General surgery

at the district
hospital
edited by

John Cook
Consultant Surgeon
Department of Surgery
Eastern General Hospital
Edinburgh, Scotland

Balu Sankaran
Formerly Director
Division of Diagnostic, Therapeutic and
Rehabilitative Technology
World Health Organization
Geneva, Switzerland

Ambrose E.O. Wasunna

Medical Officer
Clinical Technology
World Health Organization
Geneva, Switzerland
and
Professor of Surgery
University of Nairobi
Nairobi, Kenya

illustrated by
Derek Atherton
and Elisabetta Sacco

World Health Organization

Geneva
1988
ISBN 92 4 154235 7

© World Health Organization 1988

Publications of the World Health Organization enjoy copyright pro-

tection in accordance with the provisions of Protocol 2 of the Uni-
versal Copyright Convemion. For rights of reproduction or transla·
tion of WHO publications, in part or in toto, application should be
made to the Offtce of Publications, World Health Organization,
Geneva, Switzerland. The World Health Organization welcomes
such applications.

The designations employed and the presentation of the material in

this publication do not imply the expression of any opinion what·
soever on the part of the Secretariat of the World Health Organ-
izalton concerning '.he legal status of any country, territory, c,ty or
area or of its authorities, or concerning the delimitation of its fron-
tiers or boundaries.

The me1tion of specific compa~ies or of certain manufacturers'

prodccts does 1ot imply that they are endorsed or reco'Tlmended
by the World '1ealth Organization in preference to others of a similar
nature that are not mentioned. Frrors and omissions excepted. the
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letters.

The contributors alone are responsible for the views expressed in

this publication.

Printed in Swi,zerland
8817648 Alar - 7000
CONTENTS

Preface 9

Contributors 10

Introductory note 11

Fundamentals of general surgery

1 Basic principles and techniques 15

Asepsis
Preparation for surgery
Prevention of transmission of human immunodeficiency virus (HIV)
Surgical methods and materials
Wound debridement
Incision and drainage of abscesses
Split-skin grafting

2 Fluid and electrolyte therapy, blood transfusion, 36

and management of shock
Fluid and electrolyte therapy
Blood transfusion
Shock

Face and neck

3 Primary care of wounds of the face 49

General principles
Lip
Tongue
Ear and nose
Cellulitis of the face

4 Eye 53
Basic principles and procedures for eye surgery
Ocular trauma
Extraocular surgery
Intraocular surgery
Enudeation of the eye

5
Contents

5 Ear 72
Removal of foreign bodies
Myringotomy
Acute mastoiditis with abscess

6 Nose 76
Control of epistaxis
Removal of foreign bodies

7 Teeth and jaws 78

Extraction of teeth
The barrel bandage
Fractures of the jaw

8 Throat 84
Incision and drainage of peritonsillar abscess
Incision and drainage of retropharyngeal abscess
Incision and drainage of acute abscess of the neck

Chest, abdomen, and gastrointestinal tract

9 Chest 89
Tracheostomy
Underwater-seal chest drainage
Simple rib fracture
Flail chest
Pneumothorax
Haemothorax
Acute empyema
Surgical emphysema and mediastinal injuries
Incision and drainage of breast abscess

10 Abdomen (general) 100

Laparotomy
Repair of burst abdomen
Abdominal injuries

11 Stomach and duodenum 113

Feeding gastrostomy
Perforated peptic ulcer

12 Gallbladder and spleen 119

Cholecystostomy
Ruptured spleen

13 Small intestine 125

Resection and end-to-end anastomosis
Repair of typhoid perforation of the ileum

6
Contents

14 Appendix 130
Acute appendicitis
Appendicular abscess
Appendicular mass

15 Colon 135
Colostomy
Sigmoid volvulus

16 Anus and rectum 141

Rectal examination
Proctoscopy
Sigmoidoscopy
Haemorrhoids
Anal fissure
Incision and drainage of perianal and ischiorectal abscesses
Rectal prolapse

17 Hemiae 151
Inguinal hernia
Femoral hernia
Strangulated groin hernia
Umbilical and paraumbilical hernia
Epigastric hernia
Incisional hernia

Urogenital system1

18 Urinary bladder 167

Drainage
Management of ruptured bladder

19 Male urethra 177

Urethral dilatation
Rupture of the urethra

20 Male genital organs 181

Scrotal hydrocele
Circumcision
Vasectomy
Exploration of scrotal contents

Paediatric surgery

21 General principles for paediatric swgery 193

Special considerations
Cut-down to umbilical vein

1For detailed descriptions of obstetric and gynaecological procedures, see Surgery at the dirtn'ct horpital:

obstetrics, gy11tJecol()gy1 orlhopaedits, a'1d traumatology (Geneva, World Health Organization, in preparation).

7
Contents

22 Abdominal wall and gastrointestinal tract 196

Operative reduction of intussusception
Rectal prolapse
Relief of strangulated inguinal hernia

23 Urethra and genital organs 201

Meatal dilatation
Exploration of scrotal contents
Treatment of paraphimosis

Annex 1 Surgical trays 205

Annex 2 Essential surgical instruments, equipment, 217

and materials for the district hospital

Index 227

8
Preface

This handbook is one of three 1 to be published by the World Health Organization

for the guidance of doctors providing surgical and anaesthetic services in small
district hospitals (hospitals of first referral) with limited access to specialist
services. The advice offered has been deliberately restricted to procedures that
may need to be carried out by a young doctor with limited experience in
anaesthesia, surgery, or obstetrics, using the facilities that can reasonably be
expected in such hospitals. Wherever possible, the drugs, equipment, and
radiodiagnostic and laboratory procedures described conform with WHO and
UNICEF recommendations.

Although the handbooks contain detailed descriptions and illustrations, the

advice they offer is no substitute for practical experience. The reader is expected
to have been exposed to all the relevant techniques during undergraduate or
early postgraduate education. When necessary the text indicates which patients
should be referred for specialized care at a higher level, as it is important to
developing health services that young doctors and their superiors understand the
limitations of practice at the district hospital.

It has, of course, been necessary to be selective in deciding what to include in the

handbooks, but it is hoped that any important omissions will be revealed during
field testing. WHO would also be pleased to receive comments and suggestions
regarding the handbooks and experience with their use. Such comments would
be of considerable value in the preparation of any future editions of the books.
Finally, it is hoped that the handbooks will fulfil their purpose - to help doctors
working at the front line of surgery throughout the world.

The three handbooks have been prepared in collaboration with the following
organizations:

Christian Medical Commission

International College of Surgeons
International Council of Nurses
International Federation of Gynaecology and Obstetrics
International Federation of Surgical Colleges
International Society of Burn Injuries
International Society of Orthopaedic Surgery and Traumatology
League of Red Cross and Red Crescent Societies
World Federation of Societies of Anaesthesiologists
World Orthopaedic Concern.

1Also available: .A.nautbesia at the district hospitill; and in preparation: Surgery at the dislrict hospital; obstetrks,

gynaecology, orthopaedics, and trautnato/ogy.

9
Preface and contributors

Acknowledgements

This handbook has been prepared as part of a collaborative activity between

WHO and the International Federation of Surgical Colleges, which reviewed
and endorsed the draft manuscript and illustrations. The editors acknowledge
the valuable suggestions received from Dr G. Isaksson, Lund, Sweden, and
Mnene Hospital, Mberengwa, Zimbabwe, and from Mr R.F. Rintoul, Nevill Hall
Hospital, Abergavenny, Wales. Acknowledgements are also due to Churchill
Livingstone, Edinburgh, the publishers of Farquharson's textbook of operative surgery
(6th edition, 1978), for permission to adapt the drawings for Figures 13. lD,
16.1A, 18.3C,F, and 18.SA,B.

Contributors
Professor E.A. Badoe, Professor of Surgery, University of Ghana Medical
School, Accra, Ghana

Professor R. Carpenter, Professor and Head, Department of Surgery,

University of the West Indies, Kingston, Jamaica

Mr J. Cook, Consultant Surgeon, Department of Surgery, Eastern General

Hospital, Edinburgh, Scotland

Ms J.S. Garner, Chief, Prevention Activity, Hospital Infections Program,

Center for Infectious Diseases, Centers for Disease Control, Atlanta,
GA, USA

Dr M. Ijaz-ul-Hassan, Medical Superintendent and Chest Surgeon, Mayo

Hospital, Lahore, Pakistan

Dr A.E.O. Wasunna, Medical Officer, Clinical Technology, World Health

Organization, Geneva, Switzerland, and Professor of Surgery, University
of Nairobi, Nairobi, Kenya

10
Introductory note

This handbook describes a limited number of surgical procedures.

They have been chosen as appropriate for the doctor who does not
have a formal surgical training, but who nevertheless has experi-
ience, gained under supervision, of all the relevant techniques.
With the exception of vasectomy, which may be an important part
of national family planning programmes, the procedures included
are considered essential for saving life, alleviating pain, preventing
the development of serious complications, or stabilizing a patient's
condition pending referral. Operations that require specialist skills
or that could add unnecessarily to the doctor's workload have been
avoided, and simple but standard surgical techniques have been
selected whenever possible. Nevertheless, certain procedures that
may appear technically difficult (for example resection and anas-
tomosis of the small intestine) are included because they may offer
the best chance of saving a patient's life.

11
FUNDAMENTALS OF
GENERAL SURGERY
Fundamentals

For details of radiodiagnostic and laboratory techniques and drugs appropriate

for the district hospital, the reader is referred to the following WHO publica-
tions:

Manual of basic techniques for a health laboratory. 1980.

PALMER, P.E.S. ET AL. Manual ofradiographic interpretation for generalpractitioners

( WHO Basic Radiological ..[y.rtem). 1985.

WHO Technical Report Series, No. 689, 1983 (A rational approach to radio-
diagnostic inwstigations: report of a WHO Scientific Group on the Indications
for and Limitations of Major X-Ray Diagnostic Investigations).

WHO Technical Report Series, No. 770, 1988 (The use ofessential drugs: third
report of the WHO Expert Committee).

14
1
Basic principles and techniques

Surgical operations must satisfy three basic conditions: the wound must be
inflicted without pain; haemorrhage must be arrested; and the wound must heal.
It is especially the ability to ensure wound healing, by means of aseptic treatment,
that has given impetus to modern surgery. Indeed, the necessity for asepsis
regulates the conduct of surgeons, the "ritual" of operation, the form of instru-
ments, and even hospital design and construction to such an extent that it is often
taken for granted. Yet an understanding of the practical details of this system is
imperative for any surgeon.

Asepsis
The most important cause of impaired wound healing is infection. Microorgan-
isms reach the tissues during an operation or during changes of dressings or any
other minor interference with the surgical wound. They are carried and trans-
mitted by people (including the patient and anyone else who touches the wound
or sheds organisms into the surrounding air), inanimate objects (including
instruments, sutures, linen, swabs, solutions, mattresses, and blankets), and the
air around a wound (which can be contaminated by dust and droplets of moisture
from anyone assisting at the operation or caring for the wound).

The aseptic treatment of a wound is an attempt to prevent contamination by

bacteria from all these sources, during the operation and throughout the first
week or so of healing. Modem methods of preventing infection in "clean"
wounds also include the use of surgical techniques designed to make the wound
less receptive to bacterial growth: gentle handling, sharp dissection, good haemostasis, and
accurate apposition ofthe wound edges without tension when the wound is being closed. Bacteria
can never be absolutely eliminated from the operating field, but practicable
aseptic measures can reduce the risk of contamination to an acceptable level.

Asepsis is influenced by innumerable details of operating technique and behav-

iour. The probability of wound infection increases in proportion to the number
of breaches of aseptic technique. There is no great difficulty in applying this
technique to a single operation, but in practice the surgical team will be gathered
for several operations - an operating list. Between operations the theatre floor
is cleaned, instruments are resterilized, and fresh linen is provided. Potential
breaches of aseptic technique can be minimized by proper ordering of patients on
the list so that "clean" operations are done first. The longer the list the greater the
chances of error; the risk of wound infection therefore increases as the list
proceeds. For this reason, the surgeon should carefully consider the length and
order of the list. A list system should not be considered at all without a certain
minimum of equipment and a well-trained theatre staff.

15
 Fundamentals

/
:.i
'I
\1
111
1..
\\\ W,.
(
Fig. 1.1. Preparation of the skin with antiseptic solution. Working from the centre of the
operating field (A) to the periphery (B).

Certain types of surgery, which are beyond the scope of the practice described
here, require an exceptionally strict aseptic routine. But for the most part, safe
surgery depends on well-tried and well-understood systems of asepsis, which are
practicable in the district hospital. Asepsis depends on personal discipline and
careful attention to detail, rather than on antibiotics and complicated equip-
ment. There is no doubt that the level of discipline in operating theatres has
declined since the dangers of wound infections have been mitigated by anti-
biotics. Antibiotics, however, play little part in actually preventing wound con-
tamination. This remains to be achieved by attention to people, inanimate
objects, and air.

Preparation for surgery

The patient The patient's stay in hospital before an operation should be as short as possible.
Therefore, any tests and treatment that could prolong the preoperative stay
beyond 24 hours should be carried out as outpatient services, if possible. Before
the operation, correct gross malnutrition, treat serious bacterial infection, inves-
tigate and correct gross anaemia, and control diabetes. As a routine, measure the
patient's haemoglobin level and test the urine for sugar and protein.

Skin preparation The patient should bathe the night before an elective operation. Hair in the
operative site should not be removed unless it will interfere with the surgical
procedure. If it must be removed, clipping is preferable to shaving (which can
damage the skin) and should be done as close as possible to the time of opera-
tion.

16
 Basic principles and techniques

Fig. 1.2. Draping the patient. The operating field is isolated (A, B) and the drapes are secured
with towel clips (C) at each comer.

Just before the operation, wash the area around and including the operative site,
and prepare the skin with antiseptic solution, starting in the centre and moving
out to the periphery (Fig. 1.1 ). This area should be large enough to include the
entire incision and an adjacent working area, so that you can manoeuvre during
the operation without touching unprepared skin. Ethanol 70% (by volume) is
recommended as an antiseptic, except for delicate skin, such as that of the
genitalia and near the eye, and for children; 1% cetrimide (10 g!litre) is an
alternative, as is 2.5% iodine in ethanol (25 g!litre).

For major operations involving an incision and requiring the use of the operating
room, cover the patient with sterile drapes, leaving no part uncovered except the
operative field and those areas necessary for the maintenance of anaesthesia (Fig.
1.2).

Duties towards the patient It is your duty to discuss with the patient the need for surgery and to explain in
simple terms the nature of the proposed operation. Ensure that the patient
understands, particularly if the operation involves amputation of a limb, removal
of an eye, or construction of a colostomy, or will render the patient sterile, for
example hysterectomy for a ruptured uterus. You must obtain the patient's (or, if
necessary, a close relative's) informed consent for the operation. It is your
responsibility to ensure that the side to be operated on is clearly marked; recheck
this just before the patient is anaesthetized. Also check that all relevant pre-
operative care, including premedication, has been given. The patient's notes,
laboratory reports, and radiographs must accompany him or her to the operating
room.

The surgical team Anyone entering the operating room, for whatever reason, should first put on
clean clothes, an impermeable mask to cover the mouth and nose, a cap or hood
to cover all the hair on the head and face, and a clean pair of shoes or clean
shoe-covers.

17
 Fundamentals

i
\
\ \\~
Fig. 1.3. Scrubbing up. Washing with soap and running water (A); further application of soap
(B) before scrubbing the fingernails (C); washing the forearms with soap and running water (D);
position of hands and forearms at the end of scrubbing to allow water to drip off the elbows (E);
turning off the tap with the elbow (F).

Scrubbing up Before each operation, all members of the surgical team - that is those who will
touch the sterile surgical field, sterile instruments, or the wound - should
cleanse their hands and arms to the elbows, using soap, a brush (on the nails and
finger tips), and running water (Fig. 1.3). The team should scrub up for at least 5
min before the first procedure of the day, but between consecutive clean opera-
tions a minimum of at least 3 min is acceptable.

18
 Basic principles and techniques

)
~

Fig. 1.4. Putting on the sterile gown (A); an assistant adjusts the gown (B) and ties the straps
(C).

After scrubbing their hands and drying them with sterile towels, the members of
the surgical team should put on sterile gowns and sterile gloves (Fig. 1.4 & 1.5). A
glove punctured during the operation should be promptly changed.

The operating room Keep all doors to the operating room closed, except as needed for the passage of
equipment, personnel, and the patient. Keep to a minimum the number of
personnel allowed to enter the operating room, especially after an operation has
started. Clean the operating room between operations, and more thoroughly at
regular intervals, according to procedures established by the hospital. When
necessary, the operating room may be disinfected by mopping the floor, swab-
bing down the walls, and wiping all furniture with a liquid disinfectant, diluted as
recommended qy the manufacturer. Sterilize all surgical instruments and supplies.

Sterilization The methods of sterilization in wide use are autoclaving, exposure to dry heat,
and treatment with chemical antiseptics.

Autoclaving At the district hospital, sterilization should be largely based on autoclaving (Fig.
1.6A,B). For efficient use, an autoclave demands a trained operator in regular
practice and depends heavily on good maintenance. Most autoclaves in current
use are too large and too complicated, and carry high maintenance costs. It is
therefore hoped that more effort will be put into developing smaller and simpler
autoclaves that require little maintenance and are possibly solar-powered, espe-
cially for use in isolated rural hospitals in developing countries.

19
Fundamentals

Fig. 1.5. Putting on sterile gloves. Stalling with one hand (A) and proceeding to the second (B);
folding the sleeves of the gown (C) and tucking them into the gloves (D).

The selection of a suitable autoclave requires serious consideration not only of

the cost but also of servicing needs and the expected work-load. Desirable
features of an autoclave are a horizontal cylindrical drum, a single circular door, a
small chamber capacity, and a short cycle, especially for the post-sterilizing
phase. In general, the smaller the capacity, the shorter the whole process and the
less the damage to soft materials. It is often more practical to use a small
autoclave several times a day than to use a large machine once.

The basic operational criteria for an autoclave are steam at 100.0 kPa (750
mmHg) above atmospheric pressure and a temperature of 120 °C maintained for
15 min (or for 30 min for packs). Appropriate indicators must be used each time
to show that sterilization has been accomplished. At the end of the procedure, the
outsides of the packs of instruments should have no wet spots, and the moisture
retained by each pack should not cause more than a 3% increase in its
weight.

20
 Basic principles and techniques

A B

_..,,-
/::::

~
0
ooo
(?) II
<!)

c '
Fig. 1.6. An autoclave (A, B); a hot-air oven (C, D).

Dry heat Sterilizing by hot air is a poor alternative to autoclaving since it is suitable only
for metal instruments and a few natural suture materials. The oven most com-
monly available is of the type used by bacteriologists to sterilize laboratory
glassware (Fig. 1.6C,D). Instruments must be clean and free of grease or oil. They
are then sterilized by exposure to a temperature of 170 °C for 2 hours. A fan to
circulate the hot air within the oven will improve the efficiency of steriliza-
tion.

Other methods Boiling of instruments is now regarded as an unreliable means of sterilization,

and it is not recommended as a routine in hospital practice.

21
 Fundamentals

In general, instruments are no longer stored in liquid antiseptic. However, sharp

instruments, other delicate equipment, and certain catheters and tubes can be
sterilized by exposure to formaldehyde, glutaral (glutaraldehyde), or chlorhex-
idine. If you are using formaldehyde, carefully clean the equipment and then
expose it to vapour from paraformaldehyde tablets in a closed container for 48
hours. Be sure that this process is carried out correctly. Glutaral is a disinfectant
that is extremely effective against bacteria, fungi, and a wide range of viruses.
Follow manufacturers' instructions for use.

When normal methods Failure of an autoclave or a power supply may suddenly interrupt normal ster-
of sterilization fail ilization procedures. In such circumstances an antiseptic technique will allow
some surgery to continue.

Immerse towels and drapes for 1 hour in a reliable antiseptic such as aqueous
chlorhexidine, wring them out, and lay them moist on the skin of the patient.
Gauze packs and swabs can be treated similarly, but should be rinsed in diluted
(1 :1000) chlorhexidine solution before being used in the wound. During the
operation, gauze in use should be rinsed from time to time in this solution.
Immerse instruments, needles, and natural suture materials in strong antiseptic
for 1 hour, and then rinse them in weak antiseptic just before use.

Before entering the operating room, put on a clean, dry surgical gown or apron; if
you are a member of the surgical team, pin a moist antiseptic towel over this.
Wash gloved hands for 5 min in strong antiseptic and rinse them in a weak
solution of the same. If gloves are not available, wash the bare hands for at least 5
min in clean, preferably running water and steep them briefly in 70% ethanol.
Allow them to dry before touching the wound.

Prevention of transmission of human

immunodeficiency virus (HIV)

All body fluids from a person infected (or suspected of being infected) with HIV
should be considered potentially infectious. HIV may be transmitted: (1) by
needles or sharp instruments contaminated with blood or body fluids and not
properly sterilized; (2) by contact between open wounds, broken skin (for
example caused by dermatitis), or mucous membranes and contaminated blood
or body fluids; and (3) by transfusion of infected blood or blood products, semen
donation, and skin or organ transplantation. The prevention of HIV infection
requires special attention to these means of transmission as well as the strict
application of aseptic routine.

Most of the small number of reported infections of health workers with HIV
have resulted from injuries caused by needles (for example during recapping) and
other sharp instruments. After use, disposable needles and scalpel blades should
be put into a puncture-proof receptacle, preferably containing a sodium hypo-
chlorite disinfectant. Reusable needles should also be placed in a special con-
tainer of disinfectant before being cleaned and sterilized.

Surgical gloves prevent transmission of HIV through contact with blood, but
there is always the possibility of accidental injury and of a glove being punctured.
Thick gloves should therefore be worn when needles and sharp instruments are
being cleaned. Where HIV infection is prevalent among patients, needles and
instruments should routinely be soaked in a chemical disinfectant for 30 min
before cleaning.

