(CLINICS) Surgery Notes +CPG

 

SURGERY

SURGERY CLINICS

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HISTORY TAKING   Should not delay resuscitation resuscitation of the acutely

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ill patient

  2 types: 1)  OPD / ER -  With a specific complaint -  DX through History & PE with

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diagnostic tests and imaging -  DRE is a must

2)  Elective Surgery -  Assess if patient is suitable for operation -  Assess if procedure planned is correctly indicated

  Components: o  Source & Reliability

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 Religion is important   General Information –  Religion

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  Chief complaint o  History of present illness o  Past Medical History -  Chronological -  All diseases ( previous to present) o

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-  Previous operations / accidents acc idents (adhesions) -  Food and drug allergy o  Family History -  Heredofamilial disease -  Cancer o  Personal & Social History -  Diet -  Mental status -  Vices: alcohol, smoking, drug use -  Bowel and urinary patterns -  Sleep -  OB and Menstrual History o  Physical Exam o  Formulation (paragraph form) -  Primary impression -  Differential diagnosis -  Diagnostic plan -  Treatment plan  Definitive (Surgery)  Supportive (Medical)

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COMMON COMPLAINTS TO SURGERY: 1)  2)  3)  4)  5)  6) 

– most common (abdominal) PAIN  – MASS / SWELLING VOMITING  –– ex. Obstruction due to mass, GERD BLEEDING  –– ex. PUD DISCHARGE  –– ex. Soft tissue infection, Diabetic Foot DEFORMITY  –– ex. Trauma cases

ABDOMINAL PAIN:  

SITE   ONSET   SEVERITY            

NATURE PROGRESSION DURATION AGGRAVATING & ALLEVIATING FACTORS RADIATION PAIN SCORE

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 EXAMINATION OF THE ABDOMEN: Nipple to Knee    EXPOSURE: Lower extremity flexed at the hip to relax

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the abdominal muscles

  Steps: 1.  Inspection 2.  Auscultation 3.  Percussion

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4.  Palpate

  Check MASS:   Location   Color and Texture of overlying skin   Temperature   Tenderness   Shape   Size   Borders   Consistency   Reducibility (hernia)   Pulsatility, Compressibility (Vascular)

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DRUGS USED FOR PROPHYLAXIS IN SURGERY: ACUTE & UNCOMPLICATED APPENDICITIS: Dosage Adults

CEFOXITIN 

2 g IV single dose 

Children

40 mg/kg IV single dose 

Alternative agents 

AMPICILLINSULBACTAM AMOXICILLINCLAVULANATE

1.5-3 g IV single dose  1.2-2.4 g IV single dose

75 mg/kg IV single dose  45 mg/kg IV single dose For patients with allergy to β -lactam antibiotics:  80-120 mg IV 2.5 mg/kg IV GENTAMICIN single dose single dose + 600 mg IV 7.5-10 mg/kg IV CLINDAMYCIN  single dose single dose

BREAST SURGERY: (Mastectomy, Axillary lymph node dissection, Reduction mammoplasty, Excisional biopsy and lumpectomy) Dosage (Adults)

CEFAZOLIN  CEFUROXIME SURGERY CLINICS

2 g IV single dose  Alternative agents  1.5 g IV single dose  Page 6 of 53 

 

DRUGS USED FOR PROPHYLAXIS IN SURGERY:

INGUINAL HERNIA SURGERY: Antibiotic prophylaxis is NOT recommended in elective groin hernia surgery.

