Surgery

Question 1

What is surgery?

Answer 1

Branch of medical practice that treats injuries, diseases, anddeformitiesby the physical removal, repair, orreadjustmentof organs and tissues, often involving cutting into the body

Question 2

Types of surgery

Elective, urgent, emergent

Answer 2

Dependent on the diagnosis of the patient

Elective
Does not mean the surgery is optional
Scheduled in advance based on patient choice and availability of scheduling
For a non-life-threatening condition

Urgent
Required to preserve health
Typically performed within 24- 48 hours of diagnosis

Emergency
Performed immediately for a life-threatening condition

Question 3

Major surgery

Answer 3

Procedure that involves the removal of an organ or body part, or the repair of a large body part

Cesarean section
Organ removal
Joint replacement
Full hysterectomy
Heart surgeries
Bariatric surgeries, including gastric bypass

Question 4

minor surgery

Answer 4

Procedure that neither penetrates or exposes a body cavity, nor induces permanent impairment of physical or physiologic function

Cataract surgery
Tooth extraction
Circumcision
Breast biopsy
Arthroscopy
Laparoscopy
Burn debridement procedures

Question 5

Scalpel

Answer 5

Used for initial incision and cutting of tissue
Contains a blade and a handle
Often referred to by the blade number
Blade types:
#10 Blade
Used for making large incisions (laparotomy)
#11 Blade
Used for making precise or sharply angled incisions
#15 Blade
Small version of the #10 blade used for making finer incisions
Handle
#3 handle fits blades #10, #11, #12, and #15

Question 6

Scissors

Answer 6

Used for cutting tissue, suture, or for dissection
Can be straight or curved

Scissor types:
Mayo scissors
Heavy scissors
Straight – used for cutting suture “suture scissors”
Curved – used for cutting heavy tissue (fascia)

Metzenbaum scissors
Light scissors used for cutting delicate tissue (heart) and blunt dissection

Iris scissors
Used for fine dissection and cutting fine suture

Question 7

Forceps or “Pickups”

Answer 7

Also known as non-locking forceps, grasping forceps, or pick-ups
Used for grasping tissue or objects
Can be toothed (serrated) or non-toothed

Forcep types:
Tissue forceps
Non-toothed; used for fine handling of tissue and traction during dissection
Adson forceps
Toothed at the tip; used for handling dense tissue (skin closure)
DeBakey forceps
Non-toothed; used for atraumatic tissue grasping during dissection (vascular procedures)

Question 8

Clamps

Answer 8

Also known as locking forceps
Used to hold tissue or objects, or to provide hemostasis
Can be traumatic or atraumatic

Clamp types:
Crile hemostat
Atraumatic and non-toothed clamp used to grasp tissue or vessels that will be tied off
Can be used for blunt dissection
Kelly clamp
Larger size variation of hemostat used for grasping larger tissue or vessels
Allis clamp
Rounded jaws used for grasping intestine
Babcock clamp
Rounded jaws used for grasping intestine

Question 9

Retractors

Answer 9

Used to hold an incision open, hold back tissues or other objects to maintain a clear surgical field, or reach other structures
Can be hand-held or self-retaining via a ratcheting mechanism

Retractor types:
Deavor retractor
Army-Navy retractor
Richardson retractor
Malleable retractor- Can be bent to customize to the particular procedure

Question 10

Needles

Answer 10

Tapered needle
Round and tapers to a simple point
Pierces the tissue without cutting it
Used in softer tissue (intestine or hollow organs)

Reverse cutting needle
Cutting surface on the convex edge
Used for suturing skin

Conventional cutting needle
Triangular in shape, and have 3 cutting edges to penetrate tough tissue
Used for suturing skin

Needle shape
Curved – general surgical procedures
Straight – skin and subcuticular suturing

Question 11

Answer 11

Grasp the needle approximately 2/3 along the length of the needle, perpendicular to the needle driver

Grabbing the needle too close to the tip or to the swage (where the suture inserts) risks bending the needle

Question 12

Suture

Answer 12

Strand of material used to ligate blood vessels or to approximate tissues (“Approximate, don’t strangulate!”)