Linen soiled by a patient who is or may be infected with HIV should be handled
with gloves and should be collected and transported in leak-proof bags. It should
be washed with detergent for 25 min at a temperature of at least 71 °C. If this is

22
 Basic principles and techniques

not possible, it should be soaked in a hypochlorite disinfectant before wash-

ing. ·

Liquid wastes, such as blood and fluids removed by suction, should be carefully
poured down a drain connected to a sewer o r into a pit latrine. Otherwise, they
should be chemically disinfected. Solid waste should be incinerated or disposed
of in a pit latrine; chemical disinfection may be a temporary expedient.

Proper sterilization of all surgical instruments and supplies is crucial in pre-

venting HIV transmission. All viruses, including HIV, are inactivated by steam
sterilization (autoclaving) for 20 min at 100 kPa above atmospheric pressure or
by dry heat in an oven for 2 hours at 170 °C.

Several points of aseptic routine applicable to members of the surgical team are
also particularly relevant to the prevention of transmission of HIV:
• Areas of broken skin and open wounds should be protected with
watertight dressings.
• Gloves should be worn during exposure to blood or body fluids and the
hands should be washed with soap and water afterwards.
• Frequent use of ethanol or other antiseptics on the hands and arms
should be avoided, because it may lead t0 broken skin.
• Protective glasses should be worn where blood splashes may occur, as
during major surgery; if the eyes are inadvertently splashed, they should
be washed out as soon as possible with saline.

It should be appreciated that the whole purpose of the aseptic method is to

prevent transmission of infection, and that strict attention to every detail of
asepsis, with special care to avoid accidental injury during operation, is the best
protection against HIV.

Surgical methods and materials

Anaesthesia It is the anaesthetist's responsibility to provide safe and effective anaesthesia for
the patient. The anaesthetic of choice for any given procedure will depend on the
anaesthetist's training and experience, the range of equipment and drugs avail-
able, and the clinical situation. For a detailed discussion of anaesthetic tech-
niq ues suitable for the surgical operatio ns described here, see Dobson, M.B.,
Anaetthesia at the dittrict hospital (Geneva, World Health Organization, 1988).

Operative technique The surgical team should strive to handle tissues gently, to prevent bleeding, to
minimize dead space and the amount of devitalized tissue and foreign material in
the wound, and to work efficiently to avoid prolonging the operation unneces-
sarily. Plan the incision to give adequate exposure. Incise the skin with bold
sweeps of the belly of the knife, while stretching the skin between the thumb and
fingers of the other hand (Fig. 1. 7). Control initial oozing of blood from the cut
surfaces by pressure over gauze. Individual bleeding vessels may be caught in fine
forceps and twisted offor ligated with fine catgut or fine thread (Fig. 1.8). Cut the
ligature short. As a routine, use a reef knot, but make a triple knot or a surgeon's
knot if additional security is required. Avoid diathermy near the skin. Similarly
deepen the wound to reach the target organ, making sure that the wound is laid
open along its whole length. A clean knife is commonly used to gain access to a
body cavity, for example for incising the peritoneum.

Close the operation wound in layers with catgut, thread, or nylon (but avoid
thread in potentially contaminated wounds because it can form a focus for
infectio n). Use different types of sutures as appropriate, for example simple,
interrupted, continuous, mattress, or purse-string. Aim to bring the wound edges

23
 Fundamentals

D
~~)

Fig. 1. 7. Making an incision. Alternative ways of holding the knife (A, B); stretching the skin
between the fingers and thumb (C); a skin knife (D).

together loosely, but without gaps, taking a "bite" of about 1 cm of tissue on

either side and leaving an interval of 1 cm between each stitch (Fig. 1.9A-D).
Remember that a "suspect" (possibly contaminated) or grossly contaminated
wound is best left open and lightly packed with plenty of dry gauze, with sutures
inserted for delayed primary closure after 2-5 days (Fig. 1.9E,F).

Suture materials Sutures and ligatures consist of absorbable or non-absorbable materials. Catgut
remains the most popular absorbable material because of its pliability and
superior handling qualities. Chromic catgut lasts for 2 or 3 weeks in the tissues
and is excellent for ligatures and for approximating tissues, though it is no longer
used for closing abdominal wounds and in other situations where prolonged
support is needed, because of the rapid loss of tensile strength as it is absorbed.
Plain catgut is absorbed in 5-7 days, but is useful when healing is expected within
this period, and for suturing the bladder mucosa.

Non-absorbable materials include braided lengths of natural products (such as

silk, linen, and cotton) and synthetic monofilaments (such as nylon and poly-
propamide). Choice among these materials depends on cost, availability, indi-

24
 Basic principles and techniques

c D

Fig. 1.8. Control of bleeding by ligation and by pressure over gauze (A); the ligature knot is
pushed well down (B); suture ready fur tying (C); making a knot (D): a reef(square) knot (E); a
triple knot (F); a surgeon's knot (G).

vidual preference in handling, security of knots, and the behaviour of the

material in the presence of infection. In this book braided materials are referred
to as "thread" and synthetic monofilamem materials as "nylon".

Never use thread for sutures deep in a wound that may be contaminated.
Monofilament nylon, however, may be left in the deeper layers; it is better used
as a continuous stitch, as its knots are less secure than those of thread. All
varieties of suture material may be used in the skin. Thread is easier to use for

25
 Fundamentals

Fig. 1.9. Skin closure. Inserting and tying a simple stitch (A, B); inserting and tying a mattress
stitch (C, D); packing a contaminated wound and inserting sutures for delayed primary closure
(E, F).

26
 Basic principles and techniques

intemtpted stitches, while nylon marks the skin least and is convenient for
continuous stitches. Use absorbable material in the urinary tract to avoid the
encrustation and stone formation associated with non-absocbable sutures.

Size and strength of Sutures are graded according to size on two scales: an old system that runs
materials upwards from Oto 4 and downwards to about 6/0, and a metric system running
from Oto 8. Most surgeons continue to use the old gauge, and this is referred to
throughout the text; a rough conversion table is given below,

Old 6/0 5/0 4/0 3/0 2/0 0 1 2 3 4

Metric 1.5 2 2.5 3 4 S 6 7 8

Most common operations can be completed with suture materials between si7.es
3/0 and 1. The strength of sutures varies little between the usual materials.

Use of drains Drains are no substitute. for good surgery, but when indicated, they should be
retained for no longer than 72 hours. The ideal drainage is by suction, but when
this is not available you may substitute a corrugated latex drain running into a
closed colostomy bag (Fig. 1.10). When neither suctio!l nor a colostomy bag is
available, use a corrugated drain running into gauze dressings, though this is far
from satisfactory. India rubber drains should not be used.

Use of antimicrobial Patients often present with infections requiring treatment with antimicrobial
drugs drugs or develop such infections after operation. When antimicrobial treatment
is indicated, keep in mind several principles:
Treatment of infections
• systemic rather than topical agents should be used , except for the
eye;

• narrow-spectrum antimicrobial drugs directed against specific organ-

isms should be used whenever possible, as broad-spectrum drugs can
lead to superiofe.ction and favour the selection of resistant microor-
ganisms;

• the choice of a particular agent from a broad group of antimicrobial

drugs should depend on the target microorganism, if known, and its
drug sensitivity, and on factors such as the drug's antimicrobial spec-
trum, record of use in the clink, safety, efficacy, and potential to favour
the selection of resistant organisms;

• cost should determine the choice of drug when microbiological, phar-

macological, and o ther relevant properties are similar for several
agents;

• antimicrobial treatment should be discontinued as soon as the patient's

clinical condition permits.

Prophylaxis Parenteral antimicrobial prophylaxis should not be routine, but is recommended

for operations associated with a high risk of infection, for example bowel resec-
tion. It is also recommended for operations after which infection, although not a
frequent problem, can have. severe or life-threatening consequences (for exam-
ple craniotomy). In addition, antimicrobial prophylaxis is essential for patients
with valvular heart disease, who are at risk of developing bacterial endocarditis
as a result of transient bacteraemia from instrumentation in the mouth or other
parts of the body.

27
 Fundamentals

)/'
,,,c"· ,···:

Fig. 1.10. Drainage. Drainage by suction through a tube with several holes (A, B); a corrugated
latex drain (C); drainage into a colostomy bag (D, E).

Start parenteral antimicrobial prophylaxis immediately before the operation and

continue it for 1-2 days.

Wound care Generally, do not close wounds by primary suture if they are or may be con-
taminated, and do not touch an open wound directly with bare, unsterilized
hands. A repaired wound can be regarded as sealed after 24 hours, and dressings
may then be changed without sterile gloves but with a "no-touch" technique.

Remove dressings over closed wounds if they become wet or if the patient shows
signs or symptoms suggestive of infection, for example fever or unusual wound
pain. After removing the dressing, inspect the wound for signs of infection and
sample any discharge for bacteriological examination.

28
 Basic principles and techniques

Records Keeping accurate records on patients is the doctor's responsibility. Write down
all clinical information about the patient immediately after such information is
obtained. Indicate the date and time for every record made, and ensure that all
records are legible and easily understood. Notes on surgical procedures under-
taken, including the findings at operation and instructions on postoperative
management, must be recorded without delay at the end of every operation.
Specific mention should be made of the operation as being either "clean",
"clean-contaminated", "contaminated", or "dirty and infected". This will allow
for an evaluation of postoperative wound infection rates. Such evaluation, which
should be the regular duty of one member of the hospital team, permits assess-
ment of the application of aseptic routine within the hospital.

Even ward patients who are not seriously ill should be assessed at least once a day
and progress notes made, if only to indicate that there has been no change in the
patient's condition. On discharging the patient from the ward, record the defini-
tive diagnosis and give instructions about his or her further management as an
outpatient. Remember that clinical notes are important for review and discus-
sion to determine how patients (including future patients) should be managed,
for insurance and medico-legal purposes, and for research.

Wound debridement

Debridement is a procedure used in the initial management of non-surgical

wounds to remove dead tissue and foreign material in order to facilitate healing.
Wound toilet and debridement are systematic procedures, applied first to the
superficial and then to the deeper layers of tissues. Gentle handling of tissues will
minimize bleeding, which can be further controlled by local compression or by
ligation of the spurting vessels.

Anaesthesia should be provided as appropriate. If necessary, clip or shave hair

from around the wound. Wash the wound with toilet soap and water, irrigate it
with physiological saline, and scrub the surrounding area thoroughly (Fig.
1.11A,B). There should be no soap left in the wound. Meticulously remove any
loose foreign material such as dirt, grass, wood, glass, or clothing and prepare the
skin with antiseptic. It is generally wise to extend the wound longitudinally to
reveal the ·full extent of damage. Excise only a very thin margin of skin from the
wound edge (Fig. 1.11C).

Excise all dead tissue from the wound (Fig. 1.1 lD,E). Dead or devitalized
muscle will be dark in colour and will be soft or easily torn and damaged; it will
not contract when pinched with toothed forceps or bleed when cut. Remove all
adherent foreign material along with the dead muscle. In cases of compound
fracture, remove only very small, obviously free fragments of bone, provided that
their removal does not affect the stability of the fracture. It is unwise to strip
muscle and periosteum from a fractured bone.

Vessels, nerves, and tendons that are intact should be left alone after the wound
has been cleansed. Ligate divided vessels regardless of whether they are bleeding.
Large vessels that have been damaged and contused may need to be divided
between ligatures, but first test the effect on the distal circulation by temporary
occlusion of the vessel with tape or rubber clamps.

Loosely appose the ends of divided nerves by inserting one or two fine, black silk
stitches through the nerve sheath. Tendon ends may be similarly fixed to prevent
further retraction. Formal repair of nerves or tendons is best undertaken later, if
possible by a specialist surgeon.

29
 Fundamentals

A B

Fig. 1.11. Wound debridement. Washing the wound (A, BJ; excising a small skin margin (C);
excising all dead tissue (D, E); inserting stitches, which are left untied, and packing the wound (F,
G),

30
 Basic principles and techniques

Generally leave the wound open after debridement, inserting stitches but leav-
ing them untied for delayed primary closure 2-5 days later (Fig. 1.11 F,G). Pack
the wound lightly with dry, sterile gauze. Always administer tetanus prophylaxis.

Incision and drainage of abscesses

Infections with abscess formation are a major problem in many developing
countries. Treatment is often delayed or inadequate. Yet there are few surgical
procedures that have as dramatic results, in terms of the patient's satisfaction and
confidence in health staff, as the prompt and adequate drainage of an acute
abscess.

Incision and drainage of an abscess are indicated if there is evidence of localized

pus: throbbing pain; hot, local swelling with tight, shiny skin; and marked
tenderness. Fluctuation is the most reliable sign, though it may be absent in a
tense or deep abscess. Interference with sleep is a pressing indication for sur-
gery.

For more specific discussion of mastoid, peritonsillar and retropharyngeal, neck,

breast, appendicular, and perianal and ischiorectal abscesses, see pages 74, 84, 85,
98, 134, and 148, respectively.

Assessment and If in doubt about the diagnosis, confirm the presence of pus by needle aspiration.
preoperative management (An aneurysm may mimic the features of an abscess, but it pulsates and lies in the
line of a major vessel.) Measure the patient's haemoglobin level and test the urine
for sugar and protein.

Equipment See_ tray for Incision and drainage of abscess, Annex 1.

Technique Prepare the skin with antiseptic, and give a local anaesthetic if necessary. Per-
form a preliminary needle aspiration to confirm the presence of pus if this has not
already been done (Fig. 1.12A).

Make an incision over the most fluctuant or prominent part of the abscess, in a
skin crease if possible (Fig. 1.12B). Take a sample of pus for bacteriological
examination. Introduce the tip of a pair of sinus or artery forceps into the abscess
cavity and open the jaws to improve drainage (Fig. 1.12C). Explore the cavity
further with a finger to break down all loculi (Fig. 1.12D).

It may be necessary to extend the incision or convert it into a cruciate form to

deroof the abscess completely (Fig. 1.12E,F), but take care not to open up
healthy tissues or tissue planes beyond the abscess wall. The abscess cavity can
then be cleaned with swabs soaked in saline or antiseptic solution.

Introduce a large corrugated drain, positioning it well into the depth of the
cavity. A counter-incision may be necessary to ensure free and dependent drai-
nage. Fix the drain to the edge of the wound or counter-incision with a stitch of
2/0 thread, and mark it with a safety pin before cutting off the excess drain. Dress
the wound with several layers of gauze, the gauze of the deeper layers having
been first soaked in antiseptic solution and wrung out. Leave the drain in place
for about 2 days, until a track has formed through the tissues or until the drainage
is minimal. Alternatively, pack the abscess cavity with a ribbon of petrolatum
gauze, leaving one end outside the wound, marked with a safety pin. Control
excessive bleeding from the cavity by tight packing with dry gauze; this may be
removed after about 12 hours and replaced with a petrolatum gauze pack or a
drain.

31
 Fundamentals

A c

Fig. 1.12. Incision and drainage of abscess. Preliminary aspiration (A); incision (B); intro·
ducing the tip ofa pairofforceps to improve drainage (C); breaking down loculi with a finger (D);
further incision (E); trimn1ing the corners of the cruc.iate incision to deroof the cavity (F).

Too small an incision and failure to provide free drainage are common mistakes
in this procedure, leading to chronicity or recurrence of the abscess. The wound
edges must not be allowed to close while the abscess cavity remains.

After-care Treatment with antibiotics is unnecessary, unless there is evidence of spreading

infection with signs of toxicity or unless the abscess is in a region of crucial
importance, such as the hand, ear, or throat.

32
 Basic principles and techniques

Split-skin grafting
Skin is the best cover for a raw surface caused by, for example, trauma or burns. 1
The recipient area for the graft should have healthy granulation tissue with no
evidence of infection.

Equipment See tray for Skin grafting, Annex 1.

Technique The patient should be given a general anaesthetic.

The most commonly used donor site is the anterolateral or posterolateral surface
of the thigh. First clean the selected donor site with antiseptic and isolate it with
drapes. Apply petrolatum or liquid paraffin (mineral oil) to lubricate the area.
Hold the assembled skin-grafting knife (Humby) (Fig. 1.13A) in one hand and
press the grafting board against the patient's thigh (or alternative donor site) with
the other hand. Instruct an assistant to apply counter-traction to keep the skin
taut by holding a second board in the same manner. Cut the skin with regular
back-and-forth movements while progressively withdrawing the first board
ahead of the knife (Fig. 1.13B).

After cutting a length of about 2 cm of skin, inspect the donor area: homo-
geneous bleeding confirms that the graft is of split-skin thickness; exposed fat
indicates that the graft is of full thickness, i.e., too deep, in which case you should
check the adjustment of the blade. As the cut skin appears over the blade, instruct
an assistant to hold it gently out of the way with non-toothed dissecting forceps.
Place the newly cut skin in saline and cover the donor area with a warm wet pack
before dressing it with petrolatum gauze. Spread out the cut skin, with the raw
surface upwards, on petrolatum gauze (Fig. 1.13C).

If a skin-grafting knife is not available, the graft can be taken with a razor blade
held with straight artery forceps. Start by applying the cutting edge of the blade at
an angle to the skin but after the first incision lay the blade flat.

Before applying the skin graft, clean the recipient area with saline. Wet the graft
frequently with saline to prevent it from drying out. Do not pinch it with
instruments. To graft a large piece of skin, first suture it in place at a few points
and then continue to place sutures around the edges of the wound. Sutures are
not necessary for a small piece of skin.

Haematoma formation under the graft is the most common reason for graft
failure. It can be prevented by applying a "bolster" dressing made of moist cotton
wool moulded in the shape of the graft and tied over the graft with sutures. As an
alternative, make several small perforations in the graft (Fig. 1.130), or cut the
graft into small pieces (postage-stamp grafts) and place them a few millimetres
from each other to leave space for bridging during the re-epithelization pro-
cess.

After-care Hold the graft in place with petrolatum gauze, unless you have already sutured it
and applied a bolster dressing. Then apply additional layers of gauze and cotton
wool, and finally a firm, even bandage. Leave the graft undisturbed for 2-3 days
unless infection or haematoma is suspected. Change the dressing daily br every
other day thereafter (a bolster dressing will no longer be needed by this stage),
but never leave the grafted area uninspected for more than 48 hours. If the graft
is raised, puncture it to release any serum underneath. Otherwise interfere as

1For further details of the treatment of burns and other forms of trauma, see Surgery at the district hospital:

obstetric.;, gynaecology, orlhopfJBdics, and traumatology (Geneva, World Health Organization, in preparation).

33
 Fundamenlals

JI] .il\\\\\\\\\\\\\\:\\\iim\\1\\\\1\\:\\\\\\\\\\\\\\\\:II\\\~·

D
Fig. 1.13. Skin grafting. A skin-grafting knife (Bumby type) (A); cutting skin (B); spreading
out the cut skin (C); making perforations in the graft (D).

34
Basic principles and techniques

little as possible. It may be possible to expose the graft to the air at this early stage
if the area can be protected by splints or mosquito netting, but only if there is
adequate nursing supervision. After 7 to 10 days, remove any sutures, wash the
grafted area, and lubricate it with liquid paraffin (mineral oil) or petrolatum.

The second week after grafting, instruct the patient in regular massage and
exercise of the grafted area, especially if it is located on the hand, the neck, or one
of the limbs. These exercises should be continued for at least 9 months. To
prevent bum contractures, apply simple splints for flexure surfaces and keep the
grafts under tension using whatever means is available. For example, simple
tongue depressors can serve as finger splints and plaster of Paris can be used
for extremities.

35
 2
Fluid and electrolyte therapy,
blood transfusion,
and management of shock

Fluid and electrolyte therapy

Normal distribution The amount of water in the healthy body depends on the size, weight (particu-
and composition of larly lean body mass), and sex of the individual. Body water is usually expressed
body fluid as a percentage of body weight and is approximately 60% in men, 50% in women,
65% in children older than one year, and up to 75% in neonates. The water
present within the cells, intracellular fluid, accounts for 40% of the body weight
in men. The extracellular fluid makes up 20-25% of the body weight in men and
40-50% in neonates, and is subdivided into plasma and interstitial fluid. Phy-
siologically, these three compartments of body water are interdependent (Fig.
2.1).

Plasma contains proteins (chiefly albumin) and ions (mainly sodium, chloride,
and bicarbonate). Water and electrolytes move freely between plasma (intravas-
cular compartment) and the interstitial fluid, but plasma proteins enter the
interstitial fluid only when the capillary endothelium is damaged, for example as
a result of septic shock or burns. The protein in plasma is responsible for the
intra vascular colloid osmotic pressure, a major determinant of the movement of
fluid across the capillary endothelium. Only a small proportion of the body's
potassium is present in plasma, but the concentration of potassium ions is crucial
to cardiac and neuromuscular function.

Interstitial fluid has an ionic composition similar to that of plasma. If there is a

water deficit in the intra vascular compartment, water and electrolytes pass from
the interstitial compartment to restore the circulating blood volume. Electrolyte
solutions, such as physiological (normal) saline and Ringer's lactate solution
(Hartmann's solution), can pass into the interstitial space when they are admin-
istered intravenously. For this reason, they are effective in raising the intravas-
cular circulating volume for only a short time if there is a deficit of fluid
throughout the extracellular compartment. Blood, plasma, and colloids used as
plasma substitutes, for example dextran, hydroxyethyl starch, and gelatin solu-
tions (which are known as "plasma expanders"), remain in the intravascular
compartment longer and are therefore more effective in maintaining the circu-
lation.

Intracellular fluid has a different ionic composition to extracellular fluid. The

main cations are potassium and magnesium, with phosphates and proteins as the
major anions.

After intravenous infusion, the water contained in physiological saline tends to

remain in the extracellular compartment, but the water contained in glucose
solutions is distributed throughout all body fluid compartments, the glucose
being metabolized. Never give pure water intravenously, as it causes dangerous
haemolysis.

36
 Fluid/ electrolyte therapy and shock

,---------------~65k
I g , - - - - - - - , 2k
I
I I g
I I I
I I I
I I I
I
I : I
I I I
I I I
I I I
I I I
I
I I I
I I
I I
I I
.................
:::: lntravascular :;:
:;:; (Blood 85ml/kg):;:
·.· .............. ·.·

-~-

·"-----' ...___,,·

ADULT NEONATE
Fig. 2.1. Fluid compartments of the body.