BILIARY SURGERY: (Cholecystectomy; Sphincterotomy; Cholecystectomy + (Cholecystectomy; sphincterotomy; Choledochoenterostomy: Choledochoduodenostomy, Choledochod uodenostomy, Choledochoduodenostomy Choledochoduodenostomy + sphincterotomy, Choledochojejunostomy; Cytsojejunostomy; CBD exploration) Dosage (Adults)

CEFAZOLIN  CEFUROXIME

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1 g IV single dose  Alternative agents  1.5 g IV single dose 

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DRUGS USED FOR PROPHYLAXIS IN SURGERY:

GASTRIC & DOUDENAL SURGERY: (Gastric ulcer, Chronic or Bleeding gastric Ulcers, Bleeding or Obstructing duodenal ulcers) Dosage (Adults)

CEFAZOLIN  CEFUROXIME

1 g IV single dose  Alternative agents  1.5 g IV single dose 

COLORECTAL SURGERY: (Right hemicolectomy; Left hemicolectomy; Transverse colectomy; Segmental colon resection; Anterior resection; Low anterior resection; rese ction; Hartmann’s procedure; Abdominoperineal resection; Total abdominal colectomy) Dosage (Adults)

ERTAPENEM 

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1 g IV single dose 

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DIFFERENTIAL DIAGNOSES OF ABDOMINAL PAIN  BY LOCAION

Harrison's Principles of Internal Medicine (19th edition)

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SKILLS

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SURGICAL HANDSCRUBING & GOWNING Purpose of surgical hand scrubo:   Remove debris and transient microorganisms from the nails, hands, and forearms 

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the resident microbial count to a minimum, and    Reduce Inhibit rapid rebound growth of microorganisms.

All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to the scrub is an efficient way to ensure proper technique.

SURGICAL SCRUB TECHNIQUES   Remove all jewelry (rings, watches, bracelets).   Wash hands and arms with antimicrobial soap.   Clean subungual areas with a nail file.   Scrub each side of each finger, between the fingers, and the back and front of the hand.   Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria-laden soap and water from contaminating the hand.   Wash each side of the arm to three inches above the elbow.   Repeat the process on the other hand and arm, keeping hands above elbows at all times.   Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.   Proceed to the operating room suite holding hands above elbows. 

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  Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.

Source: http://www.infectioncontroltoday.com/ How to Perform Surgical Hand Scrubs ARTICLE; May 1, 2001

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GOWNING:   When gowning oneself, grasp the gown firmly and bring it away from the table. It has already been folded so that the outside faces away. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.   Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to slide outside the gown cuff. The circulator will assist by pulling the gown up over the shoulders and tying it. 

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CLOSED GLOVING: g own. The fingers of   Lay the glove palm down over the cuff of the gown. the glove face toward you.   Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve.   Unroll the glove cuff so that it covers the sleeve cuff.   Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove. 

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OPEN GLOVING: 1.  Pick up the cuff of the right glove g love with your left hand. Slide your right hand into the glove until you have a snug fit over the thumb joints and knuckles. Your bare left hand should only touch the folded cuff –  the rest of the glove g love remains sterile.

2.  Slide your fingertips into the folded cuff of the left glove.

3.  Use gloved left hand pick up folded cuff of right glove and pull glove up to gowned wrist.

4.  Place the fingers of the gloved right hand under the cuff of the partially gloved left hand. Unfold the cuff down over your gown sleeves. Make sure your gloved finger tips do not no t touch your bare forearms or wrists.

Source: https://stratog.rcog.org.uk/tutorial/general-principles/open-gloveSource: technique-6076

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KNOT TYING (SQUARE KNOT) TWO HAND TECHNIQUE 1.  White strand placed over extended index finger of left hand acting as bridge, and held in palm of left hand. Purple strand held in right hand.

2.  Purple strand held in right hand brought between left thumb and index finger.

3.  Left hand turned inward by pronation, and thumb swung under white strand to form the first loop.

4.  Purple strand crossed over white and held between thumb and index finger of left hand.

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5.  Right hand releases purple strand. Then left hand supinated, with thumb and index finger still grasping purple strand, to bring purple strand through the white loop. Regrasp purple strand with right hand.

6.  Purple strand released by left hand and grasped by right. Horizontal tension is applied with left hand toward and right hand away from operator. This completes first half hitch.

7.  Left index finger released from white strand and left hand again supinated to loop white strand over left thumb. Purple strand held in right hand is angled slightly to the left.

8.  Purple strand brought toward the operator with the right hand and placed between left thumb and index finger. Purple strand crosses over whit strand.

