*.

'El I
o Topic III

-Topographic anatomy and operative

surgery of the vertebral column, spinal
cord and its membranes
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D Part I

Topographic anatomy of the vertebral

column, spinal cord and its membranes
I I

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'El

Curvl-::.I [7]

Thoracic [121

Lumber

Sacrum (5, ful.d]'

Coco: (4, fund)

.

Fig l. The 'li-fertehrul column viewed from the side. The five different regions are shown
rIIand labelled.
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VERTEB RAL COLUMN

I

1 'The verllfbral column is El vertical series of ugpreximalely

mall bones (known as verlebrane }, whip are
separated by inlen'erlebr:1l discs.
'~; -w:.rlebrL1l eulumn haLs four main l'uneliur1:~;:
I*-Frpleeliun - eneluses Ami pruleels the spinal e e l
within the spinal canal- Vertebral
1. lliu1ppurl - carries the weight of the burley' ab-Lwe the body
'pe '!»r'l5.
Vertebral
s.
-L
Ants - terms the eenlral asis of ll1e body-
. \ v e m e n l - fiLLs rules in bulll pa sure and nlu1»/'enlenl.
arch .
WNtaral so flvaurs
All vertebrae share a basic cernmen structure. Th
eacb ccrnsisl of a vertebral body, situated anleriu or.
and a pusleriur vertebral arch.
I. Vertebral bud v -
II is lh 'EI weight-bearing curnp-um-:nl, and its Sian: in creases as
ull- vertebral culumn descend s fhiwing lu
support in creasing amuunls of weight).
The superior and inferior aspects of ll1e vertebral body are Fig 2 .The general
lined with hyaline c a r i l age. Adj ueenl vertebral bodies .5Lru4;lurli' ul' ii '».'4:rL4:brL1E-
areiaipalraled by a l`ibrucarlilinginbus inlerverlebml disc-
 Vertebral Arch
The vertebral ateh reliers je the lateral and posterior parte el' the vertebrae.
lWilh_the vertebral body. the vertebral arch forms an enclosed hole. called
vertebral foramen. The foramina of the all vertebrae line up to form
"-_ .
--. the vertebra] canal. whteh encloses the spinal cord.
- a

The vertebral arches have a number of bony prerninences, which eel

as attachment sites for muscles and ligaments:
1.: Pedieles: [here are we of Lhese, enc Is and one right. They point
posteriorly, meeting the flatter lamina.
so Lamina: the bone between the u"ans\.=erse and spins] processes.
Jo Tra nsverse processes: these extend laterally and peslerierly away from
the pedicles. In the Lheracic venehrae. Lhe transverse prnce.sses articulate
with Lhe ribs.
4: Ar tieular processes: at the junction of the lamina and the
pedicles. superior and inferior processes arise. These articulate with the
articular processes of the vertebrae above and below.
51 dpi nous processes: posterior and inferior projection of bone. a si te of
attachment for rnuseles and ligaments.
 Spinous process
Lamina

Superior articular processes

lm Pedicles
Transverse processes

I teachmeanatumy

Fig 3. Superior view of a dunbar vertelinrae

 Cervlca l Vertebrae
There are seven cervical vertebrae in
the human body. They have three
main dislinguis l1i f i g features:
Foramen transversarium
_,he spinous process bifurcates into I

. two parts. and so is known as a bifid

spin S pr cess.
1 There are [we transverse foramina
one in each transverse process.
These conduct the vertebral arterles.
3, The vertebral foramen
is triangular in shape
There are SDITIEI cervical vertebra that
are unique. C l and CO [called the atlas
a d anus respcctlvely), are speclallsed
to allow fer the movement of the
head.
The CO vertebrae has a much longer
spr s pr cess, which d es t
bifurcate
Bifid spinouts process
© 'l.¢:i1ml».ll:NonlI'_-I_
 Thoracic Vertebrae
The iwelve thoracic vertebrae are medium-si;-Led. and increase in side as
by n a v e down the back. Their main Dunc Lion is to articulate with ribs,
odncin g the bony thorax.
Each, thoracic vertebrae has hvo 'demi l`aceLs' an each side of its vertebral
body. These articulate with the head of the respective ri b, and the rib
inferior to it. On the transverse processes of the Lhoracic vertebrae Lhere is
a Costa] facet for articulation with its respective rib.
The spinGUS processes are startled 1'nferiorly and anteriorly. This ullllel':-;
increased prulecliu
p n to Lhe spirial cord, prsvenlmne an object lily-: a l i f e
h epins cauial Lhr'o ugh Lhe iltlswvertebral discs. in rsunl rail lu Lhe
eqleri 11413' the
or
ee'11-'ie al ve ltebrse. lhs VE-lTEbl'Ell foramen is ci rcular.
Lumbar Vetrtebrae
These are Me largest of the vertebrae, of whie h there are I`ivve. They all lo
up rl the weight of tlle upper body, and have various special zaliuns lo
nnEie
'

them de this.
Lumbar vertebrae have a very
r I ares vertebra] bodies, wllleh
IC are kidney-
shaped. They lack the eharaeten stie features of other vertebrae, with ne
transverse l`oralnlna, costal l`aeets, ar bifid spinous processes.
However, like the eervieal vFenebral, they have a triangular shaped vertebral
foramen.
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_-'

The sacrum is a collectl inn of

Il1-'e fttsetl 1.»'fig rtehrae. In is
described as an upside down
triangle, witll the apex pointing
l
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_

*-.iii:tericrly. On the lateral walls of 0 Sacrum

the sacrum are facets, for
articulation with the pelvis at the 0 Corey:
sa.crc»iIiac jciints.
The ;ccccyR is a small bone, which
i Pelvis
articulates with the ape:-t of Lite
sacrum. lt is reccanised by its
is%s of vertebral arches. Due to
the lack of vertebral arches, there
is no vertebral canal, and so the
cgccys does nat transmit the
spinal cord.
teuhlneinltnmy
'I-11-1
 .IOINTS
Each vertebra has live articulations. The vertebral bodies indirectly articulate
with each other, and the articular processsee also Iform joint
.']`he `§.fertebral body job fits are cart ilagino
ous joints, designed for weighi-
"beating The articular surfaces are covered by hsaline cartilage, and are
:connected by a Ii brocartiiage i ntervertebra] disc.
There: are two ligaments that sire ngtlien these joints. the anterior and pos terror
longitudinal ligandents. The anteri or longitudinal Iieament is thick and
lJl'IE='l»*ti'.'[ll5} hyperestension o f the vertebral column. The posterior longitudinal
ligament is weaker and prevents hyperfl e:-don.
.I . .
The Joints between the articular facets are called facet joints. These allow for
solute gliding motions between the vertebrae. They are sirenCF 'Cf'
the tied by
various ligaments:
AL. Liganienturn Flavum: estends from lamina to lamina.
B. Interspinous and Supraspinous ligaments: these join the spinou S
processes together. The interspinous lieaments attach between processes,
and the supraspinou s ligame fits attac h to the tips.
E. Intertransverse ligand fits: extends between transverse processes.
I
MUSCLES
The muscles of the back can be divided into three groups - superficial.
iilillermediate and intro sic:
-.. uperfirsial - ssociated with m veme to f the sh lder.
'z"-- Irltermediale associated with movements if the thoracic cage.
3. Deep - associated with movements of the vertebrae column.
The deep muscles develop enibljvologically in the back, and are thus described
as intrinsic muscles. Th e superficial and intermediate muscles do not develop
in the back. and are classified as ex trinsic mu scles.
I. The superEeial back muscles are situated underneath the skin and superficial
fascia. They originate from the vertebral column and attach to the bones Of' the
bones of the holder - the clavicle, scapula and humerus. All these muscles
l . . .
are therefore associated with movements of the upper limb.
The muscles in this group are the trapezius, Ialissimus dnrsi, levatnr scapulae
and the rhnmbnids. The trapezius and the latissimus d o s i lie the most
superficially, with the trapeziums covering the rhomboids and levator scapulae.
 l. The trapeiills is a broad. list and trisuigulsr muscle. T'he muscles en esch
I.. siidc form E1 trapezoid shape. It is the must superficial of all the buck muscles.
"»L Attachments: originates from the skull. ligamenlum nuchae and the spineus processes of
L TIE. The fibred attach lu the clavicle. EICrumiun and the scapula spine .
i. I
Illl'IEi'vali{JIl: motor innervation is from the acces scajv nerve. II Elll'-l»{J receives
pmpriueeplur fibres from CO and CO spinal nerves.

Acljgnsi the upper fibres of the trapeaius elevates the scapula and rotates it during
ubducliun of the arm. The middle fibres retract the scapula and the lower fibres pull the
scapula in feriurly
y.
2.
1 1 i . .I
1 he latlsscmus durst cfriginules 1`rum the lower Pam of the buck. where II
..

overs s wide area.

it ..
Attachments: has u bread .Urig if T
arising from the spinuus proLrcesse H- of T6-Tl ill HC
-
crust, thclraculumbar 1`usciu and the iuferiur three ribs. The fibres ccrnverge intra tentlcn
that attaches to the intertubercular sulcus of the humerus.

Inne*'rvatinn: lhurucudunaul news

Actions: extends. adducts and medium 3' rulales IJ14: upper limb.
 Levatnr Scapulae* i s F1 small slap-like mu je. II begins in the neck, and
do-:_s+;r:nLls lu attach lu the scapula-
iiiiillrnunls: uriginales frurn the transverse processes of the Cl-C4 vertebrae and
r C hes lu
LE llle medial b-order of the scapula.
'-»._ Innervaliun: dursad scapular nerve.
'--. .I
Atllgns - elf valley the mapula.
Q
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Rhnmbmds
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There are wu thumb-uid muscles- rnujur and miner. The rhomboid minor is situated
:superiorly lu the n1auljL1r.
A. Rhurrrbuid Mnjur
Ailaehnleni5: {_'|riginules orum the spinuus precesses L11IT2-T5 vertebrae. Allaches lu the
médiel border of the scullEL. belween the scapula spine and lnferier angle.
Innervaliun: dorsal seupulur nepre.

Actions: relrale LE and rotates the updrl.

B. Rhumhuirf ,Hiller
Alla lmlenlsz unginules lavern the spinuus prueesses ullC7-TI verlebrse Allsehes lu llle
medial border of the sespula. al the level of the spine of sespuls.
innervation: durssl seapulur nerve.
Aeliuns: relic Ls and relates the scapula
 Levatnr
Tl"lPE'.il.I5
scapula:

Rhgfnbgid
m nor
Rhgfnbgid
Major

Latisiirnus
duril

Fig 4. Thc superficial

muscles. of lhc back
 The intermediate group contains two muscles - the serratus
posterior superior and ser raMs posterior inferior. These muscles run
from the vertebral column to the ribcage, and assist with elevating and
depressing the obs. They are thought to have a slight respiratory
function.
The serratus posterior superior i s a thin, rectangular shaped muscle.
It lies deep to the r 'I It] I air. ITILISC les on the upper baclc
Attachments: originates from the lower part of the ligamentum nuchae,
and the cervical and thoracic spines (usually C7 - TO). The fibres pass in
an inferolateral direction. attaching to oh S ._-5.
2
Innervation' intercostal nerves.
Actions: elevates ribs 2-5.
2. Tlle s-erratus posterior inferior is broad and strong. It lies
underneath the latissimus dorsi.
Attachments: originates from the thoracic and lumbar spines (usually Tl l
- L3). The fibres pass in a superolateral direction. attaching to ribs 9-12.
Innervation intercostal nerves.
Actions: depresses obs 9-12.
 - _

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- - 2

5-.1*i'|Iu.
pg1[..rlg.r
Inhrlnr

-
l THE e~a4:rru1'LI1!l-3 [TI-D§[48riur
- _

inf4;=riur.
-_ -
 IILThe deep muscles [If the back are well-develupecl. und culleclivel y eslencl
m the sucrurn lu the base c+1` the skull- They' are associated with the mcwernenls c}1` the
verlebrul culurnn. and the cunlrul u1` puslure.
The muscles themselves are covered by deep fasciu. which plays H key rule in their
gunisuliun
1'

Anulq-inicully, the d EI?p back muscles can be divided inly three layers :
ii; - ' The superfieial
e muscles :ire ulsu known as the spinulrunsversules. There are wu
muscles in hi s grewup - splenius cspilis and splenius cervicis. Th by' are belh
issueruled with mcwemenls of the herd and neck.
Theylare
ylzu lnested un the pbslerul
L* uterul uspecl u1` the neck. c~Lwering the deeper nee k muscles.

ul §'plsniusQcspiris;
Aimnchnlent 5: Un-ginLEl es 1`rum the lower aspect
T
e of the ligun
g lenlum nuehale. and the spinuus
.
prneesses of C -TH/4 vertebrae The ii res seeno. all bechin g lu the malslnid prneess
a d the ueeipilal lune ell` the skull.
Innervaliun: Pusleriur rsrni of split:JLl nerves C3 and CO.
Actions: Rulale head lu the same side.
b} Splenius Cervleis
Alliaehnientsz Originules orDH] the spin el usérrucesses of T3-T5 verlebue. The fibres ascend,
alltuehing lu lhe lrainsverse pruee sses ofi' l -3x'f-l.
Innervaliun: Fusleriur rzlmi of ll1e lower eentieal spinal nerves.
Aetinns: Rntnle head to the same side.
.*.".* Toile tow .rplen€u.r u:u.rrle.r can also :or rog'erIle*r In erremi the Fiend frmzf Greek.
 I
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'D-.
_ -* 1 I
-l

I
al Gil.

Splenius
capitis

Splenius
cervlcls

p 5. Thu pleniu muscatEt, l+:rcaLud with Lhe s.up-crficiu] I Llg,'cr of inLrinsi4: buck l11u5L'l-l:5.
 {-'There are thre~l;..inteljmetlia.te intrinsic back muscles - tl1e ilianuuslulis. lungissinlus
|
L
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and spinal is. Together these muscles term 11 column. ltnuvt . n as the eruf tur spinae-
I

"the eréctttr spinae is situated p-usterctlaterallv lu spinal column. between the vertebral
spinuus processes and the costal angle u1` the ri 5.
,»~""
lthree muscles can be subdivided
icis and capiti H J. They alt:» all
'.._et.-:
be their superior attachme fits (into lumburum. thcfracic.
ave El common lendinuus origin, which arises 1`rc»m:
. Lumbar and lower tJ1ur'dr.: in: vertebrae
.. -EaCrum-
Posterior aspect c»l` iliac cre sl.
Sal'rc+iliac and supraspinctus ligaments
II The ilimcstalis muscle is located laterally' within the erecter spine. It is associated
with Lhe ribs, and can be divided into three paris - lumbcrum. thcfracis. and
cervicis.
Attachments: Arises from the ccrmmun lendinctus origin. and attaches lu ll1e costal angle u1`
the ribs and Lhe cervical transverse processes.
Innervutiun: Ptnsterictr rami of the spinal nerves.
Actions: Acts unilaterally' lu laterally lies the vertebral column Acts bilaterally lu extend Me
vertebral column and head.
2) Lungissimtlit is situated between the ilictcustalis and spinalis. It i s the largest up the
three columns. It can be divided into three parts - lhuracic. cervicts and capilis.
Attachments: Arises l`rum the ccvmmctn tendinout -origin. and attaches to the lower ribs. ll1e
transverse price sses L11IC2 - T I 2. and the r11;1:;luld PIUCEHS of the skull.
Innervatiuu: Pustericlr rami of the spinal nerves.
Actions: Acts unilaterally to laterally [les the vertebral column. Acts bilateralljv to extend l.he
ver tpbral column and head.
|

1.-"'

"'-»..

L-ongissimus

llincnstalis

Fig in. The 1i'rtctL1»r spinmc-

I
3) . I Spinalis is vealed medially within llle ereeler spine. II is llle smallest of he
Lhree muscle eulumns. II can be divided irllu ll1e lhuraeie, eenficls and eapilis (allh ugh U

the eewieis pail is absent in some individuals).

AIEil;°l1mEnI5: Aria;-:H 1`run1 IJ14: cumnlun lendinuus origin. and utluchus l LJ the spinuus
processes of C", T I -TO and lh-.=: uccipilul Huns of the skull.
7'

Inrlervutiun. Pnsleriur rumi of the spinal nerd: ':-L

A c l l n s ; ACLH unllulerully lu lLllerLLll3' flex ll'l¢: w'edebrM cu lumn Acts bllslerslljy' lu extend
the wttebrsl column and head
3. ITlw dfffp intrinsic mu:sfl=E~5.sre located undemeallh lhe ereelur spine. They are 8
group of shun muscles. associated with the lnmsverse and spinuus processes of the
vertebral column
l .
4- Tllere me three fun|.|nr.rr deep
. . .
l.FItll"l.FI.5'l[' nruseles
.LD flus. gruup- lhe . . l

senllsplnLLl1H.
rn LlLilldus and rulelure 'I-L.
L The semispinalis is the mesh superfieizll e»'l` the deep inlrinsie muscles. Much like the
inlermedisle muscles in can be divided is i s superior :llLuehmenLs inly lhnmeie, eewieis
a d eupitis.
Attachments: uriginules rum the lrunsverse prueesses of Cd-TIG. The filnres useend 4-6
verlebrul segments. ulluehing lu the spinuus prueesses of C2-T+l-. and lu the uceipilal
bone of the skull.
Innedvatiun' pesleri Urrzlrni L11' the spinal I1-ETVE S.

Aetiuns* extends and euntruluterully rerlutes the herd and vertebral eulurnn.
I
 2. D+-'Iullilidus is localed undemealh the semispinalis muscle. II is best developed in the
1 I
. lumbar area.
_*

Attachments: has a breed origin. - arises 1`rum Me sacrum. pusleriur iliac spine. curnnwn
'Ll'-
lendincus origin of d e ereclcrr spine. manlllary processes u1` lumbar vertebrae.
-It
transverse processes cilTl-T3 and articular processes of C4-C7. Tlle fibres ascend 2-4
veflebral segments, attaching lite splnuus processes of the vertebrae.
Inneivaliun* pusleriur rum of the spinal nerves.
Actions: slablises the vertebral column.
3. Rulatures
The rcrlalcres are mcsl pruminenl in the lhclracic region
Attachments: eriginales from the vertebral transverse processes. Th 'E fibres ascend and 'l

attach lc the lamina and spincrus processes of the immediately superior vertebrae.
Innervaliun: puslerier rami of llle spinal nerve s.
Actlrlns: stablises the vertebral column. and has a prepricceplive funclinn.

Millar Deep I :HHnsin Eltfrrsd'e.v.'

1. Interspifalls.- Spans between adjacent pincus processes. Acts je stablise tlle vertebral
column.
2. Inlerlranversari - Spans between adj cent transverse prucesraes. A#.:L"-L lu slublise hl.-:
verte b a l column .
3. Levatmes castarum - Uriginates Frern tl1e transverse processes c}tlE'7-TI I . and
attaches to the rib immediately below. Acts to elevate the ribs
Semispinalis

Multifidus

Fig E. The: so-mispi nu Es

and mulLl'idus muscles.

via-#mann-t
 THE QPINAL CORD
L
The spinal euro is El lubulur bundle of nerve UH tissue and supp-urlingT be II H lhul extends fruln
the rain stem lu the lumbar w'en:brue. TL1~gE then, tl1e spinal euro and the brain furl the
beRudi nerv"UUCP by Sl-EITL
`~

lhaspinal surd is El cylindrical structure, greenish-white in CUIUUT. II has a relatively simple

anatumieal {"lJ'l.II'l'iEI
11 »| . . . . . -
Q t of the
The spinal euro arises eranlallv as an eununuauun of tl1e medulla ublungala Lpar
brainstem}.
It then travels inlleri4:Jrlv within the vertebral canal. surrounded is the spinal meninges
euntaining eerebruspinal fluid.
Al the LE vertebral level the spinal surd tapers u IT. furling the eunuch medullaris.
As a result of the lerminaliem of the spinal eerd al LZ. in occupies around we thirds of the
vertebral canal. The spinal nerves flat from the end of the spinal e n d are bundled
tngdther. forming a sl;ru4: lure kntltwn as the eauda equine
Uuri fig tl1e eeurse up the spinal surd. lllere are two points elf enlargement. The eervieal
enlargement is lueated preaimallv. al llle C4-Tl level. II represents the origin u1` the
brachial plexus. Between Tl I and S l is the lumbar enlargement. representing the origin
tJl` the lumbar and sacral plexus.
The spinal cu rd is marked by twu depre ssiuns un its surfaee- The anleriur median fissure is
a deep groove extending ll1e length of the anterior surface of the spinal euro. Un the
T

p-Dsl'E ricer aspect dlere is a slightly shall'U' wer depression - tl1e pusleriur median sudeus.
 Fans
Medull.
nblnngata

*. Cervical
'El
enlargement Cgnug
medullarls

Lumbar cistern
{sub-arachnnld space)

Lumbar Eb!-H
enlargement Filum
*HH
Conus termlnale
I
medullarls

Filum
termlnale
I*j.'lrhh'ln.nllqmv

Ln l

I
Fig 9. The Extcmul sutucmrc ul' Lhe Fig IU. '1`l*14: expanded sub-aruch ruin sPuL'1:
spins] cord. lhrming Lhc lulnhm cislurn.
 THE SPINAL MENINGES
.
. F

. '. The spinal meninges are three membranes Mat surround the spinal cord - the dur mater.
"
- arachnoid mater. and pin mater. They contain cerebrospinal fluid. no ting lo support and
t( protect tlle spins! cord. They me analogous with the cranial meninges.
. istalljr. the meninges form a strand -of tibrou E- tissue. the Elum terminate. which attaches to
""' the vertebral bodies of the coccya- It acts aw an anchor for the spinal cord and meninges.
11 Dura Mater is the most ealemal of the mering s. It extends from the foramen
magnum to the slum terminate. separated from the walls of tl1e verte bal canal by
Ureleptuur-at space. This space contains some loose connective tissue. and the internal
vertebral venous plexus. As the spinal nerves edit tl1e vertebral canal. they pierce tl1e dur
mater. temporarily passing in the epidural space. in doing so. the dura mater surrounds the
nettle root. and fuses with the outer connective tissue covering of the nep»'e,
the epineurium.
It Aracbnoid .N-'later is a delicate membrane. located between the dura mater and tl1e Pia
mater. lt is separated from the latter be the subarachnoid space. which contains
cerebrospinal fluid. Distal to the conus medullaris. d e subarachnoid space expands.
forming1 th-E lumbar cislcrn This space accessed during a lumbar puncture (to obtain
CSI Fluid) and spinal anesthesia.
 Pia guntar

Subaachnuud space

ArBd'H'l-DIEI mats: Subdural rpm;

Dura mair

LE .Q-¢

CLl'II*ll'llUt"i-I UV'
 11 lrlahrr is the innermusl u1` the meninges. II is a thin menlbrLLn4.=: that cuvena the spinal
cord. nude ru4Jls and lhuir blue+;J~LI vessels. In ilrriurly. he spinal pin mph-:r buses with
the filum lurminsle. Between the rene rL1-mls, the pill nlLller lhieke rls lu fun the
hlielllaflé ligameiili. These ligsmenls sllseh lu the ursehneid miler. suspending the
nal herd in the verlebrall canal.

