O.

LECTURE #1
01-OCT-2020
SURGERY
TYPES OF SURGERY
VITAL Immediate Surgeries in life threatening conditions
ABSOLUTE Surgery is required for treatment but can be
Scheduled
RELATIVE Treatment can be done with or without Surgery
SOCIAL / COSMETIC Done upon Patient’s request
PROPHYLACTIC To Prevent an expected disease to come in future
DIAGNOSTIC To diagnose a Medical Condition

VITAL SURGERY: Immediate / Urgent surgery

• Life Threatening conditions / Major Bleeding / Appendicitis

ABSOLUTE SURGERY: Surgery that is compulsory for a disease

treatment but can be Scheduled according to the availability of
Patient / Surgeon team
• Tumors / Symptomatic Hernias
RELATIVE SURGERY: Surgery which is done for a disease that
can also be treated by Medication / Non-Surgical Procedures
• Asymptomatic Hernia / Gall stones / GERD
SOCIAL / COSMETIC SURGERY: Done on patient’s request
(No harm would occur even without surgery but, patient asks for it)
• Breast Augmentation / Bariatric Surgery
PROPHYLACTIC SURGERY: Surgery which aims to prevent an
expected disease
• Negative Appendectomy (Appendix is normal but is prone to get
infection)
• FAP (Familial Adenomatous Polyposis)

DIAGNOSTIC SURGERY: Surgery done to diagnose a medical

condition
• Biopsies
• Diagnostic Laparoscopy

Incision upon body, inserting something into body or taken out is

called surgery (Pure definition doesn’t exists)

PRE-REQUESTIES OF SURGERY
Things to consider before surgery
PROPER PATIENT: Is patient eligible for the Surgery (Adequate
Indication of Surgery)
• Informed consent taken from patient
PROPER TIMING: Patient must be in best possible condition for
Surgery
• Also wait for the Staff to be best in condition

PROPER CIRCUMSTANCES: Staff must have required

equipment for the Surgery otherwise refer the Patient to appropriate
Healthcare
However, in Urgent surgeries some factors written above are
neglected

ROLE OF SURGEON
• He must have vast Knowledge about the Surgery he’s about to do
(Experience / Risk / Benefits)
• Audition of the results (Learn from Mistakes
• He must have Knowledge about the Patient (History / Examination /
Disease Course)
• He must be able to think Out of the Box (Is there any other better
Non-Surgical Procedure)

INDICATION – CONTRA-INDICATION
To make decision is as important as Surgery itself
• Carefully review all the Available Data as, wrong Decision can lead to
Death / Life-Threatening Complications
• Decision Requires Adequate knowledge of Disease / Patient / Nature
of Intervention / Surgeon’s Expertise & Limits
Sometimes it is Easier to Operate than not to Operate
• Decision is not FINAL, It applies only to the given condition of the
Patient at the given Time in the given Institute

ESTABLISHING THE INDICATION

• Diagnosis (Does patient really requires surgery?)
• Consider Symptoms (if Inaccurate Diagnosis)
• Timing of the surgery (Immediate / Urgent / Scheduled)
• Operative Load
• Operative Tolerance
• Operability (Technical / Medical / Oncological)
• Alternative Treatment Modalities
• Prognosis
• Personal / Financial Circumstances
• Patient consent
Always consider cost / Benefit Ratio

CONTRA-INDICATION OF SURGERY
There is no Contra-Indication in case of Vital Surgery
• Contra-Indication applies to the given patient at the given time

ABSOLUTE CONTRA-INDICATION
These are Temporary / Can be Modified by time
• Moribund State / Coma
• Severe Cardiac Failure
• Hemorrhagic Shock without Surgical cause (Gastro-Intestinal
Bleeding)
• Severe Metabolic / Hemostatic Imbalance
• Without Informed Consent (Except in Life-Threatening Condition)

RELATIVE CONTRAINDICATIONS
These are Permanent / Cannot be changed by time
• Age
• Pregnancy (depends on Trimester)
• Co-Morbid Conditions
• End-Stage Incurable Disease
• Better Alternative Treatment is available
• Technical reasons (Instruments / Staff / Circumstances)

Before every Surgery, Lab tests / chest X-ray / Special Investigations

(If required) / Anesthesiologic Examination to Prevent Surgical Risks

C.LECTURE #1
05-OCT-2020
PREPARATION FOR SURGERY
MODIFIABLE FACTORS: Diabetes
• Heart Failure (Pace-Maker)
• Blood pressure
• Hematologic Diseases
• Nutritional State (Obesity / Cachexy)
• Infectious Sources (Teeth / Ulcers)
• Certain Medication (Warfarin / Platelet Adhesion Inhibitors / Anti-
Depressants)