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9.  By further supinating left hand, white strand slides onto left index finger to form a loop as purple strand is grasped between left index finger and thumb

10. Left hand rotated inward by pronation with thumb carrying purple strand through loop of white strand. Purple strand is grasped between right thumb and index finger.

11. Horizontal tension applied with left hand away from and right hand toward the operator. This completes the second half hitch.

12. The final tension on the final throw should be as nearly horizontal as possible

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ONE-HAND TECHNIQUE 1.  White strand held between thumb and index finger of left hand with loop over extended index finger. Purple strand held between thumb and index finger of right hand.

2.  Purple strand brought over white strand on left index finger by moving right hand away from operator.

3.  With purple strand supported in right hand, the distal phalanx of left index finger passes under the white strand to place it over tip of left index finger. Then the white strand is pulled through loop in preparation for applying tension. 4.  The first half hitch is completed by advancing tension in the horizontal plane with ht left hand drawn toward and right hand away from the operator.

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5.  White strand looped around three fingers of left hand with distal end held between thumb and index finger.

6.  Purple strand held in right hand brought toward the operator to cross over the white strand. Continue hand motion by flexing distal phalanx of left middle finger to bring it beneath white strand.

7.  As the middle finger is extended and the left hand pronated, the white strand is brought beneath the purple strand.

8.  Horizontal tension applied with the left hand away and right hand toward the operator. This completes the second half hitch of the square knot. Final tension should be as nearly horizontal as possible. Source: http://www.uphs.upenn.edu/surgery/Education/medical_students/square_knot.html    http://www.uphs.upenn.edu/surgery/Education/medical_students/square_knot.html 

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WOUND SUTURING

Various types of sutures. From Dorland's, 2000.

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SUTURING TECHNIQUES General Principles Many varieties of suture material and needles are available. The choice of sutures and needles is determined by the location of the lesion, the thickness of the skin in that location, and a nd the amount of tension exerted on the wound. Regardless of the specific suture and needle chosen, the basic techniques of needle holding, needle driving, and knot placement remain the same.

Suture placement A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon’s preference. The needle holder is tightened by squeezing it until the first ratchet catches. cat ches. The needle holder should not b be e tightened excessivel y, because to bothand the longitudinally needle and the needle holder mayexcessively, result. The needle isdamage held vertically perpendicular to the needle holder. Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and placing the index finger on the fulcrum of the needle holder to provide stability. Alternatively, the needle holder may be held in the palm to increase dexterity. The tissue must be stabilized to allow a llow suture placement. Depending on the surgeon’s preference, preference, toothed or untoothed unt oothed forceps or skin hooks may be used to grasp the tissue gently. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis.

Forceps are necessary for grasping the needle as it exits the tissue after a pass. Before removal of the needle holder, grasping g rasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.

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The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the two sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.

Knot tying Once the suture is satisfactorily placed, it must be secured with a knot. The instrument tie is used most commonly in cutaneous surgery. The square knot is traditionally used. First, the tip of the needle holder is rotated clockwise around the long end of the suture for two complete turns. The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, so that the two ends of the suture are on opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of the suture. The short end is then grasped with the needle holder tip and pulled through the loop again.

The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound

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edema. Depending on the surgeon’s preference, one or two additional throws may be added.

Properly squaring successive ties ties is important. In other words, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is is inherently weaker than a properly squared knot. When the desired d esired number of throws is completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be placed.

PLACEMENT OF SPECIFIC SUTURE TYPES A.  Simple interrupted suture The most commonly used and most versatile suture in cutaneous surgery is the simple interrupted suture. This suture s uture is placed by inserting the needle perpendicular perpendicular to the epidermis, traversing the epidermis and the full thickness of the dermis, and a nd exiting perpendicular to the epidermis on the opposite side of the wound. The two sides of the stitch should be symmetrically symmetricall y placed in terms of depth and width. In general, the suture should have a flask-shaped configuration, that is, the stitch should be wider at its base (dermal side) than at its superficial portion (epidermal side). If the stitch encompasses a greater volume of tissue at the base than at its apex, the resulting compression at the base forces the tissue upward and promotes eversion of the wound edges (see the image below). This maneuver decreases the likelihood of creating a depressed scar as the wound retracts during healing.