The Epinal nerves un: mixed nerves that uriginale from the spinal euro, 1`um1ing ll1e
peripheral l'l'EI"!h"'UUl'-i svslern-
I

Each spinal I`l*.'II"v"E begins as an anlerier (meter) and a pusleri'Ur (sensory) nerve re-ul. These
re-uls 1`rerrn the spinal eetrd. and unite al the `Lr!ll er\-'ertebral foramina lbmling a
single spinal nerve.

The spinal nerve Lben leaves the vertebral canal via the inlerverlebral 1`uranlina, and Lhe n
divides inly wu:
A. Fhrsteriur ram - supplies nerve libres lu the synovial juinls of the vertebral COlurnn.
deep rnuseles of the back. and Lhe everliving skin.
H, Anleriur ram - supplies nerve libres lu much of Ll1e remaining area el the b1'.J~Ll.v. bulk
motor and sensuljr.

The llerve reels L*-S5 arise frurn the distal end of the spinal cord forming a bundle up
2

nélves lurer as the eauda equine

 I' '\.

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Spinal
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"'°~...,..""
i 1 PJ..4
I _
1I

\
|
I
'
. . I

| . I
.I

|'. I I
I
I

I . I

Thuraclc
I |.

|
I I
I
_
I
I'
Posterior
I l
I
I
I
.
rout
I
| I

i
I

I
Antorlor I
I
1

Lumbar root
Antorlor I Posterior
!I
ram rlml
x I

'KI I..
I
I
L l

'1

I
"l
1

L -I I
I
I .| II n I I

I Fig ll- The origin of Lhc spinal rl4:rve5 from the spinal cord .
r 'lu]`he*spipal.cord
I
is.primarilylsuppli.ed*.by three longitudinal arteries. as
ll.l.l.

i t descends from the brainstem to the conus medullaris. These are:

Anterior spinal artery- farmed from branches of the vertebral
arten' es, travelling in the anterior median fissure. Gives rise to the
sulcal arteries, which enter the spinal cord.
~..2i".-._,Two posterior spinal arteries- originate from the vertebra] artery or
- 'the posteroinferior cerebellar artery, anastomosing with one another in
the Pia mater.
Howiever. below the cervical level supply from these longitudinal arteries
is' insufficient. There is support via anastomosis with the segmental
medullary and radieular arteries.
The anterior and posterior segmental medullary arteries are derived
from spinal branches of a number of arteries, before entering the
vertebral canal through the intervertebral foramina.
The great anterior segmental artery of Adamkiewicz reinforces
circulation to the iiderior 2/3 of the spinal cord. and is found on the left
in the majority of individuals.
The radieular arteries supply (and follow the path of) the anterior and
posterior nerve roots. Some radicular arteries may also contribute to
supplying the spinal cord.
 Posterior spinal vein
.»"
Posterlalateral Pusterluf spinal artery
spinal vein

Hadlcufar artery
1

Anterior M Spinal artery

spinal 3"*W
l

Anterior
spinal vein -

Internal vertebral
venous plexus
DUE mater
Ii
®
The spinal cord is supplied by three anterior and three posterior spinal veins.
These veins are valveless, and form an anastomotic network along the surface
of the spinal cord. They also receive venous blood front the radicular veins.
Tlgjpinal veins drain into the internal and external vertebral pleases, which in
turn empty i to the svstelnic segmental veins. The internal vertebral
plexus also E lnpties into the dural venous sinuses superiorly.

Posterior
internal plexus

Posterior
external plexus Anterior
external plexus

Tea1:hd-'lrAII.tnlllf

Fig 11. The external and internal ventral w:nnu.s plcxu see..
 D
I

Part II
Operative surgery of the vertebral
al column, spinal cord and its membranes
 LUPVIBAR PUNCTURE
.
,of Lumbar puncture i LP J. also known as a spinal tap. is a medical procedure in which El
_,e
neg dl e is inserted into the spinal canal. most commonly' lu collect cerebrospinal
.fluid (CSF) for diagnostic testify g, nr =.-ery rarely as lTEi1lmEl1l ( "therapeutic lumbar
To. *-. puncure" ) to 'D relies'
ac increased intracranial pressure.
-,1 . . -.| -.
Lumbar puncture La a procedure that la often performed in the emergency g department lu
obtain inLllomlation about thE cerebrusplnul 1`luid (CSF). A llh U ugh g u '.t-1rally used fur
d i a Tn us lie purposee lu rule out polentaI ii fe-lilreall;-:ningcundiliuns ( bacterial
meningitis Ur subarachnoid hemorrhage), it i s al an sometimes used for llurrapeulics
purposes (treatment o1` pseudoturnor cerebri J. -CSF iluitj analysis can also aid in the
di gnosis o1` various other conditions tdernyelinating diseases and CEll-[Ii I'l{JIll£ll{JU5
meningitis).

Lumbar puncture should be performed only after a neurologic eszunination but should
never delay potentially life-saving interventions. such as the administration of
antibiotics and ateniids to patients w
with suspected bacterial meningili s.
 Lumbar Puncture
,|_»_
-

*_ .i |
,m 11 I

i'i'il f no II'
r

'I-

Lying Position Sitting Position

l]1u:-itmliun depiclingcunullcrn positions fur lumbar puncture procedure.

Technique:
gositicrn the patient in the hed. Generally. the lateral decubitus peaitioa
to preferred. Arch the patient's hack towards yrau.
Identify and mark anatomic landmarks. The LE spincnus precess ia at
*the level of the pnsterinr - supericlr iliac crests.
3. Prepare the akin with antiseptic snlutinn . Apply a circular mcrtinn
with a gradually increasing circumference.
4. Apply the sterile drape.
5. Create a wheal with anesthetic in the skin cvyerlyina the entry site.
'i[}1en, infiltrate and anesthetize the deeper tissue.
6. Insert the needle in the midline. Held the needle parallel to the bed,
and advance it tcrward the Luuhilicus. Remove the styler periodically
to check for CSF.
7. CSF will flew from the needle hub when the subarach"maid space has
l e n penetrated.
8. Attach the manometer and measLu'e the cipening pressure.
9. Collect the CSF sample in sequential . numbered vials.
IO. Replace the sly let befcure removing the needle.
 EPIDURAL ANESTI-IESIA
L Epidural anesthesia can be used as sale
r

,J anesthetic fur prueedures involving the lower

*-. limbs. pelvis. perineum and lower abdomen. II
ipnssible lu perll4;Jrrn upper abdurninal and
m '1-
*-.. thuraeie prueedures under epidural anestllesia iII

akme. but the height of bluek required. with Splnal cord

its attendant side effects. make ii dillllieult je
avoid signilieant patient diseumlbrt and risk. LE Epidural space
The advantage of epidural 'LJ"v"El' spinal
unellmsia is the ability lu maintain -In
euntinutlus are sthesia alter placement of an LE
1.-:piciurul gulf eter. thus making it suitable l`ur
Eubarachnoid Epact
pr o4¢:Llu.res of lu fig duration. This Fe ature also
e I`L:l 14:5 the use of this technique into the
r

puslup~er:1li~»/'e period fur analgesia, using

lower ouncentratiuns of oatmeal anesthetic drugs Epidural spate IeJtLr:;t4.iurH.l space.) is luut1lt`2r»d
Ur eumbinatiun with different agents. m
' spine ennnl between Hgnmenfa j'7uwr and
dum .rnul'e.rt Contains Inns: cnnneetive tissue.
The pressure in epidural space is lower than
stntnspherieni pressure iw'ill be usefuI l.
Epidural spree is 3-5 mrn wide.
,J Pusilinningz
'l'fI+.: sitting p-usilinn i H 1:un1n1unl}t en1pluj,n.-rd- Inslrucl the pulienl rest his -Ur her legs un El
Ste 1 slum! and hold El pilluv. r. Inslruul lh4: paalienl In arch funsfmd like an angry' call lu
disease lumbar lnrdusis.
l'11_1e lateral decubilus pusiliun is anulher p-ussi ble p-usilicln.
1: prom: p-usiliun i bi employed when epidural nerve block is used in chronic pain
-li°I, l'l{:lg'EI'1l'L'l'llll+ HUUTUH-CD py i rally required.
-E

I Lumbar level.:,
. Use the lumbar level of insertion fur anesthesia and postoperative analgesia fer lower
abdominal, pelvic. and lower extremity procedures.
. Stan a peripheral intravenous line lu adnUnister fluids anti medications.
. Position the patient in llle seated or lateral dee ubi us prnsiliun with the back arched lu
mininase llle lumbar lordosis.
. Prpare the buLL with puvidcrne-iodine sululiU n (et, Beladine] and place a slerile drape.
Use chlorhexidine glueunaie al-libiclens} fur patients who are allergic to puvidune-iudine
solluli u n
. Falpale the spinuus processes. The midline inlerlaminar approach is used in lumbar
regions because d e spinuus pre-cesses are less angulated in lllese regions.
. After the skin and subculaneuus tissues are aneslheliaed w1 ll1 local aneslhelie. inlruduce
lhel'Tuc+hy* needle lulu the lower part of Lhe inlerspace and advance fur abuul 2-3 em
use ll1e needle is firmly' placed ill the inlerspace.
Instruments fur epidural c El lJ1eleri;-Laxiiunz philter. cu&eler. Tuuhy needle and syringe.
 llach llle -gl ass syrinbe [prefilled with air Ur saline 2 ml`]» lu llle needle and continue
advancing in slow increments. frequently chee ki fig fur less of resistance. A gentle tap
un the glass syringe pi s o n is enough lu determine-E Ihe rest 5-lance. Sometimes, a small
bubble of air in lhhe billline is helpful. The bubbl-E compresses with ever.v lap un the
]J'L'i»l'L]'l'l.

H the II`5an1entum flavunl is reached. the res i 'etlance increases to a firm and gritty
:elmg. nee the epidural space is re ached, resistance in l cal. When ll1e piston is
-Wendy lapped. it easily plunges in the syringe. The air bubble in llle saline nu longer
fumpresses. and saline is easily injected into the epidural space.
. Once the epidural space is reached. aspirate lc-[J rule c up cerebrospinal fluid (CSF)-
. ]1` perlbrmin g a single shot procedure. injec l the medication and remove ll1e needle.
. If plac ing a catheter. gently advance the c alheler through llle 'needle fur about 4-5 cm
an
and lh en remove the needle.
Ccmnecl a ccrnnectcr lc the end of llle catheter and remove 'llle sterile drape.
Secure the epidural catlleter lc tlle patient's back with steril e Tegaderm dressing, and
.inject a lest dose of medication. The test dose rules cut intralhecal or inlravamular
Jucaticn of the catheter-
*With a successful neuraaial blockade. a one of cliff renlial s.v mpalllelic nervous
system bloc kade typically clccurs
c at the spinal level. The zone of' differential motor
blocksade may average up to-il segment s below llle sensory level in epidural ralller
than spins I blockade.
 I .
;nra1:n: level:
-*Ll the law thoracic llsvcls. the angulatiuIl of the* spinuus processes is
incrcs sccl, and less intcrlsminsr spsce is svsilsblc. Grcstcr scccss to lhc
epidural space is avsilsblc when the psrsmcdisn spprcrsch is used; thcrcfcms.
the psmt11cdi.sn lntc~r!11nlinsr approach is cssicr and dcsirsblc st low lhorscic
]cvcLs.
.I in the pmmnadm approach. inst':rt the nnttdla slightly In the side of the
midline and advantza it straight until the lamina is reached.
1
.I
-I . l -. . I

lSLlbscqucnlly. dlrcct the needle ill s ccpholsd snd modus] dirccnon Lmnl it is
. .
l

lpvalkod oil' lhc su pcrior sspect of the lamina, lhcn sdvsncc it toward. lhc
ligsmcnlum 1'1svun\. using the loss of rcsistsncc technique. Either sir or soling
-'can be usocl to Sid with the loss of rcsislsncc lochliiquc.
'I .Tho rcsl of [he procedure is the ssmc ss described for the lu mbar icvcl sbovc
I
I
 Spine Surgery
In lhé up1;~11 surgery or nlirlilnL=L11y iiivasivf: spine Surger 5' (IR-'HSS) [ha spine can M
accessed frnnl diIlti:n:lll dirnrslinns. Thasu are re,-famad to ass urgical approaches
and are 48::~Lp1;uln=3:d be-nw:
I. A]r}7¢*riur npprornrlr as the cosmo implies. the surgeon HCCCSSBS the spine from the
tro*11l ui' body. llu'oL\g]1 [ho Elhdomon.
2. Pnsrerfor approach' an incision is m Ada: ink ac k.
3. Lateral approach' the pathway to your spine is misdo Ihmu oh side.

Corrrmon surgical procedures:

l. Disk*Er:tnmy nr Ik-'licrudiscetlumy: r=.":n1+:rv:t11 of a licrniatcd intervcrtcrbral disc.
Tllcruforc. nxmmfing pressure from the CDIIIPFE cssfcd ncrw.
2. Laminedum -|=v: removal of the thin bony plan: on the back of the wfcnebm called
the lamlinaar to in1:r4:asc space w thin do spinal carlat and mlicvc prcssluwzs.
3. Laminnhmmjy : ramuval of a portion of the via-rtabral arch (lamina) th E*lI C'D\."42l"8- the
firm!al cord. A laminntnmy rcmnvas lass: bona than a iamincctam y. Both
u1nina'c't'urHj»' and furn ifaff trfrny are detnrrtprassinrr procedures. "DL:cc»mpl'1:ssinn"
usually m~l;*anF, tiara carnprasaiitg a spinal name ia rcittcwcd.
 Furaminnl my' removal of bono or tissue at fin the passageway (called
this nerftrrmforttntrni where rondo roots branch oft the spinal cord and omit the spinal
column.
" -' -m
Disfc rvplacenwnl: A s a n alarm ativo to f'usion. the injmod disc is roplaood with an
\\EMEoia1 Ono.
6. Spinal fusion' asurgioal tocltniquo used to join two verteb obtain. Spinal fusion [Tl He
aft wall1 or without instrumentation
intrludo II IC USE of bona graft .A s (of, rods, soros).
There
o are dffcr oront typos of bone s':'a1'i'1 such ss own bono ( autos raft) and donor
be1no lallmmi).
rs Afu sign o n bo aocontplishod by dttoront appro aches:
a) Amprior Lumbar Init=:rbody Fu s i g n (AL ALlF)
b) Posterior Lumbar lntorborly Fusion [ PLLF )
cj Transllorarninal Lumbar Inlerbody Fusion (TLIF) indicates a surgical
approach lhrou ahh Ll1e foramen.
d) L'aleral Intorbody Fusion (LLF ) in which the rninirnally invasive approach
is-1train tlta sitio of the body .
ALIF, PLIF, "l`LlF, LuIF: all pertain to lumbar interbedy fusion used to stabilize the
spinaI to nebulae and eliminate movement between the benes.
 I-Ierniated disc
Spinal hcmiatcd disc, also known as aslippcd disc.
is a media+:aI condition affe+;*Ling, Lhe S pine i n which
atab in the outer. fibrous ring of an intervertebral
*-dggallows the son. central portion to bulge out
beyond the damaged outer rings.
i. I
'Disc hcrnilinn i s usually due to agerelated
degeneration of the outer ring. lmown as the anulus
tibrbsus. although trauma. lifting injuries. or
straining have been implicated as well. Tears are
aln st alwayis postern -lateral lon Lhe bazk of the
s i d e owing to Lhe presence of the posterior
longitudinal ligament in the spinal canal. This tear
Hlniltud
in the disc ring may result in the release of Did:
chenlicals causing inflammation. which may
directly cause severe pain even in the absence of
nerve root compression.
The majority of spinal disc herniation cases occur in
the lumbar region 195% in L4-L5 or L5-S I J- The
second most common si te is Lhe cervica I region
(CE--CB. Chi-CT). Herniations usually occur
posterolateraily. where the anulus librosus is
relatively thin and is not rei nlOrced by the posterior
or anterior longitudinal
Cr
D ligament
 Gl:rvle.l die hcmialicns occur in the neck. most often
bet een Lhe lilih & sixth (CS/BJ and Lhe sixth and
'.l
:
'.F

seventh rust?) eewical vertebral bodies.

t, Svlnplienis can affect the back eflhe skull. Lhe neck,
she l d e r girdle. sapula. arm, and hand- The nerves o f
" u;|¢3l"4sn'i'»:r:1 pf.s.1'l.r.r and £1run-:friup p!e.m'lr.s can be
affected. Usually. El pesterelateral disc hemi wil I aftiecn
"HI the here reel exiting at the level eft.he disk. blues
rents are numbered aeeerdi fig to Lhe vertebral body
below them [except the CS rene reel. Thus. a C5:'EI
disc hernia will nermallv alLLlecl Lhe Co .nerve reel.
Lumbar disc herniations occur in the Iewer hack. most I

often between the tburth and fifth (JL-U L5JIL1lnbar

vertebral bodies or between the t"Ultl1 and the sacrum-
S vn1ptl:Jms can affect the lower bask. butteclts. thigh . PHHIM
ay
genital reg-en (via Lbe perinea rene), and may disc al
:
'-*1
r
radiate into the feet and»'e»r tee. The seialic nerve is the r

:»-
must cemmenlv affected nerve. causing svmptems
of so:°iatica. The femnrd nerve can also be affected and
caUse the patient to esperienee a numb. tingling feeling
threttghettt one or beth legs and even feet or even a
burning feeling in the hips and legs. A hernia in the I.

lumbar region often cunipresses Lhe l`iIE'I"!l-'E FDDI exiting

a t tl1e Ievel below the disk. Thus., a hemialiun of Lhe
L4»'§ disc will cunipress the L5 nerve root-
Stages of the disc herniatic-n

A dl: prolix-l-bun. Ur bulqg, 1DI'11.I mu

0D¢i#"l drum punurl on
U1-I' unc uuu-.l 1l'1l» l'l"H.-llJJl
ID "b.ll-n»nn" nun. wllhnul
NDIUMD-

.
Uh: inmdms up¢url
drum IM :nulu»s runtutll;
Manning purliun ul' lhl
rutll-In in lqanll num. Ll..l=l"l'lbl-l'd11l-C1
It »-1?-1»

DH: mquullrlllon cancun

when -n pnrtbnn Ur Thu H-'lr'-IFI FIIH
nl.l-lrllu11-qunull out and
llplnll-I [mm the dllt.
I Lumbar Discectomy Teclmjique:
1
r'

Hr l)Approach: open discoctomy [with nr without the use of an operating

microscope) or minimally invasive approach.
2)The prreposed midlife € incision site is marked and the 5urgical field prepared and
i.
x wlLh 1: 100,000
"\idraped. The l[llclslDlll sue is infiltrated wlth 1% llducallle n117ced
Eptnephrine. A midline skin incision is mode with a scalpel N210 along the
:marked 1n+:1s;1+:;':l1. The dlssec l lDlll of llni: sllbclltancolls l1s5L1es
l][4g1.,r1[51iS1"'lf is
completed using the ntonclpalar cilaictrnc aiitery.
3) Th; subcutaneous tissues are retracted using self-retaining Weitlaner retractors.
Th'b lumbodorsal fascia is then identified and opened along the spinous process
just off the midline using the monopoly electrocautery. At this stage. the
desired spinal level should be confirmed with intraoperative radiography.
4) The paraspineus muscles are stripped from the spinuus precesses using a
subperiosteal technique dew n along the lamina lo the edge of Ihe facets either
bluntly r with 'i n p jar a tery. F r a disc I Ty, p s re t the medial
edge of the facet joints is generally adequate. (I "L1rLl1cr lateral dissectjun cart dutnagc the
capsule of the facet job.nl und curl potentially lead to instability at that level). TI te surgical level
can again he confined before proceeding witll bony removal.
5) The nticroscopc covered w ith s terile drapes is brought into tlte field at this
stage. The ligamentum flavor is deteched from the inferior surface of the
lamina using an angled curette. and a hentilaminetunty is then perfenned using
the combillatioll -of the high-speed drill and Kcrrison rongeurs.
 5.) The decal alu fig with U1E nerve reel, is lIlen relrseleil mediall y. and the underlying
disc: surface can be seen. Th e pole ri Ur lungiiudinul
'U T ligumenl and annulus fihrusus is
I""-ll1-e'n eul using al seulpel Ne I I nr 15. Airer culling open the unnulus, disc material may

'
. b"% n lu eslrude and sun be removed using piluilauy fureeps. (When pl acing ll1e pituitary
'n the di space. CEIIE nlusl
anleriur luungiludinal jig
1 be taken nut lu insert l ee deep in case of an incompetent
game nl that could result in injury lu the iliac vessels. UP- and
"d uvvn-angled
-I curettes ca be used lu help release residual disc fragments Ur lamp duwn a
central disc bulge).
T)Allter the surgeon is satisfied that an adequate amuunl ufdisc has been remclved. the
thecal see and llle nerve root is inspected fur residual cctmpressiun and ESF leak. Some
surgeclns place sleruids (40 mg of melhvlprednisulcne acetate Ur 4 mg desamelhasune al
over llle nerve rest at tllis stage to decrease pusLs urgical inflammaliun. Placement uI a
free fat graft ever the fecal sac has alscl been attempted lu prevent adhesion l`urmalicln.
3) 'Its' fuseiul Iuyer is elused using 10 Vicljyl, which is imp-u+rtaml lu prevent wound
breakdown. The skin luger is e fused with El subculicular 4-D Munucryl.
 L4-»5 Disc: Herniation with Discectomy

A nn-ullllnlununun-in l.r»»l»u¢»-uw-nu-»liu»u.u»
Pranpurailvl Culldthnli rinunuunnnnuununru 5"""""""*"""""'L'I»""
.1 l - - . - 1 Ln
H
u-luuan
W!HWIiWWF *

'oh illllllu
l*** nasairi
I
Nu-.ui

alrmuiw
he-.

w-.nina

.='.r in iihr '¢"l1'r-l"nl1-llilil hiIifl-:hdl.diIlr1' D trupnnaunnluipunul

m h l m » d ¢ §
"'-""~..Tof I w-hnuuuh.