NON-MODIFIABLE FACTORS: Age / Sex / Chronic Disease

PREPARATION FOR SURGERY

Right before Surgery
• No Oral Feeding from the night before Surgery
• Bowel preparation
• Blood volume resuscitation
• Metabolic balance (Diabetes / Renal Functions)
• Antibiotics
• Thrombosis prophylaxis (Should be started before Surgery)
• Thorough cleaning of Skin (Surgical Skin Preparation)
• Emotionally / Psychological Patient Preparation

PATIENT RIGHTS
• Medical Treatment
• Getting all Information related to him
• Self-Determination
• Rejection of Medical Treatment
• Medical Privacy
• Recognize all data created during their treatment
• Having contact Persons
 MALPRACTICE
Mostly due to:
• Inadequate Communication
• Manners
• Unwanted Results / Outcome
• Actual Profession Mistakes

INFORMED CONSENT
The most important goal of informed consent is that the patient
have an opportunity to be an informed participant in his health care
decisions
Proper Informed Consent consists the following facts:
• Nature of the Decision / Procedure
• Reasonable Alternatives to Proposed Intervention
• Relevant Risks / Benefits / Uncertainties related to each Alternative
• Assessment of Patient Understanding the Acceptance of the
Intervention by the Patient
 COMPLICATIONS OF
SURGERY
Divided into Due to Anesthesia / Due to Surgery

DUE TO ANESTHESIA
Depends upon mode of Anesthesia (General / Regional / Local) &
Toxicity of Anesthetic Agent used

LOCAL ANESTHESIA
• Pain
• Hematoma
• Nerve Trauma
• Infection
• Ischemic Necrosis (Due to Vaso-Constriction)
• Allergic Reactions / Toxicity (Systemic Complications)

REGIONAL ANESTHESIA
Also called Spinal / Epidural / Caudal
• Administered into L4-L5 segment
COMPLICATIONS:
• Technical Failure (Administering Anesthesia other than the L4-L5
segment which would cause C.S.F leakage Resulting in Constant
headache after Surgery)
• Intra-Thecal Bleeding
 • Nerve / Spinal Cord Damage
• Para-Spinal Infection
• Systemic Complications (Severe Hypotension)

GENERAL ANESTHESIA
Administered Orally
• Mouth / Pharynx Trauma
• Slow Recovery from Anesthesia due to Drug Interactions /
Inappropriate choice of Drug dosage

• Hypothermia due to long operations with Extensive Fluid

replacement / Cold Blood transfusion

ALLERGIC REACTIONS
MINOR EFFECTS: Postoperative Nausea / Vomiting
MAJOR EFFECTS: Cardio-Vascular collapse / Respiratory
Depression)

HAEMODYNAMIC PROBLEMS
• Vasodilation / Shock

DUE TO SURGERY
PRE-OPERATIVE: Hemorrhage / Organ Damage / Electro-Cautery
(Electrolyte Imbalance)
POSTOPERATIVE: Immediate / Late
 IMMEDIATE POST-OPERATIVE
COMPLICATIONS
RESPIRATORY
• Collapse
• Consolidation
• Aspiration

CARDIO-VASCULAR
• Hemorrhage (Primary / Reactionary / Secondary)
• Shock (Hypovolemic / Septic / Cardiogenic / Neurogenic)
• Myocardial Infarction
• Deep Venous Thrombosis

THROMBO-EMBOLIC

SEPTIC
• Wound
• Abscess collections

GASTROINTESTINAL
• Intestinal Obstruction
• Anastomotic Leakage
• Intra-Abdominal Abscess formation
• Entero-Cutaneous Fistulae

WOUND COMPLICATIONS
• Infections
• Dehiscence
 RENAL
• Oliguria (Decreased Urination)
• Acute Renal Failure

HEPATIC
• Jaundice
• Hepato-Cellular Dysfunction
• Insufficiency

CEREBRAL
• Psychological
• Neuro-Psychiatric Complications (Delirium / etc.)