Daily water and In the normal individual, the amount of water and electrolytes excreted each day
electrolyte exchanges balances what is taken in in foods and fluids (Tables 1 & 2). The kidney regulates,
to a large degree, the volume and composition of body fluid. To a lesser degree
the skin and lungs affect water losses, but do not regulate them.

Acid-base balance Hydrogen ions (H+) and large amounts of carbon dioxide (C0 2 ) are produced
during the normal metabolic activity of the body. The hydrogen ions are dis-
charged into body fluids, and the carbon dioxide combines with water to form
carbonic acid (H2C0 3).

The body has extremely efficient mechanisms for buffering acids, but in disease
these mechanisms are often disturbed. Of the buffer systems, the bicarbon-
ate/carbonic acid system is the most important, but proteins, and especially

37
 Fundamentals

Table 1. Average daily water exchanges (in ml) in an adult male

Tropical countries Temperate countries

Loss
Through lungs and skin 1700 1000
In urine 1500 1500
In faeces (variable) 200 200
Total 3400 2700
Gain
Water of oxidation 200 200
Net requirement 3200 2500

Table 2. Average daily losses of sodium and potassium (in mmol) in an

adult male

Tropical countries Temperate countries

Sodium
Urine 114 80-110
Sweat 16 0
Faeces 10 10
Total 140 90-120
Potassium
Urine 47 60
Sweat Negligible 0
Faeces 10 10
Total 57 70

haemoglobin, are also important as intracellular buffers. The normal plasma pH

of approximately 7.4 is maintained within narrow limits through these buffering
systems, through the control of carbon dioxide elimination by the lungs, and
through the regulation of plasma bicarbonate (HC0 3) concentration by the
kidney.

Disturbances of Changes in the volume or composition of the body fluids (which may occur
body-fluid status before, during, or after surgery) can cause a severe physiological disturbance and
should therefore be corrected promptly. The volume changes seen in surgical
practice often affect the extracellular fluid. This fluid may be lost not only
externally, for example through external haemorrhage, but also internally
through sequestration (translocation or redistribution) into injured tissues, as in
patients with burns, crush injuries, peritonitis, or an obstructed loop of the
bowel. This internal redistribution of the extracellular fluid, at times referred to
as fluid loss into the "third space", is often overlooked, yet it can markedly reduce
the circulating fluid volume.

How to assess volume Take a detailed history from the patient or from his or her relatives and make a
depletion careful examination to determine the nature and approximate amount of fluid
lost; the diagnosis should be mainly clinical. The clinical state of the patient
depends on the amount and rate of fluid loss, the underlying or associated
disease, and the efficiency of compensatory mechanisms. Reliable tests for
determining the amount of fluid lost are not available; in particular, the con-
centration of sodium ions in the serum can be misleading. Nevertheless, the
patient's blood can yield useful information: the blood urea concentration may

38
 Fluid/electrolyte therapy and shock

Table 3. Mass concentration of components of a solution of oral

rehydration salts (ORS)

Component g/litre

Sodium chloride 3.5

Trisodium citrate, dihydrate• 2.9
Potassium chloride 1.5
Glucose, anhydrous b 20.0

a Or sodium hydrogen carbonate (sodium bicarbonate) 2.5 g

b Or glucose, monohydrate 22.0 g; or sucrose 40.0 g.

Table 4. Substance concentration of components of a solution of oral

rehydration salts (ORS)

Component mmol/litre

Sodium 90
Potassium 20
Chloride 80
Citrate a 10
Glucoseb 111

a Or bicarbonate 30 mmol/litre
D Or sucrose 117 mmol/litre.

be elevated if there is an uncorrected deficit of extracellular fluid, and the

severity of dehydration (loss of water and electrolytes) may be indicated by the
haemoglobin concentration or erythrocyte volume fraction. The dehydrated
patient is usually thirsty with a dry mouth, sunken eyes, and reduced skin
elasticity; the blood pressure may be low, associated with a small pulse pressure
and tachycardia. If the fluid loss is acute and severe, the patient may develop
hypovolaemic shock. Urinary output may be low and the relative density (speci-
fic gravity) of the urine high.

Treatment of fluid If the patient is suffering fluid loss but with minimal signs, administer fluids
imbalance orally, unless contraindicated; a solution of oral rehydration salts (ORS) in water
is suitable for this (Tables 3 & 4). In patients with burns, oral rehydration salts are
a useful supplement to fluids given intravenously. The ideal solution to infuse is
one whose composition most closely resembles that of the fluid lost. Replace the
fluid already lost, administer fluid for daily maintenance, and anticipate and
replace any continuing unusual losses. Remember that patients receiving fluid
and electrolyte therapy, except those with diarrhoea, are not likely to pass faeces,
so daily requirements must be adjusted accordingly. Table 5 shows the main
features of the commonly available replacement fluids.

In patients suffering fluid loss and showing obvious signs, it is convenient to

begin replacement by infusing a balanced salt solution such as physiological
saline (containing sodium chloride at 9 g/litre) or Ringer's lactate solution. In
hot countries, water loss is proportionally greater than electrolyte loss, so infuse
balanced salt solutions with caution and consider infusing 5% glucose (SO
gllitre) as well. Insert a bladder catheter and measure the hourly urinary output
and its relative density (specific gravity). Adjust the rate of infusion and the total
amount of fluid in accordance with the patient's response, as indicated by the
trend in the symptoms and signs, and in particular by the hourly urinary output
and the jugular venous pressure. The ideal urinary output is at least 0.5 ml/kg of
body weight per hour. Record clinical observations and assess the effect of
therapy hourly. Establish a fluid input/output chart, and give clear, written

39
 Fundamentals

Table 5. Commonly available replacement fluids

Carbo- Energy con-

Ions {mmol/litre)
hydrate tent
Fluid Na+ Cl- K+ {g/litre) {kJ [kcai..n Uses

Blood a 140 100 4 5-8 NA Blood loss

Physiological saline 154 154 0 0 0 Blood/extracellular fluid loss
(9 g/litre)b
Hartmann's solution (Ringer's 131 112 5 NA NA Blood/extracellular fluid loss
lactate solution)c
Glucose 50 g/litre 0 0 0 50 837 [200] Dehydration
Glucose/saline (glucose 31 31 0 40 669 [160] Maintenance of electrolyte and
40 g/litre + sodium chloride water balance
1.8 g/litre)
Sodium bicarbonate 84 g/litre 1000 0 0 0 0 Acute acidosis
Dextran 70 in physiological 144 144 0 0 0 lntravascular replacement
saline
Polygeline 145 150 0 0 669 [160] lntravascular replacement

a Also contains ca2+ at 2.3 mrnol/litre.

b The same as a 0.9% solution
(..' Also contains ca2 1 at 3 mmol/litre and lactate at 28 mmol/litre, which is converted to bicarbonate and is therefore useful for correcting acidosis.
NA, not applicable

instructions about the infusion programme; it is preferable to update these

instructions every 6-8 hours rather than only once a day, as losses and require-
ments may change rapidly.

Treatment of electrolyte Hypernatraemia (an excess of sodium ions in the serum, which can be confirmed
imbalance by a blood test) may be caused by infusion of excessive quantities of saline or by
tube feeding without sufficient water supplementation. Associated clinical fea-
tures are restlessness, tachycardia, dry, sticky mucous membranes, and often an
elevated body temperature. Correct hypernatraemia by salt restriction and an
intravenous infusion of 5% glucose in water.

Hyponatraemia may follow the intravenous infusion oflarge volumes of salt-free

fluids, such as glucose solutions. It can also follow oral or rectal administration of
large amounts of water or other salt-free fluids. It is a recognized complication of
water enema in infants and children, especially in those with Hirschsprung's
disease, and any form of enema in children and infants should therefore be
avoided. The affected patient is lethargic and hypertensive, with tachycardia and
cold extremities; oliguria or even anuria is present. Treat hyponatraemia by
restricting the patient's water intake. Do not give hypertonic saline infusions in
an attempt to "normalize" the level of serum sodium.

Imbalances of serum potassium concentration have more serious clinical con-

sequences than those of serum sodium concentration. Potassium is crucial
to cardiac and neuromuscular functions, and its level in serum (3.5--4.5
mmol/litre) varies with the acid-base status and renal function of the individual.
Hyperkalaemia may occur after severe trauma (including burns and surgical
operations) and in patients suffering from acidosis, various catabolic states, and
acute renal failure. Although the patient may complain of nausea, vomiting, ab-
dominal colic, and diarrhoea, the symptoms are a poor guide to hyperkalaemia.
The electrocardiogram usually has a peaked T wave, a widened QRS complex,
and a depressed S-T segment; dysrhythmias are more likely than usual and may
lead to cardiac arrest. Give specific treatment intravenously, in the following
sequence:

40
 Flukl/eleclrolyte lherapy and shoclc

• 20 ml of a 10% (100 g,llitrc) solution of calcium gluconate, over a

period of 20 min ;

• 100 mmol (8.4 g) of sodium l:>icarbona.te in solution (in an acidotic

patient this will encourage the entry of potassium ions into cells);

• 100 ml of a 50% (500 g/litre) glucose solution, with insulin at l In-

temarional Unit for every 5 g of glucose.

Recovery of cardiac function is usually prompt with this treatment. If the

patient's hyperkalaemia is due to acute renal failure, refer the patient im medi-
ately after resuscitation, if possible. If refexral is not possible, begin peritoneal
dialysis.

Hypokalacmia often results from prolonged administration of diuretics or exces-

sive losses of fluid through the gastrointestinal tract, for example in cases of
prolonged diarrhoea or vomiting. The patient has flaccid limbs, reduced tendon
reflexes, and paralytic ile us. TI1e electrocardiogram shows a flat T wave and a
depressed S-T segment. An adequate urine output (0. 5 ml/kg ofbody weight per
hour) must be established before correction of the potassium deficit is started.
Potassium is given as potassium chloride mixed in the drip fluid : add 40 mmol of
the salt to 1 litre of either saline or 5% glucose. Infuse this fluid very slowly so as
to deliver not more than 40 mmol of potassium per hour, and estimate the serum
potassium concentration after giving every 40 mm ol. The bottle of flu id con-
taining potassium chloride must be clearly labelled. Never give a concentrated
solution of a potassium salt by direct intravenous injection.

Blood transfusion
Transfusion with whole blood is generally indicated in cases of acute, severe
blood loss amounting to over 15% of blood volume. However, the decision to
proceed with t ransfusion should be taken only after careful consideration of the
risk of transfusing blood contaminated with infectious agents, including human
immunodeficiency viruses.

It is not necessary to replace all Jost blood w ith blood. To reduce the requirement
for whole blood after acute blood loss, infuse plasma expanders such as dextran,
hydroxyethyl starch, and gelatin solution, if available. These plasma expanders,
however, cannot transport oxygen. They can also interfere with the cross-
matching of blood, so blood samples should be taken before infusion.

If anaemia is recognized before surgery, it is best to investigate the cause and treat
it appropriately. But in an emergency yo u may have to correct the anaemia by
slow transfusion, preferably with packed red cells. Take particular care with
haemostasis during the oper ation. Measure the blood Joss and replace this with
whole blood. If you anticipate a loss of more that 500 ml during the operation,
group and cross-match donor blood in advance.

Technique Clearly record the reasons for transfusion. Also record the history of previous
transfusions, as well as any reactions to these. If the patient is a woman, record
the history of any previous pregnancies, including miscauiages, st illbirths, or
infants who suffered from haemolytic disease of the newborn. Finally, record the
patient's current or last known haemoglobin level.

Take 10 ml of venous blood from the patient with a dry syringe, and allow it to
clot in a dry, sterile specimen bottle or tube clearly labelled with the date and the
patient's name, hospital number, and ward. Venepuncture may be difficult in

41
 Fundamentals

infants, so use a heel stab instead, and allow 10-20 drops of blood to drip into a
sterile tube. Except in emergencies, make requests for grouping and cross-
matching of blood at least 24 hours before the proposed transfusion. This will
help avoid errors and will allow time to obtain blood and carry out any tests
indicated by the patient's condition.

Ideally the blood used for transfusion should match the patient's own blood
group. To avoid risks to future pregnancies or transfusions, always use Rh-
compatible or Rh-negative blood for premenopausal female patients. If there is
difficulty in obtaining blood, especially in an emergency, apply the following
rules:

Group A patient: ideally give blood group A, but you may give
group 0.

Group B patient: ideally give blood group B, but you may give
group 0.

Group AB patient: ideally give blood group AB, but you may give
group A, B, or O (in that order of preference).

Group O patient: give only blood group 0.

Even if these rules are followed, it is still important to cross-match the serum of
the patient against the red cells of the donor (compatibility test) to make sure that
the blood is safe to give.

Store blood for transfusion in a special refrigerator at 4-6 °C until the time for
transfusion. There is an increased risk of sepsis if the blood is artificially warmed;
it will reach room temperature as it passes down the giving set. Do not transfuse
blood if it is purple, if the plasma layer is pink, or if the date of transfusion is more
than 21 days from the date of donation. Always use a giving set with a filter, and
start transfusion slowly until about 200 ml have been given. For an anaemic
patient use a slow transfusion rate throughout the procedure, but do not allow
longer than 4-6 hours per unit of blood because of the risk of sepsis in blood kept
at room temperature. Limit the transfusion of whole blood to 20 ml/kg of body
weight for infants weighing less than 25 kg and to 10 ml/kg for neonates (up to 1
year old).

Complications The manifestations of transfusion reactions vary, but pyrexia (at times with rigor)
is common, and the patient may develop oliguria or anuria after a severe reac-
tion. If a reaction occurs, stop the transfusion at once and investigate the cause.
The reaction may be due to incompatibility between blood-group antigens and
antibodies (ABO incompatibility); transfusion of haemolysed blood (for exam-
ple blood older than 21 days); transfusion of infected blood; transfusion of blood
containing allergens; accidental injection of air with the blood (causing air
embolism); overloading of the circulation; or transfusion of blood containing
(non-ABO) antigens or antibodies incompatible with the antibodies or antigens
of the patient.

Certain diseases can be transmitted in the blood. They include malaria, syphilis,
trypanosomiasis, leishmaniasis, viral hepatitis, and acquired immunodeficiency
syndrome (AIDS). Always test for syphilis, and in endemic areas also make blood
films to check for malaria, trypanosomiasis, and infection with Leishmania don-
ovani. It is hoped that appropriate screening tests for viral hepatitis and for AIDS
will soon be widely available.

Autotransfusion Autotransfusion, i.e., using the patient's own blood for transfusion, is a conve-
nient, useful, and safe procedure in cases of massive internal bleeding. The main

42
 Fluid/electrolyte therapy and shock

Fig. 2.2. Filtration of blood {for autotransfusion) into a. collecting bottle containing anticoagu~
lant.

indication for autotransfusion is a ruptured spleen or a ruptured ectopic preg-

nancy, although it can also be used in the case of a large haemothorax. The blood
is collected from the peritoneal (or pleural) cavity, filtered, and mixed before use
with citrate to prevent coagulation.

Equipment Specific equipment requirements are two or three sterile, 0.5-litre bottles with
stoppers, each containing 60 ml of 3.8% sodium citrate. (38 g/litre.) or 120 ml of
"acid-citrate-glucose" solution (containing trisodium citrate dihydrate, citric
acid mono hydrate, and glucose); a large sterile funnel with eight layers of sterile
gauze for filtering; and a sterile gallipot or jug.

43
 Fundamentals

Technique Scoop out blood from the abdominal cavity with a gallipot (do not use a sucker),
filter it through the gauze in the funnel, and allow it to drain into the collecting
bottle (Fig. 2.2). Mix it gently with the anticoagulant by tilting the bottle from
side to side. If any clot particles drain through, refilter the blood. Then stopper
the bottle. The blood is now ready for transfusion into the patient.

Contraindications Do not use this procedure for blood that has been in the abdominal cavity for
more than 24 hours, or if the blood is or may be contaminated, as for example in a
patient with bowel trauma.

Complications Complications are unlikely provided that sterility is maintained throughout

autotransfusion. Rarely the blood may become haemolysed or contaminated.
Contaminated blood can give rise to septic shock or even septicaemia.

Shock

Shock is a useful clinical diagnosis, but it lacks a clear pathophysiological basis.

Some degree ofhypovolaemia is usually present, as after haemorrhage or the loss
of other body fluids, for example because of acute burns. The patient suffering
from hypovolaemic shock is often anxious; the pulse is rapid and thready, the
blood pressure low, and the skin cool and clammy; and the extremities are often
cyanotic. In addition, the patient's urinary output is reduced. Normovolaemic
shock may occur as a complication of massive sepsis. In most cases its features are
similar to those of hypovolaemic shock, but sometimes the patient is confused,
with an increased (rather than reduced) peripheral blood flow, as indicated by
warm, pink, and oedematous extremities.

Management Treat or control the cause of shock: arrest haemorrhage from wounds by firm
pressure over a sterile dressing, and incise and drain an abscess without delay.
Simultaneously begin the correction of circulatory and metabolic disturb-
ances.

Delay in restoring the circulating volume of a patient with hypovolaemic shock

can rapidly cause severe irreversible damage to the kidney and the brain.
Therefore, insert a wide-bore cannula or the largest available needle (for exam-
ple 14-gauge/2.0 mm) into a large vein in the cubital fossa or into the external
jugular vein, and immediately start infusion of physiological saline or Ringer's
lactate solution, since these fluids are usually readily available. (The infusion
solution may be changed later, if necessary, ideally to the fluid that most closely
resembles the fluid lost, and the infusion may be transferred to the long saphe-
nous vein when there is time for a surgical "cut-down" at the ankle.) Elevate the
patient's legs to increase venous return, but do not lower the trunk and head, as
this impairs breathing. Measure and record the patient's pulse rate and blood
pressure every 30 min.

Insert a catheter into the bladder to measure the hourly urinary output. This
variable and the jugular venous pressure (estimated clinically) are indicators of
the patient's fluid status and cardiac output (unless there is cardiac failure).
Continue fluid replacement until the urinary output is at least 0.5 ml/kg of body
weight per hour and the jugular venous pressure indicates adequate filling of the
venous circulation.

Metabolic acidosis due to circulatory failure will subside if fluid replacement is

adequate.

If no urine is draining, first check that the catheter is not blocked by measuring
the circumference of the abdomen and performing bladder washout. Provided
that the bladder catheter is patent, persistent anuria in a patient with restored

44
Fluid/electrolyte therapy and shock

circulation (normal blood pressure, adequate filling of the jugular veins, and
pink, warm extremities) suggests acute renal failure. If possible, refer the patient
immediately for further treatment; otherwise begin peritoneal dialysis.

In cases of shock due to massive sepsis (septic shock), manage the patient as
outlined above, but also take a blood sample as soon as possible for a direct smear
examination. Leukocytosis and immature granulocytes in the smear will support
the diagnosis. Give a broad-spectrum antimicrobial drug or a combination of
antimicrobial drugs selected according to the most likely organisms responsible
for the sepsis. Gentamicin with metronidazole is a useful initial combination.
Metronidazole may be best given as a suppository, since the preparation for
intravenous injection is more expensive.

45
FACE AND NECK
 3
Primary care of wounds of the
face

Although the doctor at the district hospital is usually expected to treat patients
with small facial wounds, patients with large wounds or wounds associated with
tissue loss should normally be referred for specialized care. 1

If referral is necessary, first ensure that it is safe to transport the patient. Maintain
a clear airway, if necessary by tracheal intubation or tracheostomy. Arrest any
obvious bleeding. If immediate referral is impossible, confine treatment of
extensive wounds to thorough cleaning of the wound area and tethering of the
wound edges using local skin landmarks as a guide for alignment.

General principles

When you are treating facial wounds, whether minor or serious, your priority is
to keep the patient's airway clear at all times. Remember too that a severe facial
injury may be associated with other injuries, which may also require your atten-
tion.

The choice of anaesthetic for the patient will normally depend on the nature of
the injuries, but general anaesthesia is preferable in children. Use good lighting
and fine instruments when examining and treating wounds of the face; oph-
thalmic instruments are ideal for this. Unless the wound is near the eyes, clean it
with soap and water, while protecting the patient's eyes, and then irrigate it with
saline. Make every attempt to preserve tissue, especially skin, but remove all
foreign material and all obviously devitalized tissue. A small, soft brush will
facilitate this process.

Always administer tetanus toxoid. Cellulitis, a potentially serious complication,

can be prevented by meticulous surgery and by prophylactic benzylpenicillin 600
mg (10 6 units) given twice a day intramuscularly.

Equipment See tray for Minor operations, Annex 1, and add the following ophthalmic instru-
ments:

Eyelid speculum, I
Eyelid retractors, 2
Forceps, 0.5 mm or 0.9 mm, toothed, 1
Forceps, 0.5 mm or 0.9 mm, non-toothed, 1
Straight ring scissors, 1 pair
Small needle holder, 1
Scalpel handle with No. 11 blade, 1

lf'or discussion of the care of facial wounds with associated bone injuries, see Surgery at the di!trict hospital:
obstetn·cr, gynaecology, orthopaedict, and traumatology (Geneva, World Health Organization, in preparation).

49
 Face and neck

A B

Fig. 3.1. Repairing a lip wound. The wound (A); the key suture ensures anatomical alignment
(B); repair in layers: mucosa (C), muscle (D), and skin (E).

Lip

Lip injuries are common. It is safe not to suture small lacerations of the buccal
mucosa, but advise the patient to rinse the mouth frequently with salt water,
particularly after every meal.

For an isolated laceration of the lip that requires suturing (Fig. 3.1A), local
anaesthesia is usually adequate. Proper anatomical alignment is essential for
wounds that cross the vermilion border. Achieve this by planning the first stitch
to join the border accurately (Fig. 3. tB). This region may be distorted by swelling
caused by local anaesthetic, so to ensure accuracy, premark the border with
gentian violet.

After this key suture has been inserted, repair the rest of the wound in layers,
starting with the mucosa and progressing to the muscles and finally the skin (Fig.
3. tC,D,E). Use fine, interrupted sutures of 4/0 or 3/0 chromic catgut for the
inner layers and thread or monofilament nylon for the skin.