-nun
-umm

1-11-1
du

Hllllllll-nl
1 - 7
 Spinal! stenosis
Spinal stenosis is a condition ill which the spinal column narrows and starts
pressing the spinal 'E rd. This process is typically grtarloal. If' the narrowing
is .lTlilllllTi[l.l, ac: 5}'lTll]lDl1li5 will occur. TDD much narrowing can compress the
"~. serves and cause problems.
Wil spinal steno sis, the spinal canal is narrowed at the vertebral canal, which is
a foramen between the vertebrae where the spinal cord (in the cervical DI'
thoracic spine) or l`l'E','l"*»"'E roots (in the lumbar spine) pass through.
Steobsis can occur anew'here along th .
_ e spine. There are several topes of s pin Hl
steno sis, with lumbarstenosis and cervical stenosb being the indst freque ot.
L

While lumbar spinal g e n e s i s 15 inure enmlnnn, cervical spinal steno sis is more
dangerous because it 1lT'h'{]l"\-'IIZS eelltpresslen of the spinal card where as the
lumbar spinal slennsis involves eempressinn of Lhe e a d a e wina.
Several types of surgeljr am d i d to treat spinal steno sis:
l. Larninectomy is the mm-;t cunimon mpc nos Llrgeq'. A sllrgenn relnoves part of
.f

the vertebrae to provide mere rddm for the nerves.

2. Fnraminntnmy is a surgery that's done to widen the part of the spine where
the mrves exit.
.
3. Slpinal l`u5 i [iii is typically peifermed in l`l]Dl"E severe cases, especiallyy when
mulliplt: lazvals of the spine art: inf alf ad, to prof ait i stability. Bone grafts or
metal implants are used t-:J attach the affected benes of the spine togeLher.
STENOSIS TYPES Healthy
Vertebrae

§-,inal Ina!
LATERAL; Harvey is plndmad as It exits the spinal canal era na
l

CEHTFML: Hen. is pinched in the main spinal canal

FDPAHIHALI Hirai ii plm:J1ud in Thu pnisag-:ways

lout:-d on nth :Ida of your vurtibra

Lutlral Cent
Stencils So-Eng; Furaminal
Steno-sis

ERACEJBBIUTY
 Spinal stenosis
Spinal slnrvnds

Normal M Stenosis
|
II'
I
II'
|
i

.1 | -i

Clnlc
"-..,.
 Scoliosis
Scoliosis i s a medi c Si cundition in whi ch aper son' 5 spin e has a sideways curve.
[. The _line has normal caves (when looking fro
rum the aide. but it ahnuld appear straight
I \when looking t o m the front'
1. K§"pl1osis is a curve in the spine seen from the side in which d e spine is bent forward.
\_* There is a normal k-vphusi:s in the middle (thoracic`} spine .

2. Lurdosis is El curve seen from the side in which'L the 5 pine is bent backward. There is s
normal lordusis in the upper (cervical) spine and tl1-E lower Llumhar) spine
People with scoliosis develop additional curves l u either side of the body, and the bone s
oil the spine twist on each ollie r. forming a "C" Gran" S" shape in the spine.
In mail cases. the reasons for the change in 5h apeare not known. but in other cases.
cerebral ,rJal.v}', muscular dystrophy. and spins bqfida are factors in the development of
scoli psis.
Surgery involves correcting tl1e c urve back lo as close lo normal as possible and
performing a spinal fusion to hold it in place.
1rl spinal fusion, surgeons connect two or more of lh e bones in the spine
p (vertebrae)
together. so they can'l move independently- Pi aces of bone Ur an b-une-like mule nul are
pla ed between the vertebrae. Metal rods. hooks, screws nr wires lypi cally
F hold Mul
par t of the spine straight and still while tile old and new bone rnalerml Fu:-ses lug;-:lJ1er.

I
 abnormal
1-1.1-1-
curve Df
spine
Carvicml Curve Ribs

Thoracic Guru I

* j
,~=.:.\
l ii._ PelviB

~*2
Luif\b:r

5.
.
.

/Fllvfc
,iv
Cunrl
Scoliosis
*.
'El I
o Topic III

-Topographic anatomy and operative

surgery of the vertebral column, spinal
cord and its membranes
I

I
 I
D Part I

Topographic anatomy of the vertebral

column, spinal cord and its membranes
I I

*.
'El

Curvl-::.I [7]

Thoracic [121

Lumber

Sacrum (5, ful.d]'

Coco: (4, fund)

.

Fig l. The 'li-fertehrul column viewed from the side. The five different regions are shown
rIIand labelled.
SURGERY
wound
wound
wound

¨ Wound, a break in the continuity of any bodily

tissue due to an external action, typified by a out,
cut, a
bruise, or a hematoma.
_ Types
Types

• TIDY
TIDY VERSUS UNTIDY wound
VERSUS UNTIDY wound
TIDY
TIDY VERSUS UNTIDY wound
VERSUS UNTIDY wound

Tidy Untidy

Clean
Clean Contaminated
Contaminated

Healthy tissues
Healthy tissues Devitalised tissues
Devitcalised tissues

Seldom
Seldom tissue
tissue loss
loss Often tissue
Cften tissue loss
loss

Incised
Incised Crushed or
Crushed or avulsed
cwulsed
Repair
Repair of
of wound
wound

• Primary
Primary repair
repair ofof all
all structures
structures (e.g.
(e.g. bone, tendon,
bone, tendon,
vessel
vessel and nerve) may
and nerve) may bebe possible
possible inin a tidy wound,
a tidy wound,
but
but a contaminated wound
o contaminated wound withwith dead tissue requires
dead tissue requires
debridement
debridement on on one
one or
or several
several occasions
occasions before
before
definitive
definitive repair can be
repair can carried out.
be carried out.
• This is especially
This is true in
especially true in injuries
injuries caused
caused by by
explosions,
explosions, bullets
bullets or
or other missiles, where
other missiles, where the the
external
external wound itself may
wound itself may appear much smaller
appear much smaller
than the
than the wider
wider extent
extent of of the injured tissues
the injured tissues deepdeep to
to
the surface.
the surface.
¨ Multiple debridements
Multipl d brid m fits are
r often
ften required
required after
after
crushing injuries
crushing injuries in
in road
road traffic
traffic accidents
accidents or in
or in
natural disasters
natural disasters such
such asas earthquakes,
earthquakes, where
where fallen
fallen
masonry causes
masonry causes widespread muscle damage
widespread muscle damage and and
compartment syndromes.
compartment syndromes.
¨ Any
Any explosion
explosion where
where there
there are multiple victims
are multiple victims atat
the
the same
same site
site or
or where
where there has been
there has been aa suicide
suicide
related
related explosion
explosion will carry the
will carry the risk
risk of tissue and
of tissue and
viral contamination.
viral contamination.
Some
Some specific
specific wound
wound

BITES
BITES
Most bites
• Most involve either
bites involve either puncture
puncture wounds
wounds or or
avulsions.
avulsions. Bites
Bites from
from small
small animals
animals are common in
are common in
children.
children.
Injuries to
• Injuries to the ear, tip
the ear, tip of nose and
of nose and lower
lower lip
lip are
are
most usually
most usually seen in victims
seen in victims of human bites.
of human bites. AA
boxingtype injury of
boxingtype inlury of the metacarpophalangeal 1oint
the metacarpophalangeal joint
may result
may result from
from a a perforating contact with
perforating contact with the
the teeth
teeth
of
of aa victim.
victim.
Managing the
Managing the acute
acute wound
wound

• ..
● Cleansing
Cleansing
•

• ..
● Exploration
Exploration and
● Debridement
Debridement
and diagnosis
diagnosis

• .
● Repair
Repair of of structures
● Replacement
structures
Replacement of of lost tissues where
lost tissues indicated
where indicated
•

•
..
●Skin cover
.Skin
● Skin
● All
cover ifif required

All of
of the
required
closure without
Skin closure
the above
above with
tension
without tension
careful tissue
with careful handling and
tissue handling and
meticulous technique
meticulous technique
Puncture
Puncture wounds
wounds

• Wounds caused by
Wounds caused by sharp
sharp objects
oblects should
should bebe
explored
explored to the limit
to the limit of tissue blood
of tissue blood staining
staining
• Needlestick injuries
Needlestick injuries should
should be
be treated
treated according
according to to
the
the wellpublished
well published protocols
protocols because
because of hepatitis
of hepatitis
and
and HIV
HIV risks.
risks.
• Xray
Xray examination
examination should
should be carried out
be carried in order
out in order to
to
rule
rule out
out retained
retained foreign
foreign bodies in the
bodies in the depth
depth of
of the
the
wound.
wound.
Haematoma
Haematoma

• If large,
If large, painful
painful or causing neural
or causing neural deficit,
deficit, a
a
haematoma may
haematoma may require
require release
release by incision or
by incision or
aspiration.
aspiration.
• . InIn the
the gluteal
gluteal or
or thigh
thigh region, there may
region, there may bebe anan
associated
associated disruption
disruption of
of fat in the
fat in the form
form of
of aa fat
fat
fracture,
fracture, which
which results in an
results in unsightly groove
an unsightly groove butbut
intact skin.
intact skin.
• An untreated hoemotomo
An untreated haematoma may may also calcify and
also calcify c d
therefore
therefore require
require surgical
surgical exploration
exploration ifif
symptomatic.
symptomatic.
•Degloving
'Deg loving

• stripped by
stripped by avulsion
avulsion from
from the underlying fascia,
the underlying fascia,
leaving neuro vascular
leaving neuro vascular structures,
structures, tendon
tendon or
or bone
bone
exposed.
exposed.
• A
A degloving injury may
deg loving injury may bebe open
open or closed.
or closed.
• An
An obvious
obvious example
example of of an
an open
open degloving is a
deg loving is a ring
ring
avulsion injury with
avulsion injury with loss
loss of
of finger
finger skin
skin
'Compartment syndromes
•Compartment syndromes

• Compartment syndromes
Compartment typically occur
syndromes typically in closed
occur in closed
lower
lower limb injuries.
limb injuries.
• They
They are characterised by
are characterised by severe
severe pain,
pain, pain
pain on
on
passive movement of
passive movement of the
the affected compartment
affected compartment
muscles, distal
muscles, distal sensory
sensory disturbance
disturbance and,
and, finally,
finally, by
by
the absence
the absence of of pulses
pulses distally.
distally.
• They can occur
They can occur with
with anan open injury ifif the
open injury the wound
wound
does not extend
does not into the
extend into the affected compartment
affected compartment
Compartment syndromes
Compartment syndromes

¨ Compartment
C mp rtm nt pressures
pr ssur S C cann be measured using
be measured using aO

pressure monitor and

pressure monitor and a catheter placed
a catheter in the
placed in the
muscle compartment.
muscle compartment.
If pressures
¨ If pr ssur S are r Cconstantly
nst fitly greater
gr aler than
than 30 mmHg
30 mmHg
or
or ifif the
the above clinical signs
above clinical signs are
are present,
present, then
then
fasciotomy
fasciotomy should
should bebe performed.
performed.
¨ .F Fasciotomy involves
sci t my inv incising the
Iv s incising the deep muscle fascia
deep muscle fascia
and
and is is best carried out
best carried out via
via longitudinal incisions of
longitudinal incisions of
skin,
skin, fatfat and
and fascia.
fascia.
Compartment syndromes
Compartment syndromes

¨ The
Th muscle
muscat will
will then
th n be
b seen
S n bulging
bulging out
out through
through the
the
fasciotomy
fcisciotomy opening.
opening.
¨ The
The lower
lower limb can be
limb can be decompressed
decompressed viavig two
two
incisions, each
incisions, each being
being lateral
lateral to
to the
the subcutaneous
subcutaneous
border
border of of the tibia.
the tibia.
¨ This
This gives
gives access
access to to the two posterior
the two compartments
posterior comportments
and
and to to the
the peroneal
peroneal and and anterior compartments of
anterior compartments of
the leg.
the leg.
Compartment syndromes
Compartment syndromes

¨ In crush
In crush inluri
injuriesS that
th t present
pr S nt several
S venal days
days after
after the
the
event,
event, a
O late
late fasciotomy can be
fasciotomy can be dangerous
dangerous because
because
dead muscle produces
dead muscle myoglobin which,
produces myoglobin if suddenly
which, if suddenly
released into the
released into the blood
blood stream, causes
stream, causes
myoglobinuria with
myoglobinuria with glomerular
glomerular blockage
blockage and
and renal
renal
failure.
failure.
¨ . InIn the
the late treatment of
late treatment of lower
lower limb injuries,
limb injuries,
therefore,
therefore, itit may
may be
be safer
safer to
to amputate
amputate the
the limb
limb
once
once viable
viable and nonviable tissues
and nonviable have been
tissues have been
demarcated.
demarcated.
High-pressure injection injuries
High-pressure injection injuries
• The use of
The use highpressure devices
of highpressure devices inin cleaning,
cleaning,
degreasing
degreasing and and painting can cause
painting can cause extensive closed
extensive closed
injuries through
injuries through small
small entry
entry wounds.
wounds.
• The
The liquid injected spreads
liquid injected spreads along
along fascial
fascial planes,
planes, a d
common site
common site being
being from
from finger
finger to
to forearm.
forearm.
• The tissue damage
The tissue damage is is dependent
dependent uponupon the
the toxicity
toxicity
of
of the
the substance
substance andand the injection pressure
the injection pressure
CARDIAC SURGERY
rF
it
i I

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up -1

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II 1
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I 1 I
INTRODUCTION:

The CARDIOTHORACIC means "pertaining to the heart and

The term CARDIGTHORACIC
chest." The term comes from the Greek word "kardiakos"
"kardiakcs" which means
pertaining to the heart, and "thcrac"
"thorac" which is Latin for chest. In general
terms, the term refers to the chest.
 While the term does refer to the chest as a whole, in medicine it is most
often used in the context of surgery.
DEFINITION:

> CARDIAC SURGERY, also called HEART SURGERY, involves


surgical operations performed on the heart under to correct life-
threatening conditions.
conditions.
> The surgery can be
 either;
he either,
 OPEN
OPEN HEART SURGERY
HEART SURGERY
 CLOSED
CLOSED HEART SURGERY or
HEART SURGERY
 MINIMALLY
MINIMALLY INVASIVE SURGERY SURGERY depending on the
conditions to be corrected.
HISTORY:

The
>The first successful surgery(Open heart) on the heart was performed by
Dr. Daniel Hale Williams of Chicago, America in 1893.
1896:
>l896: Ludwig Rehn : Suture cardiac stab.
>1920: Cutlet and Beck : Mitral Valvotomy.
1920: Valyotomy.
>1925: Henry Souttar operated successfully on a young woman with mitral
1925:
valve
y a l e stenosis.

>1937: Robert Gross : Ligation of PDA.

1937: PDA.
CONT…

1944:
>1944: Alfred Blalock, Helen Taussig, and Vivien Thomas performed the
first successful palliative paediatric
pediatric cardiac operation, in a one-year-old
girl with Tetralogy of Fallot.
In
>In 1947, Thomas Sellors operated on a Tetralogy of Fallot patient with
pulmonary stenosis and successfully divided the stenosed pulmonary
valve.
Many
>Many thousands of these "blind" operations were performed until the
introduction of cardiopulmonary bypass made direct surgery on valves
possible
CONT…

In
>In 1948 : 4 surgeons carried out successful operations on mitral valve
stenosis resulting from Rheumatic fever.
1952:
>1952: The first successful intra cardiac correction of a congenital heart
defect using hypothermia was performed by Dr’s.
Dr's. C. Walton Lillehei
and F. John Lewis. In 1953, Alexander eondueted
conducted the first eardiae
cardiac
surgery under local anesthesia.
anaesthesia.
1953: operation).
>1953: Gibbon : Cardiopulmonary bypass.(open heart operation).
In
>In 1956, Dr. John Carter Callaghan performed the first documented
open-heart surgery in Canada.
PURPOSE:

▪ The purpose of Cardiac surgery is to improve the quality of life of the

patient
patient and
and to
to extend
extend the
the patient’s
patient 's lifespan.
lifespan.
PRECAUTIONS:
Cardiac
>Cardiae surgery involves substantial risk and is only done when the
benefits outweigh the risk. Risks are highest for infants under one year of
age and adults over age 60.
CONT…

Risk
>Risk increases with age and when the individual has other health
problems such as DIABETES,CHRONIC
DIABETES,CHR()NIC KIDNEY FAILURE,
CHRONIC LUNG DISEASE, PULMONARY EDEMA, EDEMA, CCHF, HF 9

ELECTROLYTE IMBALANCES, ALCOHOLISM and PRIOR

HISTORY OF UF HEART ATTACK OR STROKE.
DESCRIPTION:

▪ To understand how cardiac surgery works, it is helpful to know

knew something
about the, common
Left
carotid artery

▪ ANATOMY OF THE HEART. Brachiocephalic artery

Left subclavian
artery
,Aorta
Superior vena cava |-

r. Left pulmonary
Right pulmonary arteries anodes
Left pulmonary
Right pulmonary veins veins
ILeft atrium

Right atrium_ . Semilunar valves

Atrioventricular
(mitral) valve
Atnoventricular
(tricuspid) valve .Left ventricle

Chordae tendineae- -Septum

Right ventricle..

Inferior vena cava -

BLOOD CIRCULATION THROUGH THE HEART:

Superior vena cava right tricusmi right pulnwomamf ulrruzma

atriurn valve ventricle valve anew
Inferior vena cava

left left
lungs
ventricle atriurn

r
EIL.l='e iiI:-r
"l."arl:a Gavel

rest
of na
aorta F"L.IIM1:IrELr],'
Arie ry
body
l='LIIrn1:1rlary
Vein

Circulation of FligI'rl
A1 ri_1rn
LE-1l
rl_lrn

F11 i'l r a j
"~*'ELh.-e

Blood FiL|IrnorELry
1ll"E,l"¢'E
LB11
?»"arrlri::
'ADD it:
'."ELh.fe

Through the T rid::LEp

'~°'8l'».'e
l=l
Ve
h'l

Heart: Irrleri-:»r"-fern III-ELVEL

PURPOSE OF THE SURGERY:

> Cardiac surgery is done to correct many different types of heart conditions. The most common are
 are::
 REVASCULARIZATION. (Et: (Eg: CABG)
▪ To
TO TREAT,
 CONGENITAL HEART DEFECTS (Et:
(Eg: ASD CLDSURE)
CLOSURE)
 CORONARY
CORDNARY ARTERY DISEASE
 VALVULAR DISORDERS (Et:
(Eg: MVR)
 ARRHYTHMIAS
 ANEURYSM REPAIR
 REMOVAL OF
oF ANY CARDIAC TUMQRS
TUMORS (Et:
(Eg: ROBOTICALLY SURGERIES)
RQBQTICALLY ASSISTED SURGERIES)
 END STAGE HEART FAILURE REQUIRING HEART TRANSPLANTATION
TYPES OF CARDIAC SURGERY:

OPEN
>OPEN HEART SURGERY.
MODERN
>MODERN BEATING HEART SURGERY.
CABG.
>CABG.
MINIMALLY
>M1N1MALLY INVASIVE SURGERY.
HEART
>HEART TRANSPLANT.
ROBOT
>R<)B<)T ASSISTED SURGERY.
CONT:

>OPEN HEART SURGERY: Surgeon makes a large incision in the chest to open
OPEN
the rib
the rib cage and operate
cage and operate on
on the
the heart. “OPEN” refers
heart. "OPEN" refers to the chest,
to the chest, not the heart.
not the heart.
Depending on the type of surgery, the surgeon also may open the heart.
.
Later
Later found that procedures
found that procedures involving opening the
involving opening the patient’s
patient 's heart could he
heart could
performed better in bloodless and motionless environment. Therefore, during
be

such surgery, the heart is temporarily stopped, and the patient is placed on
CARDIOPULMONARY BYPASS.
ON
- 0 N PUMP SURGERY: USES HEART LUNG MACHINE (CPB).It is the
traditional type of open heart surgery. It allows the surgeon to operate on a
heart that is not heating
beating and has no blood travelling through it.
OPEN HEART SURGERY:

Indicates where
the doctor will Breastbone is cut
cut the and the heart
breastbone is exposed

WMp
Cont…

MODERN
>M()DERN BEATING-HEART SURGERY: Surgeons began to perform
OFF-PUMP CORONARY ARTERY BYPASS SURGERY, which does not
use a heart lung machine and surgeon operates on an actively beating heart.
However, surgeon will slow the heart rate with medication or a device. This
type of open heart surgery is limited to a few specific procedures.
MODERN BEATING HEART SURGERY:
Cont…

CABG:
>CABG: Also called revascularization, is a common surgical procedure to
create an alternative path to deliver blood supply to the heart and body, with
the goal of preventing clot formation. The procedure is typically performed
because of CORONARY ARTERY DISEASE.
In
>In ON-PUMP CABG the heart is stopped with the body's blood supply
being maintained by the cardiopulmonary bypass (CPB) machine. ()n-
On-
pump Coronary artery bypass ((ONCAB)
ONCAB) is the more traditional method
of performing bypass surgery.
CABG:

Coronary artery bypass SUTQETY

Before After

\
Bypass grey ft
CONT…

MINIMALLY
>MINIMALLY INVASIVE SURGERY: An alternative to open-heart surgery,
which involves a five to eight inch incision in the CHEST WALL, a surgeon
may perform an ENDOSCOPIC procedure by making very small incisions
through which a camera and specialized tools are inserted.
ROBOT
>ROBOT ASSISTED HEART SURGERY: A machine controlled by a cardiac
surgeon is used to perform a procedure. The main advantage is it involves
three small holes instead of a big incision.
 MINIMALLY INVASIVE SURGERY:

Conventional Minimally Invasive

Heart Surgery Heart Surgery

DMAYD FIJUHDATIOH FDFI MEDICAL EDUCATION *Hg FIESEIHFICH NU. FIIGHTB HESEIWED.
ROBOT ASSISTED HEART SURGERY:

Robotic: surgery incisions Robotic cardiac surgery

Camera f Surgical cart

.| I

- I
_ .,; I
Computer Camera view l

__
Q .af with robotic
a
|
. .I
_
. hands"
I
I

console n

Heart
.¢¥

Patient
Ribs - -
(incisions) Nurse
Surgeon
u
Cont…

HEART
>HEART TRANSPLANT: It is a surgical transplant procedure performed on
patients with END STAGE HEART FAILURE or severe CORONARY
ARTERY DISEASE when other medical or surgical treatments have failed.
HEART TRANSPLANT:

H part transplant procedure

Ehcnncnr heat

Pulrnmnary
A~:»l*T;a anew l

connection C£IZ'l"IfllEICtiC'l"I

So perlcinr vena
cava CDHHECUDH

Patl~:9l*lt's cilsaaséci ET-umar heart In I:'lacé

heart Ls l'Qmo'-nad lnfenmr vena cava
CCII"lf"l'='El':]1ll'CIZ'III
|-

-a MF."l"D FD UN DATJDH l=ol=l MEDICAL El::»u-:.d.T l::-n A N D F\EsE.=-.Fl-:H. F.LL HIG HTS RESERVED-
 rF
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CARDIO THORACIC r

I 1 I
INCISIONS
▪ A surgical incision is an aperture into the body
body to permit the work of the
planned operation to proceed.
▪ In cardiothoracic surgery, the routinely used incisions are the midline
sternotomy, thoracotomy and pacemaker incisions.
POSITION OF THE HEART INSIDE THE THORAX:

JP
Heart S po Sition in thorax
Q
In mediastinum - behind sternum a n d pointing left,
lying o n the diaphragm
• It weighs 2 5 0 - 3 5 0 gm (about 1 p o u n d )
Base of
heart

Ribs Superior
border

Right
border Left
border

Apex of
heart

I
Inferior border
. -'-if-'V." *\J"l i-.' 't`.lII?€i F`1r-.l.' 1.-Ln-"1 E.1¢.-1-1'-.'.-61 'l"rZ'. ,;ll.,t>1-,-.r-..-.¢.;. _'1-\ Ph13rl.-nn Bn-n5.l:lrn1.n *~ 'nr-.u-Q1
LAYERS OF THE HEART:

Pericardial Fibrous
cavity pericardium

Myocardium

Endocardium

Parietal
pericardium
Visceral pericardium
(epicardium)
TYPES OF INCISIONS:

MEDIAN STERNOTOMY.
»z» MEDIAN STERNOTQMY.

PACEMAKER
*I* PACEMAKER INCISION
THORACOTOMY :
TH()RAC()T()MY

POSTEROLATERAL
~Z~POSTEROLATERAL THORACOTOMY
THGRACOTOMY
ANTEROLATERAL
ANTEROLATERAL THORACOTOMY
AXILLARY
*I°AXILLARY THORACOTOMY
 LATERAL TH()RAC()T()MY
THORACOTOMY
SUBXIPHOID
*I* SUBXIPHOID (PERICARDIAL WINDOW)
CHOICE OF INCISION:

▪ UNDERLYING PATHOLOGY.
PATHQLQGY.

▪ THE SITE (EG: LUNG,CHEST WALL, OESOPHAGUS).

▪ EXPERIENCE OF
oF THE SURGEQN.
SURGEON.
SURGERY
SURGERY : At the level of the 55thth rib for exposure of the upper thoracic
area,
At the level of the 66thth or 77thth rib for lower thoracic area (eg:
(et:
lower oesophageal or diaphragmatic surgery)
surgery)..
MEDIAN STERNOTOMY:

lncisinlI R

I '\I|l-

Sternum
site
'L

j
_ ,f.r

II
iHii"l'nIli.'=DtilF¢r$d Median S ternoromy
MEDIAN STERNOTOMY:

▪ The Median sternotomy is the most common thoracic incision. It is the

incision of choice for most cardiac surgical operations.
▪ It offers excellent exposure to the heart, pericardium, great vessels, anterior
mediastinal structures.
▪ It is predominately used for open heart surgery, such as valve replacements,
CABG, or cardiac transplant.
▪ Anatomy -– The incision is made from the substernal
suhsternal notch to around the
xiphoid process
▪ Discussion -– A widely used incision, which provides good access to the
l

thoracic cavity and the mediastinum.

CONT…

▪ ADVANTAGE::
ADVANTAGE

 The advantages of this incision are that it is quick to perform, especially

especially in hemodynamic emergencies, and it produces less pain than a traditional thoracotomy.
hemodynamic emergencies, thoracotomy.

 drawback is cosmetic, and a risk of ssternal

The main drawback t e a l mal-union exists, which is usually associated
associated with a postoperative
postoperative infection.

 predispose to significant scar formation and chronic chest pain, also Brachial plexus injury may occur.
It can predispose
PACEMAKER INCISION:

Pacemaker
1

un

Incision
Peeaneker
pulse generator

-Lead
Lead if
right alrlum

-implanted
Pacemaker
P
. Lead if
right ventricle
PACEMAKER INCISION:

 The pacemaker incision is utilised in the insertion of a pacemaker -– a device

that regulates the electrical activity of the heart.
 Typically, a 4-Scm
4-5cm incision is made in the left infraclavicular
infraclayicular region. There are
three main types of incision used -– horizontal, oblique and deltopectoral.
 Once the
the incision
incision is
is made,
made, aa subcutaneous
subcutaneous ‘pocket‘
'pocket' is created -– in which the
is created
pacemaker is implanted.
THORACOTOMY:

▪ A Thoracotomy
Thcracctcmy is an incision used to access the pleural space of the
thorax. The three main subtypes are the;
the,
▪ POSTERIQLATERAL
POSTERIOLATERAL 1nc1s1cn,
INCISION,
▪ ANTEROLATERAL INCISION, AND
▪ AXILLARY INCISION.
POSTERIOLATERAL INCISION:

f"
'

J'

JI# Long thoracic and

`i= a I
I

thoracodorsal
I
H

`
|
I

'.

nerve
1
1

I °.
incision Pactoralis Fifth rib
major muscle l I
'r.
-..Q °. '-

Latissimus
dorsa muscle Tip of
scapula
t-
Sixth rib
lnterczostal iii. -1
'l'.-
|
I "-.,:-
Serratus muscles L-._- 5 - 1.

anterior
muscle
1 ~l
F I
. I
.iv
,r
. I l.'
I

50-u1*1:::e: D. J. Sugarbaker; R. Buauo, Y. L. C4::ls»on, M. T. Jaklitsch, M. J. Knasna, S. J. l'~'la'\Eer;

m. Williams, A. Adarns: Adult Chest Surgery, End EcEtion' www.ac:r\=-q=:-=:urger5f.::nm
I:Io=l:>'gn'n-ght © McGraw-Hill Educaijorl. AJ! rights reserved.
CONT…

▪ THE POSTERIOLATERAL
POSTERIOLATERAL TH()RAC()T()MY:
THORACOTOMY: It is the gold standard
for access to the thorax. It provides access to all the thoracic viscera, and is
mainly used for pulmonary resections
resections (pneumonectomy
(pneumcnectcmy or Cr lobectomy),
lcbectcmy),
chest wall resection, or oesophageal surgery.
▪ The incision is made with the patient in the lateral decubitus position. It
starts from between the scapula and mid-spinal line, and extends laterally
to the anterior axillary line.
▪ Before reaching the thoracic cavity, the incision passes through the
latissimus dorsi and serratus anterior muscles, then transects the rhomboids
and trapezius
ANTEROLATERAL INCISION:

Excised pectoral is major m

Pectoral is minor m

Anterior serratus m
Anterolateral thoracotomy
Iracision
Pectoral is major m
CONT…

▪ THE ANTEROLATERAL THORACOTOMY: Incision can be used in a

variety of operations for cardiac, pulmonary, and oesophageal pathology.
▪ The incision runs from the lateral border of the sternum to the mid-axillary
line at the 4th or 5th intercostal space, dividing through the pectoralis
peetoralis major
major
and serratus anterior in its approach.
LATERAL THORACOTOMY:

lateral tharacotorhy
In1c:l5II::1n
Superior lclbE-

T|'~..»' spine
l__._.
mm '-.-'
Fritz: Ur HaNzumtal llssura
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Parietal l::»ileLra
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4§3' Elsevier Ltd. Drake et a l : G r a s s Anatomy f-rJ-r S-tudents www.studei1tc4:rn5=11It.l::::n1

AXILLARY THORACOTOMY:

Lil-Fig. ll14::1r=nn:'i-1: -
'-..
L.8ti:;.-:-iilTll.1:5 d~::l-r"-_1:i
re N*-a-l;°te~d

Posterior .l'!°..:1la-:rio-r
4 P

Lalurzil lhoracicb
.--in. 5 : v
AXILLARY THORACOTOMY:

▪ An axillary thoracotomy is a muscle sparing approach to the thoracic cavity, used

for pneumonectomy and pneumothorax operations
operations..
▪ The incision is made between the posterior border of the pectoralis major and
anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal
space.
▪ Choice in majority
majrarity of PDA LIGATION,PULMONARY RESECT1ONS,PA
LIGATI()N,PULM()NARY RESECTIONS,PA
BANDING.
▪ The incision reduces muscle damage and has good cosmetic outcomes,
▪ It has limited exposure to the thoracic viscera.
SUBXIPHOID (PERICARDIAL WINDOW):

ericardial
Window

. *a
I
b
lll
.v
II I I lll S

's
in

Q-,'l»
...-. ' \
A procedure in which an opening is made in the
pericardium to drain fluid that has accumulated around
the heart. A pericardial window can be made via a small
incision below the end of the breastbone (sternum) or
via a small incision between the ribs o n the left side of
the chest
CONT…

▪ INDICATIONS: pericardial effusion, pericardial biopsy, epicardial

pacemaker.
Incision site Phrenic nerve
▪ POSITION: supine. u-
-J

o
.

-'l,".L-J
',To
*

I I
. "'\
*_ \.
11

▪ INCISION: Midline incision over the

xiphoid or small incision between
xipheid L-

the ribs.
.|...._,_

"..'\

-.

Opening the pericariial sac

QUESTION:

ANS:

① Midline
Midline
sternotomy,
sternotomy,
②
/ Pacemaker scar,
®
I ③ Posterolateral
Posterolateral
®
thoracotomy,
/` ④ Anterolateral
Anterolateral
-|
CD thoracotomy,
'I_I*

I
⑤ _ Axillary
/'
thoracotomy
thoracotomy
o I

x
h<
-.v `\
 rF
it
i I

PREOPERATIVE
PREQPERATIVE up -1

F
II 1
r

ASSESSEMENT AND CARE 1

la
I I
PREOPERATIVE ASSESSMENT AND CARE:

▪ Cardiac surgery is associated with significant morbidity, mortality, and

socioeconomic costs.
▪ Preoperative assessment assists the clinician in identifying potential
complications and facilitates discussion of these risks with the patient.
▪ Careful patient selection and preparation during preoperative evaluation may
minimize morbidity, mortality, and resource use.
CONT…

▪ Preoperative care refers to health care provided before a surgical operation.

The aim of preoperative care is to do whatever is right to increase the
success of the surgery.
▪ At some point before the operation the health care provider will assess the
fitness of the person to have surgery. This assessment should include
whatever tests are indicated, but not include screening for conditions
without an indication.
▪ IT INCLUDES:
Patient
/Patient assessment.
Specific
/Specific preoperative problems and management.
Risk
/Risk assessment and consent.
Medical,
/Medical, Surgical and Anesthetical aspects of patient assessment.
PATIENT ASSESSMENT:

▪ USUAL ASSESSMENT ALGORITHM

HISTORY

EXAMINATION

INVESTIGATION
HISTORY TAKING:

▪ CHIEF COMPLAINTS (PRESENTING COMPLAINTS)

▪ HISTORY OF
oF PRESENT 1LLNESS(QNSET,
ILLNESS(ONSET, DURATION, SEVERITY,
COURSE, ALL FACTORS )
▪ PAST MEDICAL HISTORY(
HISTQRY( EG: ANGINA,
ANGINA, MI,
MI, STROKE, HTN. . .>
STROKE, HTN…)
▪ PERSONAL IIISTORY
HISTORY (OCCUPATION, MARITAL STATUS)
▪ SURGICAL HISTORY(EG: BYPASS GRAFT, STENT…)
BYPASS GRAFT, STENT. . -)
▪ DRUG HISTORY(CVS, GTI IER REGULAR
HISTORY(CVS OTHER
MEDICATIONS,ALLE
MEDICATIONS,ALLERGIES)
RG1ES)
▪ FAMILY IIISTORY
HISTORY
▪ SOCIAL IIISTORY
HISTORY (SMOKING, ALCOHOL,
ALCGHOL, DIET, SLEEP,
EVDDFTQD \
Cont…

▪ Cardiovascular -– (C
(C/O
/ O CVS PROBLEMS)Chest pain / Palpitations / Dyspnoea
PROBLEMS)Chestpain Dyspnoea / Syncope
Syncope
/ Orthopnoea / Perzpheral
Peripheral oedema
edema
▪ Respiratory –(C/O
(C / O RESP PROBLEMS)
PRCBLEMS) Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis
Haemoptysis / Chest
pain
▪ GI -– Appetite / Nausea / Vomiting / Indigestion / Dysphogio
Dysphagia / Weight loss / Abdominal pain / Bowel habit
▪ Urinary – Volume ofurinepossed/Fltequeney/
of urine passed / Frequency / D
Dysuria
curio / Urgency
Urgency / Incontinence
Incontinence
▪ CNS – Vision Heodoche / Motor or
Wsion / Headache or sensory disturbance/ Loss of consciousness
sensory disturbance/Loss consciousness / Confusion
Confusion
▪ Musculoskeletal -– Bone
Bone ondjointpczin
and joint pain / Musculorpoin
Muscular pain
▪ Dermatology -– Rushes
Rashes / Skin
Skin breaks / Ulcers
Ulcers / Lesions
Lesions
▪ METABOLIC – DM, THYROID DYSFUNCTION.
▪ OTHER – HIV,HEPATITIS,TB,MALIGNANCY.
PHYSICAL EXAMINATION:

▪ GENERAL:
GENERAL: Anaemia,
Anaemia, jaundice,
jaundice, cyanosis,
cyanosis, clubbing,
clubbing, nutritional
nutritional status
status etc…
etc. . .
▪ Local: CVS,
CVS; Pulse, BP, HR, Heart sound, Peripheral edema.
edema… ..
(INSPECTION,PALPATION,PERCUSSION AND AUSCULTATION.)
▪ OTHER
OTHER SYSTEM:
SYSTEM: Respiratory, Gastrointestinal, CNS,
Respiratory, Gastrointestinal, CNS, etc.
etc… ..
PREOPERATIVE
PREOPERATIVE ASSESSMENT of site, side of surgery, specific imaging of site
and related investigations.
Presence
Presence of bacteriaemia can decrease the surgical results, so should check for
and treat 1nfect1cn
infection in
in pre cp
op period.
perrcd.
Airway
Airway assessment, assessment of dentition(for loose dentures).
Investigations:

▪ Blood tests(CBC): check for anemia (low iron) , chemical (electrolyte) imbalances
in the blood, blood glucose level and HbAlC.
HbA1C.
▪ Serum electrolyte.
▪ Urine analysis.
▪ Coagulation screening. (CLOTTING
(CLOTTING TIME AND BLEEDING TIME).
▪ ABG
▪ PFT
▪ Chest xX ray: non-invasive test shows if fluid is building up in the lungs or if the
heart is enlarged.
▪ Electrocardiogram (EKG): non-invasive test helps detect abnormalities in heart
rhvthna and hpnr'r h p n l f h iv mp¢\Q111~ino 'rep plpr"rrir'Ql ¢\r"rivi'rv of 'rep hpnrt
▪ Echocardiogram: non-invasive imaging test that produces a picture of the
heart in motion as it beats;
beats, extremely helpful in showing heart and valve
damage
▪ Kidney function tests: help pinpoint the cause of fluid retention
▪ Stress test: an electrocardiogram done while exercising or, for people who
cannot exercise, while the heart is stimulated by medication.
▪ Transesophageal echocardiography: a diagnostic test using an ultrasound
device that is passed into the esophagus of the patient to create a clear image
of the heart muscle and other parts of the heart
▪ Angiogram: an x-ray (radiographic) study of the blood vessels. An angiogram
uses a radiopaque
radiopaque substance, or contrast medium, to make the blood vessels
PRE OPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY:

▪ INFORMED CONSENT.
▪ SURGEON AND ANAEST] To SURGERY TO
I[TIST MEET PT PRIOR TO
ANAESTHETIST T()
IDENTIFY THE PT AND CONFIRM THE SURGERY.
▪ NPO FOR 6-8 IIRS.
HRS.
▪ PLACEMENT OF URINARY CATHETER.
CATI IETER.
▪ ANTIBIOTICS
ANTIBIQTICS GIVEN AN HOUR PRIOR BEFORE SURGICAL
INCISION.
▪ START OF IV LINEAND FLUID MGT.
▪ PREPARATION OF
QF PARTS.
PRE OP MODIFICATION OF TREATMENT:

▪ Anticoagulants - These are tailed off over a few days prior to operation.
▪ Aspirin and Clopidogrel- This has a significant effect in diminishing platelet
function and can lead to increased postoperative blood loss. Ideally it should be
he
stopped 7-10 days before surgery, if not, should be stopped on the day of
admission of the patient - unless there is unstable angina.
▪ Digoxin - Continued until the day before operation.
▪ Diuretics and Potassium Supplements - Continued until the day before operation
▪ B BLOCKERS -to continue them until the day before operation.
▪ Anti Hypertensives - Maintain until operation
▪ ANTI PLATELET: Should be withdrawn a week before surgery.
/ T /\1\TTv\r*1T\1*T \T(l1 A TT\ T T r * 4 T T A TTT\1*n T\Trl1rl1/\1\Tr'r1T TT T1*
▪ Depending on the procedure after care is given.
Complications::
Complications
Excessive
Excessive bleeding, infection, and a negative reaction to anesthesia.
anaesthesia.
Other complications include the development of kidney failure, heart
arrhythmias , heart attack, blood clot formation, and stroke during or soon
after the procedure. Death is possible and occurs in about 3%
30/o of patients who
have cardiac bypass surgery and valve replacement surgery.
CONNEXIONS:

OUT
BiG
sis
Connexions:

We use an before words which begin with

vowels (a

apple eye
Connexions:
f
CLASSIFICATION OF
SHOCK
_ 1.
1.