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Simple interrupted suture placement. Bottom right image shows a flaskshaped stitch, which maximizes eversion. As a rule, tissue bites should be evenly placed so that the wound edges meet at the same level; this minimizes the possibility of mismatched wound-edge heights (ie, stepping). However, the size of the bite taken from the two sides of the wound can be deliberately varied by modifying the distance of the needle insertion site from the wound edge, the distance of the needle exit site from the wound edge, and the depth of the bite taken. The use of differently sized needle bites on each side of the wound can correct preexisting asymmetry in edge thickness or height. Small bites can be used to precisely coat wound edges. Large bites can be used to reduce wound tension. Proper tension is important to ensure precise wound approximation while preventing tissue strangulation.

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B.  Simple running suture A simple running (continuous) suture is essentially an uninterrupted series of simple interrupted sutures. The suture is started s tarted by placing a simple interrupted stitch, which is tied but not cut. A series of simple sutures are placed in succession, without the suture material being tied or cut after each pass. The sutures should be evenly spaced, and tension should be evenly distributed along the suture line. The line of stitches is completed by tying a knot after the last pass at a t the end of the suture line. The knot is tied between the tail end of the suture s uture material where it exits exits the wound and the loop of the last suture placed.

C.  Running locked suture A simple running suture may be either locked or left unlocked. The ffirst irst knot of a running locked suture is tied as in a traditional running suture and may beislocked passing the needle through the loop preceding it as each stitch placedby (see the image below). This suture is also known as the baseball stitch because of the final appearance of the running locked suture line.

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D.  Vertical mattress suture. A vertical mattress suture is a variation va riation of a simple interrupted suture. It consists of a simple interrupted stitch placed wide and deep into the wound edge and a second more superficial interrupted stitch placed closer to the wound edge and in the opposite direction. The width of the stitch should be increased in proportion to the amount of tension on the wound—that is, the higher the tension, the wider the stitch.

E.  Half-buried vertical mattress suture A half-buried vertical mattress suture is a modification of a vertical mattress suture that eliminates two of the four f our entry points, thereby reducing scarring. It is placed in the same manner as the vertical mattress suture, except that the needle penetrates the skin to the level of the deep part of the dermis on one side of the wound, takes a bite in the deep part of the dermis on the opposite side without exiting the skin, crosses back to the original side, and finally exits the skin. Entry and exit points thus are kept on one side of the wound.

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F.  Pulley suture A pulley suture is a modification of a vertical mattress suture. A vertical mattress suture is placed, the knot is left untied, and the suture is looped through the external loop on the other side of the incision and pulled across (see the image below). At this point, the knot is tied. This new loop functions as a pulley, directing tension away from the other strands.

Pulley stitch, type 1.

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G.  Far-near near-far modified vertical mattress sutures Another stitch that serves the same function as a pulley suture is a farnear near-far modified vertical mattress suture. The first loop is placed about 4-6 mm from the wound edge on the far side and about 2 mm m m from the wound edge on the near side. The suture crosses the suture line and reenters the skin on the original side at 2 mm from the wound edge on reenters the near side. The loop is completed, and the suture exits the skin on the opposite side 4-6 mm away from the wound edge on the far side. A pulley effect is thus created.

Far-near near-far modification of vertical mattress suture, creating pulley effect.

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H.  Horizontal mattress suture A horizontal mattress suture is placed by entering the skin 5 mm to 1 cm from the wound edge. The suture is passed deep in the dermis to the opposite side of the suture su ture line and exits the skin equidistant from the wound edge (in effect, a deep simple interrupted stitch). The needle reenters the skin on the same side of the suture line 5 mm to 1 cm lateral reenters of the exit point. The stitch is passed deep to the opposite opposi te side of the wound, where it exits the skin; the knot is then tied.