Sized based on the diameter of the material; stated as a number of “O’s”
The higher the number of “O’s”, the smaller the diameter

Classified as absorbableor non-absorbablematerials, then further sub-classified intosyntheticornatural

Question 13

Absorbable suture
Example

Answer 13

Broken down by the bodyvia enzymatic reactions or hydrolysis
Time of absorption variesbetween material, location of suture, and patient factors
Example: Vicryl

Question 14

Non-absorbable suture:

Answer 14

Not broken down by the body
Example: Prolene, Nylon

Question 15

Electrocautery unit or “Bovie”

Answer 15

Developed by Harvard physicist William Bovie
Device produces high-frequency alternating polarity, electrical current to:
Incise tissue
Destroy tissue throughdesiccation
Control bleeding (hemostasis) by causing the coagulation of blood

Question 16

phases of surgery

preoperative phase

Answer 16

Initial phase
Begins when the decision has been made to have a surgical procedure and ends when the patient is wheeled into surgery

Goals:
Identify and address potential concerns prior to surgery
Improve surgical outcomes

Includes:
Patient interview
Identify current complaints, expectations of planned surgery, and answer patient’s questions
Thorough medical history
Emphasis on ROS, PMH, PSH, and medications
Physical examination
Vital signs, cardiovascular and respiratory examination, surgery-related examination
Risk assessment
General and system-specific evaluations

Question 17

Phases of Surgery

Intraoperative phase

Answer 17

Second phase
Involves the surgical procedure
Starts when the patient is wheeled into the surgical suite and ends when the patient is wheeled to the post-anesthesia care unit (PACU)

Question 18

Phases of Surgery

Postoperative phase

Answer 18

Final phase
Period immediately following surgery
Focused on monitoring and managing the patient’s physiological health and aiding in postsurgical recovery

Question 19

preoperative studies
labs

Answer 19

Question 20

Factors Influencing Postoperative Outcomes

METs ≥ 4 = no further testing METs < 4 = pharmacological stress test

Answer 20

Age
Medications
Patient’s functional capacity
Subjective measure of the body’s ability to effectively respond to and adapt to physiological stress
Measured as metabolic equivalents (METs)
High the METs, the better at responding/adapting
Obesity
Smoking
Illicit drug use
Alcohol use disorder
Obstructive sleep apnea
Personal or family history of anesthetic complications

Question 21

Revised Cardiac Risk Index (RCRI)

Answer 21

Practical and frequently used cardiovascular risk assessment tool for patients undergoing a non-cardiac surgery
Required for patients that have a history or symptoms suggestive of heart disease

Includes
1 surgery-specific risk factor
5 patient-specific risk factors

Question 22

Anesthesia Evaluation
Classes

Answer 22

American Society of Anesthesiologists (ASA) classification is based on the ability of the patient to tolerate anesthesia according to the extent of disease:
As the classification class increases, so do associated-comorbidities and the risk of post-operative morbidity and mortality

Class I: normal and healthy patient
Class II: mild systemic disease
Class III: severe systemic disease that limits activity
Class IV: incapacitating disease that is a constant threat to life
Class V: patient not expected to survive without the operation
Class VI: patient declared brain-dead and undergoing theorgan donationprocess

Question 23

Airway Evaluation

Answer 23

Assess the ease of intubation and airway maneuvers
Modified Mallampati score
Describes the relative size of the base of the tongue compared to the oropharyngeal opening
Assessment is performed with the patient sitting Fowler’s position, mouth open and tongue maximally protruded, without speaking or saying “ahh”
The higher the grade, the greater the difficulty in obtaining a secure airway

Question 24

skin prep

Answer 24

Step in basic infection control
Methicillin-resistantStaphylococcus aureus(MRSA) decolonization

MRSA screening via swabs of the anterior nares weeks before elective procedures

Positive MRSA culture results are treated:
2% mupirocin twice daily for five days preoperatively to the nares OR
5% povidone-iodine solution to each nostril for 10 seconds per nostril, 1 hour prior to surgery
AND vancomycin administration at the time of surgery
Skin antiseptic
Perform a combination ofa standard soap-and-water shower and chlorhexidine gluconate cloth wash before surgery

Question 25

Medications that are typically continued:

Answer 25

Beta-blockers
Calcium channel blockers
Digoxin
Statins
Asthma inhalers
Lithium
SSRIs
Tricyclic antidepressants
Anticonvulsants

Question 26

Medications to hold prior to surgery:

Answer 26

Diuretics – hold the morning of surgery
ACE inhibitors/ARBs – hold the morning of surgery
Theophylline – hold on the evening prior to surgery
Oral hypoglycemic drugs – hold the morning of surgery
Levothyroxine – hold the morning of surgery

Question 27

Medications to discontinue prior to surgery

Answer 27

Antiplatelet medications (ASA) – discontinue 1 week prior to surgery
NSAIDs – discontinue 3 days prior to surgery
Monoamine oxidase inhibitors – discontinue 2 weeks prior to surgery

Question 28

Medication changes for diabetics

Optimal glucose level

Answer 28

Insulin is held for patients that are NPO (nil per os) and postoperatively
Optimal serum glucose level: 140-180 mg/dL
Glucose monitoring very 4 hours when NPO