2.
2.
Hypovolaemic
Hypovolcaemic shock
shock
Cardiogenic shock
Cardiogenic shock
3.
3. Obstructive shock
Obstructive shock
4.
4. Distributive shock
Distributive shock
5.
5. Endocrine shock
Endocrine shock
Hypovolaemic
Hypovoloemic shock
shock

¨ Hypovolaemic
Hyp V I mic shock
sh ck isis due
du to T a ca reduced circulating
reduced circulating
volume.
volume.
¨ Hypovolaemia may
Hypovolaemia may be be due
due to haemorrhagic or
to haemorrhagic or
nonhaemorrhagic causes.
nonhaemorrhagic causes.
¨ Nonhaemorrhagic causes
Nonhaemorrhagic causes include
include poor
poor fluid intake
fluid intake
(dehydration),
(dehydration), excessive
excessive fluid
fluid loss
loss due
due toto vomiting,
vomiting,
diarrhoea, urinary loss
diarrhea, urinary loss (e.g.
(e.g. diabetes),
diabetes), evaporation,
evaporation,
or
or ‘thirdspacing’
'thirdspacing' where
where fluid is lost
fluid is into the
lost into the
gastrointestinal tract and
gastrointestinal tract interstitial spaces,
and interstitial spaces, as as for
for
example
example inin bowel
bowel obstruction
obstruction or or pancreatitis.
pancreatitis.
¨ Hypovolaemia
Hyp V I mi is is probably
pr b loly the most common
the most common form
form
of
of shock,
shock, and to some
and 'to some degree
degree is is a component of
a component of all
all
other forms
other forms of
of shock.
shock.
¨ Absolute
Abs jut orr relative
r I tiv hyphypovolaemia must be
V I emia must be
excluded
excluded or
or treated
treated in in the management of
the management of the
the
shocked state, regardless
shocked state, regardless of cause.
of cause.
Cardiogenic shock
Cardiogenic shock

¨ Cardiogenic
C rdi g nic shock is due
sh ck is du to
t primary
primary failure
failure of
of the
the
heart to
heart to pump
pump blood to the
blood 'to the tissues.
tissues. Causes
Causes of
of
cardiogenic shock
cardiogenic include
shock include
¨ myocardial
my infarction,
C rdi I inf rcti n, cardiac
Crdi C dysrhythmias,
dysrhythmias,
valvular heart disease,
valvular heart disease, blunt myocardial injury
blunt myocardial injury and
and
cardiomyopathy.
cardiomyopathy.
¨ Cardiac
C insufficiency
rdi C insuffici mayy
ncy m also
Is be
be due
due to
to
myocardial depression
myocardial caused by
depression caused by endogenous
endogenous
factors
factors (e.g.
(e.g. bacterial
bacterial and humoral agents
and humeral agents released
released
in sepsis)
in sepsis) or
or exogenous
exogenous factors,
factors, such
such as
as
pharmaceutical
pharmaceutical agents
agents or
or drug
drug abuse.
abuse.
¨ Evidence of
Evidence of venous hypertension with
venous hypertension with pulmonary
pulmonary or or
systemic
systemic oedema
oedema maymay coexist
coexist with
with the classical signs
the classical signs
of
of shock.
shock.
Obstructive shock
Gbstructive shock

¨ In
In obstructive
bstructiv shock
sh ck ththere is a reduction
r is reduction in in preload
preload
due
due to mechanical obstruction
to mechanical obstruction of cardiac filling.
of cardiac filling.
Common causes
Common causes of
of obstructive
obstructive shock include cardiac
shock include cardiac
tamponade, tension
tamponade, tension pneumothorax, massive
pneumothorax, massive
pulmonary
pulmonary embolus
embolus or or air
air embolus.
embolus.
¨ In each
In case, there
each case, there isis reduced
reduced filling
filling of the left
of the left
and/or
and or right
right sides
sides of
of the heart leading
the heart leading toto reduced
reduced
preload
preload and and aa fall in cardiac
fall in cardiac output.
output.
-or- rI- ._
Distributive shock
Distributive shock

¨ Distributive shock
Distributiv sh ck describes
d scrib S the
the pattern
pattern of
of
cardiovascular responses
cardiovascular characterising a
responses characterising a variety
variety of
of
conditions, including
conditions, including septic
septic shock,
shock, anaphylaxis
anaphylaxis and
and
spinal cord injury.
spinal cord injury.
¨ Inadequate
In d au t organ rg n perfusion is accompanied
p rfusi n is accompanied byby
vascular
vascular dilatation
dilatation with hypotension, low
with hypotension, low systemic
systemic
vascular
vascular resistance, inadequate afterload
resistance, inadequate afterload and
and aa
resulting
resulting abnormally
abnormally fall cardiac output
fall cardiac output
¨ In
In anaphylaxis,
n phyl xis, vasodilatation
v S dil t ii n is is due
due to histamine
to histamine
release,
release, while
while in in high
high spinal cord injury
spinal cord injury there is
there is
failure
failure of
of sympathetic
sympathetic outflow
outflow and
and adequate
adequate
vascular
vascular tone
tone (neurogenic
(neurogenic shock).
shock).
¨ The
Th ccause
us inin sepsis is Iless
s psis is clearr but
ss cl is related
but is related toto the
the
release
release of
of bacterial
bacterial products
products (endotoxin)
(endotoxin) and the
and the
activation
activation of cellular and
of cellular humoral components
and humeral components of of
the immune system.
the immune system.
¨ There
Th r is is m
maldistribution
ldistributi n off blood
bl od flow
flow atat a
ca
microvascular level
microvascular level with
with arteriovenous
arteriovenous shunting
shunting and
and
dysfunction
dysfunction of cellular utilization
of cellular utilization of
of oxygen.
oxygen.
¨ In th
In the Ilater
t r phases
ph S S off septic
s ptic shock there is
shock there is
hypovolaemia from
hypovolaemia from fluid
fluid loss into interstitial
loss into interstitial spaces
spaces
and
and there may be
there may concomitant myocardial
be concomitant myocardial
depression, complicating the
depression, complicating picture .
clinical picture
the clinical
Endocrine shock
Endocrine shock

¨ Endocrine
End Crin shock mayy present
sh ck m pr S nt as
GS a combination of
ca combination of
hypovolaemic, cardiogenic
hypovolaemic, cardiogenic oror distributive
distributive shock.
shock.
Causes of
Causes of endocrine
endocrine shock include hypo
shock include hypo and
and
hyperthyroidism and
hyperthyroidism and adrenal insufficiency.
adrenal insufficiency.
¨ Hypothyroidism
Hyp thyroidism ccauses
us s a shock
sh ck state
state similar
similar to
to that
that
of neurogenic shock
of neurogenic shock due
due to
to disordered
disordered vascular
vascular and
and
cardiac responsiveness
cardiac responsiveness to circulating catecholamines
to circulating catecholamines
¨ Cardiac
C rdi C output
utput falls
f lls due
du to
t Ilow inotropy and
W inotropy c d
bradycardia.
bradycardia. There may also
There may also be
be an
an associated
associated
cardiomyopathy. Thyrotoxicosis
cardiomyopathy. may cause
Thyrotoxicosis may cause a high-
a high-
output cardiac
output cardiac failure.
failure.
HI

EMERGENCIES IN VASCULAR
SURGERY

Dr. Joel Arudchelvam

Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura
HI Some Vascular Emergencies

 Acute limb Ischaemia

 Accidental arterial injection

 Compartment syndrome

 Vascular trauma

 Deep vein thrombosis

HI Acute limb Ischaemia

 Sudden interruption of blood supply to

limb resulting in threat to the limb
viability.
 Acute limb Ischaemia
.Inside the vessel
. E embolus
.on the wall of vessel
. Th rombosis
. Trauma
. Dissection
Compression from outside
Tight bandage, cast, tourniquet
Compartment syndrome
.
l

Burn
.
]el
HI Acute limb Ischaemia
Presentation
“ P ”s
 Pain
 pallor
 Perishing cold
 Pulselessness
 Paresis / paralysis
 Paraesthesia / anaesthesia.

Beware
 After trauma
 After anaesthesia
Diagnosis – Clinical
 “do not waste time on investigation”
HI Acute limb Ischaemia
Management
 Recognize
 Start unfractionated heparin
 Loading dose 75 – 100 IU/Kg ( approximately 5000 IU )
 Followed Infusion of heparin -18U/kg (approximately -1000U/hr)
 Refer to vascular surgeon
 Pain relief
 Keep fasting
 Check the Viability of the limb - note.

 Acute limb ischemia is a clinical diagnosis -there

is no need of imaging.
HI Acute limb Ischaemia

 Surgery
 Embolectomy with
fogarty catheter
 Can be done under LA

 Post op
 Monitor distal pulse
 Continue heparin
 Start warfarin
 Monitor for
reperfusion effects
 Reperfusion effects
HI

 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion

 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure
Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
Ischemia Rape
erfu `
U5¥D!'l Ischemic
4> Injury

Fteperfusiu-I
Injury

freak Time
rent
DURING ISCHAEMIA
ISCHAEMIA
CELLULAR OEDENIA

IMPAIRED IDN PUMPS

INFLUK OF Na+ . Ca2+
REDUCED ATP
INCREASED GLycoLysls
ACIDDSIS
ACTIVATION oF
PRDTEASES

UNCCIUPLING OF
MITDCHDNDRIAL XANTHIPPE
PHOSPHDRYLATIDN DEHYDRGGENASE

ENDOQTHELIAL CELLS HANTHINE OXIDASE

PRODUCTION DF
RELEESE GF ADHESION
INFLAMMATORY CELL MEMBRANE
MOLECULES
NIEDIATGRS GAPS IN Dl5RUPTlgN

ENDOTHELIUM
URGANELLE
DISRUPTION

.IDEL
DURING ISCHAEMIA
ISCHAEMIA
CELLULAR OEDENIA

IMPAIRED IDN PUMPS

INFLUK OF Na+ . Ca2+
REDUCED ATP
INCREASED GLycoLysls
ACIDDSIS
ACTIVATION oF
PRDTEASES

UNCCIUPLING OF
MITDCHDNDRIAL XANTHIPPE
PHOSPHDRYLATIDN DEHYDRGGENASE

ENDOQTHELIAL CELLS MArTI-IINE OKIDAS

I _ PRODUCTION OF
RELE/:SE OF I n ADHE5ION
INFLAMMATORY CELL MEMBRANE
,MDLECULES
Il]l
I

EDIATGRS APS IN Dl5RUPTlgN

ENDOTHELIUM
URGANELLE
DISRUPTION

.IDEL
AFTER REPERFUSION

GAP5 IN OEDEMA AN
ENDOTI-IELIUM -C'OMPMTM E
SYNDROME

REPERFUSION
XANTHINE OXIDASE FREE RADICALS FURTHER CELL DEATH

ADHESIDN
MULECULES

RELEJNSE OF
INFLAMMATIUN
INFLAMMATORY
MEDIATORS
 AFTER REPERFUSION
HI
Ischemia Reperfusion Ischemic
4 lnlurgr

susann
in]

TllE3l* Time
ma rt
MANAGEMENT OF REPERFUSION EFFECTS

GAP5 IN OEDEMA AN
ENDDTI-IELIUM '-CUMPMTM E
SYNDROME

FDDT END EL£VANON

msczornnnv
REPERFUSION
KANTHINE DXIDASE FREE RADICALS FURTHER CELL DEATH

MANNITOL

PRODUCTION or nomaosls
ADHESIDN AMTl[DAI;iUIJUI.NT5
MDLECULES

RELEESE OF
INFLAMMATION
INFLAMMATORY
MEDIATORS

JOEL
MANAGEMENT OF REPERFUSION EFFECTS

ISCHAEMIA
CELLULAR CIEDEMA

IMPAIRED IDN PUMPS

INFLUK OF Na+ . Ca2+ cALcium c1-IAr4lueL
REDUCED ATP
INCREASED GLYCDLYSIS INHIBITORS
ACIDOSIS
ACTIVATION OF
PRUTEASES

UNCOUFLING OF
MFTDCHONDRIAL IANTHIHE
PHOSPHDRYLATIDN DEHYDRDGENASE

ALLDPURINCII.
ENDODTHELIAL CEU_5 XANTHIHEOXIDASE

PRODUCTION DF
E DF ADHESIDN
INFLGMMATURY CFLLMEMBRAHE
MOLECULES
MEDIATGRS GAPSIH DISRUPTIOH
ENDDTHELIUM
C3 convurtase inhibitor DRGANELLE
soluble complement DISRUPTIDN
rictptor 1 J
lntilaukacytl tl1.r.py
JOEL
 Reperfusion effects
HI

 Systemic
 Substances Released
 Lactic Acid
 K+
 Inflammatory Mediators
 Myoglobin
 Activated Leucocytes
 Etc.
 Reperfusion effects
HI

 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure
HI Reperfusion effects

 Mangement

 Ligation of vessel if not responding to other

supportive measures
HI Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.

 Compartment Perfusion Pressure (CPP)

 Mean Arterial Pressure (MAP)
 Intra Compartmental Pressure (ICP)

CPP = MAP – ICP

HI Compartment syndrome
Causes

 Trauma (muscle contusion)

 Haematoma
 Reperfusion
 Intracompartmental extravasation of fluids
 Tight bandage, cast
HI Compartment syndrome
Clinical features

 Excessive pain - pain on passive movements

 Numbness -e.g. anterior compartment first toe web
(deep peroneal nerve )
 Tense swollen leg
 Do not look for absent distal pulse – late
HI Compartment syndrome
Treatment

 Recognize

 Remove the cause

 Reduce intracomparmental pressure

 Remove bandages and cast

 Fasciotomy
HI Compartment syndrome
Treatment
S

Imzhaemia
.r
Reduced
Ell1:-r;1=:;1 Flow

Oedema
'|.

llncreaged . Fa5clotomy
Cmmparmtent
Pressure
Compartment Syndrome

Fasciotomy
anterior comp\
l3ll.CI]mp

.
deep plostéonup sup.posf.comp
joel
HI Accidental intra-arterial
injection
 Problems
 Haematoma / false aneurysm
 Ischaemia
 Due to arterial dissection and thrombosis
 Due to the effects of the drugs
 Accidental intra-arterial injection
Drugs causing ischaemia / necrosis
HI
Hyperosmolar Acids/alkalis Vasoconstrictors
Calcium chloride Aminophylline Epinephrine
Calcium gluconate Amiodarone Dobutamine
Magnesium sulphate Amphotericin Dopamine

Parenteral nutrition Diazepam Metaraminol

Potassium chloride Phenytoin Norepinephrine

Vasopressin
Sodium bicarbonate Thiopental

Vancomycin
HI Pathophysiology

 Arterial Spasm

 Chemical Arteritis

 Crystal Formation
 Accidental intra-arterial
HI injection
Recognition

 Flashback -pulsatile.
 Flashback blood redder than usual.
 Haematoma formation

 severe discomfort distal to the site

of injection
 Signs of distal ischemia
 Pain
 Pale /cyanosis
 Perishing Cold
 Absent pulse
 Paresthesia / anaesthesia
 Paresis / Paralysis
HI Accidental intra-arterial
injection
Management

 Stop the injection

 Leave the cannula in place
 Vascular surgical referral
 Anticoagulation – heparin 75U/ Kg stat and 18
U/ Kg hourly
 Inject lidocaine, papaverine through cannula
HI Accidental intra-arterial
injection
Management cont…
 Calcium channel blockers
 Aspirin, Methylprednisolone – Thromboxane
blocker
 Iloprost - Prostacycline analogue
 Stellate ganglion block - vasodilatation
 Analgesia
HI Vascular trauma / injuries

Causes
 Road Traffic injuries – 60%
 Trap Gun
 Iatrogenic - 25%

 Penetrating / Sharp
 Blunt
HI Mechanism of disruption of flow
at arterial level
 Transection

 Laceration

 Contusion

 Kink

 Intimal flap
 Vascular trauma
HI
Signs of a vessel injury
 Hard signs
 Active bleeding
 Thrills, Bruits
 Signs of distal ischemia
 Absent pulse
 Pain
 Pale
 Perishing Cold
 Paresthesia / anaesthesia
 Paresis / Paralysis
 Expanding hematoma
HI Vascular trauma

 Soft signs
 Reduced pulse
 Hematoma
 Injury close to a known neurovascular bundle

 paresis/ paralysis and paresthesia / anaesthesia - late

signs
 Paresis and paresthesia - viability in immediate threat
 Anaethesia and paralysis -not viable.
Investigations

Investigations

• Hard signs
• urgent intervention

• Soft signs
• Observe
• Investigate
HI Investigations
• Hand held Doppler

• Absent Doppler flow

• Quality of signal

• Duplex scan (USS +

Doppler )

• Difficult to image in trauma

• Due to
• Pain
• Non cooperative patient
• Dressings
HI Investigations

 Angiography
 CT angiography
 Catheter angiography
HI CT ANGIOGRAPHY
 TREATMENT
HI Surgical Repair
 Prompt transport to operating room
 Entire limb cleaned should be able to palpate distal pulses.
 Thigh prepared – for venous harvest
 Mobilisation and control of proximal and distal arterial ends
and trimming
 Surgical repair (cont..)
HI
 Balloon thrombectomy
 Systemic and distal heparinisation
 Interposition graft / Direct
approximation
 Unit experience – 88.2% RSVG

 Prosthesis
 lower patency
 infection
HI Surgical repair (cont..)

REVERSED SAPHENOUS VEIN GRAFT (RSVG)

HI POST OPERATIVE MONITORING

 Monitor distal pulse / Sao2

 Keep limb elevated
 Check movement and sensation
 Follow surgical instruction regarding
anticoagulation
 Look for compartment syndrome
 Look for post perfusion effects
 Do not apply encircling dressings
Deep Vein Thrombosis

 Thrombosis – formation of solid material

within the circulation using blood
components.

 Phlebothrombosis
 Thrombophlebitis
DVT Causes - Virchows triad
BLOOD

VESSEL

FLOW
HYPERCO/-EULABILITY
a oratory Bowel Disease
Major surgery I trauma
A_Y Au ""tune condition
Malignancy

_
Estr lthetapy
Pregnancy (post a um)
Inherited thrum pink
I
Infection and sis

VASCULAR DAMAGE CIRCULATORY STASI

Thrombophledni I Immobility
Cellulitis 1 I Venous obstruction (o e , tun our, pregnancy)

Indwellin__ r
theter
Venep c re Congenital abnormalities I fig venous anatomy
Phys *rauma (e.g., May-Thurner and l L.I
-Schroétter syndrome
u.
HI Clinical presentation

 Leg swelling
 Pain
HI Investigations
 D dimer

 Originate from clot lysis

 Duplex scan ( USS +

Doppler)

 Solid material inside vessel

 Non compressible
 Absent flow
Diagnosis and treatment

Clinical suspicion of DVT

D dimer -ve D dimer + ve

I

Venous Duplex
look for other
causes +ve

High risk low risk

I I

Treat
look for other
start anticoagulation
causes
,Repeat Duplex in 1 week
ioel
Diagnosis and treatment

 LMWH (low molecular weight heparin) – e.g. Enoxaparin

(1 mg/kg twice daily SC), dalteparin, tinzaparin
 Advantages
 does not require infusion
 Does not need frequent monitoring

 Unfractionated Heparin
o Loading dose 75 – 100 IU/Kg ( approx 5000 IU )
o Followed by Infusion of heparin -18U/kg (approx -
1000U/hr )
o monitored with APTT. (Keep APTT between 60 to 80s)
Diagnosis and treatment
 Also Start
o Warfarin
o10 mg D1
o10 mg D2
o5 mg D3

 Target INR - between 2 – 3

 When INR between 2 - 3 for 2 days omit heparin.
 Continue warfarin for 3 months
Diagnosis and treatment
 Other measures
 Analgesics
 Compression stocking
 Foot end elevation
 Hydration
 Young recurrent DVT – haematology referral
HI Pulmonary embolism

 PE occurs in 60 to 80% of patients with DVT

 Only half are symptomatic

 4% massive PE, Mortality – 60%

HI Pulmonary embolism
 Clinical features depends on the size of the embolus

 Small – lodges at peripheral pulm. Vessels

 Pain (pleuritic), effusion

 Larger – at branching points

 Wedge shaped infarction
 Pleuritic pain,effusion, tachypnoea

 Massive – occludes the bifurcation

 Sudden onset pain
 SOB
 Haemodynamic instability
HI Pulmonary embolism

 Diagnosis
 Gold standard – CT pulmonary angiogram
HI Pulmonary embolism
 Other tests

 Arterial Blood Gases

 Hypoxemia
 Hypocapnia
 Alkalosis I
A.
I I
A
l
I
-a-~
 ECG – only 20% has classic changes
 S1 Q3 T3 I •

II
5
l
A

 Right heart strain

a I 11
»

 Tall P waves in lead II (P pulmonale),

I I
1
1 r r 4 I

R axis deviation, RBBB

 2D ECHO – R heart strain

 Acute Pulmonary Embolism Diagnosed by CT Pulnmonary Angiognram

1
Hemodynamliml1'5rI.ll'ble
l Hvunmenslnn
. 5-BP-:9D1n1rll-.
* Vuunrmvn
I u m p m s w u z m h a
hwevwemiwwu-w
' H'yponda nurtr!s-ul'\ril1¢w.hD,

.
-u

"°
Right Heart Sir:in
Yea
°Ed1o

No

4
Dontrah1dic-.llion in
itwrombolysin

5'h'i'l1Bnn-lc
Ho J- Yea
lntkoagulaUon . Symenic .ntlcnagulablon Cilthebei'-dirlcted
mau-ual
I
$-nr:-an-i: Tliumbnlviii
dl4*un1bohr5la
`.
C8tlietrfdlrlcbed
pharmacumechanical
womhoivds
HI Vascular emergencies

 Look for / monitor

 Recognize

 Refer
HI

Thank You
hemostasis
 y

SH- II
»

Shock
@ Shock
ž is a
is a systemic
systemic state of low
state of low tissue
tissue
perfusion that
perfusion that isis inadequate
inadequate for normal
for normal
cellular respiration.
cellular respiration.
o . With
ž With insufficient
insufficient delivery of oxygen
delivery of oxygen and
and
glucose, cells
glucose, cells switch
switch from aerobic to
from aerobic to
anaerobic metabolism.
anaerobic metabolism.
If perfusion
o If
ž perfusion is is not
not restored in a
restored in a timely
timely
fashion, cell death
fashion, cell death ensues
ensues
PATHC)PHYSi- l
I
»Go
CELLULAR
©CELLULAR
ž
As
oAs
ž perfusion to
perfusion to the
the tissues
tissues isis reduced,
reduced,
cells are
cells are deprived
deprived of
of oxygen
oxygen and must
and must
switch from
switch aerobic to
from aerobic anaerobic meta
to anaerobic meta
bolism.
bolism.
The product
oThe
ž product of
of anaerobic
anaerobic respiration
respiration isis
not carbon
not carbon dioxide
dioxide but
but lactic
lactic acid.
acid.
When enough
o When
ž enough tissue
tissue isis underperfused,
underperfused,
the accumulation of
the accumulation of lactic
lactic acid
acid in
in the
the
blood produces
blood produces a a systemic metabolic
systemic metabolic
acidosis.
acidosis.
CE JLAR

@ As
ž As glucose
glucose within cells is
within cells is exhausted,
exhausted,
anaerobic respiration
anaerobic ceases and
respiration ceases and there is
there is
failure
failure of
of sodium/potassium
sodium/potassium pumps pumps in in the
the
cell membrane
cell membrane and and intracellular
intracellular organelles.
organelles.
Intracellular lysosomes
o Intracellular
ž lysosomes release
release autodigestive
autodigestive
enzymes and
enzymes and cell
cell lysis ensues.
lysine ensues.
Intracellular contents,
o Intracellular
ž contents, including
including potassium,
potassium,
are released
are into the
released into blood stream
the blood stream
 AR
@ As
ž As tissue ischaemia progresses,
tissue ischaemia progresses, changes
changes inin
the
the local milieu result
local milieu in activation
result in activation ofof the
the
immune and
immune and coagulation
coagulation systems.
systems.
Hypoxia and
o Hypoxia
ž and acidosis
acidosis activate
activate complement
complement
and prime
and prime neutrophils,
neutrophils, resulting in the
resulting in the
generation of
generation of oxygen
oxygen free
free radicals and
radicals and
cytokine release
cytokine release
o . These
ž These mechanisms
mechanisms leadlead to injury of
to injury of the
the
capillary endothelial
capillary endothelial cells
cells
These, in
o These,
ž in turn,
turn, further activate the
further activate immune
the immune
and coagulation
and coagulation systems
systems
ž
@ Damaged endothelium
Damaged endothelium loses its integrity
loses its integrity and
and
becomes
becomes ‘leaky’.
'leaky'.
o . Spaces
ž Spaces between
between endothelial
endothelial cells
cells allow
allow
fluid
fluid to
to leak
leak out
out and
and tissue oedema ensues,
tissue oedema ensues,
exacerbating cellular
exacerbating cellular hypoxia
hypoxia
 Am. ¢~ DV
SYSTEAM I I I I