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Half-buried horizontal suture A half-buried horizontal suture (also referred referred to as a tip t ip stitch or threepoint corner stitch) begins on the side of the wound on which the flap is to be attached. The suture is passed through the dermis of the wound edge to the dermis of the flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the skin to which the flap is i s to be attached. a ttached. The needle is directed perpendicularly and exits the skin; the knot is then tied.

Half-buried horizontal horizontal suture (tip stitch, st itch, three-point corner stitch).

J.  Dermal-subdermal sutures A dermal-subdermal suture is placed by inserting the needle parallel to the epidermis at the junction of the dermis and the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to the epidermis. The needle is inserted parallel to the epidermis in the papillary dermis on the opposing edge of the wound, curves down through the reticular dermis, and exits at the base of the wound at the interface between the dermis and the subcutis and parallel to the epidermis. The knot is tied at the base of the wound wo und to minimize the possibility of tissue reaction and extrusion of the knot. If the suture is placed more superficially in the dermis at 2-4 mm from the wound edge, eversion is increased.

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K.  Buried horizontal mattress suture A buried horizontal mattress suture is a purse-string suture. The suture must be placed in the mid-to-deep mid- to-deep part of the dermis to prevent the skin from tearing. If tied too tightly, the suture may strangulate the approximated tissue.

L.  Running horizontal mattress sutures A simple suture is placed, and the knot is tied but not cut. cu t. A continuous series of horizontal mattress sutures is placed, with the final loop tied to the free end of the suture material.

M.  Running subcuticular sutures A running subcuticular suture is a buried form of a running horizontal mattress suture. It is placed by taking horizontal bites through the papillary dermis on alternating sides of the wound. No suture marks are visible, and the suture may be left in place for several weeks.

Subcuticularr stitch. Skin surface remains intact along length of suture line. Subcuticula

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N.  Running subcutaneous suture A running subcutaneous suture begins with a simple interrupted subcutaneous suture, which is tied but not cut. The suture is looped through the subcutaneous tissue by successively passing through the opposite sides of the wound. The knot is tied at the opposite end of the wound by knotting the long end of the suture material to the loop of the last pass that was placed.

O.  Running subcutaneous subcutaneous corset plication stitch Before the needle is inserted, forceps are used to pull firmly on at least 12 cm of tissue to ensure tissue strength. The corset plication includes at least 1-2 cm of adipose tissue and fascia within each bite. After the first bite is tied, bites are taken on opposite sides of the wound in a running fashion along the defect. The free end is pulled firmly to reduce the size of the defect, and the suture is then tied.

P.  Variations of tip (corner) sutures s utures Modified half-buried horizontal mattress suture

In a modified half-buried horizontal mattress suture, an additional addi tional vertical mattress suture is placed superficial to the half-buried horizontal mattress suture. A small skin hook instead of forceps is used to avoid trauma of the flap. Deep tip stitch

A deep tip stitch is essentially a fully buried form of a three-corner stitch. The suture is placed into the deep dermis of the wound edge to which the flap is to be attached, passed through the dermis of the flap tip, and a nd inserted into the deep dermis of the opposite wound edge.

Source: Suturing Techniques Technique (Jul 11, 2017) http://emedicine.medscape.co http://emed icine.medscape.com/article/1824895-techniq m/article/1824895-technique#c4 ue#c4  

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 BREAST EXAM EX AM THE FEMALE BREAST A. INSPECTION   Inspect the breasts and nipples with the patient in the sitting 

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position and disrobed to the waist.

  Includes Includes:: careful inspection for skin changes, symmetry, contours,

and retraction in four views —arms at sides, arms over head, arms pressed against hips, and leaning forward.   Adolescent girl  girl  –  – assess her breast development d evelopment according to Tanner’s sex maturity ratings  a.  Arms at Sides  1.  Appearance of of the skin skin, including:   Color    Thickening of the skin and unusually prominent pores, which 