DRUG-RELATED
• Anesthetic
• Antibiotics
• Specific Medical Disease Treatment Toxicity

NERVE INJURIES:
• Compression
• Traction
• Nerve Cautery (Nerve Cut)
• Severed

LATE POST-OPERATIVE COMPLICATIONS

WOUND
• Hypertrophic Scar
• Keloid (Scar on healed Tissue)
• Wound sinus (Blind ended track that extends from surface into
Abscess
• Implantation Dermoids ???
• Incisional Hernia

ADHESIONS
• Intestinal Obstruction
• Strangulation (Abnormal blood flow due to Constriction)

ALTERED ANATOMY / PATHOPHYSIOLOGY

• Bacterial Overgrowth
• Short Gut Syndrome (Malabsorption disorder caused by a lack of
functional Small Intestine resulting in Diarrhea / Dehydration /
Malnutrition)
POST-GASTRIC SURGERY SYNDROMES: Food moves from
Stomach to Small Intestine too quickly
• Also called Dumping Syndrome
• Patient experiences Abdominal Cramps / Diarrhea 10-30 mins after
Meal
• Usually results after GIT Surgeries

SUSCEPTIBILITY TO OTHER DISEASES

• Malabsorption
• Incidence of Cancer
• Tuberculosis
O.LECTURE #2
08-OCT-2020
CAUSES OF FRACTURE
Divided into Extrinsic / Intrinsic

EXTRINSIC CAUSE
Can be caused by Direct / Indirect force
Following are the Extrinsic Forces which cause the Fracture:

TORSIONAL FORCE
Twisting Force is applied to the Long axis of Bone

COMPRESSION FORCE
Compressive Force along the Long axis of Bone

SHEARING FORCE
Shearing Force transmitted along the axis of Bone

INTRINSIC CAUSE
• Facture caused due to Violent Contraction of a Muscle
• Pathological Fractures

TYPES OF FRACTURES
Depends upon Magnitude / Direction of Force causing it

TRANSVERSE
Facture occurs right at the Point on which Force was Exerted
• Usually represent 3-Point Force System

SPIRAL / OBLIQUE
Caused due to Twisting Force applied distant from site of Fracture
• Usually at each end of a Long bone (such as Tibia)

GREENSTICK
The bone bends without Fracturing across completely, Cortex on
Concave side (After Fracture) usually remains Intact
• Occurs only in Children, whose bones are Soft / Yielding

CRUSH
Occurs in Cancellous bone (i.e Trabeculae of long bones) as a result
of Compression force

BURST
Usually Occur in short bones (i.e Vertebrae) due to Strong direct
Blow upon it
 AVULSION
Caused due to Traction Force, A Bony Fragment usually being torn
off by a Tendon / Ligament

DISLOCATION / SUBLUXATION
Involves Joint / Results in Malalignment of Joint Surfaces

FRACTURE EMERGENCY
TREATMENT OF SHOCK
Airway / Control of Cervical Spine
Breathing / Oxygenation
Circulation / Control of bleeding
Disability
Exposure / Avoidance of Hypothermia
Fractures
Get the Patient to the Hospital

APPLY SPLINT
• Reliefs Pain
• Reduces Bleeding
• Easy Transfer
 CRITERIA OF
FUNCTIONAL REDUCTION
• Alignment of the axis of Bone
• Length Correction
• Rotation of the axis of the bone should be corrected to be as close as
possible to that of the normal side

IMMOBILIZATION OF FRACTURE TO
HEAL
• External Fixation
• Internal Fixation
• O.R.I.F (Open Reduction & Internal Fixation)
• C.R.I.F(Closed Reduction & Internal Fixation)
• IM Nailing
• Plating
• K-Wires

CLASSIFICATION OF
FRACTURES
SALTER / HARRIS CLASSIFICATION
Classifies Epiphysial Fractures in Children which may Interfere with
Bone Growth
• The Fracture line normally runs through the Calcifying layer of the
Epiphysis on the side away from Germinal Layer

PHYSIS: Part of Metaphysis present between Epiphysis / Metaphysis

which is responsible for Bone Growth

TYPE-I
Fracture line passes all the way through Growth Plate (Physis)
• This type tends to occur in young Children / Babies / Pathological
Conditions

TYPE-II
Fracture line runs across the Physis and then Obliquely / Shearing
off a small Triangle of Metaphysis

TYPE-III
Fracture of Physis that Extends into the Epiphyses and Joint

TYPE-IV
Fracture extends through the Metaphysis / Physis / Epiphysis
• This type may interfere with growth because union may take place
across the Growth Plate

TYPE-V
Severe crushing of the Physis
• May occur from Longitudinal Compression
• Very likely to result in growth Arrest / Deformity
GUSTILO-ANDERSON CLASSIFICATION
OF OPEN FRACTURES
TYPE-I
Skin lesion is less than 1cm
• Clean
• Simple Bone Fracture with Minimal Comminution
TYPE-II
Skin lesion Greater than 1cm
• No Extensive Soft Tissue Damage
• Minimal Crushing
• Moderate Comminution / Contamination