Tongue

Most wounds of the tongue require no suturing and heal rapidly, but you may
need to suture lacerations with a raised flap in either the lateral border or the
dorsum of the tongue (Fig. 3.2). Suture the flap to its bed with 4/0 or 3/0 buried,
catgut stitches. Local anaesthesia is usually sufficient.

50
 Facial wounds

A ~)··.f,, ' '~.

.. ·-·'" '\

Fig. 3.2. Repairing a laceration of the tongue. The wound, with flap (A); suture of the flap to its
bed (B); the knot is buried as the suture is tied (C).

Instruct the patient to rinse the mouth regularly with salt water, until healing is
complete.

Ear and nose

The three-dimensional curves of the pinna and the presence of cartilage can
present difficulties in the repair of ear injuries. The wounds are commonly
irregular, with cartilage exposed by loss of skin. Use the folds of the ear as
landmarks to restore anatomical alignment.
After the patient has been anaesthetized, as appropriate, close the wound in
layers with fine sutures, using catgut for the cartilage. Dressing is important: the
pinna should be supported on both sides by moist cotton pads and firmly ban-
daged to reduce haematoma formation (Fig. 3.3).
Make every attempt ot cover exposed cartilage either by wound suture or by
split-skin graft (see page 33).
The principles of repair of ear lacerations also apply to wounds of the nose.

Complications Wounds of the ear and nose may result in deformities or necrosis of the carti-
lage.

Cellulitis of the face

Cellulitis of the face, which can be a complication of facial wounds, carries the
serious risk of cavernous-sinus thrombosis, so the patient's initial response to
treatment with antibiotics is best obsl!'rved in hospital. The organisms re-
sponsible are likely to be penicillin-sensitive. The patient must resist squeezing
or otherwise manipulating any infected foci on the face, even if such foci are
small.

51
Face and neck

Fig. 3.3. Repairing a laceration of the ear. The laceration (A); anatomical alignment (B); skin
suture of the anterior surface (C, D); the laceration as seen from the back, after suture of the
anterior surface (E); suture of the cartilage (F); completing skin suture (G); dressing the wound
(H-J).

If severe oedema suggests involvement of the cavernous sinus, attempt to pre-

vent thrombosis by administering heparin, 5000 International Units every 8
hours by subcutaneous injection.

52
 4
Eye

The purpose of eye surgery at the district hospital is to save sight and to prevent
the progression of eye conditions that could produce further damage if left
untreated. The surgical correction of squints an<l the treatment of congenital
cataract should not be attempted.

Basic principles and procedures for eye surgery

Ocular tissues are delicate, and eye surgery requires careful operative procedures
with maximum precision. Good lighting is essential for safe surgery, and mag-
nification by means of an operating loupe (X 2 or more) is always advisable.

When the patient is admitted to hospital, carefully examine the eye and test
visual acuity. Look for infection in the eye, including the lacrimal sac, and treat
this as necessary. Check for raised intraocular pressure. Avoid elective surgery if
the patient has hypertension or severe diabetes, or is undergoing long-term
treatment with anticoagulants or steroids.

Twenty-four hours before surgery, wash the patient's eye and start treatment
with antibiotic eye drops. On the day of the operation, carefully irrigate the eye
with fresh sterile saline and, if intraocular surgery is planned, cut the lashes.
Clean the eyelids and surrounding skin with soap or cetrimide. Properly mark the
eye to be operated on, and recheck this just before surgery.

Use of eye ointment Eye medication may be required both before and after surgery. Eye ointment
and eye drops gives a more prolonged action than do eye drops and can be used, for example,
after surgery on the eyelid. Avoid steroid-containing antibiotic preparations and
restrict the use of preparations containing steroids in combination with other eye
medications unless they have been prescribed by an ophthalmologist.

Measurement of If you suspect a rise in the patient's intraocular pressure either before or after
intraocular pressure surgery, measure the pressure by means of a Schii:itz tonometer. With the patient
prone, instil anaesthetic drops in both eyes. Instruct the patient to look up,
keeping the eyes steady. With your free hand gently separate the lids without
pressing the eyeball, and apply the tonometer at right angles to the cornea (Fig.
4.1). Note the reading on the scale and obtain the corresponding value in
millimetres of mercury or kilopascals from a conversion table. Verify readings at
the upper end of the scale by repeating the measurement using the additional
weights supplied in the instrument set. Repeat the procedure for the other eye.
An intraocular pressure above 25 mmHg (3.33 kPa) is above normal but not
necessarily diagnostic. Values above 30 mmHg (4.00 kPa) indicate probable
glaucoma, for which the patient will need immediate referral or treatment
followed by referral. It is very important that the tonometer be regularly cleaned
and maintained, to avoid false readings.

53
 Face and neck

~·

\
Fig. 4.1. Measuring intcaocular pressure. Schiotz tonometer (A); additional weights (B); sep-
arating the lids and applying the tonometer to the cornea (C).

Care of instruments Most instruments used for eye surgery are delicate and should therefore be
handled with special care. Clean all instruments after surgery and sterilize them
before re-use. Sterilize sharp instruments using appropriate chemical solutions
such as chlorhexidine and glutaral; sterilize other instruments using an autoclave
or dry heat. In an emergency, instruments may be sterilized by immersion in 70%
ethanol for 1 hour.

Anaesthetic techniques General anaesthesia is normally recommended for major intraocular surgery, for
example for enucleation of the eye, and for children. Otherwise conduction
(regional) anaesthetic techniques are usually suitable.

Always instil anaesthetic eye drops, for example tetracaine 0.5% (5 g/litre),
before surgery.

Facial block To produce facial block for intraocular surgery, inject ]idocaine into the area 2 cm
in front of and below the tragus of the ear (Fig. 4.2A,B). As an alternative,
infiltrate the supraorbital and infraorbital branches of the facial nerve by injec-
tion along the orbital margins (Fig. 4.2C).

Retrobulbar block The purpose of retrobulbar block is to anaesthetize the eye and also to prevent its
movement. Use this block only for major intraocular surgery, and only if general
anaesthesia is not available and the patient is already in grave danger of going
blind. Always be aware of the possible complications of this technique. Retro-
bulbar block is to be particularly avoided if the patient has perforating injuries of
the eye, as it can cause a dangerous increase in the volume of orbital contents,
which may cause tissues to extrude from the eye.

54
 Eye

Fig. 4.2. Facial block. The facial nerve and i<s branches (A); injecting local anaesthetic in front
of and below the tragus of the ear (B); as an alternative, injecting local anaesthetic along the
orbital margins (C).

Retrobulbar block is effected by injecting 2. 5 ml of 2% (20 gllitre) lidocaine into

the cone formed by the rectus muscles. With the patient supine, palpate the orbit
of the eye to locate the lower outer border. Introduce a 23-gauge, 2.8 cm needle
vertically at this point (Fig. 4.3A). Penetrate the skin and then the orbital
septum; resistance will be encountered as the needle passes through each of these
two layers. Once the tip of the needle is lying below and behind the globe, angle
the needle in the direction of the junction between the roof and the medial wall
of the orbit (Fig. 4.3B,C). Introduce it further and penetrate the muscle layer,
which will be indicated by a slight resistance. Draw back the plunger of the
syringe (to make sure that the tip of the needle is not in a vein) and inject the local
anaesthetic. It should flow freely. Resistance may mean that the tip of the needle
is lodged in the sclera, in which case move the tip of the needle slightly from side
to side until it is disengaged.

If the needle has accidentally entered a vein, resulting in haemorrhage and a

rapid swelling of the orbit, abandon the procedure. Delay the operation for at
least 1 week, after which it can be performed with the patient under either a
repeat retrobulbar block or, preferably, general anaesthesia.

Postoperative care Postoperative care for the patient who has undergone extraocular surgery is quite
simple: change the dressing the day after surgery and apply tetracycline 1% eye
ointment daily for about 1 to 2 weeks. Remove sutures as indicated, after about
5-14 days.

After intraocular surgery, the patient should remain in hospital for at least 5 days.
Strict immobilization is usually unnecessary, but the patient should avoid physi-
cal strain during the week following surgery. Dress the eye daily and apply
appropriate topical medication. Remove conjunctiva! sutures after a week and
corneoscleral sutures after about 3 weeks.

55
 Face and neck

D
Fig. 4.3. Retrobulbar block. Palpating the lower orbital margin and inttoducing the needle
perpendicularly, close to it• outer comer (A); angling the needle towards the junction of the roof
and the medial wall of the orbit behind the globe (B, C); drawing back the plunger as the needle
penettates the muscle (D).

Postoperative Possible postoperative complications of intraocular surgery include infections,

complications prolapse of the iris, flattening of the anterior chamber, and intraocular haemor-
rhage. The patient who develops any of these will require prolonged hospital-
ization. Further management will depend upon the complication, but may
include systemic or local administration of antibiotics, revisional surgery (with
or without excision of the iris) with suturing, pressure-bandaging, or immobil-
ization to re-establish the anterior chamber and reduce intraocular bleeding.

In cases of postoperative infection, such as active corneal infection with hypo-

pyon, a subconjunctival injection of gentamicin (20 mg) may be given daily until
there is improvement. Use a 2 ml syringe with a small hypodermic needle. First
anaesthetize the conjunctiva with tetracaine drops, and then lift it slightly with
the tip of the needle. Give the injection in the lower half of the bulbar con-
junctiva (Fig. 4.4).

56
 Eye

A
Fig. 4.4. Subconjunctival injection into the lower half of the bulbar conjunctiva with a small
hypodermic needle.

Ocular trauma

Eye injuries are common and are an important cause of blindness. Early diag-
nosis and proper treatment are imperative if blindness is to be prevented.

Superficial injuries

Equipment See tray for Tarsorrhap~, Annex 1, and add 2% sodium fluorescein, an eye spud, a
27-gauge needle, a syringe (2 ml) with a small hypodermic needle, and several
cotton-tipped applicators.

Technique Superficial injuries of the eyelid, conjunctiva, or cornea do not require surgical
intervention. Providing that no foreign body is present, copiously irrigate the
eyelid and eye with sterile physiological saline and apply tetracycline 1% eye
ointment. Dress the eyelid and eye with a simple sterile eye pad, with the eyelids
closed. Leave the dressing in place for 24 hours, and then re-examine the eye and
eyelids. If the injury has resolved or is improving, continue applying tetracycline
1% eye ointment three times daily for 3 days. Otherwise inject gentamicin
subcutaneously and arrange to refer the patient.

Small foreign bodies may be embedded superficially in the conjunctiva or cornea.

If a foreign body is embedded in the conjunctiva, wash it out with sterile saline
or, after administering a topical anaesthetic, wipe it away with a sterile, cotton-
tipped applicator. Eversion of the lid may be necessary to expose the foreign
body. If you suspect a corneal foreign body, first instil two drops of 2% sodium
fluorescein to make the foreign body (or breach of the epithelium) easier to
detect. Remove a superficial corneal foreign body with an eye spud or a 27-gauge
needle, and then manage the eye as for a superficial injury.

If the cornea remains infiltrated after removal of a foreign body, instil atro-
pine 1% eye drops or ointment once daily, apply tetracycline 1% eye ointment
every 8 hours, and give a subconjunctival injection (Fig. 4.4) of gentamicin 20 mg
daily (after applying a topical anaesthetic) for 3 days. Refer patients with corneal

57
 Face and neck

c D
Fig. 4.5. Repairing a laceration of the eyelid. Laceration (A); inserting the key suture to align
the lid ma.rgin (B); suturing the conjunctiva and tarsus (C, the knots arc tied away from the
eyeball); suturing the skin and muscle (D).

foreign bodies that cannot be removed and patients who show no decrease of
corneal infiltration after 3 days of treatment.

Admit to hospital any patient with inflammation of the globe with hyphaema
(blood in the anterior chamber). Place the patient at complete rest, with sedation
if required, and patch both eyes. If intraocular pressure is elevated, as indicated
by a total hyphaema or pain, administer acetazolamide 250 mg orally every 6
hours. Examine and dress the eye daily. If the hyphaema has not clearly
improved in 5 days, refer the patient.

Lacerations and
penetrating injuries The patient should be anaesthetized as appropriate.

Equipment See tray for Cataract operation, Annex 1, and add 6/0 thread and catgut.

Eyelids Make every attempt to preserve tissue, but carry out wound toilet and, if neces-
sary, debridement. Do not shave the brow or invert hair-bearing skin into the
wound. If the laceration involves the eyelid margin, place an intermarginal
suture behind the eyelashes; precise alignment of the wound margins is essential
(Fig. 4.SA,B). Carry out the repair in two layers: the conjunctiva and tarsus with
6/0 catgut, and the skin and muscle (orbicularis oculi) with 6/0 thread (Fig.
4.SC,D). Tie suture knots away from the eyeball.

Lacerations involving the inferior lacrimal canaliculus require canalicular

repair, so the patient should be referred for specialized surgical management. If
this is impossible, repair the lid margin and laceration as described above.

58
 Eye

Immunize the patient against tetanus with tetanus toxoid and give penicillin
systemically.

Globe Manage perforation of the cornea without iris prolapse and with a deep anterior
chamber by applying atropine 1% eye drops or ointment and by administering
gentamicin, either in 1% eye drops or as a subconjunctival injection of 20 mg
(after a topical anaesthetic has been applied). Dress the injured eye with a sterile
pad and examine it daily.

After 24 hours, if the anterior chamber remains formed, apply atropine 1% and
tetracycline 1% eye ointment daily for another week. If the anterior chamber is
flat, apply a pressure bandage for 24 hours. If there is no improvement, suture the
cornea after applying a topical anaesthetic.

A patient with perforation of the cornea with iris incarceration and with a deep
anterior chamber should be treated in the same way.

Manage corneal or corneoscleral laceration with prolapse of the iris, lens, or

vitreous body by excising the prolapsed intraocular elements (with the patient
anaesthetized as appropriate) and then closing the corneal and corneoscleral
wounds with 8/0 thread. If possible, refer the patient to an ophthalmologist. If
referral is not possible, treat the patient postoperatively with atropine 1% drops
or ointment and with gentamicin 20 mg injected subconjunctivally (after a
topical anaesthetic has been applied). Dress the injured eye with a sterile pad and
shield for 24 hours. Change the dressing and apply atropine 1% and tetracycline
1% eye ointment daily for 1 week. Remove the sutures after about 1 month.

Posterior rupture of the globe is to be suspected if there is low intraocular

pressure and poor vision. Instil atropine 1%, protect the injured eye with a sterile
pad and shield, and refer the patient to an ophthalmologist.

If, on the basis of X-ray and clinical examinations, you suspect the presence of an
intraocular foreign body, apply atropine 1%, dress the eye with a sterile pad and
shield, and refer the patient to an ophthalmologist.

All patients with injuries to the globe should be immunized against tetanus.

Extraocular surgery
Removal of chalazion Chalazion is a chronic inflammatory granuloma or cyst, usually the size of a small
pea, within one of the tarsal glands of the eyelid. Surgery is indicated if the
swelling is long-standing and does not respond to local medical treatment. The
condition sometimes recurs in adjacent glands.

Equipment See tray for Removal of cha/azion, Annex 1.

Technique After establishing topical anaesthesia with 0.5% tetracaine, inject 1-2 ml of 2%
lidocaine around the chalazion through the skin. Apply the chalazion clamp with
the solid plate on the skin side and the fenestrated plate around the cyst, tighten
the screw, and evert the lid. Incise the cyst at right angles to the lid margin and
remove its contents with the curettes (Fig. 4.6). Remove the clamp and apply
pressure on the lid until bleeding stops. Apply tetracycline 1% eye ointment, and
dress the eye with a pad and bandage. Apply ointment daily until the conjunctiva
is healed (about 5 days). It is usually unnecessary to re-examine the patient unless
there is a recurrence.

Tarsorrhaphy Tarsorrhaphy is the surgical joining of the upper and lower eyelids to close the
eye partially, as a temporary protection to the cornea. Tarsorrhaphy is indicated
in cases of facial nerve paralysis or when there is a loss of corneal sensation.

59
 Face and neck

A
Fig. 4.6. Excision of chalazion. Chalazion clamp (A); incising the cyst after applying the clamp
(B); removing the contents with a curette (C).

Equipment See tray for Ta,,orrhaphy, Annex 1.

Technique First determine the length of join required (Fig. 4. 7A). After administering a
topical anaesthetic, infiltrate each lid with 2 ml of 2% lidocaine. Incise to a depth
of2 mm along the grey line of both lid margins in the lateral canthus (Fig. 4. 7B).
Join the two lids by inserting mattress sutures of 4/0 thread passed through
rubber tubing about 5 mm below the lash line (Fig. 4. 7C,D). Apply a sterile eye
pad and secure it with adhesive tape. Remove the sutures when the lids have
united, after about 14 days.

Apply tetracycline 1% eye ointment daily until the stitches are removed.

Opening a tarsorrhaphy Once the tarsorrhaphy is no longer needed, the eye may be opened. After
administering a topical anaesthetic, infiltrate the upper and lower lids with
2% lidocaine. Pass one blade of a pair of scissors posterior to the adhesion and
one anterior, and separate the lids with a single cut.

Treatment of trichiasis Trichiasis is a condition in which the eyelashes grow inwards and irritate the eye.
and entropion In entropion the lid margin is also inverted, and rubs on the cornea (Fig. 4.8A).
The most important and common cause of these conditions in many developing
countries is trachoma, usually affecting the upper eyelid; other features of tra-
choma may also be apparent, for example pannus formation.

Equipment See tray for Treatment of entropion, Annex 1.

Technique In cases of trichiasis, epilation can give temporary relief, but surgery may become
necessary if the condition progresses to entropion. There are various techniques
for surgically correcting enrropion. The procedure described here is simple and
widely used, and closely resembles the one described by Trabut, for which
standard instrument sets are available.

60
 Eye

c D
Fig. 4.7. Tarsorrhaphy. Estimating the length of join required (A); incising along the grey line
of the lid margin (B); joining the lids with mattress sutures passe<l th,ough shon pieces of rubber
tuhiug (C. D; about three stitches are usually sufficient).

Clean the eyelids with sterile saline and apply drapes. Administer a topical
anaesthetic and infiltrate 2 ml of 2% lidocaine (1 ml at each of two points)
midway between the lid margin and the eyebrow (Fig. 4.8B). Next evert the lid
and hold the tarsal surface exposed with forceps. Make an incision in the pal-
pebral conjunctiva, approximately 2 mm from the lid margin (Fig. 4.8C); a
supporting plate (or eyelid clamp) will facilitate this. Raise the larger tarsal plate
as a flap from the lid by undercutting as far back as the insertion of the levator
palpebrae muscle; also undercut the smaller segment to the lid margin (Fig.
4.8D,E). It is important to incise and undercut the tarsal plate in the entire
lash-bearing part of the lid Now insert two mattress sutures of 4/0 thread
through the skin and the larger tarsal flap, and make a knot at the skin surface
(Fig. 4.8F-T). Leave the distal tarsal flap unstitched. Apply a sterile eye pad,
followed by another pad and a bandage.

After-care Apply tetracycline 1% eye ointment daily for 2 weeks. Remove sutures after 8
days. Inpatient care is necessary for patients who have had simultaneous opera-
tions on both eyes.

61
 Face and neck

Fig. 4.8. Correction of entropion. Entropion (A); infiltrating the lid margin with local anaes-
thetic at two points (B); incising the palpebral conjunctiva of the everted lid (C) and raising flaps
of tarsal plate (D, E); inserting two mattress sutures through the skin and the proximal (larger)
tarsal flap (F, G); tying the stitches (H, I).

Excision of pterygium A pterygium is an overgrowth on to the cornea caused by a chronic degenerative

change in the conjunctiva. It is triangular, with its base at the limbus and its apex
pointing towards the centre of the cornea (Fig. 4. 9 A). Advanced pterygium can
lead to loss of vision.

Small pterygia should be left alone. Only where the pterygium extends to the
central optical zone of the cornea should surgery be considered. Surgical results,

62
 Eye

Fig. 4.9. Excision of pterygium. Characteristic shape and site of a pterygium (A); freeing the
head of the ptcrygium from the cornea with a pterygium knife (B); excising the pterygium with
conjunctiva] scissors (C); hot-point cautery (D) is used to stop bleeding from the bare area of the
sclera (E).

however, are generally poor and recurrences are frequent, so patients whose
pterygia require excision should be referred. If referral is impossible, proceed as
follows.

Equipment See tray for Excision ofpterygium, Annex 1.

Technique Apply 0.5% tetracaine topically and infiltrate the subconjunctiva with 1 ml of2%
lidocaine.

Grasp the neck of the pterygium and free its head from the corneal surface using
the pterygium knife (Fig. 4. 9B). Excise the freed pterygium with the conjunctiva!

63
 Face end neck

scissors 4 mm from the limbus (Fig. 4.9C), leaving a bare area of sclera. Stop any
bleeding with hot-point cautery (Fig. 4.9D,E). Apply tetracycline 1% eye oint-
ment and dressings. Continue daily application of the ointment and of fresh
dressings for 1 week. If there is a recurrence after surgery, the patient must be
referred.

lntraocular surgery

Cataract extraction Although cataract extraction may be performed in district hospitals, it should be
done only by general practitioners who have received the necessary training or
by ophthalmic surgeons through an "outreach" programme. The following
description is intended solely as an aide-memoire for persons who have previous
experience of the operation.

Cataract is an opacity of the crystalline lens of the eye. Minor lens opacities are
extremely common, but more extensive lens opacities interfere with light pass-
ing through the crystalline lens and therefore reduce vision. Most cataracts occur
in the elderly; they are usually classified as "senile" cataracts and their causes are
unknown. Congenital cataract, which affects infants and young children, can
cause lifelong blindness if left untreated. However, surgical treatment is more
difficult than for senile cataract, and patients suffering from congenital cataract
should therefore be referred. Also refer patients with cataracts secondary to
trauma and those with cataracts complicating other ocular or systemic diseases,
for example corneal opacity.

Serious visual impairment due to bilateral senile cataract that interferes with the
patient's daily activities is the main indication for surgery at the district hospital.
It is not necessary to operate on unilateral cataract if there is useful vision in the
other eye. If both eyes are badly affected, operate first on the eye with the poorer
vision. In general, operate only on patients over 50 years of age.