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may accompany lymphatic obstruction   The size and symmetry of the breasts. Some difference in the size of the breasts, including the areolae, is common and usually normal. masses,,   The contour of the breasts. Look for changes such as masses dimpling,, or flattening dimpling or flattening.. Compare one side with the other.  other.  2.  Characteristics of the nipples  shape, direction in which they point, any rashes or   Size and shape, ulceration,, or any discharge ulceration   Occasionally, the shape of the nipple is inverted , or depressed below the areolar surface. It may be enveloped by folds of areolar skin, as illustrated. Long-standing inversion is usually a normal variant of no clinical consequence co nsequence,, except for possible difficulty when breast-feeding.  breast-feeding.  b.  Arms over over Head; Hands Hands Pressed Against Against Hips; Leaning Forward  Forward     bring out dimpling or retraction that may otherwise be invisible 

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B. PALPATION 1.  The Breast     Best performed when the breast tissue is flattened = patient supine.   Plan to palpate a rectangular area extending from: line & o  clavicle to the inframammary fold or bra line & p osterior axillary line and well into o  midsternal line to the posterior the axilla for the tail of the breast.   A thorough examination will take 3 minutes for each breast.   Use the fingerpad  fingerpadss of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed.   Vertical strip pattern - best validated technique for detecting breast masses.   Palpate in small , concentric circles at each examining point, if possible applying light, medium, and deep pressure. pressure . 

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a.  Lateral portion of the breast  –  – PX roll onto the opposite hip,, hand on her forehead , shoulders pressed against the hip bed or examining table (flattens table (flattens the lateral breast tissue)  tissue)   b.  Examine the breast tissue carefully for:  for:  o Consistency of the tissues     Physiolog Physiologic ic nodularity  before  before menses.   Firm transverse ridge of compressed tissue (lower margin of the breast, especially in large la rge breasts) = Normal inframammary ridge, not a tumor. o  Tenderness , as in premenstrual fullness

  Nodules    Lumps or mass that is qualitatively different from or

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larger than the rest of the breast tissue = dominant mass (may reflect a pathologic change)   Assess and describe the characteristics of any nodule: 1.  Location Location— —by quadrant or clock, with cm from the nipple 2.  Size Size— —in cm  cm  3.  Shape Shape— —round or cystic, disc-like, or irregular in contour   contour

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4.  Consistency —soft, firm, or hard  hard  5.  Delimitation Delimitation— —well circumscribed or not  not  6.  Tenderness  7.  Mobility —in relation to the skin, pectoral fascia, and chest wall. Watch for dimpling dimpling.. 2.  The Nipple –  elasticity

THE MALE BREAST   Inspect - nipple and areola for nodules, swelling, or ulceration ulceration     Palpate the areola and breast tissue for nodules  nodules    Gynecomastia

Source: Bates' Guide to Physical Examination and History Taking T aking (11th edition)

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DIGITAL RECTAL EXAM 

  Suitable patient positions for conducting the examination: o  Patient to stand and lean forward  with his upper body resting across the examining table and hips flexed  – satisfactory and allows good visualization of the Side-lying position –   perianal and sacrococcygeal areas.

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  Ask the patient to lie on his left side with his buttocks close to the edge of the examining table near you. Flexing the patient’s hips and knees, especially in the upper leg, stabilizes his position and improves visibility. Drape the patient appropriately and adjust the light l ight for the best view. Glove your hands and spread the buttocks apart.   Inspect the sacrococcygeal and perianal areas  for lumps, ulcers, inflammation, rashes, or excoriations. Adult perianal skin is normally more pigmented and somewhat coarser than the skin over the buttocks. Palpate any abnormal areas, noting lumps or tenderness.   Examine the anus and rectum. Lubricate your gloved index finger, explain to the patient what you are going to do, and tell him that the examination may trigger an urge to move his bowels but that this will not occur. Ask him hi m to strain down. Inspect the anus, noting any lesions.

  As the patient strains, place the pad of your gloved and lubricated index finger over the anus.   As the sphincter relaxes, gently insert your fingertip into the anal canal in the direction pointing toward the umbilicus. If you feel the sphincter tighten, pause and reassure the patient. When, in a moment, the sphincter relaxes, proceed.

