Principles of General Surgery - Essay Example

Surgery (from the Greek “cheirourgia” meaning "hand work is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. General surgery deals with surgical treatment of abdominal organs, e.g. intestines inclusive esophagus, stomach, colon, liver, gallbladder and bile ducts, and furthermore of the thyroid gland (depending on the availability of head and neck surgery specialists) and hernia. The 20th century witnessed several new surgical technologies to supplement the techniques of manual incision. Lasers are now widely used to destroy tumours and other pigmented lesions, some of which are inaccessible by conventional surgery. They are also used to surgically weld detached retinas back in place and to coagulate blood vessels to stop them from bleeding. Stereotaxic surgery uses a three-dimensional system of coordinates obtained by X-ray photography to accurately focus high-intensity radiation, cold, heat, or chemicals on tumours located deep in the brain that could not otherwise be reached. Cryosurgery uses extreme cold to destroy warts and precancerous and cancerous skin lesions and to remove cataracts. In the late 20th century, some traditional techniques of open surgery were being replaced by the use of a thin, flexible fibre-optic tube equipped with a light and a video connection; the tube, or endoscope, is inserted into various bodily passages and provides views of the interior of hollow organs or vessels. Accessories added to the endoscope allow small surgical procedures to be executed inside the body without making a major incision (Johanson, 1994). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see stomach, kidney, liver, etc.) Diseases affecting the abdominal cavity are dealt with generally under their own names (e.g. appendicitis). The three most common abdominal surgeries are described below. Exploratory Laparotomy – a surgical maneuver involving an incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy. In a diagnostic laparotomy, the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and laparotomy is required for its therapy. Usually, only diagnostic laparotomy is referred to as a surgical operation by itself; and when a specific operation is already planned, laparotomy is considered merely the first step of the procedure. Depending on incision placement, it may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum and colon), the liver, pancreas and spleen, the bladder, the female reproductive organs (the uterus and ovaries) and the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes) The most common incision for laparotomy is the midline incision, a vertical incision which follows the linea alba. The upper midline incision usually extends from the xiphoid process to the umbilicus, while a typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly. Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery. Midline incisions are particularly favored in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity. Other common laparotomy incisions include: the Kocher (right subcostal) incision (after Emil Theodor Kocher); appropriate for operations on the liver, gallbladder and biliary tract; the Davis or Davis-Rockey "muscle-splitting" right lower quadrant incision for appendectomy; the Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis, most often employed for cesarean section; Lombotomy consists of a lumbar incision which permits access to the kidneys (which are retroperitoneal) without entering the peritoneal cavity. It is a common operative approach in renal surgery (Moreno et al., 1998). A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by an laparoscopic access. Appendectomy – the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated conservatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery. Appendicectomy may be performed laparoscopically or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy. In general terms, the procedure for an open appendicectomy is as follows: Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. The abdomen is prepared and draped and is examined under anaesthesia. If a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurneys point, one third of the way from the anterior superior iliac spine (ASIS) and the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable) (Belachew et al., 1998). All surgery carries some degree of risk. One of the most common complications following appendectomy is infection. Around 20 per cent of people who have a ruptured appendix develop an abscess (ball of pus) within the abdominal cavity some two weeks or so after the appendectomy. These abscesses must be surgically drained. Another common type of infection following appendectomy is infection of the wound. Laparoscopy – also called keyhole surgery (when natural body openings are not used), bandaid surgery, or minimally invasive surgery (MIS), is a surgical technique. Medically, laparoscopic surgery refers only to operations within the abdomen or pelvic cavity. Laparoscopic surgery belongs to the field of endoscopy. The most common illnesses diagnosed through laparoscopy are endometriosis, pelvic inflammatory disease, ectopic pregnancy, ovarian cysts and appendicitis. In many cases it is possible to perform operations through the laparoscope itself. Most sterilisations today are performed through a laparoscope. Cysts on the ovaries can be punctured and opened, while adhesions caused by ovarian diseases or other diseases of the pelvic organs can also be loosened. Most ectopic pregnancies can be treated laparoscopically as can many cases of endometriosis. Laparoscopic surgery is becoming increasingly popular with patients because the scars are smaller and their period of recovery is shorter. A laparoscope contains a fibre optic system to illuminate the operative site, a lens system to view the operative site that is usually connected to a video camera (videoscopic procedures using a laparoscope or endoscope) and a channel to allow access for intervention using long, thin instruments. Through small incisions a surgeon can introduce additional instruments through side ports. Rather than a 20 cm cut as in traditional cholecystectomy, two or five cuts of 5-15 mm will be sufficient to perform a laparoscopic removal of a gallbladder. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space (Fielding et al., 1999). This approach is intended to minimize operative blood loss and post-operative pain, and speeds up recovery times. However, in some cases the pain caused by the carbon dioxide leaving the body is severe and painkillers have little to no effect. The restricted vision, difficult handling of the instruments (hand-eye coordination), lack of tactile perception and the limited working area can increase the possibility of damage to surrounding organs and vessels, either accidentally or through the difficulty of procedures. Minor complications include bleeding or bruising around the skin cuts or bruising of the skin at the front of the abdomen. There is usually pain around the cuts in the skin and often a sense of general discomfort over the abdomen after the surgery. Many patients report pain at their shoulder tip, which is due to the indirect effect of small amounts of carbon dioxide remaining in the abdomen. Most patients are fully recovered within 48 to 72 hours (Johanson, 1994). Complications of abdominal surgery include bleeding, infection, shock, and ileus (short-term paralysis of the bowel). Sterile technique, aseptic post-operative care, antibiotics, and vigilant post-operative monitoring greatly reduce the risk of these complications. Planned surgery performed under sterile conditions is much less risky than that performed under emergency or unsterile conditions. The contents of the bowel are unsterile, and thus leakage of bowel contents, as from trauma, substantially increases the risk of infection. Works Cited: Belachew, M., Legrand, M., Le Docte, N., & Deschamps, V. (1998). Appendix and appendictomy. World Journal of Surgery, 22, 955-963. Fielding, G. A., Rhodes, M., & Nathanson, L. K. (1999). Laparoscopic gastric banding for morbid obesity. Surgical Endoscopy, 13, 550-554. Johanson, D. (1994) General surgery guide. New Haven: Yale University Press Moreno, Pau, et. al. (1998). The effect of laparotomy (coeliotomy) on patients. Archives of Surgery, 133(2), 189-193. Read More