Diagnosis The criteria for diagnosis of cataract are a history of progressive loss of vision and
an absence of or a markedly diminished red reflex from the fundus of the eye, as
viewed with an ophthalmoscope.

Assessment and If surgery is indicated, first take the history of the illness and assess the patient's
preoperative management vision, particularly as to accurate light projection. Examine the eye, including the
reaction of the pupil to light. Check the red reflex and determine the intraocular
pressure. Carefully wash the patient's face when he or she is admitted to hospital.
Apply tetracycline 1% eye ointment and atropine 1% every 8 hours to the eye to
be operated on, up to the time of surgery. This treatment should be started at the
latest 24 hours before operation. In addition, give acetazolamide 250 mg orally 8
hours and 2 hours prior to surgery.

Equipment See tray for Cataract operation, Annex 1.

Technique Intracapsular cataract extraction (extraction of the cataract within its capsule) is
recommended here, as extracapsular cataract extraction is technically more
difficult and prone to complications such as corneal damage, infection, and
opacification of the posterior capsule.

After sedating the patient, produce facial block by the injection of 2-3 ml of
lidocaine 2% into the temporal portion of the upper and lower lids over the
orbital rims, and inject a further 2 ml of lidocaine into the retrobulbar area.
Achieve topical anaesthesia with one drop of tetracaine 0.5%. To help lower
intraocular pressure, massage the closed eye with a finger for 1 min.

64
Eye

Fig. 4.10. lntracapsular extraction of cataract. Position of the patient (A, as seen by the surgeon
at the head of the table); turning the eye down and passing a suture beneath the superior rectus
tendon (B); site of conjunctival incision (C); incising along the limbus and inserting a suture
across the groove (D); excising a small piece of the iris (E).

Clean the ocular adnexa and face with 1% cetrimide and drape the surgical field
with sterile towels. Irrigate the surface of the eye and fornices with sterile
saline.

Stand at the head of the operating table, so that the patient's face appears
upside-down (Fig. 4. lOA). Insert an eyelid speculum for lid retraction. With
toothed forceps, grasp the conjunctiva at the edge of the cornea in the region of
12 o'clock, 1 and turn the eye down (away from you). With another pair of forceps,

1To interpret references to 12 o'clock, 9 o'clock, etc., imagine a clock face superimposed on the patient's

cornea, with 12 o'clock nearest the patient's supraorbital margin.

65
Face and neck

Fig. 4.10. Intracapsular extraction of cataract (continued). Extracting the lens (F); tying the
preplaced suture and inserting funher sutures to close the co.rneoscleral incision (G); reforming
the anterior chamber by injecting a srnall air bubble (H); drawing the conjunctival flap down over
the wound and anchoring it (I).

grasp the superior rectus tendon through the conjunctiva, about 8 mm behind the
first pair of forceps. Lift the tendon from the globe and pass a piece of 3/0 thread
beneath the tendon, taking care not to puncture the sclera (Fig. 4.lOB). Clip the
suture to the drape above the eye so as to rotate the eye downwards and away
from you. (Do not clip it too tightly.) Incise the conjunctiva at the limbus from
9 to 3 o'clock (Fig. 4. lOC), and then separate it from the limbus with conjunctiva)
scissors. Achieve haemostasis with hot-point cautery.

66
 Eye

Make an incision perpendicular to the surface of the globe from 10 to 2 o'clock

along the limbus, cutting through one-half to two-thirds of the depth of the
corneoscleral tissue; insert an 8/0 thread suture across the groove at 12 o'clock
and loop it aside (Fig. 4. 1OD). Open the anterior chamber with a No. 11 blade or
keratome, and extend the corneoscleral section along the groove using corneal
scissors.

Ask an assistant to lift the cornea gently with the looped suture, while you grasp
the iris at its base at 12 o'clock, with iris forceps. Gently withdraw the iris outside
the incision and excise a small piece at its base with iris scissors, to form a
peripheral iridectomy (Fig. 4.1 OE). Avoid routine intraocular irrigation, but
keep the cornea moist. As your assistant gently lifts the cornea, extract the lens by
grasping the anterior lens capsule at 6 o'clock with capsule forceps and pulling it
out while applying light pressure with a muscle hook at the inferior limbus (Fig.
4.10F). If the lens capsule ruptures, remove the lens nucleus with capsule forceps
or a vectis while you apply pressure at the limbus at 6 o'clock and posteriorly to
the wound at 12 o'clock. Wash out the remaining lens material with sterile
saline.

In the event of prolapse of the vitreous body, the anterior chamber may be freed
of vitreous material by either aspiration or excision, followed by sponging.

Draw down and tie the preplaced suture, and place at least four additional 8/0
thread sutures at regular intervals to close the corneoscleral incision (Fig.
4. lOG). Through a cannula on a syringe, inject just enough air behind the cornea
to reform the anterior chamber (Fig. 4.10H). Draw the conjunctiva) flap down
over the cornea and anchor it at 3 o'clock and 9 o'clock using 8/0 thread (Fig.
4.101).

Remove the superior rectus suture and inject gentamicin 20 mg subconjuncti-

vally. If gentamicin is not available, crystalline benzylpenicillin 12 mg (20 000
units) may be given. Apply tetracycline 1% eye ointment in the inferior fornix,
and dress the eye with a sterile pad and shield.

After-care After 24 hours, at the first change of dressing, carefully inspect the eye for
evidence of early postoperative complications such as a cloudy cornea (due to
oedema), a shallow anterior chamber, or hyphaema.

Administer atropine 1% eye drops and tetracycline 1% eye ointment daily for 5
days. Add hydrocortisone 1% eye ointment from the second postoperative day.
The patient may be discharged after 5 days. Hydrocortisone application can
normally be continued for another 2-3 weeks, but only if treatment can be
supervised. The patient should make postoperative follow-up visits at 2 weeks, 6
weeks, and 6 months.

Remove the corneoscleral sutures after 2-3 weeks, with the patient under topical
anaesthesia if necessary, and provide spectacles for aphakia at 6 weeks.

Complications If the patient develops a shallow anterior chamber with air behind the iris, fully
dilate the pupil with atropine so that air may re-enter the anterior chamber.

If there is a shallow anterior chamber with a suspected wound leak or a gaping

wound, apply a pressure bandage for 2 days. If the wound is obviously leaking,
place additional corneoscleral sutures, preferably with the patient under general
anaesthesia.

If hyphaema develops, pad the eye bilaterally and prescribe bed-rest for 5
days.

67
Face and neck

Fig. 4.11. Peripheral iridectomy for acute angle-closure glaucoma. Site of incision above the
upper limbus (A, as seen by the surgeon at the head of the table); opening the anterior chamber by
incision in the comeoscleral junction (B); excising the prolapsed part of the iris (C); closing the
comeoscleral wound (D); the conjunctiva! flap is replaced and sutured (E).

If there is prolapse of the iris, excise the iris and resuture the corneoscleral
wound, preferably with the patient under general anaesthesia.

In case of infection, administer a topical anaesthetic and inject gentamicin or

penicillin subconjunctivally.

68
 Eye

Treatment of acute Acute angle-closure glaucoma is an ocular surgical emergency, and its manage-
angle-closure glaucoma ment should be prompt, with the aim of lowering intraocular pressure rapidly by
a course of drugs. Immediate management is followed by surgery (peripheral
iridectomy). Administer acetazolamide orally in an initial dose of 500 mg,
followed by 250 mg every 6 hours. Instil one drop of pilocarpine 2% into the
affected eye every minute for 5 min, then every 15 min for 1 hour, and then
hourly until the tension is controlled. Give suitably flavoured glycerol 1 glkg of
body weight orally daily.

It is best to refer the patient, but if this is impossible, undertake curative surgery
after intraocular pressure has been reduced to less than 25 mmHg (3.33
kPa).

Equipment See tray for Cataract operation, Annex 1.

Technique Prepare the patient as recommended for cataract surgery, but do not use atro-
pine.

Stand at the head of the operating table, so that the patient's face appears
upside-down. Make a 10 mm incision in the conjunctiva, 4 mm above and
parallel to the upper limbus (Fig. 4.11A). Undercut the conjunctiva and reflect it
onto the cornea. Achieve haemostasis with hot-point cautery.

Using a No. 11 blade, make a 4 mm incision perpendicular to the surface of the

globe in the region of 12 o'clock in the corneoscleral junction. Deepen the
incision to open the anterior chamber (Fig. 4.11B). Gently depress the conjunc-
tiva! flap over the cornea, thus causing a small peripheral part of the iris to be
prolapsed through the incision. Excise the prolapsed part of the iris (Fig. 4.11 C),
and then gently return the rest of the iris to its original position. Close the
corneoscleral wound with a single 8/0 thread suture (Fig. 4.110). Replace the
conjunctiva! flap and suture it with two to three stitches of 8/0 thread (Fig.
4.11E).

Apply homatropine 2% eye drops, tetracycline 1% ointment, and a sterile eye pad
to the eye. Continue to give the patient acetazolamide 250 mg every 6 hours for
2 days.

As acute angle-closure glaucoma is often a bilateral disease, the patient should be

referred for investigation and, if necessary, treatment of the other eye. Until
referral, give the patient pilocarpine 1% eye drops to instil daily into the
untreated eye.

Enucleation of the eye

Enucleation of the eye is the surgical removal of the entire globe.

The prospect of losing an eye can have a devastating emotional impact on both
the patient and his or her relatives. The decision should be taken only after a very
careful consideration of the state of the affected eye, when all efforts to save the
eye have failed, and when the eye is clearly useless. Seek the opinion of an
ophthalmologist, whenever possible. If this is not possible, consider enucleation
only for painful eyes with long-standing, obvious, and complete blindness (no
perception of light). Always give a careful explanation of what is involved to the
patient and relatives concerned, and obtain the patient's written consent to
surgery. In cases of ocular trauma, always attempt to repair the globe and then
refer the patient to an ophthalmologist.

Equipment See tray for Enudeation of the eye, Annex 1.

69
 Face and neck

Fig. 4.12. Enucleation of the eye. Incising the conjunctiva all around the limbus (A); dissecting
the conjunctiva and the fascial sheath from the sclera (B); identifying and cutting the rectus
muscles, leaving a small fringe on the globe (C); identifying and cutting the tendons of the
oblique muscles (D); freeing the globe from the fascia! sheath (E); identifying, clamping, and
dividing the optic nerve (F); applying pressure over gauze after removing the globe (G); closing
the fascial sheath with a purse-string suture (H); suturing the conjunctiva (I).

70
 Eye

General anaesthesia is preferable, but retrobulbar block with infiltration anaes-

thesia of the eyelids is an alternative. Also give a topical anaesthetic.

Technique Stand at the head of the operating table, so that the patient's face appears
upside-down. Incise the conjunctiva with scissors all around the limbus (Fig.
4.12A). Lift the conjunctiva and fascia] sheath (Tenon's capsule) from the sclera
by blunt dissection with scissors (Fig. 4.12B). Identify the rectus muscles and
isolate them with a muscle hook. Cut each muscle, leaving a small fringe on the
globe (Fig. 4.12C). Next identify and isolate the tendons of the superior and
inferior oblique muscles with a muscle hook and cut them (Fig. 4.12D). With a
steady hold on the fringe of the medial or lateral rectus to stabilize the eye, free
the globe from the fascia] sheath by blunt dissection (Fig. 4. t 2E). Identify and
clamp the optic nerve with curved forceps. Cut the nerve between the globe and
the forceps with enucleation scissors, but do not tie off the nerve (Pig. 4.12F).
Apply pressure over gauze until all bleeding is stopped (Fig. 4.12G). Close the
fascia] sheath with a purse-string suture of 4/0 chromic catgut (Fig. 4.12H), and
suture the conjunctiva with interrupted 5/0 or 6/0 plain catgut (Fig. 4.121).
Apply tetracycline 1% eye ointment, a sterile eye pad, and a pressure ban-
dage.

After-care Administer analgesics to relieve pain, and apply tetracycline 1% eye ointment
daily for at least 8 weeks. The patient can later be referred for the fitting of a
prosthesis.

71
 5
Ear

Removal of foreign bodies

Children often insert foreign bodies, such as beans, peas, rice, beads, fruit seeds,
or small stones, into their ears. Accumulated ear wax can be confused with
foreign bodies and is common in both adults and children.

Equipment See tray for Removal offoreign bo4J from the ear, Annex 1.

Techniques Administer a basal sedative before proceeding.

Syringing the ear will remove most foreign bodies, although it should be avoided
if the foreign body absorbs water, for example grain or seeds. A foreign body can
also be removed by gentle suction through a soft rubber tube introduced into the
ear to rest against the object (Fig. 5. lA,B). The procedure is simple, painless, and
usually effective.

As an alternative, an aural curette or hook may be passed beyond the foreign

body and then turned so that the foreign body is withdrawn by the hook (Fig.
5. lC,D). This requires a gentle technique and a quiet patient; children should
therefore first be adequately sedated or be given a general anaesthetic.

A mobile insect in the ear is, at the very least, irritating. Before removing the
insect by syringing, immobilize it by irrigating the ear with glycerol.

To remove accumulated ear wax, syringe the ear with a warm, weak solution of
sodium bicarbonate. If the wax remains, instruct the patient to instil glycerol
drops several times a day for 1-2 days before you attempt further syringing.

Myringotomy

Myringotomy is the incision of the tympanic membrane, usually to drain pus

from the middle ear. The main indication for myringotomy is acute otitis media
when there is severe intractable pain despite treatment with analgesics, a
markedly bulging membrane, a poor response to 24-48 hours of antibiotic
therapy, features suggestive of early mastoiditis (swelling and tenderness), or
facial nerve palsy. Relief of pain after this operation is often immediate and
dramatic.

Assessment and Measure the patient's haemoglobin level and test the urine for sugar and protein.
preoperative management Obtain a radiograph of the mastoid bones to check for possible mastoiditis, and
take a sample of the discharge from the ear for bacteriological examination.
Continue treatment with analgesics and antibiotics.

72
 Ear

Fig. 5.1. Removal of a foreign body from the ear. Removal by suction (A, B); removal using a
hook (C, D).

Equipment See tray for Myringotomy, Annex 1.

Technique General anaesthesia may be used, but local anaesthesia is often adequate. Sedate
children before administering a local anaesthetic. Prepare the skin of the pinna
and the external auditory canal with an antiseptic solution and, if local anaes-
thesia has been chosen, infiltrate the external canal _with 1% lidocaine. Insert a
speculum and view the bulging membrane (Fig. 5.2A). Using a scalpel with a
partially covered blade, make a curved incision in the antero-inferior quadrant of
the membrane to let the pus drain (Fig. 5.2B,C), and take a sample for bac-
teriological examination. Clean the ear and apply a cotton-wool dressing.

After-care Continue the administration of antibiotics and analgesics. Keep the auditory
canal dry, and change the dressing when necessary.

Acute mastoiditis with abscess

This condition is usually a complication of acute otitis media.

The patient, usually a child, complains of fever and of pain in the affected ear,
with disturbed hearing. There may be a discharge from the ear. Characteristically

73
 Face end neck

Handle of
A

Fig. 5.2. Myringotomy. The tyn1panic membrane as seen through an auriscope (A); incising
the membrane (B) using a scalpel with a partially covered blade (C).

there is a tender swelling in the mastoid area, which pushes the pinna forward
and out.

Treatment Although the ideal treatment is exposure of the mastoid air cells, this operation is
usually beyond the scope of the doctor at the district hospital, who should treat
the patient only to relieve immediate pain and tension by simple incision and
drainage of the abscess down to the periosteum. The patient should then be
referred.

Assessment and Measure the patient's haemoglobin level and test the urine for sugar and protein.
preoperative management A radiograph of the mastoid bones (both sides to allow for comparison) will show
clouding of the affected bone. If there is a discharge from the ear, take a sample
for bacteriological examination. Treat the patient with analgesics and antibiot-
ics.

Drainage of mastoid
abscess

Equipment See tray for Incision and drainage of abscess, Annex 1.

74
 Ear

Technique A general or local anaesthetic should be given, in addition to basal sedation.

Make a curved incision over the mostfluctuant part of the abscess or, if this is not
obvious, at about 1.5 cm behind the pinna. Deepen the incision to the perios-
teum or until pus is found. Take a sample of pus for bacteriological examination
and establish free drainage. Apply petrolatum gauze or a small, corrugated drain,
and dress the area with gauze.

After-care Continue the administration of antibiotics and analgesics, and change dressings
as necessary. Remove the drain after 24-48 hours.

75
 6
Nose

Control of epistaxis
Epistaxis (nosebleed) often occurs from the plexus of veins in the anterior part of
the nasal septum (Fig. 6.1A). In children it is commonly due to nose-picking.
Other causes include trauma, the presence of a foreign body, Burkitt's lympho-
ma, and nasopharyngeal carcinoma.

Equipment See tray for Control of epistaxis, Annex 1.

Technique With the patient in a sitting position, administer a mild sedative. Remove any
blood clots from the nose and throat. Pinch the nose between fingers and thumb
or with a clothes-peg, while applying ice-packs to the nose and forehead. This
usually stops the bleeding within 10 min. Should bleeding continue, pack the
nose with cotton wool, soaked in ice-cold water and wrung out, and repeat the
above procedure.

Rarely bleeding may continue even after this treatment. If this happens, apply
pressure to the nasopharynx either by packing it with gauze ribbon or, more
effectively, by inserting a Foley balloon catheter. If you decide on the latter
method, lubricate the catheter, and pass it through the nose until its tip reaches
the oropharynx. Withdraw it a short distance to bring the balloon into the
nasopharynx. Inflate the balloon with water, just enough to exert an even
pressure but not to cause discomfort (5-10 ml of water is usually adequate for an
adult, but use no more than 5 ml for a child). Gently pull the catheter forward
until the balloon is held in the posterior choana (Fig. 6.1B). The balloon should
flatten slightly as this is done. The catheter can then be secured to the forehead or
cheek in the same manner as a nasogastric tube. It can be removed after 48
hours.

Removal of foreign bodies

Children often insert foreign bodies into the nose. Visualize the foreign body,
determine its nature, and ascertain its position before making any attempt to
remove it.

Equipment See tray for Removal of nasal fareign bo4),, Annex 1.

Technique First sedate the patient and then proceed gently. The best method of removing a
foreign body depends upon its nature. To remove a foreign body with rough

76
Nose

Fig. 6.1. Epistaxis. A common site of bleeding (A); controlling the bleeding with a Foley
catheter (B).

surfaces, use angled forceps, or pass a hook beyond the foreign body, rotate the
hook, and then draw out the object in front of the hook. Other types of foreign
body can be withdrawn by suction, through a soft rubber tube introduced into the
nose to rest against the object.

77
 7
Teeth and jaws

Extraction of teeth
Extraction is the best way to drain an apical abscess when there are no facilities
for treatment of the root canal. Otherwise, a tooth should be removed only if it
cannot be preserved, if it is loose and tender, or if it causes uncontrollable pain.

Immediate first-aid treatment for dental pain can be afforded by cleaning the
painful socket or cavity and applying oil of cloves; pack a painful socket with
cotton wool soaked in oil of cloves and a tooth cavity with a paste of oil of cloves
and zinc oxide.

Assessment and Identify the offending rooth. Take appropriate precautions if the patient is
preoperative management suffering from any other medical conditions such as valvular disease of the heart
(which would require prophylactic antibiotic cover), bleeding disorders, or dia-
betes. It may be helpful to obtain a radiograph of the jaw. Check the patient's
haemoglobin level and test the urine for sugar.

Explain the procedure to the patient and obtain permission to remove the
tooth.

Equipment See tray for Extraction of teeth, Annex 1.

Dental forceps are designed to fit the shape of the teeth including their roots;
accordingly, forceps come in sets of six appropriate shapes, but the inexperienced
operator will find it simpler to rely on one pair of universal forceps for the upper
jaw and one for the lower (Fig. 7. lA-D). Remember that the upper molars have
three roots, two buccal and one palatal, whereas the lower molars have two, one
mesial and one distal. The upper first premolars have two roots side by side, one
buccal and one palatal. All the other teeth are single-rooted.

Technique Local infiltration analgesia should usually be sufficient for extraction of all but
the lower molars, which may require a mandibular nerve block. Occasionally
general anaesthesia may be appropriate.

Administer a sedative to children and anxious adults. Seat the patient in a chair
with a back high enough to support the head. After the patient has rinsed the
mouth, swab the gum with 70% ethanol. To effect local infiltration anaesthesia,
insert a 25-gauge, 25 mm needle at the junction of the mucoperiosteum of the
gum and the cheek, parallel to the axis of the tooth (Fig. 7.1E). Advance the
needle 0.5 to 1 cm, level with the apex of the tooth, just above the periosteum.

78
Teeth and jaws

Fig. 7.1. Extraction of teeth. Upper universal forceps from above (A), from the side (B), and as
held in the hand (C); lower universal forceps (D); injecting local anaesthetic (E); exttacLion
(F).

The bevel of the needle should face the tooth. Infiltrate the tissues with 1 ml of
lidocaine and epinephrine and repeat the procedure on the other side of the
tooth. Wait at least 5 min and confirm the onset of numbness before handling the
tooth.

If you are right-handed, stand behind and to the right of the patient when
extracting lower right molar or premolar teeth. Face the patient, to the patient's
right, when working on all other teeth. Separate the gum from the tooth with a
straight elevator. While supporting the alveolus with the thumb and finger of
your other hand, apply the forceps to either side of the crown, parallel with the
long axis of the root. Position the palatal or lingual blade first. Push the blades of

79
Face and neck

the forceps up or down the periodontal membrane on either side of the tooth,
depending on which jaw you are working on (Fig. 7.1 F). The secret of successful
extraction is to drive the blades of the forceps as far up or down the periodontal
membrane as possible.

Firmly grip the root of the tooth with the forceps and loosen the tooth with
gentle rocking movements from buccal to lingual or palatal side. If the tooth does
not begin to move, loosen the forceps, push them deeper, and repeat the rocking
movements. Avoid excessive lateral force on a tooth, as this can lead to its
fracture.