H ASc AR
@ As
ž As preload and
preload and afterload
afterload decrease,
decrease, there is a
there is a
compensatory baroreceptor
compensatory baroreceptor response
response
resulting in increased
resulting in increased sympathetic activity
sympathetic activity
and release
and release ofof catecholamines
catecholamines into
into the
the
circulation.
circulation.
This results
o This
ž results in
in tachycardia and systemic
tachycardia and systemic
vasoconstriction ((
vasoconstriction
RESPiRAT-)R
The
@ The
ž metabolic acidosis
metabolic acidosis and
and increased
increased
sympathetic
sympathetic response
response result in an
result in an increased
increased
respiratory
respiratory rate and minute
rate and minute ventilation
ventilation to
to
increase the
increase excretion of
the excretion of carbon dioxide .
carbon dioxide
RE B

Decreased
@ Decreased
ž perfusion pressure
perfusion pressure in in the kidney
the kidney
leads
leads to
to reduced
reduced filtration
filtration at at the
the glomerulus
glomerulus
and a
and a decreased
decreased urine
urine output.
output.
o . The
ž The renin–angiotensin–aldosterone
renin-angiotensin-aldosterone axis axis is
is
stimulated,
stimulated, resulting
resulting in in further
further
vasoconstriction and
vasoconstriction and increased
increased sodium and
sodium and
water
water reabsorption
reabsorption by by the kidney.
the kidney.
 | |
ENE >CR E
ž
@ activation
activation ofof the
the adrenal
adrenal andand renin–
renin-
angiotensin
angiotensin systems, vasopressin
systems, vasopressin
(antidiuretic
(antidiuretic hormone)
hormone) is is released
released from
from the
the
hypothalamus in
hypothalamus in response
response to to decreased
decreased
preload and
preload and results in vasoconstriction
results in vasoconstriction and and
resorption
resorption of of water
water inin the
the renal collecting
renal collecting
system.
system.
Cortisol is
o Cortisol
ž is also
also released
released from
from the
the adrenal
adrenal
cortex, contributing
cortex, contributing to to the
the sodium
sodium andand water
water
resorption
resorption andand sensitising cells to
sensitising cells to
catecholamines.
catecholamines.
iSCHAEMiA-REPERFUSi()N
6Y ")M E
Introduction to
Introduction to Neurosurgery
Neurosurgery

MD11 and Gregory J. Zipfel, MD

Brian L. Hoh, MD MD22
1University
lUniversity of Florida, 22Washington
Washington University
University

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Disclosures
Disclosures
• No commercial interests

Acknowledgements
Acknowledgements
Katie Orrico,
• Katie Orrico, AANS/CNS
AANS/CNS Washington Committee
Washington Committee

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Definition of
Neurosurgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Neurosurgery
Neurosurgery
Constitutes a medical discipline and surgical specialty that
• Constitutes that provides care for
for adult
and pediatric
pediatric patients
patients in the treatment
treatment of pain or pathological
pathological processes that
that may
modify the function
modify the function or activity
activity of the
the central nervous system (e.g. brain,
brain, hypophysis,
hypophysis,
and spinal cord), the peripheral
peripheral nervous system (e.g. cranial, spinal, and peripheral
peripheral
nerves), the
the autonomic
autonomic nervous system,
system, the
the supporting
supporting structures
structures of these systems
(e.g. meninges, skull & skull base, and vertebral column),
column), and their
their vascular supply
(e.g. intracranial,
intracranial, extracranial, and spinal vasculature).
Treatment encompasses both
• Treatment both non-operative
non-operative management
management (e.g. prevention,
prevention,
diagnosis -– including
including image
image interpretation
interpretation -– and treatments
treatments such as, but
but not
not limited
to
to neurocritical
neurocritical intensive
intensive care and rehabilitation)
rehabilitation) and operative
operative management
management with with
its associated image use and interpretation
interpretation (e.g. endovascular surgery, functional
functional
and restorative
restorative surgery, stereotactic radiosurgery,
radiosurgery, and spinal fusion -– including its
instrumentation).
instrumentation).

American Board of Neurological Surgery, Definition of Neurological Surgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of Neurosurgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
.• Evidence suggests that
that the first
first trepanations
trepanations may
have occurred up to 10,000 years ago
to 10,000
.• 460-370
460-370 BC Hippocrates describes types of trauma
trauma in
which trepanation
trepanation may be performed
performed
.• 129-200
129-200 AD Galen describes trepanation for
hydrocephalus

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
• Pierre Paul Broca localizes and drains brain abscess
1876 in Paris
• Sir William Macewan
Mace van excises meningioma
meningioma in 1879,
performs Iaminectomy
laminectomy in 1883

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
• 1918 Walter Dandy develops
pneumoencephalography
pneumoencephalography
• 1927 Egas Moniz performs cerebral
angiography
• 1971 Godfrey Hounsfield & Allan Cormack
develop CT scan;
scan, won Nobel Prize in 1972

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
.• Sir Victor Horsley
Horsley (1857-1916)
(1857-1916)
• Intraoperative
Intraoperative cortical stimulation
stimulation to localize
epileptic
epileptic foci
• Bone wax
• Transcranial approach to to pituitary
pituitary
• Ligation of carotid artery to treat
artery to treat aneurysm
• Intracranial division of trigeminal
trigeminal nerve root
root
to
to treat
treat trigeminal
trigeminal neuralgia
neuralgia
• Horsley-Clarke stereotactic
stereotactic frame

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
.• Harvey Cushing (1869-1939)
(1869-1939)
•' Developed anesthesia record
• Cushing response to to intracranial
hypertension
hypertension
• With
With Bovie developed
developed electrocautery
electrocautery
• Function
Function of the pituitary
pituitary gland -– Cushing’s
Cushing's
disease
• Reduced mortality
mortality from
from neurosurgical
operations
operations from
from 80-90% down
down toto 10%
• Father of American Neurosurgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
.• Walter
Walter Dandy (1886-1946)
(1886-1946)
• Trained under Cushing
• Described CSF physiology and hydrocephalus
• Developed pneumoencephalography
• Dandy-Walker malformation/syndrome
malformation/syndrome
• First described clipping of cerebral aneurysm
1938

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
History of
History of Neurosurgery
Neurosurgery
.• Wilder Penfield (1891-1976)
(1891-1976)
• Modernized
Modernized epilepsy surgery
• Research utilizing
utilizing intraoperative
intraoperative electrical
cortical
cortical stimulation
stimulation
• Published first
first homunculus
homunculus
• Penfield’s
Penfield's syndrome

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
Neurosurgery
Practice Demographics

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Neurosurgeons in
Neurosurgeons in US
US
• Approximately
Approximately 3800 practicing neurosurgeons in the
the
US

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Demographic Profiles
Profi es
2011 2006 2011 2006
Gender Years in Practice
Male 90% 91 % Less than 10 years 28% 35 %
Female 10% 4 9% 10-19 years 36% 36%
20-29 years 25 % 21%
Age 30-39 years 9% 7%
Younger than 35 3% 4% 40 years or more 1%
35-45 35% 40% I am no longer practicing 1%
46-55 350/o 37%
56-65 23% 15% Primary Practice Region
Older than 65 4% 4% South Atlantic 19% 19%
Pacific 16% 13 %
Nationality East North Central 14% 17%
Caucasian 76% 80 % Middle Atlantic 12% 11 %
Asian 12% 9% West South Central 11% 10%
African-American 2% 2% East South Central 9% 8%
Hispanic 5% 4% West North Central 9% 7%
Other 5% 4% Mountain 7% 6%
New England 4% 6%
Non-US or blank 1% 2%

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Demographic Profiles
Profi es 2011 2006
Neurosurgery Practice Setting
Neurosurgical group practice 29% 34%
(2-5 neurosurgeons)

Neurosurgical group practice 20% 22%

2011 2006 (6-15 neurosurgeons)
Type of Practice Neurosurgical group practice
Private practice 48% 49% (76+ neurosurgeons)
Private practice 19% 20%
Multi-specialty group practice 14%
(Academic affiliate
(2-5 physicians)
or appointment)
Multi-specialty group practice
Full-time academic 30% 28%
(6-15 physicians)
Military 1% 1%
Other (Federal government) 2% 1% Multi-specialty group practice 11%
(16+ physicians)
Solo 16%
Solo practice, shared facilities

Procedure Setting
Hospital 96% 95%
Freestanding Surgical Center 3% 3%
Other 0% 2%
Office Facility 1% 0%

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
REPQRTED PROCEDURES PERFORMED
IN 2011 BY SPECIALTY
Type of Procedures Performed Total Procedures Performed
Spine 1,448,400
Cranial 579,376
CSF Shunting 103,895
Pain/lnterventional/Functional 59,1605
Peripheral Nerve 55,992
Catheter/Endovascular/Percutaneous 42,193
Extracranial Cerebrovascular 8,870

TOTAL 2,296,331

Note: The annualized total procedures performed by all U.S. Neurosurgeons in 2011 is estimated at 2,296,331. This
estimate is based on survey responses provided by a portion of membership that participated in the 201 1 survey and
provided procedure data.

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Maldistribution
Ma distribution of Surgeons
.• 25% of the U.S.
u.s.
100%

90%

population
population lives in 80%

county
county w/out a m
:foes
:
neurosurgeon D
GJ
go
:s
60%
'IJ"J
"5
1, 50%

.• 50% percent
percent of the :
>
1;
m
40%

_
E
:

U s population
'LJ

U.S.
I population lives
I
30%
Even Distribution
Geneia I Surgeons

in counties w/
w/ 15.5%
20%
Neurosurgeons

5096 of the US population Ihre in an area with

10%
of neurosurgeons 0%
30% of the natic-n's general surgeons
15.5% of the nation'5 neurosurgeons

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cumulative % Population

Source: American College of Surgeons Health Policy Research Institute

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
Number of Neurosurgeons by Age
800
718
700 666 667

600 531
487
500

400
359

300 182
200 161

100

0
34-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
l Age Range

44% of practicing neurosurgeons over the age of 55

I
Source: American Board of Neurological Surgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
Neurosurgical
Neurosurgica Workforce Shortages
• Only 83% of neurosurgeons take emergency call 24/7/36524/7/365
• 178 board certified
certified pediatric
pediatric neurosurgeons
– 42% will
- will retire
retire within the next decade
– Only 6 enter
- enter workforce each year,
year falling short
short of demand
.
• 305 vacant neurosurgery
neurosurgery positions in the U.S. in 2011
– 192 generalists, spine-focused neurosurgeons, or
-
unidentified
unidentified
– 113 subspecialists, including neurovascular,
neurovascular endovascular,
pediatric
pediatric
Sources: Neurosurgery Statement to
Neurosurgery Statement to IOM -- Ensuring an Adequate Neurosurgical Workforce
Workforce American Board of
of Neurological Surgery

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Neurosurgery Compensation
Mean Median
Median 90th
90th

l l l
percentile
percent He
Overall $812,079 $670,100
$670,100 $S 1,417,038
l l l

Private $924,426
S g t / . / 26 $759,662 $1,707,635
practice
practice l l l

Academic $675,521 $569,529 $927,093

Sources :NERVES 2014 report

report based on 2013 data

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
Neurosurgery Malpractice
Ma practice
Insurance

Mean Median
Median 90th
90 th

l l l
percentile
percent He
Overall $50,723 $42,290 $S 89,672

Sources :NERVES 2014 report

report based on 2013 data

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Neurosurgery Residency Match Data
PGY 1 Positions Positions Percent
Year
Applicants Offered Filled Filled
2009 317 191
191 191 100.0
2010 309 191
191 188 98.4

2011 283 195

195 192 98.5

2012 318 196

196 194 99.0
2013 314 204 203 99.5
2014 335 206 206 100.0

Source: National Residency Matching

Matching Program

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
19\,5""'10
Neurosurgical
Neurosurgica Subspecialties
Subspecies ties
.• Spine
.• Peripheral Nerve Surgery
.• Vascular Neurosurgery (open and endovascular)
.• Neuro-Oncology
.• Neuroendocrinology
Neuroendocrinology
.• Skull Base Neurosurgery
.• Pediatrics
.• Functional Neurosurgery
.• Neurocritical Care

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Residency Training:
.• Year 1: Internship year: May include some rotations
rotations
outside neurosurgery like ICU, trauma
trauma surgery, neurology.
neurology.
.• Year 2: Junior resident: Learning the basics of neurosurgical
assessment, patient
patient management,
management, and surgical procedures
.• Year 3:3.: Senior resident:
resident:. Learning more advanced degrees
of patient
patient care and surgical procedures
.• Year 4/5/6: There are frequently
frequently some permutation
permutation of
pediatric neurosurgery,
neurosurgery, neurological electives, research
(3mons
(3m.ons to
to 2 years), and directing
directing some services
services at a Chief
Resident level of management
management
.
• Year 7: Chief Resident: Learning how
how to
to direct
direct a large
neurosurgical service,
service, transition toward being able to
transition toward to
independently
independently do the
the routine
routine neurosurgical procedures

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
The Spectrum of Neurosurgery Residencies
.• Residencies vary in size with
with some programs matching 1
resident a year up to
to 4 residents per year
.• Residencies vary in regard toto the cities in which they
they
reside: Some are in large metropolitan
metropolitan centers with
with
many large academic centers while others are in
relatively
relatively smaller cities
.
• Residencies vary in regard to to the degree of research time
time
that
that is incorporated
incorporated into
into the curriculum
curriculum however
however
research is a part
part of all residency programs
.
• With
With more than 105 programs, there are a wide range of
“personalities”
"personalities" of residencies

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
 Conclusions
Conclusions
• Neurosurgery is a rewarding and intellectually
stimulating career
• Opportunity to profoundly affect the lives of
patients, often times to save lives
• Multiple subspecialties with diverse diseases and
different types of procedures, or general
neurosurgeon who can have a broad practice
• Current and future shortage of neurosurgeons so
need for more neurosurgeons

THE SOCIETY oF
OF NEUROLOGICAL SURGEONS
GENERAL SURGERY
GENERALSURGERY

Dr, Syed Altaf

Assistant Professor

J 1
7'
/' ,s

. . o
Io

Objectives
• Introduction
Introduction to
to surgery.
S urgery.

• Definition
Definition of general surgery and its
types.
types
• Preparation of patient
patient for surgery.
• Assessment of patient
patient before surgery.
• Indication & contraindication
contraindication of surgery.

J 1
7'
/' ,s

o
.
 |-
SURGERY
Surgery is
Surgery is aa procedure
procedure that involves
that involves
cutting of
cutting of aa patient's
patient's tissues
tissues or closure of
or closure of aa
previously sustained wound.
previously sustained wound.
lb (Or)
(Or
Surgery is
Surgery is defined as the
defined as the treatment
treatment ofof
uinjuries
`furies or
or disorders
disorders ofof the
the body
body by
by
incision or
I incision or manipulation, especially with
manipulation, especially with
instruments.
instruments

“Surgery”
Surgery" word is derived from Greek s\
71.
""

(HAND WORKING)
o
/
 General
• General Surgerysurgery
is a medical discipline
that
that involves performing
performing various types
of surgical procedures to
to treat
treat a broad
range of health problems and diseases.

• These include bile ducts, liver,

pancreas,
p'ancreas, spleen, appendix, small and
large intestine,
intestine, rectum,
rectum, and the
stomach etc. y 1
~.'~
/\
is L

/
f
 TYPES OF SURGERY

'II f
Surgical procedures
Surgical procedures are
are
classified based
classified based On
On
\al1.Urgency
.Urgency
2.Risk
2.Risk
3.Purpose
3.Purpose i"
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 SURGERY BASED ON URGENCY

M' I

|
|.

°~l
|
1

fl'

1.Elective
1. surgery
Elective surgery
mfifw I- |

2.Urgent surgery
Urgent surgery
3.Emergency surgery
Emergency surgery
1_1
 ELECTIVE SURGERY
It is
• It is aa procedure
procedure that is pre
that is pre planned
planned
'II f
and based
and on patients
based on choice and
patientS choice and
availability
availabilit y of scheduling
of SC heduling for for the
the
patient, surgeon and
atient surgeon and the
the facility.
fac ility.

• Delay
Delay of surgery has
of surgery has no ill effects.
no ill effects.
J 1
7'
/' ,s
 ELECTIVE SURGERY

Examples are…
Examples are. ..
Hernia repair
 Hernia repair
 Cataract extraction
Cataract extraction
Tonsillectomy
 Tonsillectomy
 Hip
Hip prosthesis
prosthesis
J 1»1 1.
7'
/' ,s

o
 URGENT SURGERY
• Must
Must be
be done
done with in aa reasonably
W ith in reasonably
short time
short frame to
time frame to preserve
preserve health.
health.
Usually
Usua fly done
done with 24 -– 48
in 24
with in 48 hours.
hours.

• Examples are…
Examples are...
 Removal
Removal of
of gall
gall bladder
bladder
Amputation
Amputation
Appendectomy
Appendectomy /'
J
,s
1»1 1.
7'

o
 EMERGENCY SURGERY
.• Must
Mu t be
S be done immediately to
done immediately to
preserve life, aa body
preserve life, body part
part or
or
function.
function.

• Examples are…
Examples are. ..
Control
Control of
of haemorrhage
haemorrhage
Repair
Repair ofof trauma ,perforated
trauma ,perforated
ulcers
leers , intestinal obstruction..
intestinal obstruction.
s*'q 1.
L

7'
I

/
o
SURGERY BASED
l lON
l l l lDEGREE
l OF RISK

1.Major surgery
Major surgery
2.Minor surgery
Minor surgery
 MAJOR SURGERY
• Major surgery requires
Major surgery requires
hospitalization
hospitalization andand specialized
specialized
care, is
care is usually
usually prolonged,
prolonged, has
has aa
higher
higher degree
degree of
of risk, involves
risk, involves
major
major body
body organs
organs or life
or life
threatening situations, and
threatening situations, and has
has aa
greater
greater risk for postoperative
risk for postoperative
complications.
complications. J
7' 1»1 1.
L

/' ,s

o
 MAJOR SURGERY

• Examples are…
Examples are. ..
Open Cholecystectomy
 Open Cho l e y s tectomy
 Nephrectomy
Nephrectomy
 Hysterectomy
Hysterectomy
 Radical
Radical mastectomy
mastectomy
 Laparotomy
Laparotomy 'C L

Jo"
7L
/' .'~

. . o
 l
Q _
I

MINOR SURGERY

• Minor surgery is
Minor surgery is usually
usu fly brief,
brief,
carries aa low
cames low risk and results
risk and results
in
in few complications.
few complications. Minor
Minor
surgeries are
surgeries are mostly elective.
mostly elective.
• Examples are…
Examples are. ..
Teeth extraction
Teeth extraction
Cataract extraction
Cataract extraction /' 7'J
,s
1»1 1.

o
SURGERIES BASED ON PURPOSE

1.Diagnostic
. Diagnostic
2.Ablative
»
. Alolative
3.Palliative
. Palliative (Intestinal Obst)
(Intestinal Obst)

4.Reconstructive
. Reconstructive
5.Transplantation
Transplantation J 1»1 1.
7'
/' ,s

6.Constructive
" . Constructive o
 1. DIAGNOSTIC SURGERY
Surgeries to
Surgeries to make
make or confirm aa
or confirm
diagnosis.
diagnosis
•Examples are…
Examples are

of
Biopsy
Biopsy

of
Bronchoscopy
Bronchoscope

of
Endoscopy
Endoscopy i"
'~ p'
 ABLATIVE SURGERY

Surgeries To
• Surgeries
I
To remove
remove aa
diseased
diseased body
body part.
part.
•Examples are…
'Examples are. .
*I* Appendectomy
 Appendectomy
*'* Amputation
 Amputation
H
 PALLIATIVE SURGERY
I

Surgeries to
• Surgeries
I
to relieve or reduce
relieve or reduce
I
I

I
I intensity of
intensity an illness.
of an illness. I
*e 1. 'I

•• It
It is curative.
not curative
is not
,I •Examples are…
'Examples are. .
*i* Colostomy
 Colostomy
4--*§
 Nerve root
root resection
/§*y
"Nerve resection
~.
>

in /-
 RECONSTRUCTIVE SURGERY
Surgeries to
•» Surgeries to restore function to
restore function to
i traumatized or
*traumatized or malfunctioning
malfunctioning
I tissue
tissue or
or to improve self
to irnpreve self concept.
concept.
I.,
I..

to >~ Examples are.

\Examples are….
R . 'I

Scar revision
'*I*Scar revlslon

 Plastic surgery
*I*Plastic surgery
I* Internal fixation of
Internal fixation of aa fracture
fractgié
./"
*itBreast reconstruction
 | T17
reconstructen
-
I

u
•

-.-III' I
 TRANSPLANTATION SURGERY

Surgeries to
•» Surgeries to replace organs
replace organs
or structures that
or structures are
that are
diseased
diseased or
or malfunctioning
malfunctioning
f

• Examples are…
7*-ir
'In
Examples are .
s
*I* Kidney,
 liver, heart
Kidney, liver, heart
transplantation.
transplantation.
/§*
 CONSTRUCTIVE SURGERY

Surgeries To
•» Surgeries To restore functions
restore functions
in congenital anomalies.
in congenital anomalies.