TYPE-III
Extensive Skin damage with Muscle / Neuro-Vascular Involvement
• High Speed Crush Injury
• Segmental / Highly Comminuted Fracture
• Wound from High Velocity Weapon
• Extensive Contamination of Wound Bed

TSCHERNE CLASSIFICATION OF
CLOSED FRACTURES
GRADE-0
• Minimal Soft Tissue Damage
• Indirect Injury to Limb (Torsion)
• Simple Fracture Pattern

GRADE-1
• Superficial Abrasion / Contusion
• Mild Fracture Pattern

GRADE-2
• Deep Abrasion
• Skin / Muscle Contusion
• Severe Fracture Pattern
• Direct Trauma to Limb

GRADE-3
• Extensive Skin Contusion / Crush Injury
• Severe Damage to underlying Muscle
• Compartment Syndrome

PRINCIPLES
OF FRACTURE TREATMEN
• Reduction
• Immobilization
• Rehabilitation

REDUCTION
• Manipulation
• Traction
• Anatomical / Functional Preservation

C.LECTURE #2
12-OCT-2020
FRACTURE
A fracture indicates disruption of the continuity or integrity of bone

CLINICAL FEATURES
• Pain
• Deformity
• Loss of function
• Swelling
• Skin bruise

WHAT TO DO IN TRAUMA / EMERGENCY

• Remove any foreign body obstructing the air way e.g. dentures
• Preventing the falling back of the tongue by elevation of jaw
• Prevention of abnormal movement of the Cervical spine (Use
Cervical / Philadelphia Collar)
• Applying the tourniquet proximal to the bleeding site
• Do not forget to remove Tourniquet once bleeding is controlled
• Maintain I/V line
• Analgesics

TYPES OF SPLITS
ANATOMIC SPLINT
where the victim's own body is used as the splint
• Ex. Splinting a broken leg with Un-Injured leg

SOFT SPLINT
Blankets / Pillows / Towels / Virtually any Soft material can be used
as Soft splint

RIGID SPLINT
Made from Board / Cardboard / Anything which is rigid

• Secure all splints with Rags / Other material that can be tied around
the Injured part / Splint

WHY SPLINTS
• Reduce Pain
• Limit further damage
• Limit Internal / External bleeding
• Help relieve Pressure against Blood Vessels
• Prevent Closed Fractures from becoming Open Fractures
• Easy transport of Patient

TYPES OF FRACTURE
Closed / Open Fractures

TREATMENT OF OPEN FRACTURES

• Analgesics
• Tetanus (Prophylaxis)
• Injectable Antibiotics
• Wound Debridement
• External Fixation

TREATMENT OF CLOSED FRACTURES

• Fracture Reduction
• Immobilization

REDUCTION
To bring back the displaced Fractured Bone fragments to their
Anatomical position
Following are the two types of Reduction:
• Closed Reduction (Done by Traction / Counter-Traction)
• Open Reduction (surgery)

IMMOBILIZATION
• Plaster of Paris
• Slings
• Skin Traction
• Skeletal Traction
• Surgical Implants (Plates / Nails)

NON-SURGICAL OPTIONS
• Casts
• Sling
• Back Slab

TREATMENT OF
FRACTURES
• Closed Reduction / Immobilization (POP)
• Open Reduction / Immobilization (Internal Fixation)
• Closed Reduction / Internal Fixation
• Closed Reduction / External Fixation

CLOSED REDUCTION / IMMOBILIZATION

ADVANTAGES
• Fracture site not Opened
• Hematoma is not drained (Leads to Early Healing)
• Chances of Infection Reduced

DISADVANTAGES
Immobilization gives the following disadvantages
• Osteopenia
• Atrophy of Muscles
• Plaster Disease
• Stiffness of Joints

OPEN REDUCTION / IMMOBILIZATION

ADVANTAGES
• Early Mobilization
• Perfect Reduction under Vision

DISADVANTAGES
• Infection
• Drainage of Hematoma (Leads to Delayed Healing of Fracture)
 CLOSED REDUCTION / INTERNAL FIXATION
ADVANTAGES
• Hematoma is not drained (Leads to Early Healing Fracture)
• Early Mobilization
• Reduced Infection chances

DISADVANTAGES
• Image Intensifier is Required
• Specific Training of Staff / Operating Surgeons required
• Costly Equipment
However, Currently used & recommended method is C.R.I.F

CLOSED REDUCTION / EXTERNAL FIXATION

ADVANTAGES
• Can be applied Quickly in Poly-Trauma Patient
• Allow easy monitoring of Soft Tissues / Compartments