Carefully inspect the extracted tooth to confirm its complete removal. A broken
root is best removed by loosening the tissue between the root and the bone with a
curved elevator. After the tooth has been completely removed, squeeze the sides
of the socket together for a minute or two and place a dental roll over the socket.
Instruct the patient to bite on it for a short while.

After the patient has rinsed the mouth, inspect the cavity for bleeding. Repair
lacerations and arrest profuse bleeding that will not stop, even when pressure is
applied, with mattress sutures ofO catgut across the cavity. Warn the patient not
to rinse the mouth again for the first 24 hours or the blood clot may be washed
out, leaving a dry socket (with the risk of alveolar osteitis). The patient should
rinse the mouth frequently with saline during the next few days.

A simple analgesic may be needed when the effects of the local anaesthetic have
worn off. It is worth warning the patient against exploring the cavity with a
finger, explaining that the numbness is temporary and will last only for an hour
or so. Haemorrhage after dental extraction is a common emergency and can
usually be controlled by simple pressure over the socket or, if necessary, by
suturing the gum. Haemostatic substances have little advantage over simple
pressure. If gross dental sepsis occurs, administer penicillin for 48 hours and
consider giving tetanus toxoid, if necessary.

The barrel bandage

The barrel bandage (vertical jaw-bandage) is a useful, temporary support for the
fractured mandible and can also serve to maintain pressure on a bleeding tooth
socket. Take a length (about 150 cm) of a bandage 7.5 cm wide made of a
non-elastic material such as cotton. Find the middle of the bandage length and
place it under the patient's chin. Bring the ends to the top of the head and tie
them, making the first loop of a reef knot (Fig. 7.2A). Loosen and separate the
loop, placing one half over the forehead and the other half behind the occiput
(Fig. 7.2B). Take the ends from just in front of the ears up to the top of the head,
and tie them securely with a reef knot (Fig. 7.2C,D).

Fractures of the jaw

Fractures of the maxilla require specialist care, but mandibular fractures can
often be treated in the district hospital. Fractures of the ramus and the condyle of
the mandible are usually closed and require little reduction. Fractures of the body
of the mandible are usually compound, through the alveolar margin, and neces-
sitate immobilization, which can be achieved by direct wiring between the teeth
on either side of the fracture or by interdental wiring between the two jaws
(providing that the upper jaw is stable).

80
 Teeth and jaws

Fig. 7.2. Application of a barrel bandage.

Diagnosis and treatment If the patient presents with a suspected mandibular fracture, note any altered
dental occlusion and, if necessary, confirm the fracture by X-ray examination.
Check for other injuries, and decide on the priorities for treatment. Keeping the
airway clear is most important; the patient should therefore be nursed lying on
the side or in a sitting position with the head well forward. Give penicillin and
tetanus toxoid.

With the maintenance of a clear airway and the administration of antibiotics, the
patient's condition can be expected to improve considerably in the first 24 hours.

81
Face and neck

Fig. 7.3. Treatment of mandibular fracture by interdental wiring. The fracture line across the
mandible (A); inserting the looped wire between the healthy teeth on either side of the fracture
(B); bringing the ends of the wire back around the teeth (C), inserting one end through the loop
(D), and twisting the ends together (E); the procedure is repeated on the upper jaw (F); the jaws
are then wired together, additional teeth having been wired together if necessary (G).

82
 Teeth and jaws

The only urgent indication for wiring a mandibular fracture is instability of a

comminuted fracture through the incisors. In this instance, the tongue may need
to be held forward temporarily by a stitch through its tip and the teeth wired
immediately. Otherwise wiring can be delayed until the patient's condition is
stable.

lnterdental wiring of
the jaws

Equipment See tray for Interdental wiring, Annex 1.

Technique After sedating the patient, you may gently insert interdental eyelets without
anaesthesia, but nerve block (of the inferior alveolar nerve) and infiltration
anaesthesia are much preferred. General anaesthesia is an alternative but, should
the patient present with an airway that is difficult to manage or with a full
stomach, it will be extremely hazardous if the anaesthetist is inexperienced.

Clean the patient's mouth. Examine the jaws for any obvious wounds, which
should be sutured. Locate the fracture (Fig. 7.3A) and reduce it as far as possible.
If there is any doubt about the viability of a tooth in the fracture line, remove it.
The method of wiring the jaw will depend on the state of the remaining teeth.
Choose the nearest two healthy teeth, one on each side of the fracture line, and
pass a 16 cm length of wire (twisted to make an eyelet on the buccal side)
between them from the buccal to the lingual side (Fig. 7.3B). Pass the ends back
to surround the teeth, carrying one end through the eyelet and then tightening it
by twisting it against its fellow (Fig. 7.3C-E). Cut the excess wire short and bend
it away from the lip to lie flush along the jaw. Repeat the procedure on a
matching pair of teeth in the upper jaw (Fig. 7.3F). Fix the mandible to the
maxilla by wiring the upper and lower eyelets together immediately or, if there
are any worries about the patient's airway at the end of anaesthesia, at a later
session (Fig. 7.3G). Additional teeth may be wired together if necessary.

After-care The jaw should be kept immobilized until the fracture unites: 6 weeks for an
adult but only 3-4 weeks for a child. During this time, the patient should
continue to brush the teeth regularly, except perhaps for the first few days when
the mouth can be gently syringed. The patient's diet must, of course, be fluid or
semi-solid.

83
 8
Throat

Non-emergency operations on the throat (in particular tonsillectomy) should not

be attempted at the district hospital.

Incision and drainage of peritonsillar abscess

Peritonsillar abscess (quinsy) is a complication of acute tonsillitis. The patient

develops a rapidly progressing pain in the throat which radiates to the ear of the
same side and soon becomes unbearable. The neck is held rigid, and there is
associated fever, dysarthria, dysphagia, drooling of saliva, trismus, and foul
breath. Clinical examination will confirm fever and will usually reveal cervical
lymphadenopathy on the side of the lesion. Local swelling causes the anterior
tonsillar pillar to bulge and displaces the soft palate and uvula towards the
opposite side. The overlying mucosa is inflamed, sometimes with a small spot
already discharging pus. Keep in mind the possibility of diphtheria or glandular
fever.

Assessment and Measure the patient's haemoglobin level and test the urine for sugar and protein.
preoperative management Administer antibiotics and analgesics.

Equipment See tray for Incision and drainage ofperitonsil/4r/retropharyngea! abscess, Annex 1.

Technique Administer a basal sedative and place the patient in a sitting position with the
head supported. Surface anaesthesia is preferable and will avoid the risk of
inhalation of the abscess contents, which can occur under general anaesthesia.
Spray the region of the abscess with 2-4% lidocaine. Never use ethyl chloride for
this purpose, as the amount absorbed by the patient cannot be properly moni-
tored.

Keep the tongue out of the way with a large tongue depressor or ask an assistant
to hold it out between a gauze-covered finger and thumb as you proceed. Perform
a preliminary needle aspiration (Fig. 8. lA), and then incise the most prominent
part of the swelling near the anterior pillar (Fig. 8.1B). Introduce the point of a
pair of artery forceps or sinus forceps into the incision, and open the jaws of the
forceps to improve drainage (Fig. 8. lC). Provide suction, if necessary.

After-care Instruct the patient to gargle with warm salt water several times a day for about 5
days. Continue the administration of antibiotics for 7-10 days and analgesics for
as long as necessary.

Incision and drainage of retropharyngeal abscess

This abscess occurs mainly in children, with tuberculosis as the underlying

disease. It is usually a complication resulting from infection of the adenoids or

84
 Throat

Fig. 8.1. Incision and drainage ofperitonsillar abscess. Preliminary aspiration (A); incision (B);
drainage (C).

the nasopharynx. The child refuses nourishment, has a changed voice and cry, is
generally irritable, and suffers from croup and fever. The neck is held rigid and
breathing is noisy. In the early stages of the abscess, physical examination of the
pharynx may detect no abnormality but, as the condition progresses, a sweJling
appears in the back of the pharynx.

Assessment and A lateral radiograph of the soft tissue will reveal a widening of the retrophar-
preoperative management yngeal space. X-ray the chest and the cervical spine to check for tuberculosis.
Measure the patient's haemoglobin level and test the urine for sugar and protein.
It is also useful to obtain white-cell and differential white-cell counts, determine
the erythrocyte sedimentation rate, and test the skin reaction to tuberculin
(Mantoux test).

Administer antibiotics and analgesics. A patient suffering from tuberculosis will

require further treatment.

Equipment See tray for Incision and drainage ofperitonsillar/retropharyngeai abscess, Annex 1.

Technique Administer a basal sedative with the patient lying down and the head of the table
lowered. Spray the back of the throat with local anaesthetic and instruct an
assistant to steady the patient's head. Keep the tongue out of the way with a
depressor.

A strictly midline swelling is more likely to be tuberculous and should be

aspirated, not incised. If the swelling is elsewhere, incise the summit of the bulge
vertically. Introduce the tip of pair of sinus or artery forceps and open the jaws of
the forceps to facilitate drainage. Provide suction. Take a specimen of pus for
bacteriological tests, including culture for Mycobacterium tuberculosis.

After-care Instruct the patient to gargle regularly with warm salt water. Continue the
administration of antibiotics and analgesics.

Incision and drainage of acute abscess of the neck

Some abscesses in the neck are deeply situated or arise from lymph nodes, and
require a careful and possibly extensive surgical dissection with the patient under

85
 Face and neck

general anaesthesia. However, because the neck is a complex and important

anatomical region, surgical intervention at the district hospital is not recom-
mended, unless the abscess is acute and clearly pointing, when the surgical
procedure is limited to simple incision and drainage. In children, an abscess of
the neck should be treated by repeated aspiration before it points.

Assessment and Once the diagnosis has been confirmed by aspiration, carefully examine the
preoperative management patient's mouth and throat, particularly the tonsils, to exclude a primary
focus.

Measure the patient's haemoglobin level, test the urine for sugar and protein, and
obtain a white-cell and differential white-cell count. If tuberculosis is suspected,
especially in children, obtain a chest radiograph and test the skin reaction to
tuberculin (Mantoux test).

Equipment See tray for Incision and drainage of abscess, Annex 1.

Technique A small, superficial abscess may be evacuated by aspiration using a syringe with a
wide-bore needle.

Large abscesses of the neck require incision and drainage under general anaes-
thesia. Place the incision in a crease, centred over the most prominent or
fluctuant part of the abscess. Spread the wound edges with a pair of sinus or artery
forceps to facilitate drainage. Take a sample of pus for bacteriological tests,
including an examination for tuberculosis. Remove any necrotic tissue, but avoid
undue probing or dissection. Insert a soft corrugated drain and a few stitches to
bring the wound edges loosely together around it. The drain may be removed in
24-48 hours. Hold dressings of gauze swabs in place with adhesive tape.

After-care Ensure that the patient gargles regularly with salt water, and provide analgesics,
as necessary. Should a discharge from the wound persist (as evidenced by sinus
formation), refer the patient.

86
CHEST, ABDOMEN,
AND GASTROINTESTINAL TRACT
 9
Chest

Tracheostomy

The indications for tracheostomy at the district hospital are acute obstruction of
the airway, anticipated difficulty in managing the airway, and the need to
transport an unconscious patient.

Equipment See tray for Tracheostomy, Annex 1.

Technique Place the patient supine on a table or bed. Extend the neck by placing a sandbag
(or a rolled towel for infants and children) under the shoulders (Fig. 9. lA).
Prepare the skin with antiseptic, and infiltrate local anaesthetic into the skin
from the suprasternal notch along the midline to the thyroid cartilage
(Fig. 9. lB). Palpate the cricoid cartilage to ascertain its position (Pig. 9. lC), and
make a midline incision between its inferior border and the superior margin of
the suprasternal notch (Fig. 9. lD,E). Separate the strap muscles from the mid-
line by blunt dissection (Fig. 9.1 F) to expose the trachea with the thyroid isthmus
lying anterior to it. Retract the isthmus either upwards or downwards, or divide it
between artery forceps and ligate the ends (Fig. 9. lG,H). Divide and retract the
pretracheal fascia (Fig. 9.11) to expose the second and third tracheal cartilages.
Then lift and steady the trachea with small skin-hook retractors.

In infants and children, make a transverse intercartilaginous incision between

the second and third rings (Fig. 9. lJ). Avoid excising a piece of the trachea. (The
incision will open further as you extend the neck over the rolled towel.)

In adults, excise a small, rounded segment of the trachea (Pig. 9. lK). The size of
the resulting hole should conform to that of the tracheostomy tube.

Aspirate secretions from the trachea at this stage (Fig. 9.1 L), and again after
insertion of the tube.

Insert the tracheostomy tube set, remove the obturator, and loosely stitch the
skin with interrupted 2/0 thread (Fig. 9. lM,N). In children, remove the rolled
towel from under the shoulders before stitching the skin. A linen tape can be
passed behind the neck to join the wings of the tube and hold it in place
(Fig. 9.10). Dress the wound with a single layer of gauze swab.

When placing the tracheostomy tube in the trachea, ensure that it enters the
lumen accurately and completely. Assess and confirm the patency of the inserted
tracheostomy tube using the bell attachment of a stethoscope. If there is a normal
flow of air through the tube, a loud blast will be heard with each expiration. With
incomplete obstruction, the noise will be softer and shorter, accompanied by a
wheeze or whistle. If the tube has been placed pretracheally or if it is completely
blocked with secretions, no sound will be heard. Remove and replace the tube if
there is any doubt about its position or patency.

89
Chest, abdomen, and gastrointestinal tract

Fig. 9.1. Tracheostomy. Position of the patient with the neck exten<le<l (A); infiltrating the skin
with local anaesthetic (B); palpating the cricoid canilage (C); site of incision (D) and n1aking the
incision (E); separating the strap tnuscles by blunt dissection (F); retracting or dividing the
thyroid isthmus between clamps (G, II); site of division of the pretrachcal fascia (I); site of
intercanilaginous incision in children 0); excising a small rounded segment of the trachea in
adults (K).

90
 Chest

L 0
.~.

Fig. 9.1. Tracheostomy (continued). Aspirating secretions (L); inserting the tube (M); re1nov-
ing the obturator and suturing the skin (N); fixing the tube (0).

After-care Aspirate secretions from the tracheobronchial tree regularly using a sterile
catheter passed down through the tracheostomy tube. Avoid irritating the bron-
chi, which could stimulate coughing. The air around the patient should be kept
warm and humid by means of a humidifier. When necessary, instil small amounts
of sterile physiological saline into the bronchi to soften the mucus. Change the
inner tracheostomy tube at regular intervals. Should the outer tube be dislodged,
reinsert it immediately and check its position by both clinical examination and
chest radiography. Always have a spare tube available.

Refer the patient for further treatment if indicated.

Complications Complications include early postoperative bleeding, infection, surgical emphy-

sema, atelectasis, and crust formation. Stenosis of the trachea is a possible late
complication.

Underwater-seal chest drainage

Indications for underwater-seal chest drainage at the district hospital are pneu-
mothorax, haemothorax, haemopneumothorax, and acute empyema.

Equipment See tray for Underwater-real chert drainage, Annex 1.

Before beginning the procedure, check the equipment to confirm that each piece
fits properly into the next.

Technique Prepare the skin with antiseptic and infiltrate the skin, muscle, and pleura with
1% lidocaine at the appropriate intercostal space, usually the fifth or sixth, in the
midaxillary line (Fig. 9.2A,B). Note the length of needle needed to enter the

91
 Chest, abdomen, and gastrointestinal tract

Fig. 9.2. Underwater-seal chest drainage. Site for insertion of the tube (A); infiltrating all layers
of the chest wall at the proposed site with local anaesthetic (B); aspirating fluid fron1 the pleural
cavity (C); making a sn1all incision (D, E); enlarging the incision and penetrating the pleural
space with forceps (F, G); introducing and fixing the tube (H, I); underwater-seal drainage bottle
connected O, note the untied stitch).

92
 Chest

pleural cavity; this information may be useful later when you are inserting the
drain. Aspirate fluid from the chest cavity to confirm your diagnosis (Fig. 9 .2C).
Make a smal 1transverse incision just above the rib, to avoid damaging the vessels
under the lower part of the rib (Fig. 9.2D,E). In children, it is advisable to keep
strictly to the middle of the intercostal space.

Using a pair oflargc, curved artery forceps, penetrate the pleura and enlarge the
opening (Fig. 9.2F,G); employ the same forceps to grasp the tube at its tip and
introduce it into the chest (Fig. 9.2H,I). Close the incision with interrupted skin
sutures, using one stitch to anchor the tube. Leave an additional suture untied
adjacent to the tube for closing the wound after the tube is removed. Apply a
gauze dressing. Connect the tube to the underwater-seal drainage system, and
mark the initial level of fluid in the drainage bottle (Fig. 9.2)).

After-care Place a pair of large artery forceps by the bedside for clamping the tube when
changing the bottle. The drainage system is patent if the fluid level swings freely
with changes in the intrapleural pressure. Persistent bubbling over several days
suggests a bronchopleural fistula and is an indication for referral.

Change the connecting tube and the bottle at least once every 48 hours, replacing
them with sterile equivalents. Wash and disinfect the used equipment to remove
all residue before it is resterilized.

If there is no drainage for 12 hours, despite your "milking" the tube, clamp the
tube for a further 6 hours and X-ray the chest. If the lung is satisfactorily
expanded, the clamped tube can then be removed.

To remove the tube, first sedate the patient and then remove the dressing. Clean
the skin with antiseptic. l lold the edges of the wound together with fingers and
thumb over gauze while cutting the skin stitch that is anchoring the tube.
Withdraw the tube rapidly as an assistant ties the previously loose stitch.

Simple rib fracture

Diagnosis The diagnosis of rib fracture is suggested by a history of trauma, followed by a

localized, sharp chest pain that increases on breathing. Confirm the diagnosis by
physical examination and chest radiography, which will also provide informa-
tion on suspected intrathoracic injuries.

Treatment A simple rib fracture can be extremely painful. Administer analgesics first, but if
pain persists, proceed with an intercostal nerve block. In cases of single rib
fracture with no complications, strapping of the chest wall may help.

lntercostal nerve block

Equipment See tray for !ntercostai nerve biock, Annex 1.

Technique Administer a basal sedative.

Instruct the patient to sit up holding a pillow pinned between the chest and arms.
Prepare the skin over the para vertebral area corresponding to the posterior end
of the fractured rib and the two adjacent ribs.

Make a small skin wheal with 1% lidocaine with epinephrine (or 0.25% hupi-
vacaine with or without epinephrine) at the inferior margin of the neck of the

93
 Chest, abdomen, and gastrointestinal tract

X · sites of infiltration

Fig. 9.3. Intercostal nerve block for rib fracture. Position of the patient (A); sites of infiltration
with local anaesthetic (B); "walking" the needle downwards until its tip slips below the edge of
the rib (C, D).

fractured rib, about four finger-breadths from the rib's dorsal spinous processes
(i.e., close to the angle). Advance the needle until it reaches the rib border and
inject a small amount of local anaesthetic. Then "walk" the needle slowly
downwards to allow it to slip below the edge of the rib (Fig. 9.3). Advance the
needle a further 2-3 mm and inject 2.5 ml of local anaesthetic. Repeat the
procedure on the two adjacent ribs.

After-care Repeat the block once or twice a day depending on the patient's response.
Encourage the patient to cough and breathe deeply.

Complications Pneumothorax is a potential but rare complication.

Flail chest

Flail chest results from the isolation of a segment of the chest wall by the fracture
of one or more ribs in at least two sites, which leaves the segment without
support. In cases of bilateral fracture of the costochondral junctions, the flail
segment is in the anterior part of the chest, involving the sternum.

The patient has "paradoxical" respiration on the injured side (the ribs moving
inwards rather than outwards on inspiration), which reduces ventilation and
gives rise to atelectasis and hypoxia. The severity of these problems is directly
related to the size and degree of movement of the flail segment.

94
 Chest

A B

l
··.'------- ____,,,,/·

a )

Fig. 9.4. Fixing a small flail segn1ent of the chest with a pad secured by adhesive tape. The tape
extends fron1 the midline anteriorly (A) to the midline posteriorly (B).

The patient may have associated intrathoracic injuries, rendering the condition
more serious. If severe and progressive respiratory failure results, the patient can
be managed only by active resuscitation and referral.

Treatment Fix a small flail segment by securing a piece of rolled gauze or a small pad of
plaster of Paris over the segmem with adhesive tape (Fig. 9.4).

For a patient with a large flail segment and a marked disturbance of ventilation,
en<lotracheal intubation is an essential part of resuscitation before referral. In
severe cases, intermittent positive pressure ventilation may be necessary, pro-
vided for example by a self-inflating bag. As an alternative to positive pressure
ventilation, fix the flail segment by applying traction to a nylon suture passed
around a rib in the affected segment or to a towel clip attached to a rib. Treat any
haemopneumothorax with an underwater-seal intercostal drain.

In all cases, treat hypovolaemic shock if present, administer an intercostal nerve

block and analgesics, and give an appropriate prophylactic antibiotic.

Pneumothorax
Pneumothorax is the presence of air in the pleural cavity. It may be "open" or
"closed", depending on the presence or absence of a wound through the chest
wall. A pneumothorax is classified according to its cause: traumatic, sponta-
neous, or iatrogenic.

95
 Chest, abdomen, and gastrointestinal tract

The site of the leak may act as a valve, allowing air to enter, but not escape,
causing "tension" pneumothorax. Tension pneumothorax and open (sucking)
pneumothorax both require emergency surgical treatment.

Diagnosis The clinical features of pneumothorax are chest pain, which is often referred to
the shoulder, restlessness or dyspnoea, and tympanitic sounds on percussion,
with an absence of breath sounds. In tension pneumothorax the mediastinum
shifts to the uninjured side of the chest, and the patient may suffer subcutaneous
emphysema.

Most patients with open pneumothorax have associated haemothorax.

A chest radiograph is useful, but not immediately necessary.

Treatment If the patient has an open pneumothorax, act immediately to occlude the wound,
using any available dressing, and then insert an underwater-seal intercostal
drain. Treat the patient for hypovolaemic shock before debridement and suture
of the wound.