• Examples
I
are…
Examples are. .
Cleft lip Repair
1e t lip Repair
Closure
Closure of
of Atrial Septal Defect
Atrial Septal Defeat
 PREREQUISITES OF SURGERY

Proper patient
patient
- adequate indication
indication of surgery
(lack of contraindications)
- written, informed consent
written. informed

Proper timing
- wait
wait for
for the
the best condition
condition of the
the patient
patient
(depends
(dLepends on the urgency of the case)
- preferably operate
operate when the staff is in
the best condition.
condition

Proper circumstances /§*

- all the personal and material conditions

'a"llThe conditions
off a successful
sifcessful surgery are met – no time
met - time
'F M
r n n c r::ir\
 THE ROLE OF THE SURGEON
Theoretical and practical knowledge
- knowledge of the possible treatment
treatment options
- assessment of the risk/benefit
risk/benefit ratio
- experience -– beyond the learning curve
- honor your limits -– personal, material,
material, etc.
etc
- audition
audition of the
the results -– learn from the
the mistakes

Knowledge of the patient

patient
- history
- examination
examination
- disease course
|

- think out
out of the box -– are there better non-
better non
surgical
treatments?
treatments?
.. .
I!..».~l7"
Manual
al abilities
 INDICATION OF SURGERY
Vital
Vital
Can
Can only
only be
be treated
treated with immediate/urgent
with immediate/ urgent
I'
surgery, timing
surgery, cannot be
timing cannot chosen
be chosen
-major bleeding, ileus, perforation, appendicitis.
' I F

-major bleeding, ileus, perforation, appendicitis.

M:la1
II*

-Absolute
-Absolute
Can
" an only
only be
be treated
treated with surgery, can
with surgery, can be
be
~\s
scheduled
I

scheduled
-tumors, symptomatic
-tumors, symptomatic hernias
hernias or
or gall stones
gall stones

-Relative
-Relative
May
May be be treated
treated by
by non-surgical
non-surgical means
means // /§*

no harm
`r{5` harm done without surgery
done without surgery v
It- aéy%'p
r

asymptomatic
omatic hernia or gall
hernia or stones, GERI5
gall stones, GERD
I l !
 INDICATION OF SURGERY
Social/cosmetic
Social/cosmetic
No
No harm done without
harm done without surgery,
surgery, intervention
intervention is
is
performed
performed upon
upon the
the request
request of
of the
the patient
patient
I
-- breast augmentation, bariatric
breast augmentation, surgery
bariatric surgery

Prophylactic
Prophylactic
Aims
Aims toto prevent
prevent aa later
later disease or medical
disease or medical
condition
condition
-- FAP,
PAP, „negative” appendectomy
llnegative" appendectomy

Diagnostic
Diagnostic
Aims
Aims to diagnose aa disease
to diagnose disease or
or medical
medical /§*

condition
cqpdik
.it - lymph node biopsy,
ymph node biop sy, diagnostic laparoscopy
diagnostic laparoscopy
i n .1
ESTABLISHING THE INDICATION
Factors related to the
the indication
indication of surgery
- Diagnosis
- Symptoms (if no exact diagnosis is known)
- Timing of the surgery
(immediate/urgent/scheduled)
(immediate/urgent/scheduled)
- Operative load
- Operative tolerance
Operative tolerance
- Operability
Operability -– technical, medical,
medical, oncological
ecological
- Alternative treatment modalities
Alternative treatment modalities
- Prognosis
- Personal/material/(financial)
PersonaI/material/(financial) circumstances
-iatiept
Patient consent
A ? L
Always consider cost/benefit
cost/benefit ratio!
..i..ili¢v'
 QUESTION OF OPERABILITY
Medical/anesthesiological
Medical/anesthesiological
- Laboratory
Laboratory parameters
parameters (ions [K!], blood
(ions [K!], sugar, Hb,
blood sugar, Hb, INR)
INR)
I - Age
Age -– decreased significance!
decreased significance!
l to ,-| General conditions, co-morbidities
General conditions, co-morbidities
. i,m-' Drugs
Drugs (e.g. Warfarin, antidepressants)
(e.g. Warfarin, antidepressants)
'LT- Allergies, issues with
Allergies, issues with anesthesia/intubation
anesthesia/intubation
nr'm~
Surgical
illogical
- Technical
Technical (depends
(depends on surgeon and
on surgeon and institute)
institu
- Oncological
Gncological (curative intent/palliation)
(curative intent/palliation)

Operability depends
Operability depends on
on
I

an - the
the nature
nature of intervention
of intervention
- the
the type of indication
ty e of indication

Nil Nocere (don’t

(don't do harm)!
CONTRAINDICATION OF SURGERY

Absolute contraindication
Absolute contraindication
n.
- Moribund state, coma
Moribund state, coma
a'
-S
t Severe cardiac failure
evere cardiac failure l_ -.--pa

-JHemorrhagic
Hemorrhagic shockshock (without surgical
(without surgical
cause:
__use:
U

e.g. gostrointestinal bleeding)

e.g. gastrointestinal bleeding)
5 -- Severe
Severe metabolic
metabolic oror haemostatic
haernostatic
`._imbalance
irnbalance
-Lack of
-Lack of written informed consent
written informed consent /§*

(except life-threatening cases)/~

( § > j nin life-threatening cases)
Relative contraindications

- Age
Age
–- Pregnancy
Pregnancy (depends
(depends on on trimester)
trimester
b)
Co-morbidities
– Co-morbidities
Confirmed, end-stage
if.– Confirmed, end-stage incurable
incurable disease
disease
– Better alternative treatment
Better alternative modalities
treatment modalities
Technical reasons
– Technical reasons (instruments, staff,
(instruments. staff
circumstances, etc.)
circumstances, etc.
/§*
 ASSESSMENT OF SURGICAL RISK
Before
Before every surgery: lab
every surgery: lab tests, chest X-ray,
tests, chest X-ray,
anesthesiology examination
anesthesiology examination + special
+ special
investigations if
investigations if necessary
necessar y
ii ,

Assessment
Assessment ofof the general condition
the general condition of
of the
the
patient
patient
- Everyday activity of
Everyday activity of the
the patient
patient =
cardiorespiratoric reserve,
cardiorespiratoric reserve, nutrition,
nutrition, diabetes,
diabetes,
age (biologic
age (biologic ↔ chronologic), emotional
<-> chronologic), emotional and
and
social conditions
social conditions
/§*

Consultations
Congilltations V
- Anesthesiology, specialists (cardiology,
Anesthesiology, specialists EtHe,
(cardiology, ECHO,
spirometry,
Spiro-iye my, etc.)
E
 PREPARATION FOR SURGERY
Well before the surgery
Factors
Factors that can be
that can be modified
modified
- Diabetes,
Diabetes, heart failure (pacemaker)
heart failure (pacemaker)
- Blood
Blond pressure
pressure
-- Hematologic
Hematologic diseases
diseases (history)
(history)
--'Nutritional
Nutritional state
state (obesity, cachexy)
(obesity, cachexy)
- Infectious sources (teeth,
Infectious sources (teeth, ulcers,
ulcers, etc.)
etc.)
-- Certain
Certain medication
medication (Warfarin,
(Warfarin, platelet
platelet
adhesion inhibitors,
adhesion inhibitors, tricyclic
tricycle
antidepressants)
antidepressants)
/§*

Factors that cannot

Factors that cannot be modified
be modified
.

$
A
1
.'
Age,
r

I
sex,
sex,
I
l
chronic diseases
chronic diseases
u I
-.-I..¢IJ'
°
'z i'
PREPARATION FOR SURGERY
Right before the surgery
Per
Per os
1 feeding
os feeding
- Nothing
Nothing per os (NPO)
per os from the
(NPO) from the night
night of
of the
the
surgery
I surgery
Bowel
Bowel preparation
) I
I

preparation
I Blood volume resuscitation
load volume resuscitation
Metabolic
Metabolic balance
balance
- DM,
DM, renal functions
renal functions
Antibiotics
Antibiotics
Thrombosis prophylaxis
Thrombosis prophylaxis
I -- should
should be started before
be started before the surgery
the surgery /§*

Thorough cleaning
ThorOugh cleaning (+surgical skin
(+surgical skin go
preparation)
l
pfcnaration)
-r
Emotional,
Einotloal, psychological
p}3ychologicaI preparation
preparation
and tears f ow in your eyes
Always remember three things
Thank You
 PULMONAR
PULMONAR
Y SURGERY
Y SURGER Y
ID1~.
Dr. Tarpan
Tappan Shah.
Shah. MPT
MPT (CPD&ICU
(CPD&ICU care),
care),
l
(DNHE)
(DNHE)

L
Vice-Principal
Shree
\
Swam
&Asst.Prof
Vice-Pr1n c1]9at &A55t.Prof
Shree
ee Swaminarayan_yan Physiotherapy
waminarayan Ph vsjoth e r a p ycollege
P111/51 ll -illi-
• Lung
Lung surgery
surgery is
is the
the surgery
surgery to
to repair
repair or
or
remove
remove lung
lung tissue
tissue
• Biopsy
Biopsy ofof an
an unknown growth
unknown growth
• Lobectomy
Lobectomy
• Lung
Lung transplant
transplant
• Pneumonectomy
Pneumonectomy
• Surgery
Surgery toto prevent
prevent the
the build
build up
up or
or return
return of
o fl
fluid
fluid to
to the
the chest
chest (pleurodesis)
(pleurodesis)
Dr.Tarpan Shah
Dr.Tarpan Shah 2
 .
.• Surgery
l

Surgery to
to remove
remove an
an infection
infection or
or blood
blood in
in the
the
chest
chest cavity(empyema)
cavity(empyema)
l

Dr.Tarpan Shah
Dr.Tarpan Shah I
3
I . . A
• General anaesthesia
General given
anesthesia given
• Pt
Pt will
will be
be be
be asleep
asleep and
and not
not felt
felt any
any pain
pain
• Two common
Two common waysways thoracotomy
thoracotomy and
and video
video
assisted
assisted thoracoscopic
thoracoscopic surgery(VATS)
surgery(VATS)
• Thoracotomy means
Thoracotomy means open
open surgery
surgery
• Risks
Risks in
in surgey---
surgey---
• Allergic
Allergic reactions
reactions to
to medicines
medicines
• Breathing
Breathing problems
problems
Dr.Tarpan Shah
Dr.Tarpan Shah 4
 .
.• Bleeding
l

Bleeding
• Blood
Blood clots
clots
l
• Infection
Infection
• Failure
Failure of
of lung
lung to
to expand
expand
• Injury
Injury to
to the
the lungs
lungs
• Pain
Pain

Dr.Tarpan Shah
Dr.Tarpan Shah I
5
I . . A
 .
.• Prognosis---
l

Prognosis---
.• Depends
Dependsonon
.• Type
Type of
of problem
problem being
being treated
treated
l

.• How
How much
much of
of the
the lung
lung is
is removed
removed
.• Overall
Overall health
health before
before surgery
surgery

Dr.Tarpan Shah
Dr.Tarpan Shah I
6
I . . A
 I-
INDICATIONS
f N ]DICe©lTI©NS
f@ ; of FOR
ET imp
l SURGERY
sURCIERY
Q U Q l
• Commonest
Commonest is is bronchial
bronchial carcinoma
carcinoma
1.Malignancy- primary
1.Malignancy- primary bronchial
bronchial carcinoma,
carcinoma
isolated
isolated secondaries
secondaries arising
arising from
from kidney
kidney or
or
large
large intestine
intestine
2.Inflammatory-
2.Inflammatory- lung
lung resection
resection isis required
required
occasionally
occasionally for
for lung
lung abscess,
abscess, tuberculosis
tuberculosis ,
bronchiectasis
bronchiectasis

Dr.Tarpan Shah
Dr.Tarpan Shah 7
3.Trauma-
3.Trauma- stab
stab wounds, gun shot
wound s, gun shot wounds
wound s

4.Degerative-
4.Degerative- large
large bullae
bullae in
in selected
selected patients
patients
where
where there
there is
is compression
compression ofof normal
normal lung
lung

5.Congenital- lobar emphysema

5.Congenita|- Iobar emphysema

Dr.Tarpan Shah
Dr.Tarpan Shah
15 8
 INCISIONS
INCISIUNS
A)Lateral incision
A)Lateral incision

1)
l) Posterolateral
Posterolateral incision:- this follow
ineision:- this follow the the vertebral
vertebral
border
border of
of scapula and line
scapula and line of rib 55thth 66thth 77thth 88thth to
of rib to
anterior angle
anterior angle of
of costal
costal margin
margin
Muscles cut
Muscles cut are:-
are:- trapezius, LD, serratus
trapezius, LD, serratus anterior anterior,
rhomboids,
rhomboids, intercostals, erector spinae
intereostals, erector spinae

This incision
This is used
incision is used for the lung
for the operation
lung operation
I
Dr.Tarpan Shah
Dr.Tarpan Shah 9
Dr.Tarpan Shah
Dr.Tarpan Shah 10
_. A
2)
2) Antero-lateral
Antero-lateral incision:-
ineision:- this start at
this start at middle of
middle of
the anterior chest
the anterior chest up to the
up to the posterior axillary
posterior axillary
fold.
fold
Muscles
Muscles cut
cut are:-
arez- pectoralis
pectoralis major and minor,
major and minor
serratus anterior.
stratus anterior, intercostals.
intercostals.

This
This incision
incision is
is used
used for
for mitral
mitral valvotomy and
valvotomy and •
pleurectomy.
leurectomy
Dr.Tarpan Shah
Dr.Tarpan Shah 11
B) Anterior
B) Anterior incision
incision
1) Transverse:-
1) Transversez- this passes across
this passes across the one side
the one side of
of
the 44thth IC
the space to
IC space to the other.
the other.
Muscles
Muscles cut are:- pectoralis
cut are:- pectoralis major,
major
intercostals.
intercostals
2)
2) Vertical
Vertical incision:- splitting of
incisionz- splitting of the
the sternum
sternum
down
down the the middle
middle
NO MUSCLE CUT
NO MUSCLE CUT
This incision
This incision is is used
used for
for open
open heart surgery..
heart surgery

Dr.Tarpan Shah
Dr.Tarpan Shah 12
 / 1
YYP
Types
P13 of operaTion

1)
1) Pneumonectomy
Pneumonectomy
2)
2) lobectomy
lebectemy
3) Segmental
3) Segmental or
or wedge
wedge resection
resection

Dr.Tarpan Shah
Dr.Tarpan Shah 13
Dr.Tarpan Shah 14
Dr.Tarpan Shah 15
 CompliCaTion
MPLICA TI of
surgery
1)
1) Respiratory
Respiratory
- infection
infection of
of the
the lung
lung
- consolidation
consolidation // collapsed
collapsed
- pneumothorax
pneumothorax
- broncho-pleural
broneho-pleural fistula
fistula

Dr.Tarpan Shah
Dr.Tarpan Shah 16
 BronCHopleural
DNCHOPLEURJHLL
fisTula
FISTUIJIL
• It
It implies
implies breakdown
breakdown of of the
the bronchial
bronchial stump
stump
and
and itit occcurs
occcurs around
around the
the 10
10 th
th postoperative
postoperative
day ,if small
day ,if small it
it may
may not
not be
be noticed
noticed untill
untill much
much
later
• It
It is
is recognised
recognised by by dyspnea ,an irritating
dyspnea ,an irritating cough
cough
and
and possible
possible expectoration
expectoration of of dark
dark fluid
fluid
• The
The patient
patient should
should be be sat
sat up
up or
or turned
turned on on to
to
the
the operated
operated sideside to
to prevent
prevent spill
spill over
over ofof
infected
infected fluid
fluid in
in to
to the
the remaining
remaining lung
lung
Dr.Tarpan Shah
Dr.Tarpan Shah 17
 normal
lung
Huid
heart
Huid
I
I

normal
I

lung I
l
l

4*-.5 11-
ii****:
I .heart
normal
lung heart
T_r_,\_-L.-.
1. \ I* 'ITI'l

fluid
Pnumonectomlr
Dr.Tarpan
Dr.Tarpan Shah
Shah 18
_. A
 l

2) Circulatory:-
Ci 0

 DV!
DVT
 Cardiac
Cardiac arrhythmia
arrhythmia
 Haemorrhage
Haemorrhage
3)
3) Wound:-
Wound:-
 Infection
Infection l

 Failure
Failure to
to heal
heal
 Adherent
Adherent scar
scar
4) Joint
4) stiffness:-
Joint stiffness:-
 Sh
Sh joint
joint
 Thoracic
Thoracic spine
spine
 Costa-vertebral
Costo-vertebral joints
joints
r

Dr.Tarpan Shah
Dr.Tarpan Shah I
19
I . . A 1
5) Muscle
5) weakness:-
Muscle weakness:-
 LD
 Serratus
Serratus anterior
anterior
 leg
leg muscle
muscle if
if unexercised
unexercised
 other
other divided
divided muscles
muscles

6)
6) Postural
Postural deformity:-
deformity:-
 forward
forward or
or sideward
sideward bending
bending

Dr.Tarpan Shah
Dr.Tarpan Shah 20
 UMUNEC mmY
pneumoneCTomy
• Removal
Removal ofof entire
entire lung
lung
• Radical
Radical Pneumonectomy
Pneumoneetomy along along with
with that of entire
that of entire
lung
lung mediastinal
mediastinal gland
gland is
is also
also removed.
removed
Complication:-
Complication
• Damage
Damage to phrenic nerve
to phrenic nerve
• Damage
Damage toto recurrent
recurrent laryngeal
laryngeal nerve
nerve

Indication:- Carcinoma,
Indicationz- Carcinoma, bronchiectasis,
bronchicctasis
tuberculosis
tuberculosis
incision is postcro1aLc,;'aLhincision
incision is posterolateral incision
Dr.Tarpan Shah 21
 . • preoperaTive
P16 EUPQRA TI VE
pHysioTHerapy
PH Ysm TH£RA P Y
l

• Gain the
Gain the confidence
confidence of
of patient
patient
• Clear
Clear the
the lung
lung field
field
l
• Breathing
Breathing exercise
exercise
• Postural
Postural awareness
awareness
• Teach arm,
Teach arm, trunk,
trunk, leg
leg exercise
exercise
• Splinting
Splinting of
of incision
incision during
during coughing
coughing
• Bed
Bed mobility
mobility
r

Dr.Tarpan Shah
Dr.Tarpan Shah I
22
I . . A 1
 Postoperative
Postoperative chest
chest physiotherapy
physiotherapy
• Clear
Clear the
the lung
lung field
field
• Reexpansion
Reexpansion ofof the
the lung
lung
• Prevent
Prevent circulatory
circulatory complication
complication
• Prevent
Prevent wound
wound complication
complication
• Regain
Regain the
the arm
arm and
and trunk
trunk movement
movement
• Maintain
Maintain the good posture
the good posture
• Conditioning
Conditioning exercise
exercise

Dr.Tarpan Shah
Dr.Tarpan Shah 23
 Key points
Key points
• Breathing
Breathing exercises
exercises should
should be
be started
started on
on the
the
day
day of
of surgery
surgery if
if possible.
possible.
• ACBT
ACBT to
to remove
remove the
the secretion
secretion and
and restore
restore the
the
lung
lung volumes
volumes and
and capacities
capacities
• Adequate
Adequate wound
wound support
support for
for huffing
huffing and
and
coughing
coughing should
should be
be taught.
taught.

Dr.Tarpan Shah
Dr.Tarpan Shah 24
• Early
Early mobilization
mobilization J
' -I* I

r.4 ..-I
E
progressing
progressing to
to stair
stair
-I -. F-
g.1-.-...[....
-.|.

Climbing
Climbing on
on third
third day
r

day ¢»*n-6 * F -A

postoperatively
postoperatively £i-l»-Ji

• Exercise
Exercise using
using aa
bicycle
bicycle ergometer
ergo meter :ion

Dr.Tarpan Shah
Dr.Tarpan Shah 25
• Tracheal
Tracheal deviation-
deviation- result
result into
into ineffective
ineffective
cough
cough production
production
• Huffing
Huffing rather
rather than
than coughing
coughing is is emphasized
emphasized
because
because ofof less
less chances
chances of
of increase
increase in in
intrathoracic
intrathoracic pressure
pressure
• If
If suctioning
suctioning is
is required
required than
than take
take care
care of
of
stump.
stump
• Breathing
Breathing control
control with
with stair
stair climbing
climbing maymay
increase
increase exercise
exercise tolerance.
tolerance.
Dr.Tarpan Shah
Dr.Tarpan Shah 26
 l

Splinting
SpHn'dng
I

I Q
i-..'lr

| ' _
or'
._
| -
l _
I
|.