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  Occasionally, severe tenderness prevents entry and internal examination. Do not try to force it. Instead, place your fingers on both b oth sides of the anus, gently spread the orifice, and ask the patient to strain down. Look for a lesion, such as an anal fissure, that might migh t explain the tenderne tenderness. ss. note:     If you can proceed without undue discomfort to the patient, note:  o  The sphincter tone of the anus . Normally, the muscles of the anal sphincter close snugly around your finger. fi nger. Initial resting tone reflects the integrity of the internal anal sphincter. To check external sphincter tone, ask the patient to bear down and squeeze the rectal muscles. o  Tenderness, if any o  Induration  o  Irregularities or nodules    Insert your finger into the rectum as far as possible. Rotate your hand clockwise to palpate as much of the rectal surface as possible on the patient’s right side, then counterclockwise to palpate the surface posteriorly and on the patient’s left side.    Note any nodules, irregularities, or induration. To bring a possible lesion into reach, take your finger off the rectal surface, ask the patient to strain s train down, and palpate again.

  Then rotate your hand further counterclockwise so that your finger can examine the posterior surface of the prostate gland g land. By turning your body somewhat away from the patient, you can feel this area more m ore easily. Tell the patient that examining his prostate gland may prompt an urge to urinate.

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  Sweep your finger carefully over the prostate gland, identifying its lateral lobes and the median sulcus between them. Note the size, shape, and consistency of the prostate, and identify any nodules or tenderness. The normal prostate is rubbery and nontender.   If possible, extend your finger above the prostate  to the region of the seminal vesicles and the peritoneal cavity and sweep the anterior wall. Note any nodules or tenderness.   Gently withdraw your finger, and wipe the anus or give the patient tissues. Note the color of any fecal matter on your glove, and test it for occult blood.

FEMALE  

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  The rectum is usually examined after the female genitalia while the woman is in the lithotomy position. This position allows you to conduct the bimanual examination and delineate a possible adnexal or pelvic mass. It allows you to test the integrity of the rectovaginal wall and may help you to palpate a cancer high in the rectum.   If you need to examine only the rectum, the lateral position is satisfactory and affords a much better b etter view to the perianal and sa sacrococcygeal crococcygeal areas. Use the same techniques for examination that you use for men. Note that the cervix is readily palpated through the anterior wall. Sometimes Som etimes a retroverted retroverte d uterus is also palpable. pa lpable. Do not mistake either of these, or a vaginal tampon, for a tumor.

Source: Bates' Guide to Physical Examination and History T Taking aking (11th edition)

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PCS CPG

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 EVIDENCE -BASED CLINICAL PRACTI  EVIDENCE-BASED PRACTICE CE GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF ACUTE APPENDICITIS Philippine College of Surgeons (2002) Operational Definitions:

  Uncomplicated Appendicitis - includes the acutely

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inflamed, phlegmonous, suppurative or mildly inflamed appendix with or without peritonitis.

  Complicated Appendiciti Appendicitiss - includes gangrenous

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appendicitis, perforated appendicitis, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess.

  Equivocal Appendicitis - a patient with right lower

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quadrant abdominal pain who presents with an atypical history and physical examination and the surgeon cannot decide whether to discharge or to operate on the patient.

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Executive Summary:

  When should one suspect appendicitis?

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Consider the diagnosis of acute appendicitis when a patient presents with right lower quadrant abdominal pain.

  What clinical findings are most helpful in diagnosing acute

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appendicitis? Acute appendicitis should be suspected in any patient (especially male) who presents with a high intensity of perceived abdominal pain of at least 7-12 hours duration, with migration to the right lower quadrant, and followed by vomiting. Although symptoms alone have a low discriminating power, the diagnosis of acute appendicitis becomes more certain when the physical examination findings include right lower quadrant tenderness, guarding, rebound tenderness  and other signs of peritoneal irritation.

  What diagnostic tests are helpful in the diagnosis d iagnosis of acute

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appendicitis? Although the diagnosis of acute appendicitis is primarily based on the clinical findings, the following examinations may be helpful: A.  All Cases 1.  White blood cell differential count B.  Equivocal Appendicitis in Adults 1.  CT Scan 2.  Ultrasound

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Whenever feasible, CT scan should be b e preferred over ultrasonography in clinically equivocal appendicitis in adults because of its superior accuracy.