Tension pneumothorax is best treated by underwater-seal chest drainage.

However, in an emergency, a needle-puncture in the second intercostal space,
anteriorly in the midclavicular line, will provide immediate relief. Subsequently
insert an underwater-seal intercostal drain.

After-care Administer analgesics, prophylactic antibiotics, and tetanus prophylaxis, and

prescribe breathing exercises for the patient.

Haemothorax

Haemothorax is the presence of blood in the pleural cavity. Usually the result of
chest injury, it is commonly associated with pneumothorax, rib fracture, or other
thoracic injuries. Bleeding occurs from the traumatized lung or, more often, from
intercostal vessels.

Diagnosis The patient is usually restless and in pain, and may have marked dyspnoea. If
much blood has been lost, the patient is pallid with a rapid pulse and low blood
pressure. The area of the chest over the haemothorax is dull to percussion, and
there is an absence of breath sounds. The trachea may have shifted to the
opposite side of the chest.

A chest radiograph should confirm the presence of fluid in the pleural cavity.
The radiograph may, however, be difficult to interpret, especially in the presence
of severe or extensive lung contusion. In such cases, a diagnostic tap with a
needle and syringe is valuable. Investigate other suspected injuries in order of
priority.

Treatment Insert an underwater-seal intercostal drain. The chest tube should have several
holes in its intrathoracic section, so that its tip can be pushed high up into the
chest to allow blood (and any air) to escape. Observe the patient closely for signs
of hypovolaemic shock.

After-care Maintain free drainage. Measure the amount of blood in the drainage bottle
regularly. Continuing blood drainage beyond 500 ml in 24 hours or more than
100 ml/hour is an indication for referral. If the haemothorax is large, consider
autotransfusion.

96
 Chest

Administer analgesics, prophylactic antibiotics, and tetanus prophylaxis, and

prescribe breathing exercises for the patient.

Acute empyema

Thoracic empyema is the presence of pus in the pleural cavity. It can complicate
lung, mediastinal, or chest-wall infections and injuries. Rarely it may be due to
the extension of a subphrenic or liver abscess. Many different organisms, often in
combination, may be responsible for the infection. These include staphylococci,
streptococci, coliform bacteria, tubercle mycobacteria, and even amoebae (from
a liver abscess).

An empyema is either acute or chronic. It can invade adjacent tissues, the

diaphragm, or the chest wall with discharge of pus. As a result, metastatic
abscesses may occur in other organs.

Diagnosis Obtain a chest radiograph and a white-cell count, measure the patient's haemo-
globin level, and test the urine for sugar and protein.

Prompt diagnosis and treatment are essential for acute empyema. Its character-
istic features are chest pain, fever, and an irritating, dry cough. The affected area
is dull to percussion, with an absence of or markedly reduced breath sounds. A
chest radiograph shows evidence of fluid in the pleural cavity. There may be
additional features relating to the underlying disease. Perform a diagnostic
needle aspiration, and take sample of pus for examination for the infecting
organisms.

In the patient with chronic empyema, the above signs and symptoms are min-
imal or absent. Possible features are finger clubbing, mild chest discomfort or
pain, and a cough. The patient is in poor general health, and may have several
complications of chronic sepsis, including metastatic abscess and amy]oidosis.
The inflamed pleura is thickened and loculated. As it is not possible to drain the
pleural cavity adequately by underwater-seal intercostal drainage (which is
indicated for acute empyema), the patient should be referred.

Treatment At the district hospital, treat only patients with acute empyema. Treat a small
empyema by aspiration, repeated as necessary. Treat a moderate or large
empyema by underwater-seal intercostal drainage.

After-care Give antibiotics systemically; do not instil them into the pleural cavity. Admin-
ister analgesics and start the patient on breathing exercises. If there is evidence of
loculation or failure of lung expansion, refer the patient.

Surgical emphysema and mediastinal injuries

Subcutaneous surgical emphysema is usually a complication of rib fracture when

the lung has been punctured and a tension pneumothorax has developed, which
forces air out through the fracture site into the subcutaneous and peribronchial
tissues. The crepitation resulting on palpation of the affected tissues is both
characteristic and diagnostic. A variable amount of swelling is usually present.
Diagnosis is clinical, but chest radiographs can be useful in revealing associated
chest lesions, such as rib fracture or pneumothorax. Evidence of gas in the soft
tissues of the chest wall and at the root of the neck can also be seen in radio-
graphs.

97
 Chest, abdomen, and gastrointestinal tract

Subcutaneous emphysema usually resolves gradually after treatment of the

underlying pneumothorax by underwater-seal chest drainage. Rarely the emphy-
sema may be massive, involving the head and neck in addition to the chest wall,
and associated with respiratory distress. If this occurs, insert an underwater-seal
intercostal drain and make multiple deep subcutaneous incisions in the root of
the neck in the region of the suprasternal notch to allow the air to escape.

Traumatic perforation of the trachea, the bronchus, or the oesophagus can lead
to mediastinal emphysema, which usually extends to the neck. In such cases,
perform a tracheostomy and make a collar incision in the root of the neck. If
pneumothorax is also present, insert an underwater-seal intercostal tube. Refer
all patients with mediastinal injuries.

Incision and drainage of breast abscess

In developing countries, breast abscesses are extremely common in women
during breast-feeding. The causative organism, usually Staphylococcus aureus, gains
entry through a cracked nipple. While S. aureus is almost always sensitive to
penicillin in women who deliver at home or in small health institutions, it is
often resistant in those who have given birth in larger institutions where anti-
biotics have been abused.

Assessment and The features of a breast abscess are painful, tender swelling of the affected breast
preoperative management and often fever. The skin of the area is shiny and tight. Many patients present
with an advanced abscess in which the overlying skin has broken down and the
pus is discharging. In the early stages the swelling is usually tense, and fluctuation
is unusual. The most important consideration in differential diagnosis is inflam-
matory carcinoma of the breast. If you are in doubt about the diagnosis, perform a
needle aspiration to confirm the presence of pus.

Measure the patient's haemoglobin level and test the urine for sugar and pro-
tein.

Equipment See tray for Incision and drainage of abscess, Annex 1.

Technique The patient should be given a general anaesthetic. Prepare the skin of the
affected breast with antiseptic and drape the patient.

Make a radial incision over the most prominent or fluctuant part of the abscess
(Fig. 9.SA). Introduce the tip of a pair of sinus or artery forceps or a pair of
scissors to widen the opening and allow the pus to escape (Fig. 9.SB). Extend the
incision if necessary. Take a specimen of pus for bacteriological tests, including
examination for tuberculosis.

Introduce a finger into the cavity to break down all loculi, converting the lesion
into a single, large cavity (Fig. 9.SC). Clean the cavity with gauze previously
soaked in antiseptic. Insert a large corrugated drain through the wound
(Fig. 9.SD), or through a counter-incision if necessary for dependent drainage
(Fig. 9.SE). Apply an initial layer of petrolatum gau;,;e, followed by several layers
of gauze dressing. If much drainage is anticipated, cotton wool may be applied
over the gauze dressing.

After-care If the patient has been breast-feeding an infant, she should continue this unless
the child is of the age to be weaned. The child may feed from the affected breast,
but if this is painful for the mother, she may gently express the milk from the
breast instead. Give analgesics as required, but antibiotic treatment is usually
unnecessary. Change dressings as necessary, and remove the drain within 48
hours.

98
 Chest

A
JC/

(\__/ /

Fig. 9.5. Incision and drainage of breast abscess. Incision (A); introducing the tip of a pair of
forceps to improve drainage (B); breaking down loculi with a finger (C); inserting a corrugated
drain (D); a counter-incision may be made to establish dependent drainage (E).

99
 10
Abdomen (general)

Laparotomy

Laparotomy is used to expose the abdominal organs for surgery. It can also allow
the surgeon to confirm a preoperative diagnosis in a patient presenting with an
"acute abdomen". Laparotomy should be avoided, however, if the patient has
suspected acute pancreatitis.

The two incisions for laparotomy with which a surgeon should be thoroughly
familiar are the midline and the paramedian incisions. If necessary, further
exposure can be achieved by extending either incision or, rarely, by making a
supplementary transverse incision. Of these two incisions, the midline is par-
ticularly recommended, as it is technically simpler and takes less time to make
and close.

Incisions in the upper abdomen are employed for operations on the gallbladder,
stomach, duodenum, spleen, and liver, whereas incisions in the lower abdomen
are used for patients with intestinal obstruction or pelvic problems (mainly
obstetric and gynaecological). If you are in doubt about the diagnosis, you may
use a short paraumbilical incision and extend it up or down in the midline, as
indicated.

The upper midline Because an upper midline incision does not cause much bleeding, it can be made
incision quickly - an important consideration in emergencies. It provides good exposure
of the stomach, duodenum, gallbladder, left half of the liver, lesser sac of the
peritoneum, and pancreas. If better exposure is needed, the incision may be
extended downwards around or even through the umbilicus.

The disadvantage of the upper midline incision is that it generally offers poor
exposure of the spleen and the colon, although operation on these organs is
possible if the incision is suitably extended.

Equipment See tray for Laparotomy, Annex 1.

Technique Insert a nasogastric tube and empty the patient's stomach. A genera] anaesthetic
should be given.

Secure the patient to the operating table in a supine position. Apply a surgical
diathermy pad to the sacral area or lower limb. Prepare the skin with antiseptic,
from the level of the nipples down to the pubic region and to the flank on either
side. Apply sterile drapes, exposing the region between the xiphisternum and the
umbilicus.

Incise the skin in the midline between the xiphoid process and the umbilicus
(Fig. 10.1A). Carry the incision down to the subcutaneous layer and to the loose

100
Abdomen (general)

Fig. 10.1. The upper midline incision for laparotomy. Site of incision (heavy broken line),
which can be extended (light broken line) if necessary (A); dividing the linea alba (B); lifting and
dividing the peritoneum (C-E).

101
Chest, abdomet1, and gastrointestinal tract

tissue over the linea alba. Control bleeding with gauze swabs held against the
wound edge. Ligate any persistent bleeding points. Display the linea alba with its
longitudinal line of decussating fibres and incise it strictly in the midline, thereby
exposing the extraperitoneal fat and peritoneum (Fig. 10.1B).

· E.xercise care if the incision is through a previous laparotomy scar, as the gut may
be ad herent to the undersurface of the abdominal wall and thus liable to injury.
Clear the extraperitoneal fat laterally by swab and blunt dissection, securing
vessels as necessary. In fat people, this layer is often th ick, while the underlying
peritoneum is thin and "friable". '

Lift the peritoneum, making it into a "tent" by holding it with artery or tissue
forceps on either side of the midline. Squeeze the tent between the fingers and
thumb to free any gut on the undersurface, and make a small opening with a knife
(Fig. 10. lC,D). Jf the peritoneum opens up readily, steady the undersurface with
the index and middle fingers and extend the opening with scissors (Fig. 10.1E).
The peritoneal incision can then be extended to the full length of the
wound.

Examine the abdominal contents to confirm your diagnosis.

• l f there is a welling-up of greenish fluid and gas, suspect perforation of

the stomach or duodenum. Examine these organs.

• If there is free blood in the peritoneum and the patien t has a h istory of
trauma, suspect injury to the liver, spleen, or mesenrery. If the patient is
female with no history of trauma, suspect a ruptured ectopic pregnan-
cy.

• If there is a purulent exudate, suspect appendicitis, diverticulitis, or

perforation of the gut.

• l f there is a distended loop of bowel, suspect intestinal obstruction or

paralytic ileus.

• If there are free bowel contents and gas in the peritoneum, suspect
bowel perforation.

Systematically inspect and palpate the abdominal organs, except in an emergency

(for example in a patient with a ruptured spleen or a perforated peptic ulcer)
when the immediate threat to life must be contained first. Defer paJpation of any
obvious tumours and of infected or possibly infected regions until the rest of the
abdomen has been examined. When you are dealing with infection, the extent of
inspection and palpation must be restricted.

An appropriate operation can now be carried out, if indicated by the pathological

findings.

At the end of the operation, close the wound in layers. Use several pairs oflarge
artery forceps to hold the ends and edges of the peritoneal incision, and close the
peritoneum together with the overlying extraperitoneal fat with a continuous
suture ofO chromic catgut on a round-bodied needle (Fig. 10.2A). Relaxation of
the abdominal waU (provided by a muscle re.laxant drug) is necessary at this stage
to keep the intestine within the abdominal cavity. In the presence of intestinal
d istension, this may be a considerable p roblem. In such cases, a malleable copper
spatula may be placed under the wound to confine the gut (Fig. 10.2B).

lJn surgical practice, a friable tissue is one that has the consistency of wet blotting paper and disintegrates
easily.

102
 Abdomen (general)

A B c

Fig. 10.2. Closure of the ufJper midline incision. Closing the peritoneum with continuous suture
(A); using a spatula to hold down loops of intestine within the abdomen (B); using a cutting
needle (C, shown also in cross-section) to suture the linea alba (D) and finally the skin (E).

Close the linea alba with interrupted Othread or continuous monofilament nylon
on a cutting needle (Fig. 10.2C,D), but in the presence of infection or gross
contamination, use a loose continuous stitch of No. 1 nylon and avoid thread.
Close the skin with interrupted stitches of 2/0 thread (Fig. 10.2E). Regardless of
the method of suturing, it is essential to insert the needle at least 1 cm from the
wound edge and to place the suture loops about 1 cm apart.

If closing the abdomen is difficult, check the adequacy of anaesthesia and

relaxation of the abdominal wall and empty the stomach with a nasogastric tube.
Use interrupted simple all-layer (tension) sutures to close the wound (see
page 106).

In fat patients, stitching of the subcutaneous fat with 2/0 plain catgut may be
necessary. Before closing the wound, always ensure sound haemostasis, remove
any haematoma, and clean the wound thoroughly.

Use only one or two layers of gauze for dressing. Do not dress the wound tightly
or use a sealing tape over the dressing in a hot and humid climate.

The upper paramedian The upper paramedian incision may be made on either side of the midline and is
incision the incision of choice when the rectus muscles arc widely separated (divarica-
tion). Made on the patient's right, it provides good exposure of the duodenum or
stomach and can be used for operations on the gallbladder. It can be extended by
a longitudinal or a transverse incision.

103
Chest, abdomen, and gastrointestinal tract

Fig. 10.3. The pararnedian incision for Japarotomy. Site of incision (heavy broken line), which
can be extended (light broken line) if necessary (A); incising the anterior rectus sheath (B);
dissecting the sheath off the muscle (C); reflecting the rectus muscle laterally (D); dividing the
posterior rectus sheath (E).

The disadvantages of the upper paramedian incision are that, for the inexperi-
enced surgeon, it is more difficult to make than the midline incision; that the
procedure takes longer than laparotomy with a midline incision; and that it
provides only poor exposure of the organs on the opposite side.

104
 Abdomen (general)

Equipment See tray for Laparotomy, Annex 1.

Technique Insert a nasogastric tube and empty the patient's stomach. A general anaesthetic
should be given.

Make an incision longitudinally from the xiphoid process to the umbilicus at

about 2 cm from the midline (Fig. 10.3A), and then deepen it until the anterior
rectus sheath is exposed. Effect haemostasis with gauze held against the wound
edge, using diathermy or ligatures to control any persistent bleeding.

Incise the anterior rectus sheath longitudinally, leaving a medial margin of about
2 cm, but do not incise the underlying muscle (Fig. 10.3B). Instruct your assistant
to hold up the medial edge of the rectus sheath using several pairs of artery
forceps to provide an upward and medial retraction (Fig. 10.3C). In this way, the
three areas of adherence of the sheath to the anterior surface of the muscle (at the
top end, at the umbilicus, and half-way between the two) will become apparent.
Proceed carefully, as blood vessels course through these areas of adherence
(tendinous intersections).

Dissect the sheath off the muscle. Use the back of a scalpel handle or the back of a
pair of dissecting forceps, closed curved scissors, or the fingers to release the
medial border of the muscle. This allows the muscle to be retracted and slid
laterally, to expose the posterior rectus sheath (Fig. 10.3D). A few small vessels
may need to be divided and ligated between the posterior sheath and the back of
the muscle.

Lift the exposed posterior sheath, making it into a tent by holding it, medially
and laterally, with two pairs of Allis or artery forceps, and incise the sheath in
between while squeezing the tent to displace the underlying gut (Fig. 10.3E).
Deepen the incision to include the peritoneum, making the opening large
enough to admit the index and middle fingers. Use these fingers to hold up the
undersurface of the peritoneum, while extending the incision with scissors to the
full length of the wound by cutting in between the fingers. If the fakiform
ligament prevents a clear view of the interperitoneal structures, it should be
divided between clamps and ligated.

Inspect and palpate the abdomen and viscera, as detailed on page 102, and carry
out any necessary surgery.

At the end of the operation, close the incision in three layers. Stitch the peri-
toneum, any extraperitoneal fat, and the posterior rectus sheath together in one
layer with a continuous O chromic catgut. Reposition the rectus muscle and stitch
the anterior rectus sheath with continuous monofilament nylon or interrupted O
chromic catgut or thread. And finally, suture the skin with interrupted 2/0
thread or nylon stitches, taking precautions as described on page 103.

Use only one or two layers of gauze for dressing. Do not dress the wound tightly
or use sealing tape over the dressing in a hot and humid climate.

Lower abdominal Midline or paramedian incisions of the lower abdomen can be closed in the same
incisions way as upper abdominal wounds.

Wound drainage Drainage is indicated when there is a risk of haematoma formation or serous
fluid collection in the wound or when there has been gross wound contamina-
tion. The best form of wound drainage in such cases is achieved by leaving the
skin and subcutaneous fat unstitched. Close the peritoneum with catgut and the
linea alba or rectus sheath with continuous No. 1 nylon. Insert skin stitches, but
leave them untied for delayed primary closure.

105
 Chest, abdomen, and gastrointestinal tract

c D

Fig. 10.4 Tension sutures for abdon1inal wounds. Insening all-layer tension stitches (A);
layered closure of all layers below the skin is con1plcted (.B) before lhe skin is closed and the
tension sutures ate tied (C, D).

Tension sutures Tension sutures are indicated in patients debilitated as a result of malnutrition,
old age, or advanced cancer, when healing is likely to be impaired, and in
patients suffering from conditions associated with increased intra-abdominal
pressure, for example obesity, asthma, or chronic cough. Monofilament nylon is
a suitable material. Insert the tension sutures through the entire thickness of the
abdominal wall before closing the peritoneum, leaving them untied at first
(Fig. 10.4A). They may be simple (through-and-through) or mattress in type.
Insert a continuous peritoneal suture to take up the tension sutures, and continue
to close the wound in layers (Fig. 10.4B). When skin closure is complete, tie each
tension suture after threading it through a short length of plastic or rubber tubing
(Pig. 10.4C,D); the sutures should not be tied under tension. Do not remove
them for at least 14 days.

Repair of burst abdomen

A burst abdomen is a postoperative, abdominal wound dehiscence. It is often

caused by conditions in the patient that either retard healing or are associated
with increased intra-abdominal pressure (as listed above in the section on ten-
sion sutures), but it can also be the unfortunate result of poor surgical technique
in wound closure. Rarely, a burst abdomen occurs without obvious reason.

106
 Abdomen (general)

Fig. 10.5. Abdominal binder.

Most patients experience the moment of the rupture as a sensation of something

giving way, often during the act of coughing or defecation. This is followed by
the appearance of thin blood-stained fluid from the surgical wound - the most
important warning sign. In cases of complete rupture, the omentum or intestine
appears in the wound. Hypovolaemic shock and pain are unusual.

Preoperative management First allay the anxiety of the patient and any relatives present. Sedate the patient
and cover or, if necessary, bind the abdomen with a sterile towel. While making
arrangements for emergency surgical repair, insert a nasogastrie tube and begin
intravenous infusion of an appropriate fluid. If the wound is infected, administer
antibiotics.

Equipment See tray for Laparotomy, Annex 1, and add strong (No. 1 or No. 2) monofilament
nylon or thread, and tubing for tension sutures.

Technique The patient should be given a general anaesthetic with a muscle relaxant. Clean
the wound and the surrounding skin together with any prolapsed gut and
omentum with cetrimide. (Never use iodine or alcohol on the gut or omentum.)
Drape the patient and carry out wound debridement to remove all fragmented
tissues and previous stitches.

Insert tension sutures, as described on page 106, and tie them one by one to close
the wound in one layer. Do not attempt to suture the peritoneum or other layers
separately. Support the abdominal wall with a clean sheet or binder (Fig.
10.5).

After-care Control predisposing conditions, for example asthma or chronic cough. Main-
tain nasogastric suction to keep the stomach empty and to decompress the upper

107
 Ches~ abdomen, and gastrointestinal tract

gastrointestinal tract. Continue intravenous infusion of appropriate fluids. If

there is infection, continue the administration of antibiotics. As the patient
recovers, he or she may be gradually weaned off this regimen. Recovery is
indicated by the patient feeling better and by the return of bowel sounds, the
passage of flatus, a reduction in the volume of gastric aspirates, an adequate
urinary output, and a normal pulse, blood pressure, and temperature.

Remove the stitches after 14 days.

Complications The patient's chances of survival are largely determined by the predisposing
condition. Incisional hernia is a possible complication.

Abdominal injuries

General principles Penetrating injuries include gunshot wounds and wounds induced by stabbing
with sharp objects, for example knives or spears. A penetrating alxlominal
Penetrating injuries wound is an indication for exploratory laparotomy, regardless of the physical
signs or the apparently superficial nature of the wound. Signs of hypovolaemia or
of peritoneal irritatio n may be minimal or absent immediately after a penetrating
injury involving the abdominal viscera. Probing the wound may be misleading,
as the probe can fai l to traverse a track that has been d istorted by altered muscle
tone or by a change in the patient's position. First resuscitate the patient and then
perform an eme rgency exploratory laparotomy, this being the only way of
ensuring that no serious or potentially serious injury is overlooked.

Blunt injuries Blunt injuries occur most commonly as a result of traffic accidents or assault.
Assessing the need for laparotomy is more difficult than for patients with pen-
etrating injuries. In the presence of hypovolae mia, examine the chest and other
possible sites of blood loss, for example the area around pelvic or femoral
fractures.

