

Types of Shock — Hemodynamic Profile:

Type	CO (Cardiac Output)	SVR (Resistance)	CVP (Filling pressure)	Simple explanation
Cardiogenic	↓↓	↑	↑	Heart pump failing - output drops, fluid backs up
Hypovolemic	↓	↑	↓	Not enough blood volume - heart has nothing to pump
Obstructive	↓	↑	↑	Something blocking blood flow (PE, tamponade)
Distributive	↑↑	↓	↓	Blood vessels dilated everywhere (sepsis, anaphylaxis)
Neurogenic	↓↓	↓	↓	Nerve signal loss → vessels dilate + heart slows

Key trick: Distributive (septic) shock is the only one with ↑CO and ↓SVR - the heart pumps fast but blood pools in dilated vessels

Warm vs Cold Extremities:

Finding	Type
Shock + Warm extremities + MvO₂ >70%	Septic shock (distributive) - blood flowing but not being used
Shock + Cold/clammy extremities	All other types (vasoconstriction to compensate)

Shock Indices (Quick bedside tools):

Index	Formula	Critical value
Shock Index	HR ÷ SBP	>0.9 = critical shock
Modified Shock Index	HR ÷ MAP	>0.9 = critical shock
ROPE	HR ÷ Pulse Pressure	>3 = critical shock

Normal Shock Index = 0.5-0.7. As HR rises and BP falls → index rises → more severe shock

Best Indicators in Shock:

What you want to know	Best indicator
Adequacy of resuscitation (is treatment working?)	Urine Output
How much fluid is needed?	CVP
Tissue perfusion (lab)	Base Deficit + Lactate
Systemic perfusion (overall)	Lactate + MvO₂

Monitoring a Shock Patient:

Minimum (every patient)	Additional (ICU/severe)
ECG	Central Venous Pressure (CVP)
Pulse oximetry	Invasive blood pressure (arterial line)
Non-invasive BP	Cardiac output monitoring
Urine output	Base deficit + serum lactate

Flow Phase — Body's Response to Trauma/Shock:

The body releases hormones to survive:

Acute response (immediate):

↑ Cortisol (stress hormone)
↑ Catecholamines (adrenaline - speeds heart, constricts vessels)
↑ Glucagon (raises blood sugar)
↑ Growth hormone, ↑ ACTH
↑ Inflammatory cytokines: IL-1, IL-6, IL-8, TNF-α

Chronic response (prolonged stress):

↓ Insulin (can't store energy)
↓ IGF-1, ↓ Testosterone, ↓ T3 (thyroid)
Body enters catabolic state (breaking down muscle for energy)

Quick Exam Summary

Fact	Answer
SIRS needs how many criteria?	≥ 2
New sepsis definition uses which score?	SOFA ≥ 2
Septic shock lactate target	>2 mmol/L
MAP target in sepsis	>65 mmHg
Urine output target in adults	>0.5 mL/kg/hr
Sepsis Six: "Give 3"	O₂, Antibiotics, IV fluids
Sepsis Six: "Take 3"	Cultures, Lactate, Urine output
Only shock with ↑CO	Distributive (Septic)
Only shock with ↓SVR + ↓CVP	Distributive + Neurogenic
Shock index >0.9 means	Critical shock
Best clinical indicator of resuscitation	Urine output
Best lab indicator of perfusion	Lactate

This is a shared conversation. Sign in to Orris to start your own chat.