.-TO
FI".r. -a

Eilli- I I

.In
.I
|. .* 12
:
l
Q

I
I

r
l

X
I

1
-

.:'V'i

4I .; |-

I
I

I
|

I'
rr-
I'
l

I
_
|

l
l

l I

Dr.Tarpan Shah
Dr.Tarpan Shah I
27
I . .
 lobectomy
OBEC TUM Y
• Indication
Indication
• Bronchiectasis
Bronchiectasis
• Tuberculosis
Tuberculosis
• Lung
Lung abscess
abscess
• Carcinoma
Carcinoma

Dr.Tarpan Shah
Dr.Tarpan Shah 28
 Day
ay of
of operation
r
operation
• Half
Half lying
lying
• Breathing
Breathing exercise
exercise to
to expand
expand the
the whole
whole lung
lung
• Vibration
Vibration over
over unoperated
unoperated side
side
• Huffing
Huffing with
with splinting
splinting
• Foot
Foot or
or ankle
ankle exercise
exercise

Dr.Tarpan Shah
Dr.Tarpan Shah 29
 Day – 1 ( 3-
3- 4
4 session)
session)
• Analgesia
Analgesia to
to reduce
reduce the
the pain
pain so
so pt
pt will
will
cooperate
cooperate inin treatment
treatment
• Nebulizer
Nebulizer therapy
therapy or
or humidification
humidification therapy
therapy
• Breathing
Breathing exercise
exercise with
with inspiratory
inspiratory hold
hold
• Side
Side lying
lying on
on unoperated
unoperated side
side
• Chest
Chest expansion
expansion exercise
exercise on
on remaining
remaining side
side
• Postural
Postural drainage
drainage

Dr.Tarpan Shah
Dr.Tarpan Shah 30
• Exercise
Exercise of
of arm
arm
• Assisted
Assisted arm
arm elevation
elevation
• Assisted
Assisted arm
arm movement
movement in
in functional
functional pattern
pattern
• Neck
Neck exercise
exercise

Dr.Tarpan Shah
Dr.Tarpan Shah 31
 .
.• Exercise
l

Exercise for
for leg
leg
.• Foot
Foot and
and ankle
ankle exercise
exercise
.• Quadriceps
Quadriceps contraction
contraction
l

.• Hip
Hip and
and knee
knee bending
bending exercise
exercise

Start
Start ambulation
ambulation
r

Dr.Tarpan Shah
Dr.Tarpan Shah I
32
I . . A 1
 Day-2
Day-2
• Self
Self supported
supported splinting
splinting
• Chest expansion
Chest expansion exercise
exercise
• Breathing
Breathing exercise
exercise
• Unoperated
Unoperated sideside positioning
positioning
• Arm
Arm asas well
well as
as leg
leg exercise
exercise
• Start
Start trunk
trunk exercise
exercise
• Discourage
Discourage thethe pt
pt for
for crossleg
crossleg sitting
sitting it
it will
will occlude
occlude
popliteal
popliteal artery
artery and
and can
can result
result into
into DVT
DVT

Dr.Tarpan Shah
Dr.Tarpan Shah 33
 Day
Day 3- 4
• Arm
Arm and
and trunk
trunk exercise
exercise should
s hould continue
continue
• Increase
Increase the
the walking
walking distance
distance
• Stair
Stair climbing
climbing
• Group therapy
Group therapy
• Aerobic
Aerobic exercise
exercise

Dr.Tarpan Shah
Dr.Tarpan Shah 34
• Discharge
Discharge at 10-12 days
at 10-12 days of
of post
post op
op
• Home
Hone exercise
exercise programme
programme
• Aerobic
Aerobic exercise
exercise (( hyper
hyper Chest
Chest expansion
expansion
exercise
exercise

• Ventilatory
Ventilatory muscle
muscle training
training

Dr.Tarpan Shah
Dr.Tarpan Shah 35
• Pain.
Pain. Extrapleural
Extra pleural bupivicaine
bupivicaine infusion
infusion is
is an
an
increasingly
increasingly popular
popular method
method ofof pain
pain control
control
following
following aa thoracotomy.
thoracotomy.
• Bronchial
Bronchial secretions. The appropriate
secretions. The appropriate timing
timing
and
and selection
selection of
of minitracheotomy
mini tracheotomy cancan help
help reduce
reduce
the
the incidence
incidence ofof sputum
sputum retention.
retention
• Pneumonia
Pneumonia is is a
a serious
serious complication
complication with
with aa
high
high mortality
mortality rate.
rate.

Dr.Tarpan Shah
Dr.Tarpan Shah 36
• Atrial
Atrial fibrillation
fibrillation isis common
common withwith extensive
extensive
resection
resection in in the
the elderly.
elderly. Onset
Onset is
is usually
usually 2-5
2-5
days
days postoperatively.
postoperatively.
• Wound
Wound infection
infection
• Haemorrhage.
Haemorrhage. Significant
Significant bleeding,
bleeding, usually
usually
involving
involving thethe bronchial
bronchial arteries,
arteries, occurs
occurs in
in 1-2%
1-29
of
of patients.
patients. ItIt is
is more
more likely
likely after
after aa
pneumonectomy.
pneumonectomy.

Dr.Tarpan Shah
Dr.Tarpan Shah 37
 SEGMENTAL
:Q i f If ; RESECTION
SECaM§NTAL RES
5 ECTI()
I Q u

• A
A bronchopulmonary
bronchopulmonary segment
segment is
is removed
removed
with
with its
its segmental
segmental artery
artery and
and bronchus
bronchus
• Used
Used for
for tuberculosis
tuberculosis

Dr.Tarpan Shah
Dr.Tarpan Shah 38
 Q
WEDGE RESECTIQ
RESECTION
:Q
I
of |
O/ | /

• This
This non
non anatomical
anatomical resection
resection is
is used
used for
for
diagnosis
diagnosis in
in open
open lung
lung biopsy
biopsy and
and treatment
treatment
of
of well
well localised
localised peripheral
peripheral carcinomas
carcinomas in in
patients
patients with
with redused
redoesed lung
lung function
function

Dr.Tarpan Shah
Dr.Tarpan Shah 39
 THURA CUPLA s TY
ThORACOpLASTy
• This
This operation
operation is
is performed
performed toto produce
produce the
the
permanent
permanent collapse
collapse of
of a
a lung.
lung.
• This
This operation
operation is
is performed
performed in TB and
in TB and
emphysema.
emphysema
– Complication:
Complicationz deformity
deformity
paradoxical
paradoxical breathing
breathing

Dr.Tarpan Shah
Dr.Tarpan Shah 40
 pLEuRAL SuRGERy
U S A 1. SURG£R
1) Pleurectomy:
1) Pleurectomyz isis removal
removal of
of parietal
parietal layer
layer of
of
pleura
pleura e.g.
e.g. pneumothorax
pneumothorax
-Visceral
Visceral layer
layer pleura
pleura stick
stick with
with the
the chest
chest wall
wall
2)
2) Pleurodesis:
Pleurodesis: insertion
insertion ofof powder
powder into
into the
the
pleural
pleural cavity,
cavity, which
which act
act as
as a
a irritants.
irritants
- Position
Position the
the pt
pt in
in 10
10 min
min for
for each
each position
position
- Expansion
Expansion breathing
breathing exercise
exercise isis performed
performed inin
each
each position.
position

Dr.Tarpan Shah
Dr.Tarpan Shah 41
• 3)
3) Decortication
Decortication ::
- stripping
stripping of
of the
the two
two layer
layer of
of pleura
pleura that
that
have
have become
become adherent
adherent with
with eachother.
each other
• E.g.
E _g_ empyema
empyema

Dr.Tarpan Shah
Dr.Tarpan Shah 42
Dr.Tarpan Shah 43
 S urgery
HAEMORRHAGE
HAEMORRHACE
HAEMORRHAGE
}> Hemorrhage
Hemorrhage mustmust bebe recognized
recognized and and managed
managed
aggressively
aggressively toto reduce
reduce the
the severity
severity and
and duration
duration
of
of shock
shock and
and avoid
avoid death
death and/
and / or
or multiple
multiple organ
organ
failure.
failure.
}> Hemorrhage
Hemorrhage is is treated
treated by
by arresting
arresting the
the bleeding
bleeding
–- not
not by
by fluid
fluid resuscitation
resuscitation or or blood
blood transfusion.
transfusion.
}> Although
Although necessary
necessary asas supportive
supportive measures
measures toto
maintain
maintain organ
organ perfusion,
perfusion, attempting
attempting toto
resuscitate
resuscitate patients
patients who
who have
have ongoing
ongoing
hemorrhage
hemorrhage willwill lead
lead to
to physiological
physiological exhaustion
exhaustion
and
and subsequently
subsequently death
death

5
5
Pathop hbiology
}> Hemorrhage
Hemorrhage leads
leads to
to aa state
state of
of hypovolaemic
hypovolaemic
shock.
shock.
The combination
}> The combination of of tissue
tissue trauma
trauma andand
hypovolaemic
hypovolaemic shock
shock leads
leads to
to the
the
development
development of of an
an endogenous
endogenous coagulopathy
coagulopathy
called
called acute
acute traumatic
traumatic coagulopathy.
coagulopathy.
}> Up
Up to
to 25%
25%/ of
of trauma
trauma patients
patients develop
develop ATC
ATC
within
within minutes
minutes ofof injury
injury and
and it
it is
is associated
associated
with
with aa fourfold
fourfold increase
increase inin mortality
mortality

5
5
}> Ongoing
Ongoing bleeding
bleeding with
with fluid
fluid and
and red
red blood
blood
cell
cell resuscitation
resuscitation leads
leads to
to aa dilution
dilution of
of
coagulation
coagulation factors
factors which
which worsens
worsens the
the
coagulopathy.
coagulopathy.
In addition,
}> In addition, the
the acidosis
acidosis induced
induced byby the
the
hypoperfused
hypo perfused state
state leads
leads toto decreased
decreased
function
function of
of the
the coagulation
coagulation proteases,
proteases,
resulting
resulting in
in coagulopathy
coagulopathy and and further
further
haemorrhage.
haemorrhage.

5
5
}> The reduced
The reduced tissue
tissue perfusion
perfusion includes
includes
reduced
reduced blood
blood supply
supply to
to muscle
muscle beds.
beds.
}> Underperfused
Underperfused muscle
muscle is
is unable
unable toto generate
generate
heat
heat and
and hypothermia
hypothermia ensues
ensues
}> Coagulation
Coagulation functions
functions poorly
poorly atat low
low
temperatures
temperatures and
and there
there is
is further
further
haemorrhage,
haemorrhage, further
further hypoperfusion
hypo perfusion andand
worsening
worsening acidosis
acidosis and
and hypothermia
hypothermia

5
5
}> Medical
Medical therapy
therapy has
has aa tendency
tendency toto worsen
worsen
this
this effect.
effect.
}> t. Intravenous blood
t. Intravenous blood andand fluids
fluids are
are cold
cold and
and
exacerbate
exacerbate hypothermia.
hypothermia.
}> Further
Further heat
heat is
is lost
lost by
by opening
opening body
body cavities
cavities
during
during surgery
surgery
}> Surgery
Surgery usually
usually leads
leads toto further
further bleeding
bleeding and
and
many
many crystalloid
crystalloid fluids
fluids are
are themselves
themselves acidic
acidic

5
5
}> Every
Every effort
effort must
must therefore
therefore be
be made
made toto
rapidly
rapidly identify
identify and
and stop
stop haemorrhage,
haemorrhage, and
and to
to
avoid (preferably) or
avoid (preferably) or limit
limit physiological
physiological
exhaustion
exhaustion from
from coagulopathy,
coagulopathy, acidosis
acidosis and
and
hypothermia
hypothermia

5
5
Revealed an concealed
haemorr ha9 e
}> Hemorrhage
Hemorrhage may may be
be revealed
revealed or
or concealed.
concealed.
}> REVEALED
REVEALED HEMORRHAGE
HEMORRHACE is is obvious
obvious external
external
hemorrhage
hemorrhage
}> open
open arterial
arterial wound
wound
}> Concealed
Concealed haemorrhage
haemorrhage is is contained
contained within
within
the
the body
body cavity
cavity and
and must
must bebe suspected,
suspected,
actively
actively investigated
investigated and
and controlled
controlled trauma,
trauma,
haemorrhage
haemorrhage may may be
be concealed
concealed within
within the
the
chest,
chest, abdomen,
abdomen,

5
5
}> ,, pelvis,
pelvis, retroperitoneum
retro peritoneum or or in
in the
the limbs
limbs with
with
contained vascular injury
contained vascular injury or
or associated
associated with
with
longbone
long bone fractures.
fractures.
}> Examples
Examples of of nontraumatic
nor traumatic concealed
concealed
haemorrhage
haemorrhage include
include occult
occult gastrointestinal
gastrointestinal
bleeding
bleeding oror ruptured
ruptured aortic
aortic aneurysm.
aneurysm.

5
5
Primary, reactionary and s econdary
haemorrhage
}> Primary
Primary hemorrhage
hemorrhage is is hemorrhage
hemorrhage occurring
occurring
immediately
immediately due
due to
to an
an injury
injury
}> Reactionary
Reactionary haemorrhage
haemorrhage is is delayed
delayed
haemorrhage (within 24
haemorrhage (within 24 hours)
hours) and
and is
is usually
usually
due
due to
to dislodgement
dislodgement of of aa clot
clot by
by
resuscitation,
resuscitation, normalisation
normalisation of of blood
blood
pressure
pressure and vasodilatation.
and vasodilatation.

5
5
}> Secondary
Secondary haemorrhage
haemorrhage is is due
due to
to sloughing
sloughing
of
of the
the wall
wall of
of a vessel. It
a vessel. It usually
usually occurs
occurs 7–14
7-1 4
days
days after
after injury
injury and
and is
is precipitated
precipitated by
by factors
factors
such
such as
as infection,
infection, pressure
pressure necrosis (such as
necrosis (such as
from
from aa drain)
drain) or
or malignancy.
malignancy.

5
5
Surgical and non-surgical
hemorrhage
}> Surgical
Surgical haemorrhage
haemorrhage is is due
due toto a
a direct
direct injury
injury
and
and is
is amenable
amenable to to surgical
surgical control
control
}> Nonsurgical
Nonsurgical haemorrhage
haemorrhage is is the
the general
general ooze
ooze
from
from all
all raw
raw surfaces
surfaces due
due to
to coagulopathy
coagulopathy
and
and cannot
cannot bebe stopped
stopped by by surgical
surgical means
means
Treatment requires
}> Treatment requires correction
correction of of the
the
coagulation
coagulation abnormalities.
abnormalities.

5
5
 e ree an class ification
}> The adult
The adult human
human has has approximately
approximately 5 5 litres
lit res
of
of blood.
blood.
}> Estimation
Estimation of of the
the amount
amount of of blood
blood that
that has
has
been
been lost
lost is
is difficult,
difficult, inaccurate
inaccurate and
and usually
usually
underestimates
underestimates the the actual
actual value.
value.
}> External
External haemorrhage
haemorrhage is is obvious,
obvious, but
but it
it may
may
be
be difficult
difficult to
to estimate
estimate thethe actual volume lost.
actual volume lost.
In
In the
the operating
operating room,
room, blood
blood collected
collected in
in
suction
suction apparatus
apparatus can can be
be measured
measured and
and
swabs
swabs soaked
soaked in in blood
blood weighed.
weighed.

5
5
}> The amount
The amount of of haemorrhage
haemorrhage can
can be
be classified
classified
into
into classes
classes 1–4
i - 4 based
based on
on the
the estimated
estimated
blood
blood loss
loss required
required to to produce
produce certain
certain
physiological
physiological compensatory
compensatory changes
changes
}> Blood volume lost
Blood volume lost as
as percentage
percentage of
of total
total
Class 1
}> Class l 2
23344

}> <15%
< I 5% 15–30%
1 5-30 % 30–40%
30-40 % >40%
> 40%

5
5
 an agene nt
}> IDENTIFY HAEMORRHAGE
IDENTIFY HAEMORRHAGE
}> External
External haemorrhage
haemorrhage may may be
be obvious,
obvious, but
but
the
the diagnosis
diagnosis ofof concealed
concealed haemorrhage
haemorrhage may may
be
be more
more difficult
difficult
}> Any
Any shock
shock should
should be be assumed
assumed toto be
be
hypovolaemic
hypovolaemic until
until proven
proven otherwise
otherwise and,
and,
similarly,
similarly, hypovolaemia
hypovolaemia should
should be
be assumed
assumed
to
to be
be due
due to
to haemorrhage
haemorrhage until
until this
this has
has been
been
excluded.
excluded.

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5
lmme rate resu SC itative
man oeuvre s
}> Direct
Direct pressure
pressure should
should be
be placed
placed over
over the
the site
site
of
of external
external haemorrhage.
haemorrhage.
}> Airway
Airway and
and breathing
breathing should
should be
be assessed
assessed
and
and controlled
controlled asas necessary.
necessary.
}> Largebore
Large bore intravenous
intravenous access
access should
should be
be
instituted
instituted and
and blood
blood drawn
drawn for
for crossmatching
cross matching
}> Emergency
Emergency blood
blood should
should be
be requested
requested if
if the
the
degree
degree ofof shock
shock and
and ongoing
ongoing haemorrhage
haemorrhage
warrants
warrants this.
this.

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5
Identify the S its of aemorr ha9
}> Clues may
Clues may bebe in
in the
the history
history
}> For
For shocked
shocked trauma
trauma patients,
patients, the
the external
external
signs
signs of
of injury
injury may
may suggest
suggest internal
internal
haemorrhage,
haemorrhage,
but
but haemorrhage
haemorrhage into into a
a body
body cavity
cavity (thorax,
(thorax,
abdomen)
abdomen) mustmust bebe excluded
excluded with
with rapid
rapid
investigations
investigations (chest
(chest and
and pelvis
pelvis xray,
xray,
abdominal
abdominal ultrasound
ultrasound or or diagnostic
diagnostic
peritoneal
peritoneal aspiration).
aspiration).

5
5
}> Rapid
Rapid bedside
bedside tests
tests are
are more
more appropriate
appropriate for
for
profound
profound shock
shock

5
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Haemorrhage control
}> The bleeding,
The bleeding, shocked
shocked patient
patient must
must bebe
moved
moved rapidly
rapidly to
to a
a place
place ofof haemorrhage
haemorrhage
control.
control.
These patients
}> These patients require
require surgical
surgical and
and
anaesthetic
anesthetic support
support and
and full
full monitoring
monitoring and
and
equipment
equipment must
must bebe available.
available.
}> Attention
Attention should
should bebe paid
paid to
to correction
correction of
of
coagulopathy with blood
coagulopathy with blood component
component therapy
therapy
to
to aid
aid surgical
surgical haemorrhage
haemorrhage control.
control.

5
5
}> Attention
Attention should
should bebe paid
paid to
to fluid
fluid
responsiveness
responsiveness andand the
the end
end points
points ofof
resuscitation
resuscitation to
to ensure
ensure that
that patients
patients are
are fully
fully
resuscitated
resuscitated and
and to
to reduce
reduce thethe incidence
incidence and
and
severity
severity of
of organ
organ failure.
failure.

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 amage control re s u s citation
}> the
the management
management of of trauma
trauma patients with
patients with
active
active haemorrhage
haemorrhage called
called damage
damage control
control
resuscitation
resuscitation (DCR.
(DCR.
}> Anticipate
Anticipate and
and treat
treat acute
acute traumatic
traumatic
coagulopathy
coagulopathy
}> .. 2
2 Permissive
Permissive hypotension
hypotension until
until haemorrhage
haemorrhage
control.
control.
}> 3
3 Limit
Limit crystalloid
crystalloid and
and colloid
colloid infusion
infusion to
to
avoid
avoid dilutional
dilutional coagulopathy.
coagulopathy.
}> 44 Damage
Damage control
control surgery
surgery to
to control
control
haemorrhage
haemorrhage and and preserve
preserve physiology.
physiology.

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5
5
General surgery

I
I
 the coordinated physiological process which
¡ the
maintains
maintains most
most of the
the steady states of the
the
organism’
organism' ((Walter
Walter Cannon);
Cannon); i.e. complex
homeostatic
homeostatic responses involving thethe brain,
nerves, heart,
heart, lungs, kidneys and spleen work
to maintain
to maintain body
body constancy.
 ‘There is a circumstance attending
¡ 'There attending accidental
injury
injury which does not
not belong to
to the disease,
namely that
that the
the injury
injury done, has in all cases a
tendency to
tendency to produce both the deposition
both the deposition and
means of cure’
cure' i.e. responses toto injury
injury are, in
general, beneficial to
to the
the host and allow
healing/survival.
 It is important
¡ It to recognise that
important to that the
the response to
to
injury
injury is graded: the
the more severe the
the injury, the
injury, the
greater the
the response .
¡ This concept notnot only applies to
to
physiological/metabolic
physiological/metabolic changes but but also to
to
immunological changes.
¡ Thus,
Thu
¡ following
following elective surgery of intermediate
intermediate
severity, there may be a transient
severity, there transient and modest
modest
rise in temperature,
temperature, heart rate,
rate, respira tory rate,
respirer tory rate,
energy expenditure
expenditure and peripheral white
white cell
count.
count.
¡ Following
Following major
major trauma/sepsis, these
changes are accentuated, resulting in a
systemic inflammatory
inflammatory response syndrome
(SIRS), hypermetabolism,
hypermetabolism, marked
catabolism, shock and even multiple
multiple organ
dysfunction
dysfunction (MODS).
¡ It
It is important to recognise that
important to that genetic
genetic
variability plays a key role in determining the
determining the
intensity
intensity of the
the inflammatory
inflammatory response.
¡ Moreover,
Moreover, in certain circumstances, the the
severity of injury
injury does not
not lead to
to a simple
dosedependent metabolic
metabolic response, butbut
rather
rather leads toto quantitatively
quantitatively different
different
responses.
¡ Not
Not only is the
the metabolic
metabolic response graded,
but
but it
it also evolves with time.
with time.
¡ In particular, the
the immunological
immunological sequelae of
major injury
injury evolve from
from a proinflammatory
pro inflammatory
state
state driven primarily by the the innate immune
immune
system (macrophages, neutrophils,
system (macrophages, neutrophils, dendritic
dendrite
cells) into
into a compensatory
compensatory anti inflammatory
inflammatory
response syndrome (CARS) characterised by
suppressed immunity
immunity and diminished
resistance to to infection
infection
¡ In patients
patients who develop infective
infective
complications, the latter
complications, the latter will
will drive ongoing
systemic
systemic inflammation, the acute phase
inflammation, the
response and continued
continued catabolism.
¡ NEUROENDOCRINE
NEUROENDO(:RINE PATHWAYS OF THE
OFTHE
STRESS RESPONSE,
• afferent
afferent nociceptive neurones
• spinal cord
• thalamus
thalamus
• hypothalamus
• pituitary
• ..Corticotrophin
Corticotrophinreleasing
releasing factor
factor (CRF)
• adrenocorticotrophic
adrenocorticotrophic hormone
hormone (ACTH
• cortisol.
cortisol.
• adrenaline
• glucagon.
• Cathecholamines
Cathecholamines
¡ . PROINFLAMMATORY
PRC INFLAMMATORY CYTOKINES
¡ interleukin1
interleukin (IL1) 24 h
tumour
¡ tum our necrosis factor alpha (TNFα),
(TNFa), IL6 and
IL8 24h
ILL
¡ cause pyrexia
¡ augment the hypothalamic
augment the hypothalamic stress response
¡ act directly
directly on skeletal muscle to
to induce
proteolysis
proteolysis
¡ protein
protein production
production in the
the liver
¡ peripheral insulin resistance