When a patient has sustained a blunt abdominal injury, exploratory laparotomy is

indicated in the presence of any of the following:

• abdominal tenderness with rigidity;

• pain and tenderness in either hypochondrium, especially if the pain is

referred to the shoulder and if there is associated blood loss;

• free abdominal gas, as seen on a plain radiograph;

• failure to pass urine, with local signs maximal in the suprapubic area,
suggesting rupture of the bladder.

Initial management When a patient presents with abdominal injuries, first establish a clear airway and
arrest any external bleeding. Resuscitation may be necessary, but should not
unduly delay operation. Make a thorough physical examination. Establish base-
line observations of vital signs, set up an intravenous line, and infuse an appro-
priate fluid. Insert a nasogastric tube and begin suction. Even if the patient's
condition appears to be satisfactory, take a blood sample for haemoglobin
measurement, grouping, and cross-matching. X-ray the chest, abdomen, pelvis,
and any other injured parts of the body.

Prepare the patien t for emergency laparoromy if this is indicated. Insert a bladder
catheter and examine the urine for blood, sugar, and protein. Chart the pat ient 's

108
 Abdomen (general)

urinary output. Administer analgesics and, if the patient has penetrating wounds,
antibiotics and tetanus prophylaxis as well.

Make no attempt to reduce any gut or omentum protruding through the wound.
Cover it with a sterile towel while you prepare to operate.

Proceed with laparotomy if indicated.

Laparotomy and repair

of injuries

Equipment See tray for Laparotomy, Annex 1, and add several large round-bodied nee-
dles.

Technique The patient should be given a general anaesthetic. Make a generous midline or
right/left paramedian incision ; this can be further extended below the umbili-
cus, if necessary. Defer debridement and suture of the injury wound until the end
of the operation. Apply pressure over warm, moist packs to control bleeding
areas temporarily, keeping in mind that the source of bleeding is likely to be near
a large clot. Arrest any brisk bleeding temporarily with forceps, provided that the
bleeding vessel can be clearly identified. If the blood is not contaminated by
either gut contents or urine, consider autotransfusion. Control spillage of gut
contents by temporarily occluding any perforations with light tissue forceps or
with intestinal occlusion clamps.

Thoroughly clean the abdominal cavity with abdominal packs and warm saline.
Inspect the organs systematically, beginning with the small intestine and pro-
gressing to the large intestine and rectum, the bladder and uterus, the stomach
and duodenum, the liver, the spleen, and finally the pancreas and kidneys
(including the retroperitoneal area). Note each injury as it is detected, but plan
the appropriate surgical procedure only after yo1.; have made a complete assess-
ment.

Stomach Trim any ragged wound edges in the stomach. Then suture the wound in two
layers, carefully invaginating the mucosa.

Small intestine Close small punctures of the small intestine with purse-string suture, invaginat-
ing the mucosa. Close larger wounds transversely with two layers of interrupted
invaginating stitches (Fig. 10.6). The wound edges may first require trimming.
When several wounds lie close together or when repair would narrow the gut
unacceptably, resect the damaged loop and make an end-to-end anastomosis (see
page 125). Also resect gut made ischaemic by a tear in the mesentery.

Right colon Injury of the right colon requires resection of the entire right colon and exteri-
orization of the two open ends as a transverse colostomy and an ileostomy. Make
no attempt to repair this type of injury.

Transverse colon Exteriorize the site of injury as a colostomy.

Descending colon Mobilize the colon, exteriorizing the site of injury and converting 1t mto a
colostomy. Drain both the paracolic gutter and the pelvis.

Rectum Repair an injury to the rectum in two layers and construct a sigmoid colostomy.
Drain the left side of the abdomen and the pelvis.

Spleen Splenectomy is the standard treatment for injuries to the spleen, but consider
preserving the spleen in certain cases (see page 121).

109
 Chest, abdomen, and gastrointestinal tract

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11 ; ; ;
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;111~\\\C\\ \~\__\

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I I
' ' '

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E F

Fig. 10.6. Closure of a wound .in the small intestine. The wound (A); pulling the gut trans-
versely by stay sutures (B); insening the first layer of invaginating stitches to include all layers of
the gut wall (C); an alternative method of inserting stitches, while maintaining the wound edges
in apposition (D, E); a second layer of stitches con1pletes the repair (F).

110
 Abdomen (generalj

Fig. 10.7. Suture of a laceration of the liver. Excising non-viable liver tissue (A); inserting
overlapping mattress stitches on both sides of the wound (B-E) and stitching the two sides
together (E, F).

Liver Small wounds of the liver may have stopped bleeding by the time of operation
and should then be left alone. For larger wounds or tears, remove all devitalized
tissue and suture the area with mattress stitches of O chromic catgut carried on a
large, round-bodied needle (Fig. 10. 7). If a laceration cannot be sutured, pack it
with a long gauze roll, soaked in warm saline and wrung out. Bring one end of the
roll out through a separate wound. A liver pack is usually removed in several
stages after about 48 hours, if necessary with the patient under general anaes-
thesia for a short time. A large drain is indicated in all patients with liver injuries,
to be removed also after about 48 hours. Make arrangements for referral as soon
as the patient's condition permits.

Pancreas Injury to the pancreas can be confirmed by opening the lesser sac through the
gastrocolic (greater) omentum. The only safe procedure is to put a drain down to
the site of injury. The drain should traverse the lesser sac and come out in the
flank. Make arrangements for referral as soon as the patient's condition per-
mits.

111
 Chest, abdomen, and gastrointestinal tract

Retroperitonea/ haematoma A retroperitoneal haematoma should not be opened or disturbed.

Bladder and urethra Management of rupture of the bladder and urethra is detailed in chapters 18 and
19.

Kidney Do not expose the kidney unless life-threatening bleeding is indicated by con-
tinued gross haematuria. Stop the bleeding at the site of the tear by stitching or
transfixion. Refer the patient without delay.

112
 11
Stomach and duodenum

Feeding gastrostomy
Gastrostomy is indicated when feeding through a nasogastric tube is hazardous
or impossible, for example in patients with oesophageal burns or obstruction or
with oesophageal atresia. Gastrostomy enables the patient to be nourished
pending referral.

Clinical findings, and hence the laboratory tests to be requested, will depend
upon the underlying condition.

Equipment See tray for Laparotomy, Annex 1, and add a pair of intestinal tissue-holding
forceps and a Foley catheter (18-22 Ch.).

Technique Make an upper midline laparotomy incision of about 8-10 cm and inspect the
abdomen. Pick up the anterior wall of the body of the stomach with intestinal
tissue-holding forceps. Insert two circular rows of purse-string, 2/0 chromic
catgut or thread sutures to enclose a section of the gastric wall of 1.0-1.5 cm
diameter. Make an incision through the centre of this area, just large enough to
admit the catheter (Fig. 11. lA,B). Ligate or coagulate the submucosal vessels
immediately before incising the mucosa.

Make a separate stab wound in the patient's left upper quadrant, and through this
introduce the tip of a Foley catheter (size 18-22 Ch.) into the abdominal cavity,
guiding it into the stomach through the gastric opening (Fig. 11.1 C). Distend the
catheter balloon with not more than 5 ml of water and tie the purse-string
sutures, beginning with the inner one. With a pair of forceps, bring the ends of
the sutures out along the catheter to the skin surface to be tied off and cut later
(Fig. 11. lD,E).

Now pull the catheter to bring the balloon close to the gastric mucosa, which
· will at the same time draw the gastrostomy site against the undersurface
of the abdominal wall (Fig. 11. lF). Pass the ends of the sutures through the
skin edge with a cutting needle. Tie one pair of ends against each other around
the tub~, thus anchoring it, and use the other pair to close the stab wound
(Fig. 1 l.1G-I).

Close the abdominal wound and dress it with sterile gauze. Dress the stab wound
with a single layer of dry, sterile gauze.

Perforated peptic ulcer

The main sites of peptic ulceration are the duodenum and the stomach. In most
populations, duodenal ulcer is more common than gastric ulcer. The main
complications of peptic ulcer are bleeding, penetration with perforation, and
obstruction, for example of the pylorus.

113
Chest, abdomen, and gastrointestinal tract

----":~~t-

Fig. 11.1. Feeding gasuostomy. Site for introduction of the catheter (A); incising the stomach
wall, after inserting purse-string sutures (B); introducing the catheter(C); position of the tip of the
catheter "'ithin the stomach (D); fixing the catheter to the stomach wall (E, F) and to the skin (G,
H); closing the stab wound (f).

114
 Stomach and duodenum

Perforating duodenal ulcers are usually located anteriorly, while perforating

stomach ulcers can occur either anteriorly or posteriorly. Occasionally a gastric
ulcer is malignant. The hazardous effects of perforation are due to peritonitis.
Initially this is chemical, caused by spillage of the acidic gastric contents and of
duodenal fluid into the peritoneal cavity. Bacterial inflammation occurs about 12
hours after spillage. For this reason, the prognosis is greatly influenced by the
time interval between perforation and surgical closure.

Diagnosis The characteristic history includes a sudden onset of severe abdominal pain.
Some patients compare the experience to a severe stab or blow in the abdomen,
and most are able to give the precise time of the episode. Surprisingly, prodromal
symptoms are usually absent. Patients rarely give a history suggestive of the
disease, although some may already know that they have a peptic ulcer. After the
acute episode, the patient experiences an intense burning pain, mainly in the
upper abdomen. The body is held rigid and the patient finds any movement
extremely painful.

The major physical signs are in the abdomen, which does not move with res-
piration but has a board-like rigidity and is extremely tender. Bowel sounds may
be markedly reduced or absent. Later the abdomen becomes distended and
silent. The patient may show signs of hypovolaemic shock.

A plain abdominal radiograph will usually show free gas in the abdominal cavity.
Obtain the radiograph with the patient in a left lateral decubitus position or
standing, if possible, when the gas will show between the right lobe of liver and
the diaphragm.

The differential diagnosis should include acute pancreatitis and acute cholecys-
titis.

Treatment A perforated peptic ulcer is an indication for emergency operation. The aims are
to close the perforation, which will halt further contamination of the peritoneal
cavity, and to remove the irritant fluid by suction and peritoneal lavage, which
will also minimize bacterial inflammation.

A delay in operation will adversely affect the prognosis, particularly if the delay
continues beyond 6 hours from the time of the perforation. Other factors affect-
ing prognosis are the patient's age, his or her nutritional status and health before
the episode, and the degree of contamination of the peritoneal cavity.

Repair of perforated Administer morphine immediately, preferably intravenously. Once pain is con-
ulcer trolled, pass a nasogastric tube and aspirate the stomach contents. Begin an
intravenous infusion of saline and resuscitate the patient as far as possible before
Assessment and proceeding to surgery. An intravenous dose of a broad-spectrum antibiotic
preoperative management should be given 1 hour before operation and regularly for the next 24 hours.

Measure the patient's haemoglobin level and test the urine for sugar and protein.
Take blood for grouping, though blood transfusion is not usually necessary.

Equipment See tray for Laparotomy, Annex 1.

Effective suction is essential in this operation, even if provided only by foot

pump and suction bottle. Prepare 1 litre of warm sterile saline for peritoneal
lavage, adding 1 g of tetracycline to this solution just before use.

115
Chest, abdomen• and gastrointestinal tract

116
 Stomach and duodenum

Fig. 11.3. Checking for a perforated posterior peptic ulcer. Dividing the grenter omenturn to
open the lesser sac (A); inspecting the posterior wall of the stomach (B); repairing the omentum
after closing the perforation (C).

Technique The patient should be given a general anaesthetic, preferably with a muscle
relaxant. Insert a nasogastric tube, and aspirate the stomach contents. Open the
abdomen through an upper midline incision (Fig. 1 l.2A). Remove all fluid and
food debris from the peritoneal cavity using suction and warm moist abdominal
packs. Gently retract the liver upwards, draw the stomach to the left by gentle
traction over a warm pack, and identify the perforation. Continue to aspirate
fluid as necessary (Fig. 1 l.2B). Note the appearance of the gut wall adjacent to
the perforation; scarring suggests a chronic ulcer. If a perforation is not obvious,
check the posterior wall of the stomach by opening the lesser sac of the peri-
toneum (Fig. 11.3A,B).

Insert three 2/0 chromic catgut stitches in the long axis of the duodenum or
stomach so that the middle stitch passes across the perforation itself, taking the
full thickness of the gut wall about 5 mm from the edge of the perforation. The
upper and lower stitches should take a generous seromuscular "bite" of the gut.
Tie off the sutures loosely, leaving the ends long (Fig. 11.2C,D). Draw a tab of
adjacent omentum across the perforation and tie the three stitches over it
(Fig. 11.ZE). Repair the greater omentum if you have divided it to locate a
posterior perforation (Fig. 11.3C).

Thoroughly cleanse the peritoneal cavity with the prepared warm saline con-
taining tetracycline. Also cleanse the areas of the peritoneum most likely to be

117
 Chest, abdomen, and gastrointestinal tract

contaminated, especially the subphrenic spaces and pelvic peritoneum, using

gauze packs. After a satisfactory toilet there is no great advantage in draining the
peritoneum, but if in doubt, leave a tube drain below the right lobe of the liver,
bringing it out through a lateral stab wound in the abdominal wall. Further
applications of antibiotic to the peritoneum are unnecessary. Close the wound in
layers, except in cases of gross contamination when it is preferably le.ft partially
open for delayed primary closure 2-5 days later.

After-care Continue. nasogastric aspiration and the intravenous administration of fluids,

and maintain an accurate. fluid-balance chart. The insertion of an indwelling
bladder catheter may be necessary. Observe the patient's blood pressure, pulse,
respiration, and temperature. regularly. Give antibiotics and analgesics; this is
be.st done intravenously if the patient is receiving fluids via a drip. If a drain has
been inserted, re.move it 24-48 hours after the ope.ration.

The patient may be gradually weaned off the above regimen. Recovery is indi-
cated by the patient fee.ling better and by the re.tum of bowel sounds, the passage
of flatus, a reduction in the volume of gastric aspirates, an adequate. urinary
output, and a normal pulse, blood pressure, and temperature. When the patient is
able to eat normally, begin treatment for peptic ulcer.

After successful treatment of the perforation, regularly re-examine the patient as

an outpatient. The results of the ope.ration are variable: some patients, particu-
larly those with perforated acute ulcers, may not experience. any further symp-
toms; others may continue to suffer; and a few may show symptoms of severe
ulcer, re.quiring referral for elective surgery.

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 12
Gallbladder and spleen

Cholecystostomy

At the district hospital, the only indication for cholecystostomy is severe acute
cholecystitis with a distended gallbladder that is in danger of rupturing.

Diagnosis is made during a laparotomy for "acute abdomen". The gallbladder

will be inflamed, red, oedematous, distended, and possibly coated with a film of
exudate. It may contain stones. If the gallbladder is very tense and appears likely
to rupture, proceed to cholecystostomy. Otherwise close the abdomen and refer
the patient after he or she has recovered from the attack of cholecystitis.

Start treatment with antibiotics and analgesics once cholecystitis has been diag-
nosed.

Equipment See tray for Laparotomy, Annex 1, and add a Foley balloon catheter, a 20 or 50 ml
syringe with a wide-bore needle, a pair of Desjardin forceps, and a sterile, closed
drainage system.

Technique When severe acute cholecystitis is encountered during an operation and the
gallbladder is in danger of rupturing, proceed to cholecystostomy. The gallblad-
der should be packed off with gauze (Fig. 12. lA) to prevent spillage of infected
bile into the peritoneal cavity. Insert two purse-string 2/0 chromic catgut
stitches into the fundus (Fig. 12. lB). Aspirate the infected bile with a needle and
syringe to empty the gallbladder (Fig. 12.1 C), and then incise the fund us with a
pointed knife in the centre of the purse-string sutures (Fig. 12.10) and apply
suction (Fig. 12. lE). Any easily accessible stones can be extracted with the aid of
a pair of Desjardins or other suitable forceps (Fig. 12.1F); this procedure is
facilitated by "milking" the gallbladder towards the fundus.

Introduce the tip of a Foley catheter through a stab wound in the abdominal wall
and from there into the gallbladder (Fig. 12.1 G). Tie the purse-string sutures, the
inner one first, leaving the ends long, and inflate the balloon (Fig. 12. lH,I).
Bring the ends out through the abdominal wall along with the catheter and
anchor them to the stab wound. In this way, the gallbladder wall at the site of the
cholecystostomy is brought to lie against the undersurface of the abdominal wall,
deep to the stab wound.

Close the laparotomy incision. Then close the stab wound and tie the catheter
securely in position with the ends of the second purse-string suture. Connect a
sterile, closed drainage system to the catheter.

After-care Continue to give the patient antibiotics and analgesics. Nasogastric suction and
the intravenous administration of fluids are necessary for 2-3 days after the

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Chest, abdomen, and gastrointestinal tract

Fig. 12.1. Cholecystostomy. Exposing the gallbladder (A); insetting two purse-string sutures
(B); aspirating the infe<:<ed bile (C); incising the gallbladde,: in the centre of the area enclosed by
the purse-suing sutures (D); suction (E); removing any loose ston"" (F).

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 Gallbladder and spleen

Fig. 12.t. Cholecystostomy (continued). Introducing the tip of a Foley catheter into the gall-
bladder (G, H); tightening the purse-string sutures against the tube and using the ends to fix the
catheter (I).

operation. After 10 days clip off the cholecystostomy catheter for increasing
periods of time. If there is no pain or leakage of bile around the tube when it has
been closed for 24 hours, the catheter may be removed safely. The sinus to the
gallbladder generally closes rapidly thereafter. If necessary, however, the chol-
ecystostomy catheter may be left in position.

Arrange for the patient to be referred for elective cholecystectomy about 6 weeks
after the initial operation.

Ruptured spleen
In tropical countries, enlargement of the spleen due to malaria or kala-azar
(visceral leishmaniasis) is common. The affected spleen is liable to be injured or
to rupture as a result of even trivial trauma.

Diagnosis and treatment The patient with a ruptured spleen usually has a history of trauma, though the
trauma may have gone unnoticed until the symptoms of rupture developed.
Laceration of the spleen can be associated with multiple injuries, for example as a
result of a traffic accident, or with localized trauma. Pain is often present in the
left upper abdomen and may be referred to the left shoulder. The patient may
also complain of nausea and vomiting.

Physical examination reveals some degree of hypovolaemia. Abdominal tender-

ness and rigidity are maximal in the splenic area, where a diffuse mass may be
evident. A chest radiograph may show fracture of one or more of the left lower
ribs, while an abdominal radiograph may reveal a shadow in the upper left
quadrant, displacing the gastric air bubble medially.

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 Chesl, abdomen, and gastrointestinal tract

If you suspect rupture of the spleen, proceed to splenectomy if the patient is

hypovolaemic, but if the patient is in a stable state and does not need immediate
blood replacement, consider conservative management. This should consist of
careful observation, bed-rest, intravenous infusion of a colloid (and blood if
indicated), administration of analgesics, and nasogastric intubation and suction.
Should the patient's condition deteriorate, abandon conservative management
in favour of laparotomy and possible splenectomy.

Delayed rupture can occur at any time from a few days to 3 weeks after a spleen
injury. It is rare in infants and children, but adults who have received non-
operative treatment for their spleen injury should be watched for up to 3 weeks in
or near hospital.

Splenectomy The only indication for splenectomy at the district hospital is rupture.

Assessment and Take blood samples for estimation of haemoglobin content and erythrocyte
preoperative management volume fraction, and begin intravenous infusion of saline. Administer analgesics
and attend to other injuries in order of priority. Insert a nasogastric tube and
begin suction.

Equipment See tray for Laparotomy, Annex 1, and add four sterile 500 ml bottles, each
containing 60 ml of 3.8% sodium citrate, in preparation for possible autotrans-
fusion.

Technique The patient should be given a general anaesthetic with a muscle relaxant. Place
the patient supine with a pillow or sandbag under the left lower chest. Open the
abdomen through a long midline incision (Fig. 12.2A).

Collect blood for autotransfusion, if feasible, and remove clots from the abdom-
inal cavity. If bleeding continues, squeeze the splenic vessels between the thumb
and fingers (Fig. 12.2B), or apply intestinal occlusion clamps. Assess the extent
of the splenic injury and inspect the other organs. To examine the hilum of the
spleen, it may be necessary to open the lesser sac through the gastrocolic
omentum.

At this point, the decision should be made whether or not to preserve the spleen.
If bleeding has stopped, it is best not to disturb the area. A small tear with little
bleeding can be controlled with O catgut mattress sutures and then the abdomen
can be closed. This procedure is particularly advisable in infants and children
because splenectomy can impair immune responses.

If it is not possible to preserve the spleen, begin mobilization by lifting it into the
wound and dividing the taut lienorenal ligament with scissors (Fig. 12.2C).
Extend the division to the upper pole. Apply a large occlusion clamp to the
adjoining gastrosplenic omentum (containing the short gastric vessels) and
divide the omentum between large artery forceps (Fig. 12.2D,E). Ligate the
short gastric vessels well away from the gastric wall with O thread. Dissect the
posterior part of the hilum, identifying the tail of the pancreas and the splenic
vessels. Ligate these vessels three times, if possible ligating the artery first, and
divide them between the distal pair of ligatures (Fig. 12.2F,G). Now divide the
remaining gastrosplenic omentum between several clamps and, finally, divide
the anterior layer of the lienorenal ligament.

Make every effort to follow these steps, though this may be difficult when a
spleen is badly lacerated. Avoid blind application of forceps and mass ligation of
the tissues in the splenic hilum, but if you cannot identify the splenic vessels, you
may transfix and ligate the hilum piecemeal, taking care not to include the tail of
the pancreas. Drain the bed of the spleen through a lateral stab wound. Then
close the abdomen in layers.

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Gallbladder and spleen

Fig. 12.2. Splcnectomy. Site of incision (A); temporary control of bleeding by squeezing the
splenic vessels between the thumb and fingers (B); mobilizing the spleen by division of the
lienorenal ligament (C); dividing the gastrosplenic omentum between pairs of artery forceps
(D).

123