C.  Equivocal Appendicitis Appendicitis in the Pediatric Age Group 1.  Ultrasound (graded compression) 2.  CT scan

Although CT scan and ultrasound have comparable accuracy in the diagnosis of acute appendicitis in the pediatric age group, ultrasound is preferred because of its lack of radiation, cost-effectiveness and availability compared to CT scan.

D.  Selected Cases 1.  Diagnostic Laparoscopy Despite its statistically significant favorable effects, diagnostic laparoscopy should be viewed as an invasive procedure requiring anesthesia and having risks similar to appendectomy. It should be utilized at this time only in selected cases.

The following examinations are generally not useful in the diagnosis of acute appendicitis: 1.  Plain Abdominal X-ray 2.  Barium Enema

3.  Scintigraphy

  What is the appropriate treatment for acute appendicitis?

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Appendectomy is the appropriate treatment for acute appendicitis.

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  What is the recomme recommended nded approach to the surgical

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management of acute appendicitis? Open appendectomy is the recommended primary approach to the treatment of acute appendicitis in our setting. Therapeutic laparoscopic appendectomy is an alternative in selected cases.

  What is the role of laparoscopic appendec appendectomy tomy in the

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management of acute appendicitis in children? Laparoscopic appendectomy may be recommended as an alternative to open appendectomy in the pediatric age group.

  What is the role of antibiotics in the management of acute

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appendicitis?  A.  Is antibiotic prophylaxis indicated for uncomplicated appendicitis?   appendicitis? YES. Antibiotic prophylaxis is effective in the prevention of surgical site infection for patients who undergo appendectomy and should be considered for routine use. B.  What antibiotic/s is/are recommended for prophylaxis in uncomplicated appendicitis and what is the appropriate dose and route of administration? The following antibiotics are recommended for prophylaxis in uncomplicated appendicitis: o  Cefoxitin    2 g IV single dose (Adults)   40 mg/kg IV single dose (Children)

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Alternative agents: o  Ampicillin-sulbactam   1.5-3 g IV single dose (Adults)   75 mg/kg IV single dose (Children) o  Amoxicillin-clavulanate   1.2-2.4 g IV single dose (Adults)   45 mg/kg IV single dose (Children) For patients with allergy to β -lactam antibiotics: o  Gentamicin  80-120 mg IV single dose plus Clindamycin 600 mg IV single dose (Adults) o  Gentamicin  2.5 mg/kg IV single dose plus Clindamycin 7.5-10 mg/kg IV single dose (Children) C.  What antibiotic/s is/are recommended for the treatment of complicated appendicitis appendicitis and what is the appropriate dose, route and duration of administration? The recommended antibiotics for therapy of complicated appendicitis in adults are: o  Ertapenem 1 g IV every 24 hours o  Tazobactam-piperacillin 3.375 g IV every 6 hours or 4.5 g IV every 8 hours For adults with β-lactam allergy: o  Ciprofloxacin 400 mg IV every 12 hours plus o  Metronidazole 500 mg IV every 6 hours The recommended antibiotic for therapy of complicated appendicitis in pediatric patients is ticarcillin-clavulanic ticarcillin-clav ulanic acid 75 mg/kg IV every 6 hours Alternative agents for pediatric patients include: o  Imipenem-Cilastatin 15-25 mg/kg IV every 6 hours

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For children with β-lactam allergy: o  Gentamicin  5 mg/kg IV every 24 hours plus Clindamycin 7.5-10 mg/kg IV every 6 hours For gangrenous appendicitis, the recommended form of management is to treat in the same manner as uncomplicated appendicitis. The duration of therapy may vary depending on the clinician's assessment after the operation. The therapy may be maintained for 5-7 days. Sequential therapy to oral antibiotics may be considered when gastrointestinal function has returned. The absence of fever for 24 hours (temperature 0